Question 110

When considering the pathology related to Morton's neuroma of the

foot.
A : Collagen hypertrophy
B : Degenerative neural changes
C : Electron microscopy
D : Endarteritis obliterans
E : Fusiform swelling
F : Light microscopy
G : Neuritis
H : Proliferative neural changes
I : Renaut bodies
J : Separation of nerve fibres

1 : The most typical histological feature observed

2 : The presence of which histological feature represents a compressive
pathology
3 : The best method for observing the diagnostic pathological micro-
anatomy.
Klenerman L. Mini-symposium:Nerve compression syndrome (V) Nerve
compression in the foot. Current Orthopaedics (2001)15,275-280

The swelling seen in this condition is generally called a neuroma, but this is
incorrect; histological sections show that the neural changes are degenerative
in nature, not proliferative.
The microscopic anatomy shows separation of individual nerve fibres by a
proliferating
collagen matrix. The presence of Renaut bodies suggests a compressive
pathology. Renaut bodies are loosely textured, whorled, cell-sparse structures
in the sub-perineural space of peripheral nerves but this diagnostic feature is
only seen on electronmicroscopy.
Answers; B, I, C

Question 111

What would be the best method of management of knee injuries in

A : PCL and posterolateral corner reconstruction
B : Quadriceps strengthening programme
C : Acute reconstruction of PCL
D : Open reduction and internal fixation of avulsion fracture
E : Total knee replacement
F : PCL reconstruction after ACL and MCL reconstruction
G : Urgent femoral angiogram
H : Urgent knee EUA +arthroscopy
I : Reconstruction of the anteromedial band of the PCL

1 : A 25 year old who sustained a hyperflexion injury to his knee 8 weeks

ago. He has a positive quadriceps active test and a positive dial test at
30 and 90 degrees of external rotation. He has had quadriceps
strengthening physiotherapy, but still complains of instability

2 : A 70 years old man sustained a dashboard injury 10 days ago. He has

a positive posterior drawer test. Radiographs do not show any obvious
fractures. He did complain of moderate knee pain for the past 3 years or
so prior to the injury

3 : A 45 year old was involved in a motorcycle accident presenting 7

days post-injury with a swollen knee. Radiographs show an avulsion of
his posterior tibial spine

Review of Orthopaedics -Miller, 5th Edition, page 258

The PCL is most commonly injured with a direct blow to the anterior tibia with
the knee flexed, or can be injured with a fall onto the ground with a plantar
flexed foot. Non operative treatment can be carried out for isolated grade I or
II PCL injuries. Bony avulsion fractures can be repaired primarily with good
results.

Answers; A, B, D

Question 112

With respect to nerves of the lower limb

A : Common digital nerve
B : Lateral plantar nerve
C : Medial plantar nerve
D : Sural nerve
E : Deep peroneal nerve
F : Superficial peroneal nerve
G : Tibial nerve
H : Saphenous nerve

1 : This is the main innervator of extensor digitorum brevis

2 : This is in danger at the proximal portion of the lateral approach to

calcaneal fracture fixation

3 : This supplies the skin over the dorso-medial part of the great toe

4 : This pierces the deep fascia 10-15 cm proximal to the lateral

malleolus

LAST anatomy book; Miller 5th Edition Page 363

Answers; E, D, F, F

question 113

Which is the best proximal femoral fixation device for the following
patients
A : Cemented modular hemiarthroplasty
B : Proximal femoral nail
C : Uncemented Austin Moore hemiarthroplasty
D : Bipolar cemented hemiarthroplasty
E : Cannulated screws
F : Total hip replacement
G : Intramedullary hip screw
H : Dynamic Condylar screw (DCS)

1 : A fit 59 year old with a displaced subcapital neck of femur fracture

2 : An 85 year old, who walks with one stick, with a displaced,

transcervical neck of femur fracture.

3 : An active 72 year old with a displaced subcapital neck of femur

fracture with associated osteoarthritis and mini mental score of 10/10.

THR has better functional results as compared to Bipolar hemiarthroplasty in

healthy, active and lucid patients (1). Internal fixation is the method of choice
in young patients with displaced intra-capsular fractures (2). Reports have
shown that bipolar hemiarthroplasty functions as a unipolar device within
three to 12 months after surgery (3). Cemented hemiarthroplasty has less
post-operative thigh pain than uncemented (4).

1)Blomfeldt R, Törnkvist H, Eriksson K, Söderqvist A, Ponzer S, Tidermark J.

