Orthopaedics MCQ

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MedCosmos Orthopaedics

Orthopaedics Lecture Notes, Books, MCQ and Good Articles

Saturday, September 6, 2008

Orthopaedics MCQ
1. Which of the following statements about open fractures is/are
correct?
A. Intravenous antibiotics should be administered as soon as possible.
B. They should be regarded as an emergency.
C. Wound closure is necessary within 8 hours.
D. Systematic wound débridement and irrigation should be
performed.
E. They most often result from low-energy injuries.
Answer: ABD

DISCUSSION: Open fractures represent an orthopedic emergency.


They result most frequently from high-energy injuries. Current
treatment includes administration of intravenous antibiotics,
systematic wound irrigation, and débridement with respect for the
neurovascular bundles. Immediate wound closure is rarely indicated
and should be performed once the wound contamination is
determined to be low.

2. The goals of proper fracture reduction include which of the


following?
A. Providing patient comfort and analgesia.
B. Allowing for restoration of length of the extremity.
C. Correcting angular deformity and rotation.
D. Enabling immediate motion of all fractured extremities.
E. Providing a foundation for bone healing and union.
Answer: ABCE

DISCUSSION: The goals of fracture reduction include patient comfort


and analgesia through stabilization of the bone ends. Furthermore,
restoration of the length, angulation, and rotational alignment of the
extremity should be achieved to allow proper union. Reduction does
not, however, allow immediate motion for all fractures.
3. Which statement is true about the “three-column concept” of spinal
fracture stability?
A. An unstable spine consists of bone or soft tissue injury in a single
column.
B. An unstable spine involves injury to all three columns.
C. Instability results from injury to two columns plus evidence of
compression of the dural tube.
D. Instability results from significant bone and/or soft tissue injury in
two columns.
Answer: D

DISCUSSION: Denis developed a classification system for a


thoracolumbar spine injury based on a three-column concept. In this
system, the spine is divided into three longitudinal regions or
columns: anterior, middle, and posterior. Although references to such
“columns” is anatomically imprecise, the term is clinically useful in
assessing the stability of the injured spine. In general, instability
results when significant disruption is present in two of the three
columns, regardless of the presence or absence of neurologic deficit.

4. All of the following statements are true of Jefferson's fracture of the


atlas except:
A. The injury results from an axial load to the cervical spine.
B. The fracture fragments characteristically displace into the spinal
canal.
C. Neurologic injury is uncommon.
D. Computed tomography (CT) best demonstrates the fracture's
configuration.
Answer: B

DISCUSSION: Fracture of the atlas (Jefferson's fracture) occurs from an


axial load, usually to the top of the head. The resulting forces fracture
the ring of C1 and displace the fragments outward. This results in an
increase in the cross-sectional area of the spinal canal at the level of
injury. Neurologic injury is, therefore, unusual in this fracture. CT is
the best roentgenographic study available to evaluate fractures of the
atlas.

5. Which of the following statements about burst fractures of the


thoracolumbar spine are correct?
A. The injury most often occurs at the thoracolumbar junction.
B. The injury results from axial loading of the spine, often with
concomitant flexion.
C. Anterior and middle column failure are always present in this
injury.
D. Laminectomy provides satisfactory decompression.
Answer: ABC

DISCUSSION: Burst fractures result from axial compression of the


spine, frequently associated with varying degrees of flexion. These
injuries, which most often occur at the thoracolumbar junction, are
characterized by circumferential expansion of the entire vertebra with
failure of the anterior and middle spinal columns and in some cases,
the posterior ones. Middle column failure in burst fractures results in
retropulsion of the posterior superior portion of the vertebral body
into the spinal canal. With marked retropulsion, compression of the
dural tube occurs, often with associated neurologic deficit.
Surgical procedures designed to decompress and stabilize
thoracolumbar burst fractures can be performed through anterior or
posterior approaches. The major site of compression is anterior, and
for this reason laminectomy does little to relieve compression of the
spinal cord over an anterior lesion. Indeed, laminectomy further
increases the instability of the spine.

6. The neurovascular structure most commonly injured as a result of


an anterior dislocation of the shoulder is the:
A. Musculocutaneous nerve.
B. Axillary nerve.
C. Axillary artery.
D. Median nerve.
Answer: B

DISCUSSION: The axillary nerve is at greatest risk for injury.


Occasionally a more severe neurologic deficit can occur as a result of
injury to the brachial plexus. Rarely has injury to the axillary artery
been reported.

