ANATOMY2008ZOZ

1.

DuringaretroperitonealapproachtotheL45disk,whatstructuremustbeligated
tosafelymobilizethecommoniliacvesselstowardthemidlinefromlaterallyand
gainexposure?

Obturatorvein

Iliolumbarvein

Externaliliacvein

Middlesacralartery

Hypogastricartery

PREFERREDRESPONSE:2

DISCUSSION:Tomobilizethecommoniliacvesselsacrossthemidline,theiliolumbarvein
mustbeligated.Ithasashorttrunkandcanbetornifmobilizationisattemptedwithoutligation.
Itistheonlybranchoffthecommoniliacs(therearenoarterialbranches)priortotheterminal
branches,theinternal(hypogastric)andexternaliliacs.Themiddlesacralvesselsrundistally
fromtheaxillaofthebifurcationandareafactorwhenaccessingtheL5S1disk.
2.

TheinjectionshowninFigures1aand1bwouldmostbenefitapatientwhoreportswhich
ofthefollowingsymptoms?

Dorsalfootpainextendingintothegreattoe

Footpainextendingalongthelateralborderofthefoot

Painextendingintothefootinastockingdistribution

Anteriorthighandshinpainendingattheankle

Lateralfootparesthesias

PREFERREDRESPONSE:1

DISCUSSION:TheimagesdemonstrateaL5selectiverootblockasitexitstheL5S1foramen.
ThisrootblockbesthelpsrelievepainorparesthesiasintheL5distribution,whichisthedorsal
firstwebspaceandthegreattoe.ThelateralfootisanS1distributionandwouldneedtobe
blockedthroughtheposteriorfirstsacralforamen.Theanteriorshinandthighrepresentthe
L4rootwhichexitsalevelabovethisattheL45foramen.Astockingdistributionis
nonanatomicandnotindicativeofaspecificroot.
3.

InFigure2,whichofthefollowingstructuresistheprimarystabilizerinpreventing
valgusinstabilityoftheelbow?

PREFERREDRESPONSE:2

DISCUSSION:Theanteriorbundleofthemedialcollateralligamentistheprimestabilizerofthe
medialaspectoftheelbowandisindicatedbyBinthefigure.Whenintact,thisanterior
bundleofthemedialcollateralligamentisarestrainttovalgusinstabilityoftheelbow.The
posteriorbundleisregardedasasecondarystabilizerofthemedialelbow(C).Thetransverse
bundle(D),annularligament(A),andbicepstendon(E)donotplayaroleinvalgusstabilityof
theelbow.
4.

WhenperformingsurgicalexcisionofthelesionshownintheMRIscaninFigure3,
whatnerveismostlikelyatrisk?

Deepbranchoftheulnarnerve

Anteriorinterosseousbranchofthemediannerve

Recurrentbranchofthemediannerve

Recurrentbranchoftheulnarnerve

Palmarcutaneousbranchoftheulnarnerve

PREFERREDRESPONSE:3

DISCUSSION:TheMRIscanshowsalargemass(lipoma)inthethenarmusclesofthepalm.
Therecurrentmotorbranchofthemediannerveinnervatesthethenarmuscles.Theanterior
interosseousnerve(AIN)intheproximalforearminnervatestheflexorpollicislongus,pronator
quadratus,andflexordigitorumpollicistotheindexandfrequentlythemiddlefinger.The
terminalbranchoftheAINinnervatesonlythewristcapsule.Thepalmarcutaneousbranchof
theulnarnerveisasensorystructuretothehypothenararea.Thereisnocommonlydescribed
recurrentbranchoftheulnarnerve.
5.

Figure4ashowstheradiographofa20yearoldmanwhohasaninjurytotheright
shoulder.Figure4bshowsanarthroscopicview(posteriorportal).Thearrowpointstoa

rotatorcufftear.

barearea.

HillSachsdefect.

Bankarttear.

glenoidfracture.

PREFERREDRESPONSE:3

DISCUSSION:Theradiographshowsananteriordislocationoftheshoulder.Afrequently
encounteredsequelaofthisisacompressionfractureoftheposterolateralhumeralhead,
commonlyreferredtoasaHillSachsdefect.Thearthroscopicviewoftheglenohumeraljoint
visualizestheposterioraspectofthehumeralhead.Intheimage,theareadevoidofcartilageto
therightisthebarearea.TheindentationseentotheleftisaHillSachsdefect.

6.

A15yearoldgirlwhoswimsthebreaststrokehashadhippainaftertrainingexcessively
foranationallevelcompetition.BasedontheMRIscansshowninFigures5athrough
5c,whatisthemostlikelydiagnosis?

Femoralneckstressfracture

Externalrotatormuscletear

Slippedcapitalfemoralepiphysis

Superioracetabularlabraltear

Acetabulardysplasia

PREFERREDRESPONSE:2

DISCUSSION:TheMRIscansrevealopenphysesbutnoevidenceofaslippedcapitalfemoral
epiphysis,labraltear,oracetabulardysplasia.Thefemoralneckdoesnotshowevidenceofa
fracture.Themuscletearseenontherightsideliesnearthemusculotendinousjunctionofthe
externalrotatorsofthehipatthelevelofthelessertrochanter,representingtheobturator
externus.Thisisconsistentwiththeforcedmotionrequiredforthebreaststrokekick.
7.

Duringplacementofanexternalfixatorforadistalradiusfracture,themostcommonly
injurednerveisabranchofwhichofthefollowingnerves?

Ulnar

Median

Superficialradial

Lateralantebrachialcutaneous

Medialantebrachialcutaneous

PREFERREDRESPONSE:3

DISCUSSION:Pintrackinfectionsandsensoryinjuriesareamongthemostcommon
complicationsofexternalfixationfordistalradiusfractures.Theproximalpinsofmostdistal
radiusexternalfixatorsareplacedinthebareareaofthedistalradius,aboutfourfinger
breadthsabovetheradialstyloid.Thiscorrespondstotheareawherethedorsalsensorybranch
oftheradialnervepenetratesthefasciadorsaltothebrachioradialistendontobecomea
subcutaneousstructure.Injurytothesuperficialradialnervemayproducepainfuldysesthesias
andneuromas.

8.

Figure6showsasagittalobliqueMRIscan.Thearrowispointingtowhatstructure?

Buckethandletearofthemedialmeniscus

LigamentofHumphrey

LigamentofWrisberg

Posteriorintermeniscalligament

Partialtearoftheposteriorcruciateligament

PREFERREDRESPONSE:2

DISCUSSION:Themeniscofemoralligamentsconnecttheposteriorhornofthelateralmeniscus
totheintercondylarwallofthemedialfemoralcondyle.TheligamentofHumphrey(arrow)
passesanteriortotheposteriorcruciateligament,whereastheligamentofWrisbergpasses

posteriortotheposteriorcruciateligament.Oneortheotherhasbeenidentifiedin71%to100%
ofcadaverknees,withtheligamentofWrisbergbeingmorecommon.
9.

An18yearoldwomansustainsatwistinginjuryofthekneewhileskiing.Figures7a
and7bshowtheradiographandcoronalMRIscanoftheknee.Inadditiontotheinjury
shown,whatisthemostlikelyassociatedinjury?

Medialcollateralligamentrupture

Patellardislocation

Patellartendonrupture

Anteriorcruciateligamentrupture

Posteriorcruciateligamentrupture

PREFERREDRESPONSE:4

DISCUSSION:TheMRIscanshowsaSegondfracture,whichisasmallavulsionofthelateral
jointcapsulefromtheanterolateralaspectoftheproximaltibia.Itisalmostalwaysassociated
withanteriorcruciateligamentruptureandoftenwithatearofeitherthemedialorlateral
meniscus.

10.

A42yearoldathletictrainerhasapersistentpoppingsensationaboutthelateralankle
associatedwithweaknessandpainfollowingaremoteinjury.Deficiencyinwhat
structuredirectlyleadstothispathology?

Lateraltalarprocess

Superiorperonealretinaculum

Inferiorperonealretinaculum

Extensorretinaculum

Cruralfascia

PREFERREDRESPONSE:2

DISCUSSION:Thepatienthasinstabilityoftheperonealtendon.Thesuperiorperoneal
retinaculumistheprimaryretainingstructurepreventingperonealsubluxation.Itisathickening
offasciathatarisesofftheposteriormarginofthedistal1to2cmofthefibulaandruns
posteriorlytoblendwiththeAchillestendonsheath.Theinferiorperonealretinaculumattaches
totheperonealtubercleofthecalcaneusandisnotinvolvedinthispathology.Adeficient
grooveintheposteriordistalfibulamayalsobeacontributingfactorinthedevelopmentof
thecondition.
11.

A21yearoldmansustainsmultiplegunshotwoundstohisrightupperextremity.He
cannotextendhisdigitsorhisthumbbutcanextendandradiallydeviatehiswrist.An
injurytotheradialnerveoroneofitsbrancheshasmostlikelyoccurredatwhichofthe
followinglocations?

Spiralgrooveofthehumerus

Midshaftoftheradius

Radialneck

Anatomicneckofthehumerus

Surgicalneckofthehumerus

PREFERREDRESPONSE:3

DISCUSSION:Inthispatient,theradialnerveismostlikelyinjuredattheleveloftheradial
neck.Theradialnerveemergesfromtheposteriorcordofthebrachialplexusandtravelsalong
thespiralgrooveofthehumerus.Atthelevelofthelateralhumeralcondyle,theradialnerve
branchesintotheposteriorinterosseousnerveaftergivingofftwocutaneousbranches,the
superficialradialandtheposteriorcutaneous.Theposteriorinterosseousnervetravelsthrough

thesupinatormuscleandwindsaroundtheradialneck.Atthislevel,theposteriorinterosseous
nerveisvulnerabletoinjury,particularlyfollowingfractureorpenetratingtrauma.
12.

Awomanwithaneckandchesttumorhasweaknessinthebicepsandparesthesiasinthe
thumb.Brachioradialisandinfraspinatusfunctionarenormal.Thelesionisaffecting
whichofthefollowingstructures?

C6

Uppertrunk

Middletrunk

Posteriorcord

Lateralcord

PREFERREDRESPONSE:5

DISCUSSION:Thelateralcordterminatesasthemusculocutaneousnerveandalsocontributes
sensoryfiberstothemediannerve.InvolvementoftheC6rootoruppertrunkcouldpotentially
causeweaknessoftheinfraspinatusandthebrachioradialis.Themiddletrunkandtheposterior
corddonotcontributemotorfiberstothethumborsensoryfiberstothethumb.

13.

Figure8showstheradiographofa76yearoldmanwhohaskneepainandswelling.
Historyrevealsthatheunderwenttotalkneearthroplasty18yearsago.Whatisthemost
likelydiagnosis?

Loosefemoralcomponent

Loosetibialcomponent

Particlemediatedosteolysis

Polyethylenefailure

Infection

PREFERREDRESPONSE:4

DISCUSSION:Theradiographrevealscompletelossofjointspacewithparticulatemetaldebris
consistentwithtotalpolyethylenefailureandmetalonmetalarticulation.Thecomponents
appeartobewellfixedandminimalosteolysisisevident.
14.

Whichofthefollowingradiographicimagesisbestfordetectinganterioracetabular
deficiencyinthedysplastichip?