A randomised controlled trial comparing bipolar hemiarthroplasty with total hip
replacement for displaced intracapsular fractures of the femoral neck in
elderly
patients.J Bone Joint Surg Br. 2007 Feb;89(2):160-5.
2)Bhandari M, Devereaux PJ, Tornetta P 3rd, et al. Operative management of
displaced femoral neck fractures in elderly patients: an international survey. J
Bone Joint Surg [Am] 2005;87-A:2122–30
J Bone Joint Surg Br. 2007 Feb;89(2):160-5
(3)Phillips TW. The Bateman bipolar femoral head replacement: a
fluoroscopic study of movement over a four-year period. J Bone Joint Surg
[Br] 1987;69-B:761–4
(4)Parker MJ, Gurusamy K.Arthroplasties (with and without bone cement) for
proximal femoral fractures in adults.
Cochrane Database Syst Rev. 2006 Jul 19;3:CD001706. Review
Answers; E, A, F

Question 114

Of the 10 listed options which anatomical structure is most at risk

during the following surgical approaches for irrigation and debridement
of the ankle
A : Peroneus tertius tendon
B : Extensor tendons
C : Sural nerve
D : Great saphenous vein
E : Medial plantar nerve
F : Dorsalis pedis artery
G : Superficial peroneal nerve
H : Tibialis anterior tendon
I : The knot of Henry
J : Flexor hallucis longus tendon

1 : 1. Posterolateral approach
2 : 2. Anterior approach
3 : 3. Posteromedial approach

Campbell's Operative Orthopaedics

Answers; C, G, J

Question 115

Regarding the Ponseti method of correction of congenital talipes

equinovarus deformity
A : Depression of the first ray
B : Correction of equinus
C : Correction of varus
D : Correction of valgus
E : Lengthening of the achilles tendon
F : Elevation of the 1st ray
G : Tibialis posterior tendon transfer
H : Tibialis anterior tendon transfer
I : Achilles tenotomy
J : Plantar fascia release

1 : The first step in deformity correction with this technique is

2 : Surgical procedure required in approximately 90% of cases

3 : Surgical procedure required in up to 20% of cases for correction of

residual deformity

Clinical Orthopaedics and Related Research, volume 467, May 2009

Answers; F, I, H

Question 116

Regarding stability of the knee

A : Anterior cruciate ligament
B : Iliotibial band
C : Popliteal oblique ligament
D : Superficial medial collateral ligament
E : Deep medial collateral ligament
F : Lateral collateral ligament
G : Medial meniscus
H : Lateral meniscus
I : Posterior cruciate ligament
J : Posterolateral corner

1 : Is the primary restraint to valgus stress at all angles

2 : Is the primary restraint to internal rotation
3 : Is the predominant secondary restraint to anterior translation of the
tibia on the femur

Stable knee movement is achieved through primary and secondary restraints

to knee movement. The primary restraint to anterior translation of the tibia on
the femur and internal rotation is the ACL. Secondary restraints to anterior
translation have been quantified as being the iliotibial band (24%), mid-medial
capsule (22%), mid-lateral capsule (20%), MCL (16%), LCL (12%) and the
menisci. The superficial MCL is the primary restraint to valgus stress at all
angles. The deep MCL has little resistance to valgus force. The ACL acts as a
secondary restraint to valgus load.
Answers; D, A, B

Question 117

With regard to benign bone and soft tissue tumours, what is the most
likely diagnosis in the following patients?
A : Chondroblastoma
B : Enchondroma
C : Giant cell tumour
D : Glomus tumour
E : Histiocytosis X
F : Mucous cyst
G : Neurofibroma
H : Osteoblastoma
I : Osteochondroma
J : Osteoid Osteoma

1 : A 62 year old lady presents with a slowly growing swelling overlying

the dorsum of her index finger DIP joint. Radiographs show features of
osteoarthritis in the hand and erosion of the distal phalanx.

2 : A 25 year old woman who has recently had a baby presents with a 6
month history of progressively increasing pain and now, a swelling in
her wrist. Radiographs show a pure lytic lesion at the distal end of the
radius involving the metaphysis and epiphysis but not the articular
surface.

3 : An 8 year old boy presents with a painful swelling over his ring
finger. The pain wakes him up at night and radiographs show a well
circumscribed, rounded, sclerotic lesion, < 1 cm in size with a central
radiolucent nidus.

Although some of the options are bony tumours, all the provided options may
present with swelling. The scenarios in the question describe patients with
extremity swelling as a presenting feature in some of the more important and
commonly encountered benign lesions.

Explanation of answers to the scenarios:

1. G Erosion of the distal phalanx is due to pressure effect. Typically,

osteophytes at the DIP joint are found underlying this cystic lesion.
Enchondroma, glomus tumor, osteoid osteoma and giant cell tumor of tendon
sheath can also present in the fingers, but age and features of osteoarthritis
are characteristic.

2. F Giant cell tumour of bone typically affects the epiphysis of long bones, the
distal radius being the 4th common site. Purely lytic lesion is characteristic
and usually, this is limited to the subchondral margin but can fracture into the
joint later. Growth increases during pregnancy.

3. A Another finger swelling, but age, night pain (relieved by NSAIDS) and
radiological features are distinguishing. Size < 1 cm differentiates an osteoid
osteoma from an osteoblastoma.