7. The classification of fractures of the proximal humerus is based on:


A. The number of fracture segments and amount of displacement.
B. The mechanism of injury.
C. Presence or absence of associated dislocations.
Answer: A

DISCUSSION: The classification is based on fracture patterns involving


the four “segments” of the proximal humerus (anatomic neck, surgical
neck, and greater and lesser tuberosities). Fractures are one-, two-,
three-, or four-part fractures, depending on the number of fracture
segments and amount of displacement.
8. The radial nerve is at greatest risk for injury with which fracture?
A. Fracture of the surgical neck of the humerus.
B. Fracture of the shaft of the humerus.
C. Supracondylar fracture of the humerus.
D. Olecranon fractures.
Answer: B

DISCUSSION: The radial nerve lies in proximity to the humerus as it


courses laterally at the junction of the middle and distal thirds of the
shaft of the humerus. Therefore, it is at greatest risk of injury in shaft
fractures. If radial nerve paralysis is present in association with this
fracture, it is advisable to observe the patient since most nerve
injuries recover spontaneously within 6 to 12 weeks.

9. The best method of treating a supracondylar fracture of the


humerus in a child that is unstable when the elbow is flexed to 90
degrees is:
A. Hyperflexion of the elbow to 130 degrees and casting.
B. Open reduction and internal fixation.
C. Percutaneous pinning.
Answer: C

DISCUSSION: Best results with this fracture are obtained with


percutaneous pinning. Hyperflexion of the elbow usually achieves
stability but incurs the risk of occluding arterial inflow and may cause
permanent neuromuscular deficit. Open reduction is not indicated
unless the fracture is irreducible or associated with a vascular injury.

10. Both-bone forearm fractures in adults are best managed by:


A. Closed reduction and casting.
B. Closed reduction and application of an external fixator.
C. Open reduction and placement of intramedullary rods.
D. Open reduction and internal fixation with compression plates.
Answer: D

DISCUSSION: Studies have shown that function is best restored with


less complications if open reduction and rigid fixation is achieved with
compression plates. Closed reduction rarely achieves an anatomic
position and some forearm rotation is therefore usually lost. External
fixation is occasionally used in severe open fractures.

11. The most consistent sign of a fracture of the carpal scaphoid is:
A. Wrist pain during attempted push-ups.
B. Diffuse swelling on the dorsum of the wrist.
C. Localized tenderness in the anatomic snuffbox.
D. Wrist popping on movement.
Answer: C

DISCUSSION: Wrist pain during attempted push-ups or diffuse


swelling on the dorsum of the wrist may be caused by a variety of
factors. Wrist popping on movement may be the result of carpal
instability, subluxation of a tendon on extension and flexion of the
wrist, or intra-articular problems such as an articular cartilage flap or
a tear of the triangular fibrocartilage. Localized tenderness at the
anatomic snuffbox (scaphoid) is the most consistent sign of scaphoid
fracture.

12. A patient describes a fall on the outstretched hand during sports


activities. Multiple radiographic views show no distinct fracture. He is
tender to palpation in the anatomic snuffbox. The most suitable
method of management is:
A. Diagnose “sprained wrist” and apply an elastic bandage.
B. Diagnose suspected scaphoid fracture and apply a short-arm cast
to include the thumb.
C. Apply a canvas wrist splint for immobilization.
D. Prescribe salicylates and permit continued activity.
Answer: B

DISCUSSION: If the patient sustained a fall on the outstretched hand


and is tender to palpation in the anatomic snuffbox, fracture of the
scaphoid should be suspected. Neither an elastic bandage nor a
canvas wrist splint provides adequate immobilization for the
scaphoid. A short-arm cast to include the thumb is the most
appropriate treatment. Salicylates and continued activity would not
treat scaphoid fracture. If no fracture is noted initially, the cast is
applied and films are taken at 10 days to 2 weeks since nondisplaced
scaphoid fractures are often more easily visualized at that time.

13. Median nerve compression syndrome in which the patient has


motor weakness of the flexor pollicis longus and the flexor digitorum
profundus of the index finger without alteration in sensibility is due
to:
A. Compression of the median nerve at the elbow by the lacertus
fibrosus.
B. Compression of the median nerve in the axilla.
C. Compression of the anterior interosseous nerve by the arcade of
Frohse.
D. Compression of the anterior interosseous nerve by an aberrant
accessory forearm muscle.
Answer: D

DISCUSSION: Compression of the median nerve at the elbow by the


lacertus fibrosus causes symptoms at more locations than just the
flexor pollicis longus and flexor profundus at the index finger, since
the entire median nerve is affected. Compression of the median nerve
at the axilla affects both motor and sensory elements diffusely. The
arcade of Frohse is a fibrous band at the origin of the supinator
muscle. It can compress the posterior interosseous portion of the
radial nerve but does not involve the median nerve. The anterior
interosseous portion of the median nerve can be compressed by an
aberrant accessory forearm muscle (Gantzer's muscle).