Pelvicinlet

Judet

APpelvis

Falseprofile

Froglateral

PREFERREDRESPONSE:4

DISCUSSION:ThefalseprofileviewofLequesneanddeSezeisobtainedwiththepatient
standingwiththeaffectedhiponthecassette,theipsilateralfootparalleltothecassette,andthe
pelvisrotated65degreesfromtheplaneofthecassette.Thisviewbestassessesanterior
coverageofthefemoralhead.
15.

Figure9showstheAPradiographofa65yearoldmanwhohaskneepainandswelling.
Whatisthemostlikelydiagnosis?

Gout

Chondrocalcinosis(pseudogout)

Hemochromatosis

Rheumatoidarthritis

Ochronosis

PREFERREDRESPONSE:2

DISCUSSION:Althoughallthechoicesareknowncausesofjointdegeneration(secondary
osteoarthritis),onlychondrocalcinosisshowsdistinctlinearcalcificationofthecartilagedueto
depositionofcalciumpyrophosphatecrystals.Goutisarecurrentacutearthritisresultingfrom
thedepositionofmonosodiumuratefromsupersaturatedhyperuricemicbodyfluids.
Hemochromotosisischaracterizedbyfocalorgeneralizeddepositionofironwithinbodytissues.
Arthritismaybepresentbutislesscommonthanothermanifestationssuchaslivercirrhosis,
skinpigmentation,diabetesmellitus,andcardiacdisease.Rheumatoidarthritisisanonspecific,
usuallysymmetricinflammationofperipheraljointsresultingindestructionofarticularand
periarticularstructures.Ochronosisisahereditaryenzymedeficiency(homogentisicacid
oxidase)resultingindepositionofhomogentisicacidpolymersinarticularcartilage.
16.

IfasurgeoninadvertentlyburrsthroughthemidlateralwallofC5duringaanterior
corpectomy,whatstructureisatgreatestriskforinjury?

C5root

C6root

Internalcarotidartery

Vertebralartery

Vagusnerve

PREFERREDRESPONSE:4

DISCUSSION:Thevertebralarteryiscontainedwithinthevertebralforamenandthustethered
alongsidethevertebralbody,makingitvulnerabletoinjuryifadrillpenetratesthelateralwall.
TheC5rootpassesovertheC5pedicleandisnotinthevicinity.TheC6rootpassesunderthe
C5pediclebutisposteriortothevertebralarteryandisonlyvulnerableattheveryposterior
inferiorcorner.Thecarotidarteryandthevagusnervearebothwithinthecarotidsheathand
wellanterior.
17.

Inpatientswithdisplacedradialneckfracturestreatedwithopenreductionandinternal
fixationwithaplateandscrews,theplatemustbelimitedtowhatsurfaceoftheradiusto
avoidimpingementontheproximalulna?

2cmdistaltothearticularsurfaceoftheradialhead

1cmdistaltothearticularsurfaceoftheradialhead

Withina90degreearcorsafezone

Withina120degreearcorsafezone

Withina180degreearcorsafezone

PREFERREDRESPONSE:3

DISCUSSION:Theradialheadiscoveredbycartilageon360degreesofitscircumference.
However,withthenormalrangeofforearmrotationof160to180degrees,thereisaconsistent
areathatisnonarticulating.ThisareaisfoundbypalpationoftheradialstyloidandListers
tubercle.Thehardwareshouldbekeptwithina90degreearcontheradialheadsubtendedby
thesetwostructures.
18.

A57yearoldmanreportsrighthippainthathasbeenprogressiveforthepastseveral
months.Thepainisexacerbatedbyweightbearingactivitiesandimprovessomewhat
withrest.AradiographisshowninFigure10aandacoronalT1weightedMRIscanis
showninFigure10b.Whatisthemostlikelydiagnosis?

Osteoarthritisofthehip

Osteonecrosisofthehip

Metastaticcarcinoma

Femoralheadfracture

Rheumatoidarthritisofthehip

PREFERREDRESPONSE:2

DISCUSSION:Theseareclassicfindingsofosteonecrosisofthehip.Theradiographrevealsthe
subchondralscleroticpatterncommonlyseeninosteonecrosisandisquiteextensiveinthis
patient.TheMRIscanrevealsthetypicalserpentinelikeregionoflowsignalintensitywitha
centralzonewherethesignalissimilartofat.
19.

ThearrowinFigure11pointstowardafindingconsistentwithwhichofthefollowing?

Metastaticdisease

Hemangioma

Flexioncompressionfracture

Infection

Diastomatomyelia

PREFERREDRESPONSE:1

DISCUSSION:Thefindingofaunilateralabsentpedicleisoftenreferredtoasawinkingowl
signandisamanifestationofpedicledestructionfrommetastaticdisease.Asthevertebralbody
isdestroyedfromtheneoplasticprocess,itextendsintothepedicleanddestroysthecorticalrim
thatnormallycreatestheovalringofthepedicleonanAPimage.
20.

Theattachmentsofthetransversecarpalligamentincludewhichofthefollowing
structures?

Scaphoidandtheulna

Trapeziumandthehookofthehamate

Trapeziumandthetriquetrum

Trapezoidandthehookofthehamate

Trapezoidandthepisiform

PREFERREDRESPONSE:2

DISCUSSION:Thetransversecarpalligamentisthevolarboundaryofthecarpaltunnel.It
attachestothescaphoidandtrapeziumradiallyandthepisiformandthehookofthehamate
ulnarly.Theulnaandtrapezoiddonotreceiveattachmentsofthetransversecarpalligament.
21.

A23yearoldwomanfallsfromabicycleandsustainsarightkneeinjury.Figures12a
through12dshowradiographsandMRIscansoftheknee.Whatisthemostlikely
diagnosis?

Posteriorcruciateligamentavulsionfromthetibia

Anteriorcruciateligamentavulsionfromthetibia

Avulsionofthelateralmeniscusanteriorhorn

Midsubstanceposteriorcruciateligamentrupture

Midsubstanceanteriorcruciateligamentrupture

PREFERREDRESPONSE:2

DISCUSSION:TheradiographsandMRIscansbothshowanavulsionoftheanteriorcruciate
ligament,whichhasbeendescribedbyMeyersandMcKeeverinthreedifferentfracturepatterns.
TypeIfracturesarenondisplacedorhaveminimaldisplacementoftheanteriormargin.TypeII
fractureshavesuperiordisplacementoftheiranterioraspectwithanintactposteriorhinge.Type

IIIfracturesarecompletelydisplaced.Althoughtheinjuryisvisibleontheradiographs,itis
moresubtleinadultsthanchildren.Thus,MRIishelpfulinclarifyingthisinjuryinadults.
OpenorarthroscopicreductionandinternalfixationisrecommendedfortypeIIandtypeIII
fracturesthatdonotrespondtoclosedreduction.
22.

A25yearoldmanhasamassonthemedialaspectoftheleftknee.Hereportsthatthe
masshasbeenpresentforseveralyears,butarecentincreaseinphysicalactivityhas
resultedinperiodictenderness.RadiographsareshowninFigures13aand13b.Whatis
themostlikelydiagnosis?

Osteochondroma

Enchondroma

Myositisossificans

Parostealosteosarcoma

Priorbonytrauma

PREFERREDRESPONSE:1

DISCUSSION:Theradiographsrevealasessilelesionprojectingfromthemedialaspectofthe
distalfemur.Thelesionsharesthecortexwiththeboneandthebasecommunicateswiththe
medullaryspaceofthefemur.Thisistheclassicappearanceofanosteochondroma,themost
commonbenigntumorofbone.
23.

Apreviouslyasymptomatic40yearoldmaninjureshisshoulderinafall.Examination
showsthatheisunabletoliftthehandawayfromhisbackwhilemaximallyinternally
rotated.AnaxialMRIscanoftheshoulderisshowninFigure14.Whatisthemost
likelydiagnosis?

Pectoralismajortendonrupture

Supraspinatusrupture

Subscapularisrupture

Bankarttear

Humeralavulsionoftheinferiorglenohumeralligament

PREFERREDRESPONSE:3

DISCUSSION:TheMRIscanshowsdetachmentofthesubscapularisfromitsinsertiononthe
lessertuberosity.Theexaminationfindingisconsistentwithapositiveliftofftest,also
indicatingatearofthesubscapularis.
24.

Apatientistreatedwithvolarplatingforadistalradiusfracture.TheCTscanshownin
Figure15isobtainedafterunionofthefracturebecausethepatientreportsongoing
symptoms.Theprominenthardwareismostlikelyinjuringwhattendon?

Extensorpollicisbrevis(EPB)

Extensorcarpiradialisbrevis(ECRB)

Extensordigitorumcommunis(EDC)

Extensorcarpiulnaris(ECU)

Extensorcarpiradialislongus(ECRL)

PREFERREDRESPONSE:3

DISCUSSION:Extensortendoninjurieshavebeenreportedaftervolarplatingofdistalradius
fractures.TheCTscanshowsprominentdorsalhardwareafewmillimetersulnartoListers
tubercle.Thesecondcompartment,theECRLandECRB,isradialtoListerstubercle.The
ECUrunsalongthedistalulna.Thecontentsofthefourthdorsalcompartmentrunjustulnarto
Listerstubercle.TheEDCtendonislikelyirritatedinthispatient.TheEPBrunsalongthe
radialborderoftheradiusandiswellawayfromprominenthardware
25.

A9yearoldchildsustainsaproximaltibialphysealfracturewithahyperextension
mechanism.Whatstructureisatmostriskforseriousinjury?

Tibialnerve

Poplitealartery

Commonperonealnerve

Posteriorcruciateligament

Popliteusmuscle

PREFERREDRESPONSE:2

DISCUSSION:Themostseriousinjuryassociatedwithproximaltibialphysealfractureis
vasculartrauma.Thepoplitealarteryistetheredbyitsmajorbranchesneartheposteriorsurface
oftheproximaltibialepiphysis.Duringtibialphysealdisplacement,thepoplitealarteryis
susceptibletoinjury.Injuriestotheotherstructuresarelesscommon.

26.

A25yearoldtennisplayerhasshoulderpainandweaknesstoexternalrotation.MRI
scansareshowninFigures16aand16b.Whatisthemostlikelycauseofhisweakness?

Supraspinatustear

Infraspinatustear

Suprascapularnervecompression

C5radiculopathy

Subacromialimpingement

PREFERREDRESPONSE:3

DISCUSSION:TheMRIscansshowaparalabralcyst,whichismostcommonlyassociatedwith
labraltears.Compressionofthesuprascapularnerveresultsinweaknessofthesupraspinatus
and/orinfraspinatusdependingonthelevelofcompression.
27.

Theposteriorapproachtotheproximalradiususeswhatintermuscularinterval?

Extensorcarpiradialisbrevisandextensordigitorumcommunis

Extensorcarpiradialislongusandextensordigitorumcommunis

Extensordigitorumcommunisandextensorpollicisbrevis

Brachioradialisandflexorcarpiradialis

Anconeusandextensorcarpiulnaris

PREFERREDRESPONSE:1

DISCUSSION:Knowledgeofintermuscularandinternervousplanesallowssafeexposures
throughoutthebody.Theposterior(Thompson)approachtotheproximalforearmusesthe
intervalbetweentheextensorcarpiradialisbrevisandextensordigitorumcommunis.The
anterior(Henry)approachtotheproximalforearmusestheintervalbetweenthebrachioradialis
andtheflexorcarpiradialis.