1. Oxford Textbook of Orthopaedics and Trauma Volume 1 p 151-166

2. Review of Orthopaedics, Miller 4th Ed. P 444-494
Answers; F, C, J

Question 118

Which component of the physis is affected in each of the following

conditions

A : Perichondrial ring of LaCroix

B : Hypertrophic layer
C : Reserve zone
D : Zone of provisional calcification
E : Proliferative layer
F : Groove of Ranvier

1 : Rickets

2 : Gaucher's disease

3 : Achondroplasia
Stanmore guide to basic sciences, paediatric orthopaedic secrets
Osteomalacia results from inadequate mineralisation of bone matrix (osteoid).
In rickets there is inadequate mineralisation of cartilage matrix (chondroid)
and this affects the provisional zone of calcification in the physis. Rickets is
caused by a lack of serum calcium and phosphate, insufficient to allow
mineralisation of the newly formed chondroid matrix. This may be seen on
plain radiographs as a widened, thickened physis with metaphyseal flaring
due to the persistence of metaphyseal cartilage.
Answers; D, C, E

Question 119

The 3 scenarios below are of patients attending your revision ACL clinic.
Out of the 10 options below which answer best explains the cause of
ACL failure?

A : Tibial tunnel placed anteriorly

B : Tibial tunnel placed posteriorly
C : Tibial tunnel placed medially
D : Tibial tunnel placed laterally
E : Tibial tunnel placed inferiory
F : Femoral tunnel placed anteriorly
G : Femoral tunnel placed posteriorly
H : Femoral tunnel placed vertically
I : Femoral tunnel placed medially
J : Femoral tunnel placed laterally

1 : A 30 year old basketball player underwent autologous ipsilateral

single bundle hamstring ACL reconstruction. 6 months later
examination reveals that he is tight in flexion (ROM 0-100 deg) and has
laxity in extension.

2 : A 25 year old female skier underwent a BTB ACL reconstruction 4

months ago. Examination reveals fixed flexion of 10 deg with flexion up
to 110 deg. What is the cause for her reduced ROM of movement.

3 : A 22 year old footballer has had a BTB ACL recostruction 3 months

ago and examination reveals that he is tight in extension and lax in
flexion.

Christopher D. Harner, J. Robert Giffin, Roger C. Dunteman, Christopher C.

Annunziata, and Marc J. Friedman
Evaluation and Treatment of Recurrent Instability After Anterior Cruciate
Ligament Reconstruction*
J. Bone Joint Surg. Am., Nov 2000; 82: 1652.
The paper by Harner et al states that inappropariate tunnal positioning results
in excessive changes in graft length as the knee moves through its range of
movement. Only small changes in length can be accomodated before
undegoing plastic deformation, therefore a malposiitoned graft can either lead
to loss of motion or lengthening of the graft over time. Anterior femoral tunnel
placement is the most common error during ACL reconstruction.
Answers; F, A, G

Question 120

Concerning the muscle layers of the sole of the foot

A : Layer 1
B : Layer 2
C : Layer 3
D : Layer 4
E : Layer 1+3
F : Layer 2+4
G : Layer 4+5
H : Layer 3+5
I : Between first and the second layer underneath flexor digitorum brevis.
J : Between second and third layer protected by quadratus plantae

1 : In what layer do medial and lateral plantar nerves lie

2 : Flexor digitorum longus and lumbricals are part of

3 : Peroneus longus and interossei are part of

1. Online grays anatomy.

Knowing layers of foot is important for those involved in foot surgery.
First layer consists (from lateral to medial) of the ADM, FDB, & abductor
hallucis.
Medial and lateral Plantar nerve and artery lies between First and second
layer.
Second layer (from medial to lateral) tendon of FHL, tendon of FDL,
quadratus plantae & lumbricalsin
Third layer has adductor hallucis, & FHB
Fourth layer has Palmer and Dorsal interossei.

First two layers originate from calcaneal tuberosity and the other two from the
metatarsal shafts.
Lateral release of first MTP joint in an integral part of Bunion surgery. It
involves release of Adductor hallucis which lies in the third layer and often
surgeon ends up just releasing the dorsal interossei which from the dorsal
side is superficial to adductor hallucis and is in layer 4. Flexor digitorum
longus is used for tendon transfer in acquired flat foot correction.
Answers; I, B, D

Question 121

Choose the most appropriate treatment for the following scenarios in

Developmental Dysplasia of the Hip:

A : Pavlik harness
B : Double Nappies
C : Medial open reduction and hip spica
D : Salter innominate osteotomy
E : Dega Osteotomy
F : Chiari Osteotomy
G : Ganz osteotomy
H : Total hip replacement
I : Broomstick plaster

1 : 6 week old girl with a reducible hip dislocation

2 : 5 year old with a concentric hip and an acetabular index of 35

degrees

3 : 14 year old girl with a lateralized, spherical but non-concentric hip

Pavlik Harness is the treatment of choice for child 1-6 months of age with
DDH. The harness must hold the hip in more than 90 degrees of flexion with
the proximal femoral metaphysis pointed towards the triradiate cartilage. If
reduction is not obtained or maintained (clinically and ultrasonographically)
within 3-4 weeks, the harness is discontinued. If reduction is confirmed, the
harness is continued for 6 weeks after stability is established.