14. Total interruption of the radial nerve at midarm produces specific


findings on physical examination. The most complete description of
the neurologic deficit includes:
A. Paralysis of the thumb extensors, interphalangeal joint extensors,
extensor carpi radialis, and extensor carpi ulnaris.
B. Paralysis of the extensor carpi radialis longus and brevis, abductor
pollicis longus, extensor pollicis brevis, and extensor pollicis longus.
C. Paralysis of the brachioradialis, extensor carpi radialis longus and
brevis, extensor carpi ulnaris, thumb extensors, and
metacarpophalangeal (MCP) joint extensors, and loss of cutaneous
sensibility at the dorsal aspect of the thumb and index fingers.
D. Paralysis of the brachioradialis, extensor carpi radialis longus and
brevis, radialis, thumb extensors, finger MCP joint extensors, and
flexor carpi radialis, and loss of sensation in the cutaneous
distribution over the dorsal aspect of thumb and index fingers.
Answer: C

DISCUSSION: The extensor carpi radialis, extensor carpi ulnaris, and


thumb extensors are innervated by the radial nerve. Although finger
MCP joint extension is performed by the extensor digitorum
communis muscle, which is innervated by the radial nerve, the
interphalangeal joints of the fingers are extended by the intrinsic
muscles in the hand, which are innervated by the ulnar and median
nerves. The extensor carpi radialis longus and brevis, the abductor
pollicis longus, and the extensor pollicis longus and brevis are all
innervated by the radial nerve. However, answer B is not complete
because MCP joint extension of the fingers and radial sensory deficit
are not included. The brachioradialis, extensor carpi radialis longus
and brevis, extensor carpi ulnaris, thumb extensors, and finger MCP
joint extensors are all innervated by the radial nerve. The superficial
radial nerve provides sensibility to the dorsal aspect of thumb and
index finger in the dorsal radial aspect of the hand. The extensor carpi
radialis longus and brevis and thumb extensors are innervated by the
radial nerve. The superficial radial nerve provides sensibility at the
dorsal aspect of thumb and index. Not included in answer D is the
extensor carpi ulnaris. It should be remembered that although the
extensor ulnaris is on the ulnar aspect of the wrist and uses the term
ulnaris, it is innervated not by the ulnar nerve but by the radial nerve
and would not function with complete interruption of the radial nerve
at midarm. In addition, despite the fact that the wrist flexor on the
radial aspect of the wrist is termed the flexor carpi radialis, it is not
innervated by the radial nerve. It is innervated by the median nerve.
Therefore, it should not be included in this list.

15. The most common physical findings in a patient with median


nerve compression at the wrist (carpal tunnel syndrome) are:
A. Diminished two-point discrimination and dryness of the index and
long fingers.
B. Atrophy of the abductor pollicis brevis and opponens pollicis.
C. A positive percussion test at the wrist and a positive wrist flexion
test producing paresthesias at the thumb, index, and long fingers.
D. A weak grip in addition to hand cramping and difficulty writing.
Answer: C

DISCUSSION: While patients with carpal tunnel syndrome often


complain of subjective symptoms such as numbness of the thumb,
index, and long fingers, objective decreased sensibility is not usually
present. Testing with von Frey filaments produces the most sensitive
results. Decreased light touch is noted before decreased two-point
discrimination. Dryness of the skin in the median nerve distribution is
evident with severe injury to the nerve but not in the routine carpal
tunnel syndrome. Although the abductor pollicis brevis and opponens
pollicis are supplied by the motor branch of the median nerve,
atrophy of these muscles is not seen until long-term median nerve
compression has occurred. Symptomatic carpal tunnel syndrome
without evidence of thenar atrophy has a greater frequency than the
more severe median nerve compression, with demonstrable thenar
atrophy. Percussion over the median nerve at the wrist producing
paresthesias distally in the distribution of the median nerve and
paresthesias caused by wrist flexion are two of the most common
signs of median nerve compression at the wrist. Although patients
with carpal tunnel syndrome intermittently complain of weak grip and
dropping objects, cramping of the hand while writing and difficulty
writing are not routine symptoms of this condition.