28.

Whichofthefollowingstatementsbestdescribestheanatomicconsiderationsofthe
poplitealarteryposteriortothekneejoint?

Itliesposteriortothepoplitealveinand9mmposteriortotheposterioraspectof
thetibialplateauin90degreesofflexion.

Itliesanteriortothepoplitealveinand9mmposteriortotheposterioraspectof
thetibialplateauin90degreesofflexion.

Itlieslateraltothepoplitealveinand15mmposteriortotheposterioraspectof
thetibialplateauin90degreesofflexion.

Itliesmedialtothepoplitealveinand9mmposteriortotheposterioraspectof
thetibialplateauin90degreesofflexion.

Itliesanteriortothepoplitealveinand15mmposteriortotheposterioraspectof
thetibialplateauin90degreesofflexion.

PREFERREDRESPONSE:2

DISCUSSION:Poplitealarteryinjuryduringtotalkneearthroplastyisrelativelyrare.Knee
flexion,thepositionthatoccursduringmostofthearthroplastyprocedure,allowsthepopliteal
vesselstofallposteriorly,furtherawayfromharm.Anatomically,thepoplitealarterylies
anteriortothepoplitealveinand9mmposteriortotheposterioraspectofthetibialplateauin
90degreesofflexion.
29.

A62yearoldwomanreportsdiffuseachesandpainsofthehipandpelvis.Shedenies
anysignificanttraumabutdoeshaveahistoryofchronicanemia.Figure17ashowsa
radiographofthepelvis,andFigures17band17cshowT2weightedMRIscans.Whatis
themostlikelydiagnosis?

Chondrosarcoma

Diffusefibrousdysplasia

Multiplemyeloma

Osteoporosis

Boneinfarcts

PREFERREDRESPONSE:3

DISCUSSION:Theradiographrevealsdiffuseosteopeniaandareasintheproximalfemorathat
aremotheateninappearance.TheextentofthemarrowreplacingprocessisevidentontheMRI
scans,whichrevealsignalabnormalitythroughouttheentirepelvisandbothproximalfemora.
Thisrepresentsamarrowpackingprocess,ofwhichmultiplemyelomaisthebestchoice.This

diagnosisisalsosupportedbytheanemianotedonthepatientshistory.Metastaticcarcinoma
andlymphomaalsomayhaveasimilarpresentation.

31.

WhatstructureislocatedatthetipofthearrowinFigure18?

LeftL3nerveroot

RightL3nerveroot

RightL4segmentalartery

RightL4nerveroot

Leftlateraldiskherniation

PREFERREDRESPONSE:2

DISCUSSION:ThestructureshownistheexitingnerverootattheL34disk,whichistheright
L3root.
32.

ApatientundergoestheprocedureshowninFigure19.Animportantpartofthis
procedureispreservationofwhatwristligament?

Radioscaphocapitate

Scapholunateinterosseous

Ulnotriquetral

Volarradioulnar

Deepproximalcapitohamate

PREFERREDRESPONSE:1

DISCUSSION:Proximalrowcarpectomyisasalvagewristprocedurethatyieldsasurprisingly
stableconstruct.Thishasbeenattributedtotwofactors:1)thecongruencyoftheheadofthe
capitateinthelunatefossa(thisarticulationislesscongruentthanthenativelunate/lunatefossa
relationship,butsurprisinglystable),and2)preservationoftheradioscaphocapitateligament,the
mostradialofthepalmarextrinsicligaments,whichpreventsulnarsubluxationafterproximal
rowcarpectomy.

33.

A23yearoldwomanreportsrightkneepainandfullness.Thepainisworsewith
activitybutalsopresentatrest.RadiographsareshowninFigures20aand20b.Whatis
themostlikelydiagnosis?

Osteosarcoma

Chondroblastoma

Stressfracture

Posttraumaticchanges

Chondrosarcoma

PREFERREDRESPONSE:1

DISCUSSION:Theradiographsrevealapredominantlylytic,destructivelesionofthedistal
femur,althoughthereisahintofsomeblasticchangeaswell.Thelesionhasviolatedthecortex,
andthereismineralizationoutsidethecortexlaterally.Thelateralradiographsuggestsasoft
tissuedensity.Theseaggressivechangesonradiographsinthisagegrouparestrongly
suggestiveofosteosarcoma.
34.

WhatisthestructureindicatedbytheletterAinFigure21?

Annularligament

Lateralulnarcollateralligament

Accessorycollateralligament

Radialcollateralligament

Transverseligament

PREFERREDRESPONSE:4

DISCUSSION:Theligamentsshownarethecomponentsofthelateralcollateralligament
complex,andthestructureindicatedbytheletterAistheradialcollateralligament.The
lateralulnarcollateralligamentisthestructureindicatedbytheletterCandtheannular
ligamentisindicatedbytheletterB.Thetransverseligamentisacomponentofthemedial
collateralligamentcomplex.
35.

A16yearoldboysustainsatwistinginjurytotheleftkneewhilewrestling.MRIscans
areshowninFigures22athrough22c.Whatisthemostlikelydiagnosis?

Anteriorcruciateligamentrupture

Posteriorcruciateligamentrupture

Buckethandlemedialmeniscustear

Lateralmeniscustear

Osteochondrallesion

PREFERREDRESPONSE:3

DISCUSSION:TheMRIscansshowadisplacedbuckethandlemedialmeniscustearthatcanbe
visualizedoncoronal,sagittal,andaxialviews.Thesagittalviewshowsthetypicaldouble
posteriorcruciateligamentsign,inwhichthelowsignalbuckethandlefragmentparallelsthe
normallowsignalposteriorcruciateligament.Thecoronalandaxialimagesbothshowthe
displacedmedialmeniscusinthenotch.

36.

A48yearoldwomanreportsbilateralthighpainthatislimitingherfunctionasa
librarian.AradiographandabonescanareshowninFigures23aand23b.Whatisthe
mostlikelydiagnosis?

Ankylosingspondylitis

Arthrokatadysis

Osteomalacia

Rheumatoidarthritis

Developmentaldysplasia

PREFERREDRESPONSE:4

DISCUSSION:Theradiographrevealsbilateralsevereacetabularprotrusio.Thebonescanand
historyconfirminvolvementofmultiplejoints,includingthekneesandthehindfoot.Although
thefirstfourchoicescanallcausetheacetabularprotrusio,theassociatedmultiplejoint
involvementsuggeststhediagnosisofrheumatoidarthritis.Arthrokatadysis,orprimary
protrusioacetabuli,isoftenassociatedwithosteomalaciabutnototherjointdisease.
Developmentaldysplasiaisacommoncauseofbilateralhippathologybutdoesnothave
acetabularprotrusio.
37.

Attheleveloftibialboneresectionintotalkneearthroplasty,wheredoesthecommon
peronealnervelie?

Deeptothearcuateligament

Closertoboneinlargerlegs

Onthemusclebellyofthepopliteus

Onthebonyposterolateralcornerofthetibia

Superficialtothelateralheadofthegastrocnemius

PREFERREDRESPONSE:5

DISCUSSION:Attheleveloftibialboneresectionintotalkneearthroplasty,thecommon
peronealnerveliessuperficialtothelateralheadofthegastrocnemiusandisthereforeprotected
bythisstructure.InanMRIstudyof60knees,themeandistancefromthebonyposterolateral
cornerofthetibiatothenervewas1.49cm,withnodistancelessthan0.9cm.Thedistance
fromthebonetonervewasgreaterinlargerlegs.
38.

Figures24athrough24cshowthecoronalT1weighted,T2weightedfatsaturated,and
T1weightedfatsaturatedgadoliniumMRIscansoftheproximalthighofa52yearold
womanwhoreportsamassinthemedialthighandgroinarea.Shenotesthatthefullness
hasgrowninsizeoverthecourseofmanymonths.Basedonthesefindings,whatisthe
mostlikelydiagnosis?

Malignantfibroushistiocytoma

Liposarcoma

Synovialcellsarcoma

Leiomyosarcoma

Clearcellsarcoma

PREFERREDRESPONSE:2

DISCUSSION:Theimagesshowacomplex,lobularlesionofthethighthathassignal
characteristicsthatfollowfat.Thesizeofthelesion,theareasofstrandingwithinthemass,
alongwithmilduptakeonthegadoliniumsequencesandthemildedemawithinthelesiononthe
T2weightedimagemakeliposarcomathemostlikelydiagnosisandsimpleintramuscularlipoma
farlesslikely.AllotherdiagnoseslistedwouldnotfollowfatcharacteristicsshownontheMRI
sequences.
39.

ThearrowsintheaxialT1weightedMRIscanshowninFigure25showwhichofthe
followingstructures?

Ulnararteryandaccompanyingvein

Deepandsuperficialbranchesoftheulnarnerve

Radialandulnardigitalnervestothelittlefinger

Palmarcutaneousandthenarmotorbranchofthemediannerve

Dorsalcutaneousbranchoftheulnarnerveandcommondigitalarterytothe
fourthweb

PREFERREDRESPONSE:2

DISCUSSION:Thearrowsinthefigureshowthedeepbranchoftheulnarnerve(moreradial)
andthesuperficialbranchoftheulnarnervewithinGuyonscanal.Guyonscanalis
approximately4cmlongbeginningattheproximalextentofthetransversecarpalligamentand
endsattheaponeuroticarchofthehypothenarmuscles.Manystructurescomprisethe
boundariesofGuyonscanal.Thefloor,forexample,consistsofthetransversecarpalligament,
thepisohamateandpisometacarpalligaments,andtheopponensdigitiminimi.WithinGuyons
canal,theulnarnervebifurcatesintothesuperficialanddeepbranches.Theulnararteryis
immediatelyadjacentandradialtotheulnarnerve.Themediannerveisvisualizedwithinthe
carpaltunnel,andthepalmarcutaneousbranchismoreradialtoGuyonscanalandvolartothe
carpaltunnel.Theradialandulnardigitalnervestothelittlefingerarebranchesoffofthe
superficialbranchoftheulnarnervedistaltoitsemergencefromGuyonscanal.Theulnar
arteryistheroundstructurelocatedradialtothebranchesoftheulnarnervewithinGuyons
canal.Adjacenttotheulnararteryaretwosmallveins.Thedorsalcutaneousbranchoftheulnar
nervebranchesfromtheulnarnerveinthedistalforearm,wellproximaltoGuyonscanal.The
commondigitalarterytothefourthwebbranchesfromthesuperficialpalmararchdistalto
Guyonscanal.Thehookofthehamateisclearlyseeninthefigure,orientingtheobservertothe
ulnarsideofthewrist.
40.

An82yearoldmanhashadepisodicrightthighpainafterundergoingatotalhip
arthroplasty10yearsago.InitialpostoperativeradiographsareshowninFigures26aand
26b,andcurrentradiographsareshowninFigures26cand26d.Whatisthemostlikely
causeofhispain?