Salter or Pemberton osteotomy is recommended for patients younger than 8

years of age with concentric but dysplasic hips. After 2 years of age an
acetabular index over 30 degrees is definitely abnormal. There is good
evidence that acetabular dysplasia persisting beyond 5 years of age does not
adequately correct and requires a pelvic osteotomy.

A Chiari osteotomy or a shelf procedure (eg. Staheli) is warranted in non-

concentric hips. These are salvage procedures since the femoral head is
eventually covered by fibrocartilage and not repositioned acetabular cartilage.
Answers; A, D, F

Question 122

With regards to the nerve supply to the foot choose the nerve that
innervates each of the structures below.
A : Common peroneal
B : Deep Peroneal Nerve
C : Lateral Plantar nerve
D : Medial plantar nerve
E : Posterior tibial
F : Superficial peroneal nerve
G : Sural nerve
H : Tibial nerve
1 : Flexor digitorum brevis
2 : Abductor Hallucis
3 : First web space sensation

The nerve supply to the foot is essential knowledge. The cutaneous supply of
the nerves running through each compartment of the leg is also essential
knowledge for the assessment of the patient presenting with a compartment
syndrome.

Flexor digitorum longus (FDL) is in the second plantar layer of the foot and
enters the sole on the medial side of the tendon of flexor hallucis longus
(FHL), it divides into four tendons as it crosses superficial to the FHL
tendon.The four tendons pass forward on the sole deep to those of flexor
digitorum brevis (FDB) and after giving off the lumbricals they enter the
fibrous sheaths of the lateral four toes. Each tendon perforates the tendon of
FDB and inserts into the base of the distal phalanx. Its function is to flex the
lateral four toes in any position of the ankle joint. FDB is supplied by the
medial plantar nerve.

Abductor hallucis arises from the medial process of the calcaneus and from
the flexor retinaculum. It runs along the medial border of the foot before
inserting into the medial side of the base of the proximal phalanx of the great
toe, Its function is to abduct the great toe. Its nerve supply is the medial
plantar nerve.

The deep peroneal nerve runs through the anterior compartment of the leg
and supplies sensation to the first web space.
Answers: D, D, B

Question 123

Which of the following tendons is the most appropriate donor tendon for
transfer in the following scenarios:

A : Tendo Achilles
B : Peroneus brevis
C : Flexor hallucis longus
D : Flexor digitorum longus
E : Tibialis posterior
F : Tibialis anterior
G : Extensor digitorum longus
H : Extensor hallucis longus
I : Peroneus longus

1 : A 54 year old man who felt a sudden pain in his calf while playing
football 15 months ago and has subsequently had ongoing weakness of
ankle plantarflexion.
2 : A 48 year old woman with a four year history of a progressive,
painful, mobile flatfoot deformity

3 : A 63 year old man who had an episode of severe back pain a year
ago and who now has residual alteration in sensation on the medial
border of the calf and a high stepping gait with flapping foot.

4 : A 32 year old woman with flexible clawing of the hallux and a painful,
tender plantar callosity overlying a prominent first metatarsal head

The first scenario describes a chronic Achilles tendon rupture. While a tendon
transfer is not mandatory, most surgeons would use FHL as first preference
as it is easily accessed and works in phase.

The second scenario describes a grade 2 tibialis posterior tendon dysfunction.

FDL is the tendon transfer of choice as the tendon is found alongside tibialis
posterior and functions in phase.
This patient has had a far lateral L4/L5 disc prolapse affecting the L4 nerve
root, leaving a footdrop. Tibialis posterior is innervated by L5 and so is still
functional for a transfer.

This is the indication for the Jones procedure, namely hallux interphalangeal
arthrodesis and transfer of EHL into the distal metatarsal.
Answers; C, D, E, H

Question 124

Approximate age at which each of the following ossification centers

appear?

A : 2 months
B : Birth
C : 10 years
D : 6 months
E : 3 years
F : 1 year
G : 5th week gestation
H : 16 years

1 : Olecranon

2 : Clavicle

3 : Greater tuberosity of the humerus

MIller table 2.1 (p134) Ossification Centres

Answers; C, G, E
Question 125

Tumours around the knee in the young adult. Select the most
appropriate first line treatment modality of each of the following
conditions
A : Above knee amputation
B : Intra-articular chemotherapy
C : Marginal resection
D : Neoadjuvent chemotherapy
E : Radical resection
F : Radiotherapy
G : Wide local excision with endoprosthetic replacement
H : Wide local excision with joint preservation
I : Intra-lesional procedure

1 : Enneking IIa Osteosarcoma of distal femoral metaphysis

2 : Localised Nodular PVNS
3 : Large Distal femoral Aneurysmal Bone Cyst

Osteosarcomas are primarily treated with Neoadjuvent chemotherapy as this

is the most important treatment modality for improving survival. This is thought
to reduce the presence of early pulmonary micrometastasis.