16. Which of the following describes the most desirable position in


which to immobilize the hand?
A. Wrist is flexed, MCP joints are extended, and IP joints are flexed.
B. Wrist is flexed, MCP joints are flexed, and IP joints are extended.
C. Wrist is extended, MCP joints are extended, and IP joints are flexed.
D. Wrist is extended, MCP joints are flexed, and IP joints are flexed.
E. Wrist is extended, MCP joints are flexed, and IP joints are extended.
Answer: E

DISCUSSION: Plaster splints and dressings should hold the digits in


the “intrinsic plus” position. This includes 60 to 80 degrees of flexion
at the MCP joints, 10 to 20 degrees of flexion at the proximal
interphalangeal (PIP) joints, and 5 to 10 degrees of flexion at the distal
interphalangeal (DIP) joints. With the MCP joints in flexion and the PIP
joints in extension the collateral ligaments are elongated, thereby
decreasing the likelihood of ligament contracture and subsequent
joint stiffness. At times, however, the PIP joint is immobilized in
greater flexion to correct palmar angulation and to maintain proper
rotation of the digit after an unstable fracture.

17. An early sign of compartment syndrome in the hand includes:


A. Pain with passive stretch of the digits.
B. Absent radial pulse.
C. Motor paralysis.
D. Swelling of the digits.
E. Stiffness of the digits.
Answer: A

DISCUSSION: Early sign of compartment syndrome is pain with


passive motion. Paralysis occurs later, and absence of the radial pulse
is an even later finding.

18. Palmar dislocation of the PIP joint with fracture:


A. Is more common than dorsal dislocation.
B. Is treated by splinting with the PIP joint in flexion.
C. Is treated by splinting with the PIP joint and DIP joints in extension.
D. If not splinted properly, will cause a boutonniere deformity.
E. If not splinted properly will cause a swan neck deformity.
Answer: D

DISCUSSION: Palmar dislocation of the PIP joint is much less common


than dorsal dislocation. Palmar dislocation of the PIP joint can disrupt
the central slip of the extensor mechanism at the proximal part of the
middle phalanx and can disrupt the dorsal capsule in addition to the
palmar plate. If the joint is stable after reduction it is treated by
splinting to immobilize the PIP joint in extension, while the DIP is
allowed to actively flex. If not splinted properly, this injury can cause
boutonniere deformity with resultant loss of normal PIP extension
and hyperextension of the distal joint.

19. Fracture of the fifth metacarpal neck:


A. Usually requires open reduction and internal fixation.
B. Must be reduced anatomically and stabilized with pins.
C. Is called a “boxer's fracture.”
D. Will result in significant functional disability if angulated 30 degrees
dorsally.
E. Is uncommon.
Answer: C

DISCUSSION: Fifth metacarpal neck fracture is a common injury. It is


termed boxer's fracture because the mechanism of injury is often that
of hitting the fist against a firm object. This fracture does not need to
be reduced anatomically and usually does not require open reduction
and internal fixation. The relative mobility of the fifth metacarpal (as
compared with the relative lack of mobility at the index and long
fingers) allows excellent function despite dorsal angulation of 30
degrees.

20. A Bennett's fracture is:


A. An extra-articular fracture of the base of the thumb metacarpal.
B. Displaced by the pull of the abductor pollicis longus and adductor
pollicis.
C. Displaced by the pull of the abductor pollicis longus and extensor
pollicis longus.
D. Usually successfully treated with closed reduction and casting.
E. A comminuted T-type fracture of the base of the thumb metacarpal.
Answer: B

DISCUSSION: A Bennett's fracture is an intra-articular fracture of the


proximal end (base) of the thumb metacarpal. The resulting bone
fragment is held by the intermetacarpal ligament. The base of the
metacarpal is displaced laterally by the pull of the abductor pollicis
longus. The adductor pollicis pulls the proximal phalanx and distal
metacarpal toward the palm and the proximal metacarpal away from
its adjacent fracture fragment. These forces acting on the fracture
tend to displace the metacarpal, usually making cast treatment alone
ineffective. Treatment is by percutaneous pinning if closed reduction
can be achieved, or by open reduction and internal fixation if
significant displacement cannot be corrected by closed methods.
A comminuted T-type fracture of the base of the thumb metacarpal
was described by Rolando.
21. A 39-year-old male presents in the emergency room after a
high-speed motor vehicle accident. The patient has been intubated by
paramedics at the scene and is on assisted ventilation. He is
unconscious. Physical examination reveals a distended abdomen, and
initial screening x-rays reveal a displaced fracture of the pelvic ring.
Initial evaluation should include which of the following?
A. Fluid resuscitation and establishment of venous access.
B. Diagnostic peritoneal lavage.
C. Thorough physical examination, including evaluation of the urinary
and lower gastrointestinal tract.
D. Emergent application of external fixation.
E. CT of the abdomen.
Answer: ABC