Acetabularosteolysis

Femoralosteolysis

Acetabularloosening

Femoralloosening

Femoralandacetabularloosening

PREFERREDRESPONSE:4

DISCUSSION:Theseradiographsaredominatedbythesubsidenceofthefemoralcomponent.
Thereisalsoevidenceofpolyethylenewearandfemoralosteolysisintheregionofthegreater
trochanter.Thereisnoevidenceofproximal(calcar)stressshielding,andthereisathickdistal
pedestal.Enghandassociatesdefinedtwomajorsignsofosseointegrationtheabsenceof
radiolucentlinesaroundtheporoussurfacedportionoftheimplantandnewbonebridgingthe
gapbetweentheendostealsurfaceandtheporousportionoftheimplant.Implantmigration
indicatesfailureofingrowth.Osteolysisisaperiprostheticlossofbonesecondarytoparticulate
debrisanditisoftenclinicallysilentunlessitisaccompaniedbypathologicfracture.Itisoften
globular.Acetabularlooseningisbasedonradiolucentlinesandimplantmigration.Thecurrent
radiographsdemonstratesubsidenceofthestemwithpedestalformation.
41.

A37yearoldpatientwithtypeIdiabetesmellitushasaflexortenosynovitisofthe
thumbflexortendonsheathfollowingakitchenknifepuncturewoundtothevolaraspect
ofthethumb.Leftunattended,thisinfectionwilllikelyfirstspreadproximallycreating
anabscessinwhichofthefollowingspacesofthepalm?

Centralspace

Hypothenarspace

Carpaltunnel

Posterioradductorspace

Thenarspace

PREFERREDRESPONSE:5

DISCUSSION:Flexortenosynovitisofthethumbflexortendonsheathcanspreadproximally
andformanabscesswithinthethenarspaceofthepalm.Theflexorpollicislongustendondoes
notpassthroughthecentralspaceofthepalmorthehypothenarspaceofthepalm.Theflexor
pollicislongustendondoespassthroughthecarpaltunnel,butthisisnotapalmarspace.The
threepalmarspacesincludethehypothenarspace,thethenarspace,andthecentralspace.The
posterioradductorspacewouldlikelyonlybeinvolvedsecondarilyafterspreadfromathenar
spaceinfection.
42.

Whattendonisclosesttoanappropriatelyplacedanterolateralportalforankle
arthroscopy?

Peroneusbrevis

Extensordigitorumlongus

Extensorhallucis

Tibialisanterior

Peroneustertius

PREFERREDRESPONSE:5

DISCUSSION:Theappropriateplacementoftheanterolateralportalprovidesaccesstothe
lateralgutterofthejointwhileavoidingthesuperficialperonealnerve.Thesafestlocationfor
theportalisapproximately4mmlateraltotheperoneustertiustendon,theclosestofthetendons
listedtotheanterolateralportal.Becausethesuperficialperonealnervelocationisvariable,
attemptstovisualize,palpate,ortransilluminatethenervearemandatory.
43.

A52yearoldwomanreportsnaggingshoulderpainthathasbeenpresentformonthsand
isslowlyprogressiveinnature.Thepatientalsoreportsnocturnalpainandnotesthatthe
painisnotactivityrelated.Figures27aand27bshowtheradiographandbonescan,and
Figures27cthrough27eshowT1weighted,T2weighted,andgadoliniumMRIscans,
respectively.Basedonthesefindings,whatisthemostlikelydiagnosis?

Aneurysmalbonecyst

Enchondroma

Plasmacytoma

Giantcelltumor

Chondrosarcoma

PREFERREDRESPONSE:5

DISCUSSION:Theradiographrevealsametaphyseallesionwithsomestippledmineralization
suggestingachondroidtumor.Thebonescanshowsincreaseduptake,beyondwhatisexpected
forasimpleenchondroma,andbeyondthelimitsofthelesion.TheMRIsequencesshowsa
lobularlesionontheT1andT2weighted(brightontheT2sequence)imageswith
inhomogeneousuptakeofgadolinium;bothfindingsaretypicalforachondroidlesion.The
historyofpain,thepositivebonescan,theageofthepatient,thesizeofthelesion,andthe
centrallocation(enostotic)ofthelesionallsuggestamalignantcartilagetumor.Theimagesare
notconsistentwiththeotherdiagnoses.Inparticular,plasmacytomaismoreuniformlybrighton
T2weightedimagesandoftenhasanegativebonescan.
44.

Figure28showsanarthroscopicviewofarightshoulderinthelateralposition
throughaposteriorportal.WhatistheareabetweenstructureB(biceps)andSS
(subscapularistendon)?

Inferiorglenohumeralligament

Superiorglenohumeralligament

Rotatorcuffinterval

Subscapularisrecess

Interiorrecess

PREFERREDRESPONSE:3

DISCUSSION:Therotatorcuffintervalislocatedbetweenthesupraspinatusandsubscapularis
andthebicepstendonisdeeptotheinterval.Itisatriangularareawherethebaseisthecoracoid
processandtheapexisthetransversehumeralligamentatthebicepssulcus.Closureor
tighteningofthisareaisoftenhelpfulinpatientswithshoulderinstability.Conversely,thisarea
isoftencontractedinpatientswithadhesivecapsulitisandmayneedtobereleased.
45.

Newpainfulparesthesiasnearthesiteoftheincisionafteranulnarnervetranspositionis
theresultofinjurytowhatnerve?

Medialantebrachialcutaneous

Lateralantebrachialcutaneous

Posteriorantebrachialcutaneous

Medialbrachialcutaneous

Dorsalantebrachialcutaneous

PREFERREDRESPONSE:1

DISCUSSION:Branchesofthemedialantebrachialcutaneousnervecanoftenbeidentified
duringroutineulnarnervesurgerycrossingthemedialaspectoftheelbow.Itshouldbe
preservedtoavoiddevelopmentofpainfulparesthesias.
46.

A23yearoldmanreportspainonthesuperioraspectofhisrightshoulderwithrepetitive
overheadactivitiesandwhenlyingonhisrightside.Figure29showsanaxialMRIscan.
WhatisthemostlikelydiagnosisbasedontheMRIfindings?

Osteoarthritisoftheacromioclavicularjoint

Acromioclavicularjointseparation

Osacromiale

Partialthicknessrotatorcufftear

Superiorlabraltear

PREFERREDRESPONSE:3

DISCUSSION:Osacromialerepresentsafailureoffusionoftheanterioracromialapophysis
andhasbeenreportedinapproximately8%ofthepopulation.Patientswithasymptomaticos
acromialeoftenreportimpingementtypesymptomswithpainoverthesuperioracromion,
especiallywithoverheadactivitiesorsleeping.Whennonsurgicalmanagementisunsuccessful,
surgicaloptionsincludeexcision,openreductionandinternalfixation,andarthroscopic
decompression.
47.

Followingachevronbunionectomyperformedthroughadorsalapproach,apatienthas
persistentnumbnessonthedorsalandmedialaspectofthehallux.Whatnervehasmost
likelybeeninjured?

Lateralplantarnerve

Deepperonealnerve

Duralnerve

Medialplantarnerve

Dorsomedialcutaneousnerveofthehallux

PREFERREDRESPONSE:5

DISCUSSION:Thedorsomedialcutaneousnerveofthehallux,whichisadistalbranchofthe
superficialperonealnerve,suppliessensationtotheskinonthedorsalandmedialhalfofthe
halluxandmaybeinjuredduringachevronbunionectomy.Injurytothenerveleadsto
particularlypainfulneuromasthatdirectlyimpingeontheshoe.Forthisreason,directmedial
approachesaretypicallypreferredforaccesstothemedialaspectofthemetatarsophalangeal
joint.

48.

A74yearoldmanreportsprogressivelefthippainwithweightbearingactivities.
AradiographisshowninFigure30.Whatisthemostlikelyunderlyingdiagnosis?

Infection

Lymphoma

Pagetsdisease

Massiveboneinfarct

Oldpelvictrauma

PREFERREDRESPONSE:3

DISCUSSION:Theradiographshowsenlargementofthebone,coarsetrabeculation,ablastic
appearance,andthickeningofthecortex,revealingtheclassicappearanceofPagetsdiseasein
thescleroticphase,themostcommonpresentation.Whilelymphomamaypresentasablastic
lesion,itwillnothavethesameenlargement,coarsetrabeculationofbone,andthesignificant
sclerosisseenhere.
49.

Theanatomyofthesciaticnerveasitexitsthepelvisisbestdescribedasexiting
throughthe

greatersciaticnotchandpassingbetweentheinferiorgemellusandtheobturator
externus.

greatersciaticnotchandpassingbetweenthepiriformisandthesuperior
gemellus.

obturatorforamenandpassingbetweentheobturatorinternusandtheobturator
externus.

lessersciaticnotchandpassingbetweenthepiriformisandthesuperiorgemellus.

lessersciaticnotchandpassingbetweenthesuperiorgemellusandtheinferior
gemellus.

PREFERREDRESPONSE:2

DISCUSSION:Thesciaticnerveisformedbytherootsofthelumbosacralplexus.Itexitsthe
pelvisthroughthegreatersciaticnotchandappearsinthebuttockanteriortothepiriformus.
Fromthatpoint,thesciaticnervepassesposteriorlyoverthesuperiorgemellus,obturator
internus,inferiorgemellus,andquadratusfemorisbeforeitpassesdeeptothebicepsfemoris.
Thetendonoftheobturatorinternuspassesthroughthelessersciaticnotch.
50.

Whatcomplicationismorelikelyfollowingexcessivemedialretractionoftheanterior
coveringstructuresduringtheanterolateral(WatsonJones)approachtothehip?

Numbnessovertheanterolateralthigh

Ischemiatotheleg

Quadricepsweakness

Abductorinsufficiency

Footdrop

PREFERREDRESPONSE:3

DISCUSSION:Thefemoralnerveisthemostlateralstructureintheanteriorneurovascular
bundle.Thefemoralarteryandveinliemedialtothenerve.Retractorsplacedintheanterior
acetabularlipshouldbesafe,althoughneurapraxiaofthefemoralnervemayoccurifretraction
isprolongedorforcefulleadingtoquadricepsweakness.Thefemoralarteryandnervearewell
protectedbytheinterposedpsoasmuscle.Damagetothelateralfemoralcutaneousnerve,
causingnumbnessovertheanterolateralthigh,canoccurwhiledevelopingtheintervalbetween
thetensorfascialataeandsartoriousintheanterior(SmithPetersen)approachbutlesslikelyin
theWatsonJonesapproach.Superiorglutealinjuryandaccompanyingabductorinsufficiency
mayoccurduringexcessivesplittingofthegluteiduringthedirectlateral(Hardinge)approach.
Footdropsecondarytosciaticinjuryismorecommonwithaposteriorexposureorposterior
retractorplacement.

51.

Inthemostcommonconditioncausingawingedscapula,whichofthefollowingnerves
isaffected?

Longthoracicnerve

Spinalaccessorynerve

Suprascapularnerve

Dorsalscapularnerve

Thoracodorsalnerve

PREFERREDRESPONSE:1

DISCUSSION:AwingedscapulaismostoftenassociatedwithParsonageTurnersyndrome,a
conditionthoughttobeduetoaninflammatoryorimmunemediatedmechanism.Certain
musclesarepredisposed,particularlytheserratusanteriormuscleinnervatedbythelongthoracic
nerve.Otherlesscommonnervelesions(eg,thespinalaccessoryanddorsalscapularnerves)
mayalsocausewingedscapulae.
52.

A17yearoldwomanseenintheemergencydepartmentreportsrightkneepainand
swellingthathasprogressivelyworsenedoverthepastseveralweeks.Radiographsare
showninFigures31aand31b.Whatisthemostlikelydiagnosis?