Nodular PVNS can be resected locally unless it has breached the joint
capsule. There is however a high recurrence rate and re-resections are often
combined with adjuvent radiotherapy.

Aneurysmal bone cysts and Giant Cell Tumours can be treated with curettage
and impaction bone grafting - a form of intralesional resection.
Answers; D, C, I

Question 126

Which of the following muscles must routinely be detached (in part, or

in full) to facilitate the approach stated?

A : Vastus Medialis
B : Rectus Femoris
C : Obturator Externus
D : Piriformis
E : Quadratus Femoris
F : Vastus Lateralis
G : Gluteus Medius
H : Sartorius
I : Psoas

1 : Anterior approach (Smith-Peterson) to the hip?

2 : Posterior approach to the hip?

3 : Direct lateral approach (Hardinge) to the hip?

Smith Peterson Approach - This approach utilises the internervous plane

superficially between sartorius and tensor fascia lata and more deeply rectus
femoris and gluteus medius. The rectus is detached in part during part of the
exposure.

Posterior Approach - This approach involves detachment of the piriformis

muscle and release of the short external rotators to gain access to the hip
joint.

Watson - Jones - This approach utilises the interval between tensor fascia lata
& gluteus medius. Gluteus medius can be detached in part during part of the
exposure
Answers; B, D, G

Question 127

With regards to the cruciate and collateral ligaments of the knee, which
structure need to be damaged to result in
A : Superficial MCL
B : Anterior Cruciate Ligament
C : Posterior Cruciate Ligament
D : Deep Part of MCL
E : Lateral Collateral ligament
F : Popliteus Tendon
G : Medial Meniscus
H : Lateral meniscus
I : Lateral Meniscofemoral Ligament
J : Gastronemius Tendon

1 : Loss of roll-glide mechanism

2 : Positive Valgus stress test
3 : Loss of screw home mechanism and increased tibial external
Rotation

Goldblatt JP, Richmond JC. Anatomy and biomechanics of the knee.

Operative techniques in Sports Medicine,2003; 11(3): 172-186.
Martelli S, Pinskerova V. The shapes of the tibial and femoral articular
surfaces in relation to tibiofemoral movement.
Freeman MAR, Pinskerova V. The movement of the normal tibio-femoral joint.
J Biomech,2005; 38:197-208.
Answers; B, A, F

Question 128
The following pathologies are associated with which of these clinical
conditions?
A : Cerebral Palsy
B : Rett's syndrome
C : Poliomyelitis
D : Guillain-Barre syndrome
E : Charcot-Marie-Tooth Disease
F : Freidrich's Ataxia
G : Spinal Muscular Atrophy
H : Duchenne's Dystrophy
I : Becker's Dystrophy
J : Werdnig-Hoffmann Disease

1 : Genetically determined demyelination and/or axonal degeneration in

peripheral nerves

2 : Periventricular Leukomalacia

3 : Autoimmune mediated demyelination and/or axonal destruction in

peripheral nerves

CMT has been classically divided into demyelinating and axonal forms. But
research indicates that demyelination renders the axon susceptible to
degeneration and henec the 2 pictures can co-exist.

Periventricular leukomalacia and intra and periventricular haemorrhages are

frequent MRI finidings in Cerebral palsy. The former results from an ischemic
insult to the arterial watershed area close to the ventricular walls.

GB Syndrome is now the commonest cause of acute flaccid paralysis in

children in the west. It is characterised by symmetric motor and sensory
paresis of the limbs and at times the trunk. The disease is auto-immune and
directed against peripheral nervous system myelin, axon or both. It is
triggered by a preceding bacterial or viral infection.
Answers; E, A, D

Question 129

Concerning lumbar intervertebral discs

A : Type III Collagen

B : Type VI Collagen
C : Type II Collagen
D : Type IV Collagen
E : Type X Collagen
F : Type I Collagen
G : Type XI Collagen
H : Type IX Collagen
1 : Which type of collagen is most prevalent in the nucleus pulposus
affected by age related change?

2 : Which type of collagen is most prevalent in the nucleus pulposus of

the normal disc?

3 : Which type of collagen is involved in the cross linking of aggregates

in the intervertebral disc?

1. The collagen content of the nucleus increases and changes from type II to
type I Collagen rendering the nucleus more fibrous during the ageing
process[1]. The concentration of cells and proteoglycans however decrease
within the disc with age.

2. Type IX collagen cross links aggregates which are held together by type II
collagen.
Answers; F, C, H

Question 130

When designing a study which factor needs to be considered if

A : Power analysis
B : Null hypothesis
C : Parametric test
D : Type II error
E : Type I error
F : Linear regression
G : Independent variables
H : Matching
I : Randomisation

1 : You are trying to calculate the sample size needed

2 : You are choosing the rate of false positive errors

3 : You are comparing two continous variables

A power analysis is a method of determining the number of patients required

in a study to have a reasonable chance of showing a difference if one exists.

The null hypothesis is an assumption that any difference seen is purely by

chance. Studies are designed to either prove or disprove this assumption.

A parametric test assumes data is sampled from a particular form of

distribution such as a normal distribution. Non-parametric tests make no such
assumption
Errors arise when accepting or rejecting the null hypothesis.
A type I (alpha) error occurs when a difference is found but in reality there is
not a difference. A type II (beta) error occurs when no difference is found but
a difference does exist.

Linear regression Correlation is a term used to describe the relationship

between two parameters. Linear regression is when the relationship can be
plotted on a straight line such as with parametric data. Regression can also
be curved or logistic.

For variables to be independent, there needs to be no chance that a subject

could appear in both groups being compared. An unpaired T test would be
used to compare independent variables provided they follow a normal
distribution.

Matching is a process of identifying subjects in different groups that have

certain similar characteristics (eg. Age, sex, co-morbidities)

Randomisation ensures that all prognostic variables, known and unknown, will
be distributed evenly among the treatment groups. Randomisation can be
simple (eg. Computer-generated tables), stratified, or block.

Basic Orthopaedic Sciences. The Stanmore Guide. Ramachandran M.

Hodder Arnold.
Answers; A, E, F

Question 131

Regarding the treatment of L5/S1 spondylolithesis:

A : L5-S1 posterolateral fusion

B : Regular review and repeat radiographs
C : In situ posterolateral fusion including L4 in the arthrodesis
D : Anterior fusion alone
E : Reduction of the spondylolisthesis
F : Physiotherapy
G : Facet joint injection
H : Kyphoplasty

1 : A grade II slip in an asymptomatic adolescent patient should be

managed by

2 : A grade II slip in a patient with persistent back pain should be

managed by

3 : A grade II slip in a patient with progressive slips should managed

with

4 : A grade III slip is best treated by

L5/S1 fusion is the gold standard for patients with grade II slips with
progressive slips, persistent back pain, neurological deficits.

With grade III slip, the treatment of choice is an insitu posterolateral fusion
including L4 in the arthrodesis. Anterior fusion alone, in the absence of
posterior column stabilisation, is not biomechanically stable enough.
Answers; B, A, A, C

Question 132

With regard to nerves at risk during surgical approaches to the hip:

A : Pudendal nerve
B : Nerve to obturator internus
C : Superior gluteal nerve
D : Inferior gluteal nerve
E : Sciatic nerve
F : Posterior femoral cutaneous nerve
G : Lateral femoral cutaneous nerve
H : Nerve to quadratus femoris
I : The cluneal nerves
J : The anterior and posterior divisions of the obturator nerve

1 : Which nerve may be injured during a medial approach?

2 : Which nerve may be injured during a anterior approach?

3 : Which nerve may be injured during a lateral approach?

The anatomy of the medial approach is the anatomy of the adductor

compartment of the thigh. The obturator nerve is derived from the anterior
division of the L2-L4 nerve, and divides in the obturator notch into anterior and
posterior divisions. The nerve lies on the anterior surface of the adductor
brevis. The posterior division of the obturator nerve runs dially on the surface
of the adductor magnus.

The anterior approach internervous plane lies between the sartorius and the
tensor fascia lata. The lateral femoral cutaneous nerve passes either over,
behind or through the sartorius muscle.

The lateral approach allows exposure of the hip joint for joint replacement.
The superior gluteal nerve runs between the gluteas medius and minimus 3-
5cm above the greater trochanter and can be damaged with proximal
dissection.
Answers; J, G, C

Question 133
With regards to bone tumours choose the most appropriate response
for each of the following

A : Osteosarcoma
B : Chondrosarcoma
C : Enchondroma
D : Ewings sarcoma
E : Osteoid osteoma
F : Unicameral bone cyst
G : Non-ossifying fibroma
H : Giant cell tumour
I : Chondroblastoma
J : Metastatic bone tumour

1 : Associated with Paget disease

2 : Lytic lesion in adults that can extend to subchondral area, narrow

zone of transition
3 : Mirel's score

4 : Can be treated by radio-frequency ablation

Apley's
Miller
Ramachandran Basic Sciencs
Answers; A, H. J, E

Question 134

For each of the following patients select the most appropriate diagnosis
from the list?

A : Labral tear
B : Meralgica paraesthetica
C : Rectus femoris avulsion tear
D : Psoas tendonitis
E : Psoas haematoma
F : Hamstring avulsion
G : Gluteus medius avulsion tear
H : Ruptured ligamentum teres
I : Cam impingement
J : Trochanteric bursitis

1 : A 65 year old patient presents with right groin and thigh pain without
an injury. He has a mechanical aortic valve. His knee gives way and he
has noticed numbness over the lower anterior thigh and upper shin.