Giantcelltumor

Infection

Chondrosarcoma

Osteosarcoma

Chondroblastoma

PREFERREDRESPONSE:4

DISCUSSION:Theradiographsrevealablasticlesionoftheproximaltibialmetaphysiswith
corticaldestruction,mineralizationextendingintothesofttissuelaterally,indistinctmargins,and
destructionofthenormaltrabecularpattern.Inthisagegroup,withthisaggressiveappearance,
osteosarcomaisthemostlikelydiagnosis.Chondroblastomaandgiantcelltumoraregenerally
geographicandlytic.Chondrosarcomaisrareinthisagegroupandwouldlikelybeasecondary
lesionfromanunderlyingchondroidtumorthatisnotpresenthere.Whereasinfectioncanhave
awidevarietyofappearances,ittendstobemorelyticintheacutepresentation.
53.

A26yearoldmanhashadhandpainandprogressiveswellingintheknuckleforthepast
severalmonths.Hedeniesanytraumatothehand.Theringfingermetacarpophalangeal
jointistender,andthereislossofmotioninthedigit.Figure32ashowstheradiograph
andFigures32bthrough32dshowtheT1weighted,T2weighted,andgadoliniumMRI
scans,respectively.Whatisthemostlikelydiagnosis?

Infection

Giantcelltumor

Nonossifyingfibroma

Enchondroma

Osteosarcoma

PREFERREDRESPONSE:2

DISCUSSION:Theradiographrevealsasubchondrallesioninthemetacarpophalangealjoint
thatislyticandexpansile.TheMRIscansshowamassthatismoderateinintensityonthe
T2weightedimageandhassomegadoliniumuptake.Therearenocysticcomponentsinthis
lesion.Thesubchondrallocationandexpansilenaturearehighlysuggestiveofgiantcelltumor
ofbone.Alesionwiththisappearancemightalsorepresentananeurysmalbonecyst,giventhe
amountofexpansionpresent.
54.

Whichofthefollowingbestdescribestherelationshipofthemediannervetotheflexor
carpiradialistendonjustproximaltothecarpalcanal?

Mediannerveisvolarandulnar

Mediannerveisradialandvolar

Mediannerveisdorsalandulnar

Mediannerveisdorsalandradial

Mediannerveisvolarandradial

PREFERREDRESPONSE:3

DISCUSSION:Themediannervehasanintimateassociationwiththepalmarislongusandthe
flexorcarpiradialisattheproximalaspectofthecarpalcanal.Themediannerveliesjustulnar
anddorsaltotheflexorcarpiradialistendon.
55.

Whichofthefollowingmuscleshasdualinnervation?

Pronatorteres

Flexordigitorumsuperificialis

Coracobrachialis

Latissimusdorsi

Brachialis

PREFERREDRESPONSE:5

DISCUSSION:Thebrachialismuscletypicallyreceivesdualinnervation.Themajorportionis
innervatedbythemusculocutaneousnerve.Itsinferolateralportionisinnervatedbytheradial
nerve.Theotherslistedhavesingleinnervation.Theanteriorapproachtothehumerus,which
requiressplittingofthebrachialis,capitalizesonthisdualinnervation.

56.

Figure33ashowsalinedrawingofanormalhemipelvis.Theanterioracetabularrimis
bold.Figure33billustratesahemipelviswithacrossoversign,whichisindicativeof
whatacetabularpathology?

Lowacetabularindex

Excessiveacetabularretroversion

Deficientanteriorcolumnbone

Labraldetachment

Pelvicdiscontinuity

PREFERREDRESPONSE:2

DISCUSSION:InanormalAPpelvisradiograph,theanteriorrimoftheacetabulumruns
mediallyanddistally,divergingfromtheposteriorrimwhichrunsmuchmorevertically.In
excessiveacetabularretroversion,theanteriorrim(boldlineinFigure33b)andposteriorrim
startlaterally,andastheselinesprogressmediallyanddistally,theanteriorlinecrossesthe
posteriorline.Thispredisposestofemoralacetabularimpingement.
57.

Whichofthefollowingstructuresismostvulnerableduringamedialsesamoidectomyof
thehallux?

Abductorhallucistendon

Intermetatarsalligament

Plantarmedialcutaneousnerveofthehallux

Dorsomedialcutaneousnerveofthehallux

Crista

PREFERREDRESPONSE:3

DISCUSSION:Theplantarmedialcutaneousnerveisatriskwiththesurgicalapproachtothe
medialsesamoid.Itisfounddirectlyunderlyinganincisionmadeatthejunctionoftheglabrous
skinofthehalluxandmustbeidentifiedbeforetheapproachcanproceed.Transectionwill
resultinapainfulneuromathatimpingesontheplantarmedialsurfaceofthetoeandcause
problemswithshoewear.Theonlyotherstructurethatliesnearthesurgicalfieldistheabductor
hallucistendonwhichliesdorsaltotheincision.
58.

Whatstructureismostatriskforinjuryfromaretractoragainstthetracheoesophageal
junctionduringananteriorapproachtothecervicalspine?

Esophagus

Trachea

Superiorlaryngealnerve

Recurrentlaryngealnerve

Sympatheticchain

PREFERREDRESPONSE:4

DISCUSSION:Althoughanyofthesestructurescanbeinjuredbypressurefromthemedial
bladeofaselfretainingretractor,therecurrentlaryngealnerverunscephaladintheinterval
betweentheesophagusandtracheaandisvulnerabletopressureifcaughtbetweentheretractor
andaninflatedendotrachealtubeballoon.
59.

A40yearoldmanhashadhippainwithincreasedactivityoverthepastyear.
Examinationrevealsrestrictionofmotionandtendernesswithcombinedhipflexion,
adduction,andinternalrotation.AnAPradiographisshowninFigure34.Whatisthe
mostlikelydiagnosis?

Developmentaldysplasiaofthehip

Osteonecrosis

Perthesdisease

Pseudogout

Femoralacetabularimpingement

PREFERREDRESPONSE:5

DISCUSSION:Femoralacetabularimpingement(FAI)isapathologicentityleadingtopain,
reducedrangeofmotioninflexionandinternalrotation,anddevelopmentofsecondaryarthritis
ofthehip.TherearetwotypesofFAI:camimpingementandpincherimpingement.Cam
impingementisseenwhenanonsphericalfemoralheadproducesacameffectwhenthe
prominentportiontothefemoralheadrotatesintothejoint.Thismechanismproducesshear
forcesthatdamagearticularcartilage.Radiographsrevealearlyjointdegenerationandflattening
oftheheadneckjunction(thesocalledpistolgripdeformity)asseeninthisimage.The
pinchertypeofimpingementinvolvesabnormalcontactbetweenthefemoralheadneckjunction
andtheacetabulum,inthepresenceofasphericalfemoralhead.
60.

Figure35showstheradiographofa44yearoldwomanwithrheumatoidarthritiswho
reportsneckpain.Belowwhatthresholdnumberissurgicalstabilizationwarrantedfor
theintervalshownbythearrow?

8mm

10mm

12mm

14mm

16mm

PREFERREDRESPONSE:4

DISCUSSION:Theposterioratlantodensintervalrepresentsthespaceavailableforthespinal
cordandadistanceoflessthan14mmispredictiveofneurologicprogression,thuswarranting
considerationforfusion,evenintheabsenceofsymptoms.
61.

Anaxillarynervelesionmaycauseweaknessinthedeltoidandthe

teresmajor.

teresminor.

teresmajorandteresminor.

latissimusdorsi.

latissimusdorsiandteresmajor.

PREFERREDRESPONSE:2

DISCUSSION:Whilethemostprominentfunctionaldeficitfromaxillarynervelesionsoccurs
fromdenervationofthedeltoid,denervationoftheteresminoralsooccurs.
62.

Figure36showsanAPradiographofa65yearoldmanwhoreportsactivityrelated
groinpain.Historyrevealsthatheunderwenttotalhiparthroplasty12yearsago.What
isthemostlikelydiagnosis?

Chondrosarcoma

Infection

Wearinducedosteolysis

Corrosiveeffectduetodissimilarmetals

Metastatictumor

PREFERREDRESPONSE:3

DISCUSSION:TheAPradiographdemonstratesextensiveperiacetabularosteolysis.The
centralholeeliminatorhasdissociatedfromtheshellandmigratedintoalyticdefectinthe
ischium.Inaretrievalstudy,mostperiacetabularosteolyticlesionshadaclearcommunication
pathwaywiththejointspace.Lesionswithcommunicationtothejointviaseveralpathwaysor
throughacentraldomehole(asinthispatient)werelargerandmorelikelytobeassociatedwith
corticalerosion.Althoughperiprosthetictumorshavebeendescribed,theyarerareandparticle
inducedinflammationaroundaprosthesisdoesnotseemtoincreasetheriskforcarcinogenesis.
63.

A21yearoldmanwhowasinjuredinasnowboardingaccident18monthsagonow
reportswristpain.AnMRIscanisshowninFigure37.Basedontheimagefindings,
whatisthemostlikelydiagnosis?

Preisersdisease

Scaphoidnonunionandosteonecrosis

Kienbocksdisease

Intraosseousganglion

Scapholunatedissociation

PREFERREDRESPONSE:2

DISCUSSION:ThecoronalMRIscanofthewristshowsthescaphoid.Thereisasubtlefracture
linewithastepoffattheradialsurfaceconsistentwithanonunion.Thesignalintensityis
markedlydifferentbetweenthetwofragmentsofthescaphoid.Thisstronglysuggests
osteonecrosis.Preisersdiseaseisosteonecrosistypicallyinvolvingmostorallofthescaphoid.
Kienbocksdiseaseinvolvesthelunate.IntraosseousgangliaareeasilydiagnosedonMRIbut
typicallyhaveafluidfilledareasurroundedbydenserboneintheperiphery.Scapholunate
dissociationcanbeseenonMRIasaninjurytothescapholunateligamentandwideningofthe
scapholunateinterval,neitherofwhichisseenonthisimage.
64.

An82yearoldwomanreportsactivityrelatedkneepain.Historyrevealsthatshe
underwenttotalkneearthroplasty16yearsago.APandlateralradiographsandabone
scanareshowninFigures38athrough38c.Whatisthemostlikelydiagnosis?

Particlemediatedosteolysis

Metastaticcarcinoma

Stressshielding

Septicjoint

Osteosarcoma

PREFERREDRESPONSE:1

DISCUSSION:Theradiographsrevealalargefemoralmetaphyseallyticlesionwith
welldefinedborders.Jointspacenarrowingmediallyisconsistentwithpolyethylenewear.
Themostlikelydiagnosisisparticlemediatedosteolysis.Metastatictumorsandprimary
sarcomasadjacenttoanarthroplastyareextremelyrare.Inaddition,malignanttumorsand
infectionwouldmorelikelyrevealadestructivelesionwithpoorlydefinedbordersandincreased
uptakeonabonescan.Stressshieldingwithmassivebonelosshasnotbeendescribedinknee
arthroplastyliterature,althoughthisentityhasbeenobservedinfullyporouscoatedfemoral
implantsintotalhiparthroplasty.
65.

Whichofthefollowingtendonsisfoundinthesamedorsalcompartmentofthewristas
theposteriorinterosseousnerve?

Extensordigitiminimi

Extensorcarpiradialisbrevis

Extensorpollicislongus

Extensorindicisproprius

Abductorpollicislongus

PREFERREDRESPONSE:4

DISCUSSION:Theterminalbranchoftheposteriorinterosseousnerveiscontainedinthefourth
dorsalcompartment.Thecontentsofthevariousdorsalwristcompartmentsareasfollows:

1stCompartment:Abductorpollicislongus,extensorpollisbrevis
2ndCompartment:Extensorcarpiradialisbrevis,extensorcarpiradialislongus
3rdCompartment:Extensorpollicislongus
4thCompartment:Extensordigitorumcomminus,extensorindicusproprius,posterior
interosseousnerve
5thCompartment:Extensordigitiminimi
6thCompartment:Extensorcarpiulnaris

Theextensorindicispropriusisalsocontainedinthefourthdorsalcompartment.Theextensor
digitiminimiislocatedinthefifthdorsalcompartment.Theextensorcarpiradialisbrevisis
locatedintheseconddorsalcompartment.Theextensorpollicislongusislocatedinthethird
dorsalcompartment,andtheabductorpollicislongusislocatedinthefirstdorsalcompartment.
66.

Figures39aand39bshowtheMRIscansofa25yearoldmanwithrightshoulderpain.
Figure39cshowsthearthroscopicviewfromaposteriorportalinthebeachchair
position.Whatisthemostlikelydiagnosis?

Bankartlesion

Superiorlabraltear

Partialarticularsurfacesupraspinatustear

Partialbursalsurfacesupraspinatustear

Fullthicknesssupraspinatustear

PREFERREDRESPONSE:3

DISCUSSION:TheMRIscansshowcoronalobliqueandsagittalobliqueviewsofapartial
articularsurfacesupraspinatustearortendonavulsion(PASTAlesion).Thearthroscopicviewis

aposteriorportaloftheglenohumeraljointviewingthearticularsurfaceofthesupraspinatus.
Thesetearsareacommonsourceofshoulderpainandareoftenamenabletotranstendon
arthroscopicrepairwithoutdetachmentoftheintactbursalsurface.
67.

Theposteriorhornofthemedialmeniscusreceivesitsprimarybloodsupplyfromwhat
artery?

Middlegenicular

Medialinferiorgenicular

Medialsuperiorgenicular

Lateralsuperiorgenicular

Inferiorlateralgenicular

PREFERREDRESPONSE:1

DISCUSSION:Themiddlegeniculararterysuppliestheposteriorcapsuleandintracapsular
structures(anteriorcruciateligament,posteriorcruciateligament,posteriorhornsofthe
meniscus).Themedialandlateralinferiorgeniculatesanastomoseanteriorlytoformacapillary
networktosupplythefatpad,synovialcavity,andpatellartendon.Thelateralsuperiorand
inferiorgeniculararteriessupplythelateralretinaculum.
68.

Inrecurrentposteriorshoulderinstability,whatistherecommendedapproachtothe
posteriorcapsule?

Ateresminorsplittingapproach

Aninfraspinatussplittingapproach

Betweentheinfraspinatusandteresminor

Betweenthesupraspinatusandinfraspinatus

Intherotatorinterval

PREFERREDRESPONSE:2

DISCUSSION:Usinganinfraspinatussplittingincisionallowsforexcellentexposureofthe
posteriorcapsuleandminimizestheriskofinjurytotheaxillarynervewhichliesinferiortothe
teresminorinthequadrilateralspace.
69.

Followinganklearthroscopyperformedthroughaposterolateralportal,apatient
notesnumbnessonthelateralhalfoftheheelpadofthefoot.Whatisthemostlikely
injuredstructure?

Suralnerve

Lateralplantarnerve

Lateralcalcanealnerve

Firstbranchofthelateralplantarnerve

Deepperonealnerve

PREFERREDRESPONSE:3

DISCUSSION:Thelateralcalcanealnerveisabranchofthesuralnervethatrunsalongthe
lateralborderoftheAchillestendontoinnervatethelateralheelpad.Anklearthroscopyinvolves
posteriorportalsthathugtheAchillestendontoavoidthemaintrunksofthesuralnerveand
tibialnerve;however,thelateralcalcanealbranchremainspotentiallyvulnerable.Thefirst
branchofthelateralplantarnerveisactuallyamedialstructurethatpartiallyinnervatesthe
plantarfasciaandtheabductordigitiquinti.Thedeepperonealnerveisanteriortotheankle.
70.

Figure40showstheMRIscanofa23yearoldmanwithahistoryofrecurrentanterior
shoulderinstability.Whatisthemostlikelydiagnosis?

Humeralavulsionoftheinferiorglenohumeralligament(HAGLlesion)

OsseousBankartlesion

Pertheslesion

Anteriorlabroligamentousperiostealsleeveavulsion(ALPSAlesion)

Glenolabralarticulardisruption(GLADlesion)

PREFERREDRESPONSE:4

DISCUSSION:TheMRIscanshowsanALPSAlesion.Thisisalsoknownasamedialized
Bankartwithmedialdisplacementofthetornanteriorlabrum.Duringsurgicalstabilization,the
labrumandperiostealsleevemustbemobilizedandrepairedlaterallytoreducerecurrent
instability.APertheslesionisanondisplacedlabraltear.AGLADlesionrepresentsa
nondisplacedanteriorlabraltearwithanassociatedarticularcartilageinjury.

71.

Figure41showstheMRIscanofa38yearoldweightlifter.Whatdoesthearrowonthe
MRIscanindicate?

Bicepstear

Pectoralisminortear

Pectoralismajortear

Subscapularistear

Abscessformation

PREFERREDRESPONSE:3

DISCUSSION:Pectoralismajorrupturestypicallyoccurinavidweightlifters(oftenon
supplements)andtypicallywhilebenchpressing.Clinicallythereissignificant

discoloration/bruisingoverthepectoralisandintotheaxilla.MRIhelpsconfirmthediagnosis
andmayhelpdetermineifthetearisinthemusclebellyoratthebonetendonjunction.
72.

Whichofthefollowingdescribesthecorrectproximaltodistalprogressionoftheannular
andcruciformpulleysofthedigits?

A1,C1,A2,C2,A3,A4,C3

A1,A2,A3,C1,C2,C3,A4

A1,C1,C2,A2,A3,A4,C3

A1,A2,C1,A3,C2,A4,C3

A1,A2,A3,A4,C1,C2,C3

PREFERREDRESPONSE:4

DISCUSSION:ThecorrectprogressionoftheannularandcruciformpulleyinthedigitsisA1,
A2,C1,A3,C2,A4,C3.Thetwocruciformpulleysarecollapsibleelementsadjacenttothe
morerigidannularpulleysoftheflexortendonsheath.Thisarrangementenablesunrestricted
flexionoftheproximalinterphalangealjoint.
73.

A75yearoldwomanbeganawalkingprogram2monthsafterundergoingrighttotal
kneearthroplasty.Shehadtostoptheprogramafter4weeksbecauseofhindfootpain
andankleswelling.RadiographsareshowninFigures42aand42b.Whatisthemost
likelydiagnosis?

Plantarfasciitis

Osteochondrallesionofthetalus

Heelspur

Insufficiencyfractureofthecalcaneus

Chondrocalcinosisoftheanklejoint

PREFERREDRESPONSE:4

DISCUSSION:Itisoftentemptingtoassignadiagnosisofplantarfasciitisinpatientswith
hindfootpain.Inthispatient,theradiographsconfirmadiagnosisofacalcanealinsufficiency
fracture.Thedensecondensationofboneonthelateralviewconfirmsthediagnosis.Thereisno
radiographicevidenceofaheelspur,osteochondrallesions,orchondrocalinosis.
74.

Figure43showsanarthroscopicviewofarightshoulderthroughalateralportalinthe
beachchairposition.Thearrowispointingtowhatstructure?

Bicepstendon

Coracohumeralligament

Superiorglenohumeralligament

Middleglenohumeralligament

Inferiorglenohumeralligament

PREFERREDRESPONSE:1

DISCUSSION:Thisviewfromthelateralportalshowsafullthicknessrotatorcufftear.The
glenohumeraljointcanbevisualizedthroughthistear.Theglenoid,labrum,andbicepstendon
attachingtothesuperioraspectoftheglenoidareeasilyviewedfromthisportal,andthearrowis
pointingtothebicepstendon.Arthroscopicrotatorcuffrepaircanbeperformedwhile
visualizingfromthisportalandusinganteriorandposteriorworkingportals.
75.

InCharcotMarieToothdiseaseaprogressivedeformitydevelopsinthefoot.Which
functionalmusclespredominateindeformityformation?

Posteriortibialisandperoneuslongus

Posteriortibialisandperoneusbrevis

Anteriortibialisandperoneuslongus

Anteriortibialisandperoneusbrevis

Extensordigitorumandanteriortibialis

PREFERREDRESPONSE:1

DISCUSSION:InCharcotMarieToothdisease,theposteriortibialisandperoneuslongus
tendonsremainstrong,servingtoinvertthehindfootanddepressthefirstmetatarsalheadthus
causingthecavovarusfootassociatedwiththisdisease.Incontrast,thetibialisanteriorand
peroneusbrevisarelessfunctionalandthereforecannotdorsiflextheankle,elevatethefirst
metatarsal,orevertthefoot,contributingtothedeformity.
76.

Bleedingisencounteredwhiledevelopingtheinternervousplanebetweenthetensor
fascialataandthesartoriusduringtheanteriorapproachtothehip.Themostlikely
causeisinjurytowhatartery?

Ascendingbranchofthelateralfemoralcircumflex

Superiorgluteal

Femoral

Profundafemoris

Medialfemoralcircumflex

PREFERREDRESPONSE:1

DISCUSSION:Theascendingbranchofthelateralfemoralcircumflexarterycrossesthegap
betweenthetensorfascialataandthesartoriousandmustbeidentifiedandligatedorcoagulated.
Theothervesselsareoutofthefieldofdissection.
77.

A36yearoldwomanwithfamilialneurofibromatosishasanenlargingmassinthe
posteriorthigh.Thelesionhasslowlyincreasedinsizeandisnowconstantlypainful.

Pressureonthemasscausesdysesthesiasinthefoot.Figures44athrough44cshow
T1weighted,STIR,andT1weightedfatsaturatedgadoliniumscans,respectively.
Figure44dshowsaPETscan.Whatdoesthislesionmostlikelyrepresent?

Peripheralnervesheathtumor

Malignantperipheralnervesheathtumor

Malignantfibroushistiocytoma

Liposarcoma

Synovialsarcoma

PREFERREDRESPONSE:2

DISCUSSION:Theimagesrevealalargemassintheposteriorthigharisingfromthesciatic
nerve.Thelesionisedematous,andthegadoliniumimagerevealsrimenhancement,suggesting
necrosis,giventhattheSTIRimageisnotuniformlybrightaswouldbeseeninacysticlesion.
ThePETscanhasincreaseduptake,inthiscaseastandardunitvalue(SUV)ofgreaterthan2.0.
Thesefindingsareallverysuggestiveofamalignantprocess.Thehistoryofneurofibromatosis
makesamalignantperipheralnervesheathtumor,orneurofibrosarcoma,themostlikely
diagnosis.Thetermperipheralnervesheathtumorhasreplacedneurolemmomaand
schwannoma.
78.

InDupuytrensdisease,theretrovascularcordtypicallydisplacestheradialproperdigital
nerveoftheringfingerinwhatdirection?