2 : A patient has been treated for lateral right “hip” pain. This was
particularly troublesome going up and down stairs and lying on the left
side. She was told she had a bursitis. Multiple cortisone injections to the
outer side of the hip were performed in the clinic over a period and
although initially helpful the symptoms have now changed to pain with
weight bearing and a limp.

3 : A patient following a cemented Charnley right total hip replacement

has never been 100% improved. The severe nocturnal pain has been
relieved but the patient has new annoying groin pain. The patient has
noticed when driving a car she has to lift the right leg out of the car to
limit groin discomfort.

Operative repair of bilateral spontaneous gluteus medius and minimus tendon

ruptures. A case report. Fisher DA, Almand JD, Watts MR. J Bone Joint Surg
Am. 2007 May;89(5):1103-7.
Gluteus medius tendon tears and avulsive injuries in elderly women: imaging
findings in six patients. Chung CB, Robertson JE, Cho GJ, Vaughan LM,
Copp SN, Resnick D.
AJR Am J Roentgenol. 1999 Aug;173(2):351-3.

Spontaneous iliopsoas hematoma is a rare but well-recognized complication

of anticoagulation that may result in significant neurological disability due to
pressure on the Femoral nerve.
Gluteus medius tendon rupture can present as debilitating lateral hip pain. It is
also commonly known as Rotator cuff tear of the hip. It can be misdiagnosed
as trochateric bursitis. Sometimes steroid injection can be a predisposing
factor.
Anterior groin pain following THR could be related to Psoas tendonitis.
Typically aggravated by certain activities like standing form low chairs.
Answers; E, G, D

Question 135

A ten year old boy presents with symptomatic rigid pes planus requiring
excision of a tarsal coalition

A : Sural nerve
B : Extensor digitorum longus
C : Superficial peroneal nerve
D : Talus and calcaneum
E : Extensor digitorum brevis
F : Sustentaculum tali
G : Calcaneum and cuboid
H : Calcaneum and navicular
I : Medial malleolus and talus
J : Deep peroneal nerve

1 : Through Ollier's approach, which structure(s) is/are most at risk

2 : An osseous bar between which structures is most likely
3 : Interposition of which structure(s) completes the procedure
Campbells operative orthopaedics vol 2 chapter 38

Disorders of the Foot and Ankle Jahss Vol 1 chapter38

Answers; C, H, E

Question 136

For each of the following clinical scenarios, select the MOST likely
anatomical abnormality

A : Anterior glenoid rim fracture

B : Bankart lesion
C : Brachial plexus injury
D : Greater tuberosity fracture
E : Hill-Sachs defect
F : Long head of biceps rupture
G : Reverse Hill-Sachs defect
H : Rotator cuff tear
I : SLAP lesion
J : Axillary nerve palsy

1 : A 70-year old man with ongoing shoulder pain and weakness, 4

weeks following 1st time traumatic anterior shoulder dislocation

2 : A 23-year old male rugby player with recurrent anterior shoulder

dislocation

3 : A 45-year old male with a dislocated shoulder following an electric

shock

Rotator cuff tears must be considered in association with anterior dislocation

with advancing age as their incidence increases with age. The Bankart lesion
is the most common pathology implicated in recurrent anterior shoulder
instability.The patient with seizure had aposterior dislocation and therefore a
reverse Hills sach lesion is the most likely abnormality
Answers; H, B, G

Question 137

What is the most appropriate step to do next in the following patients

with resurfacing hip arthroplasty?

A : Reassure and review in a year

B : Revise both components
C : Convert to a femoral stem and retain the cup
D : Perform diagnostic aspiration
E : Discharge and advise patient to return only if there is new symptom
F : Order DEXA scan to look for femoral neck osteopenia
G : Organise a CT scan of the hip
H : Order a bone scan
I : Check cobalt and chromium levels and arrange cross sectional imaging.
J : Perform chromium and cobalt levels in three months.

1 : 4 years postoperatively, patient attends routine review with no

complaint.

2 : A 60 yr old gentleman 2 yr following resurfacing has increasing pain

in the groin.

3 : A 40yr old man who has a malpositioned resurfacing prosthesis has

cobalt levels - showing 9 ppb chromium levels.