Palmarlyandradially

Dorsallyandulnarly

Palmarlyandulnarly

Dorsallyandradially

Directlydorsal

PREFERREDRESPONSE:3

DISCUSSION:RetrovascularcordsarecommoninDupuytrensdiseaseandcommonlyrequire
surgicaltreatment.NerveinjuryinDupuytrenssurgeryisaninfrequentcomplicationthat
occurspartlybecausethedigitalnervescanbedisplacedfromtheirnormalanatomic
relationshipsbyretrovascularcords.Thenervesaredisplacedsuperficially,towardthecenterof
thedigit(palmarlyandulnarly).Thisdisplacementistypicallyseenatthelevelofthe
metacarpophalangealjoint.
79.

Ganglioncystsaboutthewristmostcommonlyarisefromwhatstructure?

Firstcarpometacarpaljoint

Secondcarpometacarpaljoint

Scapholunateinterosseousligament

Radioscaphocapitateligament

Capitohamateinterosseousligament

PREFERREDRESPONSE:3

DISCUSSION:Ganglioncystsarethemostcommonmassormasslikelesionsseeninthehand
andwrist.Theyariseinavarietyoflocations,includingsynovialjointsortendonsheaths.The
mostcommonlocationisthedorsal/radialwristarisingfromthedorsalscapholunate
interosseousligament.
80.

A60yearoldwomanhasactivityrelatedhippainafterundergoingarthroplasty5years
ago.ShehassevereParkinsonismanddeniesfeversorchills.Radiographsareshownin
Figures45aand45b.Whatisthemostlikelycauseofherpain?

Chronicdeepinfection

Heterotopicbone

Femoralloosening

Parkinsonism

Acetabularloosening

PREFERREDRESPONSE:3

DISCUSSION:Theradiographsrevealbothcementdebondingatthelateralshoulderofthe
prosthesisandacementmantlefracture.Bothoftheseindicatealoosefemoralcomponent.The
radiographsshowastressfracturewithreactiveboneonthelateralfemoralcortexinconjunction
withthecementmantlefracture.Theacetabularcomponentshowsnoevidenceofloosening.
HeterotopicboneusuallyisnotasourceofpainwhenitisBrookergradeI,asinthiscase.
Parkinsonismgenerallyisnotassociatedwithhippain.
81.

A15yearoldboyreportslegpainafterbeingtackledduringfootballpractice.
RadiographsandaCTscanareshowninFigures46athrough46c.Thepatienthasa
pathologicfracturethroughwhatunderlyinglesion?

Giantcelltumor

Fibrousdysplasia

Aneurysmalbonecyst

Nonossifyingfibroma

Chondroblastoma

PREFERREDRESPONSE:4

DISCUSSION:Theimagesshowalobulated,eccentric,wellmarginatedlesionthatistypicalof
anonossifyingfibroma.Thelesionisslightlyexpansile,andtheCTscanfindingsshowthatthe

lesionisverywellmarginatedandthecortexisdisrupted,whichisacommonfinding.Noneof
thecharacteristicsofthislesionisaggressiveinnature.
82.

A28yearoldmanhasleftkneepainafterasnowskiingaccident.TheMRIscanshown
inFigure47revealswhichofthefollowing?

Osteosarcoma

Buckethandlemedialmeniscaltear

Lateralcollateralligamenttear

Bonebruise

Tibialspineavulsion

PREFERREDRESPONSE:4

DISCUSSION:BonebruisesareoftennotedonMRIafteranteriorcruciateandmedialcollateral
ligamentinjuries.Thesignificanceoftheseinjuriesawaitslongtermfollowupstudies.The
areasofincreasedsignalonT2weightedimagesrepresentareasofacutehemorrhageandare
secondarytomicrofracturesoftheadjacentmedullarytrabeculae.
83.

Followingapplicationofashortlegcast,apatientreportsacompletefootdrop.A
compressioninjuryoftheperonealnerveatthefibularneckisconfirmedbyelectrical
studies.Whichofthefollowingmusclesisexpectedtobethelasttorecoverfunction
duringtheensuingmonths?

Extensordigitorumlongus

Flexordigitorumlongus

Peroneuslongus

Extensorhallucislongus

Tibialisanterior

PREFERREDRESPONSE:1

DISCUSSION:Therecoveryprocessfromperonealnervepalsymaytakemanymonthsas
axonalregrowthoccurs.Ofthemuscleslisted,theextensorhallucisisinnervatedmostdistally
bytheperonealnerve.Theflexordigitorumlongusisinnervatedbythetibialnerve.
84.

A28yearoldmanreportskneestiffness,swelling,andaconstantachethatisworsewith
activity.Examinationrevealsaneffusion,globaltenderness,andwarmthtothetouch.
Flexionislimitedto110degrees.Figures48athrough48dshowsagittalT1weighted,
sagittalT2weighted,axialT1weightedfatsaturatedgadolinium,andaxialgradientecho
MRIscans.Basedonthesefindings,whatisthemostlikelydiagnosis?

Infection

Arthritis

Synovialchondromatosis

Pigmentedvillonodularsynovitis(PVNS)

Reactivesynovitis

PREFERREDRESPONSE:4

DISCUSSION:TheMRIscansshowmultiplelowsignalintensitylesionsscatteredthroughout
theknee,extendingposteriorlyinferiortothetibialplateau.Thelowsignalintensityonboththe
T1andT2weightedimages,themodestvascularitynotedonthegadoliniumimage,andthe
bloomingnotedonthegradientechoimage(ferrousladentissue)areallstronglysuggestiveof
diffusePVNS.Whereassynovialchondromatosiscanpresentasdiffusemassesintheknee,they
presentasnodulemassesthathavelowT1andhighT2weightedsignalcharacteristics.
85.

Figure49showsanacuteaxialMRIscanofaleftknee.Whatisthemostlikely
diagnosis?

Patellartendonrupture

Lateraldislocationofthepatella

Quadricepstendonrupture

Anteriorcruciateligamentrupture

Posteriorcruciateligamentrupture

PREFERREDRESPONSE:2

DISCUSSION:TheMRIscanshowsbonebruisesinthemedialaspectofthepatellaandthe
lateralaspectofthelateralfemoralcondyle.Bothofthesesignsaretypicalforalateral
dislocationofthepatellawithspontaneousreduction.Inaddition,theremaybeassociated
tearingofthemedialretinaculumordistalaspectofthevastusmedialis.
86.

Spontaneousentrapmentoftheposteriorinterosseousnervemostcommonlyoccursin
whichofthefollowinglocations?

Lateralintermuscularseptum

Extensorcarpiradialisbrevis

ArcadeofFrohse

Midsubstanceofthesupinator

LeashofHenry

PREFERREDRESPONSE:3

DISCUSSION:Theextensorcarpiradialisbrevis,supinatormuscle,arcadeofFrohse,andleash
ofHenryarepotentialsitesofcompressionfortheposteriorinterosseousnerve.Themost
commonlocationofspontaneousentrapmentisthearcadeofFrohse.Thelateralintermuscular
septumisasiteofcompressionfortheradialnerve.

87.

A72yearoldmanhashadpersistentpainafterundergoingahemiarthroplasty18months
ago.RadiographsareshowninFigures50aand50b.Whatisthemostlikelycauseof
hisproblem?

Suboptimalcementtechnique

Excessiveactivitylevel

Oversizedbipolarcomponent

Infection

Osteoporosis

PREFERREDRESPONSE:4

DISCUSSION:Theradiographsdemonstratearapiderosionofthebipolarcomponentintothe
acetabulum.Althoughacetabularerosionismorecommonwithunipolarhiparthroplasties,it
canoccurwithbipolarcomponents.Haidukewychandassociatesnotedaverylowerosionrate
butnoneinthefirst2years.Thesecondfindingontheradiographsisthelinearradiolucency
progressingfromthejointtowardtheendofthestematthecementboneinterfacesuggesting
chronicinfectionordiffuseloosening.Thepersistentpainsinceimplantationalsosuggests
chronicinfection.Highactivitylevelsandosteoporosisdonotleadtoacetabularerosioninthe
first2yearsafterhemiarthroplasty.Whilethecementtechniqueissuboptimal,looseningand
erosionshouldnotbeexpectedfromthisalone.Anoversizedbipolarheadwouldextrudeand
noterode.
88.

Whatfibersoftheanteriorcruciateligamenttightenwithextensionoftheknee?

Anterolateral

Anteromedial

Posterolateral

Posteromedial

Posterioroblique

PREFERREDRESPONSE:3

DISCUSSION:Theanteriorcruciateligamentconsistsoftwofunctionalbundles:anteromedial
andposterolateral.Duringextensionoftheknee,theposterolateralbundlebecomestaut.In
flexion,theanteromedialbundleistightandtheposterolateralbundlerelaxes.Traditionally,
anteriorcruciateligamentreconstructionprimarilyrecreatestheanteromedialbundle.Recently,
techniquesfordoublebundlereconstructionhavebeendescribedtorecreatethenormalanatomic
relationshipofthetwobundles.
89.

Inanefforttoreducecosts,alimitedMRIsequenceisplannedtodetectapossibleoccult
hipfracture.Whatistheanticipatedfracturesignal?

BrightonT1andT2

DarkonT1andT2

DarkonT1,brightonT2

BrightonT1,darkonT2

Enhancementbygadolinium

PREFERREDRESPONSE:3

DISCUSSION:Atpresent,radiologistsperformmultipleMRIimagestoruleoutallpossible
diagnoses.TheabilitytospecifytheanticipatedchangesonMRIshouldbecomemoreimportant
asameansofreducingcosts.MRIissensitivetochangesinfreewater(orhemorrhage)andthus
thiswillappeardarkonT1andbrightonT2.
90.

Whenusingthedirectlateral(orHardinge)approachforhiparthroplasty,threemuscles
aredetachedfromthefemur.Inadditiontothevastuslateralis,theyincludethe

iliopsoasandsartorius.

piriformisandobturatorinternus.

gluteusmaximusandtensorfascialata.

gluteusminimusandrectusfemoris.

gluteusmediusandgluteusminimus.

PREFERREDRESPONSE:5

DISCUSSION:Thisapproachiscriticizedfortheepisodiclimpassociatedwiththemuscle
detachmentandreattachment.Classically,twothirdsofthegluteusmediusisdetachedasa
sleevewiththevastuslateralis.ThisexposesthegluteusminimusandtheligamentofBigelow.
Thesemustalsobedetachedtoallowdislocationofthehipandosteotomyofthefemoralneck.
Therectusfemorisliesmediallyandanteriorlyanddoesnotneedtobeaddressed.The
piriformisandobturatorinternusareexposedduringtheposteriorapproach.Neitherthegluteus
maximusnortensorfascialataattachtotheanteriorfemur.Thesartoriusandiliopsoasarenot
exposedduringthisdissection.
91.

Figure51showsanarthroscopicviewofthepatellofemoraljointfromaninferolateral
portal.Thearrowpointstowhichofthefollowingstructures?

Loosebody

Plica

Displacedmeniscustear

Tornretinaculum

Osteochondraldefect

PREFERREDRESPONSE:2

DISCUSSION:Synovialfoldsorplicaearetheresultofincompleteorpartialresorptionofthe
synovialmembranesduringfetaldevelopmentoftheknee.Thearthroscopicviewshowsa
medialpatellarplica,whichhasbeennotedin5%to55%ofallindividualsbutbecomes
symptomaticinonlyasmallnumberofpatients.Symptomsmayincludecrepitus,pain,
snapping,andswellingandoftenrespondtononsurgicalmanagement.
92.

InajuvenileTillauxanklefracture,whatligamentcausesthedisplacementofthe
fracturefragment?

Anteriortibiofibular

Posteriortibiofibular

Deltoid

Calcaneofibular

Talonavicular

PREFERREDRESPONSE:1

DISCUSSION:ThejuvenileTillauxanklefractureusuallyoccursbecausethelateralhalfofthe
distaltibialphysisremainsopen.Duringanexternalrotationalforce,theanteriortibiofibular
ligamentholdsthelateraltibialepiphysis,separatingitthroughatthejunctionofthemiddle
closedphysisandlateralopenphysis.
93.

Whenharvestinganiliaccrestbonegraftfromtheposteriorapproach,whatanatomic
structureisatgreatestriskforinjuryifaCobbelevatorisdirectedtoocaudal?

Sciaticnerve

Clunealnerves

Inferiorglutealartery

Superiorglutealartery

Sacroiliacjoint

PREFERREDRESPONSE:4

DISCUSSION:IfaCobbelevatorisdirectedcaudallywhilestrippingtheperiosteumoverthe
iliacwing,itwillencounterthesciaticnotch.Althoughthisputsthesciaticnerveatrisk,thefirst
structureencounteredisthesuperiorglutealartery.Becauseitistetheredatthesuperioredgeof
thenotch,itisveryvulnerabletoinjuryandcanthenretractinsidethepelvis,makingitdifficult
toobtainhemostasis.Theinferiorglutealarteryexitsthesciaticnotchbelowthepiriformisand
ismoreprotected.Theclunealnervesareatriskonlyiftheincisionextendstooanteriorly,and
thesacroiliacjointcanbeenteredwhileharvestingthegraft.
94.

Figures52aand52bshowtheradiographsofaleftproximalfemorallesionnoted
serendipitouslyfollowingminortraumatothelefthip.Thepatienthasnothighpainand
isfullyactivewithoutlimitation.Whatisthemostlikelydiagnosisofthisbonylesion?

Chondroblastoma

Enchondroma

Giantcelltumor

Fibrousdysplasia

Osteoblastoma

PREFERREDRESPONSE:4

DISCUSSION:Theradiographsrevealageographiclesionoftheproximalfemurwiththe
classicgroundglassappearancenotedinfibrousdysplasia.Thisintramedullarylesionis
modestlyexpansile,demonstratessomeminimalcorticalthinning,andhasnoaggressive
features.Chondroblastoma,giantcelltumor,andosteoblastomaaremorelyticinappearance,
andthelocationisnottypicalforgiantcelltumororchondroblastoma.Whileenchondromamay
beconsidered,theuniformgroundglassappearance,lackofpunctuatemineralization,and
distinctmarginationofthelesionmakethatdiagnosislesslikely.

95.

Figure53showsthearteriogramofa45yearoldmanwhohasseverevasculitis.What
dothefindingsshow?

Apatentulnararteryanddeeppalmararch

Apatentulnararteryandsuperficialpalmararch

Apatentradialarteryanddeeppalmararch

Apatentradialarteryandsuperficialpalmararch

Apatentradialarteryandanulnararteryaneurysm

PREFERREDRESPONSE:3

DISCUSSION:Thearterialsupplytothehandisabundantandnormallyduplicated.Thedeep
palmararchasshowninthisarteriogramtypicallyreceivesitsprimarycontributionfromthe
radialarterywhichtravelsdeeptothefirstdorsalcompartmenttendonsandthenreturnstothe
volaraspectofthepalmthroughthefirstwebspace.Thesuperficialpalmararchreceivesits
supplyfromtheulnararteryandisnotvisualizedinthispatient.
96.

ApatientwithaleftsidedC67herniatednucleouspulposiswouldlikelyhavewhichof
thefollowingconstellationoffindings?

Painintothethumb,tricepsweakness,andlossoftricepsreflex

Middlefingernumbness,wristextensorweakness,diminishedbrachioradialis
reflex

Thumbnumbness,wristextensorweakness,diminishedbrachioradialisreflex

Middlefingernumbness,tricepsweakness,andlossofbicepsreflex

Middlefingernumbness,tricepsweakness,andlossoftricepsreflex

PREFERREDRESPONSE:5

DISCUSSION:AC67herniationaffectstheC7root.TheC7roothasthemiddlefingerasits
predominantsensorydistribution.Itsmotorfunctionisthetriceps,wristextension,andfinger
metacarpophalangealextension.Thereflexisthetriceps.
97.

98.

Whichofthefollowingmuscletendonsinsertsjustlateraltothelongheadofbiceps
tendonontheproximalhumerus?

Teresmajor

Latissimusdorsi

Shortheadofthebiceps

Pectoralismajor

Subscapularis

A4montholdinfantisunabletoflexherelbowasaresultofanobstetricalbrachial
plexuspalsy.Thismostlikelyillustratesapredominateinjurytowhatstructure?

C4

Uppertrunk

Posteriorcord

Lateralcord

Musculocutaneousnerve

PREFERREDRESPONSE:2

DISCUSSION:ErbspalsyisthemostcommonformofobstetricalplexuspalsyresultinginC5,
C6,oruppertrunkdeficits.Thiscauseslossofshoulderabductionandelbowflexion.The
bicepsmuscleandthebrachialismusclesarepredominatelyresponsibleforflexionoftheelbow.
Eachofthesemusclesisinnervatedbyindividualbranchesofthemusculocutaneousnervewhich

aresuppliedpredominatelybyaxonsfromtheC6nerverootandtheuppertrunkofthebrachial
plexus.

PREFERREDRESPONSE:4

DISCUSSION:Thepectoralismajorinsertionisjustlateraltothelongheadofthebiceps
tendon.Medialtothebicepsistheinsertionfortheteresmajorandlatissimusdorsi.Theshort
headofthebicepsoriginatesonthecoracoidprocess.Thesubscapularisinsertsonthelesser
tuberosityjustmedialtothebiceps.
99.

Followingafallfromaheightof5feet,apatientreportspainalongthelateralborderof
thefoot.TheCTscanshowninFigure54indicateswhatpathology?

Impactioninjuryofthecuboid

Retractedosperoneum

Fifthmetatarsalavulsionfracture

Avulsioninjuryofthebifurcate(Y)ligament

Lisfrancinjury

PREFERREDRESPONSE:4

DISCUSSION:TheCTscanrevealsanavulsionofthedorsalbeakoftheanteriorprocessofthe
calcaneus.Thiscommonfractureisanavulsionoftheoriginofthebifurcateligament,which
runsfromtheanteriorcalcanealprocesstoboththecuboidandthelateralaspectofthenavicular.
Aninversionmechanismiscommon,andthefractureisoftenmissedinevaluationfora
suspectedanklesprain.MRImaybeusefulinthediagnosisoftheseoccultinjuries,and
suspicionshouldbepresentwhentendernessexistsoverthesuperiorportionoftheanterior
processofthecalcaneus.
100.

ThepatientinFigure55isactivelyattemptingtomakeafist.Thisclinicalscenario
suggestswhichofthefollowinganatomiclesions?

Mediannervelesioninthearm

Radialnervelesioninthearm

Anteriorinterosseousnervesyndrome

Posteriorinterosseousnervesyndrome

Medianneuropathyatthewrist

PREFERREDRESPONSE:1

DISCUSSION:Theclinicalpresentationischaracteristicofahighmediannervepalsy.When
tryingtomakeafist,thepatientisunabletoflexthethumbandindexfingersduetoparalysisof
flexionofthedistalinterphalangealjointofthethumbandthedistalandproximalinterphalangel
jointsoftheindexfinger.Thishandattitudediffersfromtheanteriorinterosseousnervelesion
inwhichlossofdistalinterphalangealjointflexionisseeninthethumb,index,andmiddle
fingers.Posteriorinterosseousnervesyndromepresentswithdroppedfingersatthe
metacarpophalangealjointswithwristextensioninradialdeviation.Wristandfingerdropisthe
typicalpostureofpatientswithradialnervelesions.
101.

Youareinterestedinlearninganewtechniqueforminimallyinvasivetotalknee
arthroplasty.TheKeyholeGenuflexsystemseemsappealingtoyoubecausethe
instrumentationcomeswithwirelesscontrols.Whichofthefollowingrepresentsan
acceptablearrangement?

ThelocalKeyholerepresentativehasinvitedyouandyourspouseouttodinnerat
alocalrestauranttodiscussyourinterestintheirnewminimallyinvasivetotal
kneesystem,theKeyholeGenuflexknee.

KeyholehasofferedtopayyourtuitiontoattendaCMEcoursesponsoredbythe
AmericanAssociationofHip&KneeSurgeonswhereboththeGenuflexandthe
competingStyphtotalkneearediscussedanddemonstrated.

Keyholewillpayyourexpensestoattendaworkshop,inPhoenixattheir
companyheadquarters,tolearnhowtoimplanttheGenuflexkneeandtoseehow
theimplantismanufacturedandtested.

Keyholewillpayyou$500foreachkneethatyouimplantifyouswitchfrom
yourcurrenttotalkneesystem.

Afteryouhaveimplanted25Genuflexknees,Keyholewilllistyouontheir
websiteasaconsultant,payyouaconsultingfeeof$5,000peryear,andinvite
youtoagolftournamentfortheirconsultantsataresort.

PREFERREDRESPONSE:3

DISCUSSION:BoththeAAOSandAdvaMed,themedicaldevicemanufacturer'strade
organization,havewrittenguidelinesthataddresspotentialconflictsofinterestregarding
interactionsbetweenphysiciansandmanufacturer'srepresentativeswhenitcomestopatients'
bestinterest.TheAAOSfeelsthattheorthopaedicprofessionexistsfortheprimarypurposeof
caringforthepatientandthatthephysicianpatientrelationshipisthecentralfocusofallethical
concerns.Whenanorthopaedicsurgeonreceivesanythingofsignificantvaluefromindustry,a
potentialconflictofinterestexists.TheAAOSbelievesthatitisacceptableforindustryto
providefinancialandothersupporttoorthopaedicsurgeonsifsuchsupporthassignificant
educationalvalueandhasthepurposeofimprovingpatientcare.Alldealingsbetween
orthopaedicsurgeonsandindustryshouldbenefitthepatientandbeabletowithstandpublic
scrutiny.Agiftofanykindfromindustryshouldinnowayinfluencetheorthopaedicsurgeonin
determiningthemostappropriatetreatmentforhisorherpatient.Orthopaedicsurgeonsshould
notacceptgiftsorotherfinancialsupportwithconditionsattached.Subsidiesbyindustryto
underwritethecostsofeducationaleventswhereCMEcreditsareprovidedcancontributetothe
improvementofpatientcareandareacceptable.Acorporatesubsidyreceivedbythe
conference'ssponsorisacceptable;however,directindustryreimbursementforanorthopaedic
surgeontoattendaCMEeducationaleventisnotappropriate.Specialcircumstancesmayarise
inwhichorthopaedicsurgeonsmayberequiredtolearnnewsurgicaltechniquesdemonstrated
byanexpertortoreviewnewimplantsorotherdevicesonsite.Inthesecircumstances,
reimbursementforexpensesmaybeappropriate.