MHRA MEDICAL DEVICE ALERT ISSUED 22 APRIL 2010

For patients implanted with MoM hip replacements:

• follow up patients at least annually for five years postoperatively and more
frequently in the
presence of symptoms. Beyond five years, follow up in accordance with
locally agreed protocols

• investigate patients with painful MoM hip replacements. Specific tests should
include evaluation of cobalt and chromium ion levels in the patient’s blood and
cross sectional imaging including MRI or ultrasound scan

• consider measuring cobalt and chromium ion levels in the blood and/or
cross sectional imaging for the following patient groups:

> patients with radiological features associated with adverse outcomes

including
component position
> patients with small component size (hip resurfacing arthroplasty only)
> cases where the patient or surgeon is concerned about the MoM hip
replacement
> cohorts of patients where there is concern about higher than expected rates
of failure

• if either cobalt or chromium ion levels are elevated above seven parts per
billion (ppb), then a 2nd test should be performed three months after the first
in order to identify patients who
require closer surveillance, which may include cross sectional imaging

• if imaging reveals soft tissue reactions, fluid collections or tissue masses

then consider revision surgery
Answers; A, I, J

Question 138
Which anatomical structure around the shoulder is being discussed in
each question?

A : Transverse Humeral Ligament

B : Acromioclavicular Ligaments
C : Coracoacromial Ligament
D : Coracoclavicular Ligaments
E : Coracohumeral Ligament
F : Rotator Interval
G : Posterior Capsule
H : Fasciculus obliquus
I : Long head of biceps

1 : Primarily resists anteroposterior translation of the acromioclavicular

joint

2 : Is bound medially by the lateral coracoid base, superiorly by the

anterior edge of supraspinatus and inferiorly by the superior border of
subscapularis

3 : Prevents inferior translation of the coracoid and acromion from the

clavicle

Miller MD, 'Review of Orthopaedics' (4th Ed), pg 233

Ans; B, F, D

Question 139

With respect to replantation select the best answer

A : Transport digit cooled to 5 degree C

B : Bilateral midlateral skin incisions
C : Isolate nerves & vessels
D : Achieve skeletal fixation
E : Arterial anastomosis
F : Venous anastomosis - 2 veins per artery
G : Venous anastomosis - 2 veins only
H : Administer systemic heparin
I : Assessment using pulse oximeter monitoring
J : Loosen dressings
K : Return to operating theatre

1 : When performing a digit replantation which vascular anastomsis

should be done first?

2 : Which structures should ideally be repaired/fixed prior to vascular

repair?
3 : You are called to review a post-op replant's viability, what is the most
appropriate first step?

Greens operative hand surgery. chapter 45

Answers; E, D, J

Question 140

With regards neuromuscular disorders which diagnosis fits best with

the following patients?
A : Dermatomyositis
B : Motor neurone disease
C : Polymyositis
D : Multiple sclerosis
E : Hunter’s syndrome
F : Duchenne’s muscular dystrophy
G : Friedrich’s ataxia
H : Systemic lupus erythematous
I : Amyotrophic lateral sclerosis
J : Psoriasis

1 : A 5 year old boy with progressive weakness with difficulty in

standing up.

2 : A 15 year old girl with a progressive staggering or stumbling gait

with frequent falls

3 : A 50 year old lady presenting with pain, weakness and skin rash

Apley's System of Orthopaedics and fractures, 8th edition

Duchenne’s muscular dystrophy: x-linked inheritance. condition unsuspected
until child walks. difficulty in standing and climbing stairs. characterstic feature
- method of rising from floor by climbing up the legs (Gowers' sign).
Friedrich’s ataxia: spinocerebellar dysfuntion. progressive muscle weakness
of lower limb and trunk. degeneration of posterior root ganglia and peripheral
nerves.
Dermatomyositis: proximal, symmetric muscle weakness, elevation of serum
muscle enzymes characteristic electromyographic abnormalities and
compatible skin involvement.
Ans; F, G, A

Question 141

With regards to clinical tests for diagnosing hand pathologies please

select the correct response for each

A : Inferior Radioulnar subluxation

B : Carpal Translocation
C : Metacarpophalangeal joint subluxation and ulnar drift
D : Boutonniere deformity
E : Swan neck deformity
F : Carpometacarpal arthritis
G : Z deformity of thumb
H : Mallet finger
I : Intrinsic plus hand
J : Intrinsic minus hand

1 : Rigid extension of the distal interphalangeal joint when the patient is

asked to extend the middle phalanx against resistance

2 : Less interphalangeal flexion when the metacarpo-phalangeal joints

are hyper extended as compared to when the metacarpo-phalangeal
joints are flexed

3 : Metacarpal grind test

Green's Operative Hand Surgery

Ans; D, I, F

Question 142

With congenital constriction ring syndrome in the hand:

A : Simple constriction rings

B : Rings + distal deformity
C : Rings + distal fusion
D : Amputations
E : Urgent surgical treatment
F : Delayed surgical treatment
G : Staged surgical treatment
H : Z-plasty

1 : Acrosyndactyly implies

2 : Tight constrictions on the digits or extremities with vascular

compromise

3 : When two rings are adjacent the preferred option is

GREEN'S CHAPTER 40

rare condition, constriction ring syndrome is classified into 4 types: simple

constriction rings, rings+ distal deformity, rings + distal tethering, amputations.
acrosyndactyly refers to rings + distal tethering. early release of the tethering
prevents development of deformity but formal correction is delayed till the
child is older.
Ans; C, E, G