DISCUSSION: This trauma patient has presented with a displaced


pelvic fracture and a distended abdomen. In this setting, it is quite
difficult to distinguish intra-abdominal trauma from abdominal
distention related to a fracture of the pelvis and secondary bleeding.
Diagnostic peritoneal lavage would be indicated as well as physical
examination of the genitourinary and lower gastrointestinal tract to
rule out an open pelvic fracture. Application of an external fixator for
the pelvis would be withheld unless the patient became unstable.
Without evidence of intra-abdominal trauma, pelvic bleeding is
implicated as the source of instability. Imaging studies of the pelvis
and abdomen would be indicated after the initial resuscitation.

22. A patient sustains a displaced fracture of both columns of the


acetabulum with extension into the sciatic notch. The patient is
initially placed in traction. After treatment of other associated injuries,
pre-operative evaluation should include which of the following?
A. CT evaluation of the acetabular fracture.
B. Aspiration of the hip joint.
C. Pelvic arteriography.
D. Preoperative ventilation-perfusion lung scan.
E. Prolonged bed rest.
Answer: AC

DISCUSSION: Treatment of a displaced fracture of both columns of


the acetabulum requires careful preoperative evaluation, including CT
with three-dimensional reconstruction, if the fracture anatomy is not
clear from standard radiographic imaging. If an extended iliofemoral
approach is considered, preoperative pelvic angiography should be
performed to ascertain patency of the superior gluteal artery. For this
approach, the flap is dependent on a superior gluteal artery for
survival. Early operative intervention and expeditious mobilization
decrease the incidence of pulmonary complications, and preoperative
pulmonary evaluation is not indicated unless specific problems arise.

23. Which of the following statements about the blood supply to the
hip are true?
A. The medial femoral circumflex artery circles around to the posterior
aspect of the hip, where it becomes confluent with the retinacular
blood vessels.
B. A small portion of the blood supply of the femoral head is provided
by the obturator artery via the ligamentum teres.
C. Displacement of a femoral neck fracture can disrupt the branches
of the medial femoral circumflex artery.
D. The retinacular vessels are supplied by the lateral femoral
circumflex artery, which takes a posterior course.
E. Muscular attachments to the periarticular bone structures provide
blood supply to the femoral head.
Answer: ABC

DISCUSSION: The blood supply to the femoral head is provided


predominantly by the branches of the medial femoral circumflex
artery, which take a posterior course and are confluent with the
retinacular vessels. The lateral femoral circumflex artery runs
anteriorly.

24. A 24-year-old woman presents to the emergency room with a


dislocated knee. In transferring the patient from stretcher to
examining table, the knee is spontaneously reduced. Physical
examination reveals no palpable or “Dopplerable” pulses in the foot
on the affected side and booming pulses in the foot on the
nonaffected side. Proper treatment would include which of the
following?
A. Doppler evaluation of the arteries in the lower extremity followed
by arteriography if the Doppler study was abnormal.
B. Magnetic resonance imaging (MRI) of the affected leg.
C. Close follow-up examination.
D. Emergent transfer to the operating room for exploration of the
popliteal artery.
E. Immobilization of the knee with gentle warming of the extremity
and elevation.
Answer: D

DISCUSSION: An abnormal vascular examination after a documented


dislocation of the knee indicates damage to the popliteal artery at the
level of the knee dislocation. This is a limb-threatening injury that
requires expeditious exploration of the popliteal artery to provide
appropriate treatment and decrease the chances of vascular
compromise leading to amputation of the extremity.

25. The Ilizarov device aids in management of tibial fractures because


of its ability to:
A. Stabilize acute fractures.
B. Correct angular deformities in cases of malunion.
C. Transport bone by distraction callotasis.
D. Noninvasively provide fixation for juxta-articular fractures, such as
the tibial plateau and pylon.
E. All of the above.
Answer: E

DISCUSSION: The Ilizarov device is a very useful external fixation


device that is versatile and has had a positive impact on the
management of tibial fractures.

26. An 8 cm. by 10 cm. soft tissue defect over the proximal third of the
tibia with exposed bone devoid of periosteum is best treated with:
A. Skin graft.
B. Gastrocnemius rotational myoplasty.
C. Soleus rotational myoplasty.
D. Free tissue transfer.
Answer: B

DISCUSSION: The proximal third of the tibia can be covered effectively


with the gastrocnemius rotational flap using the medial hem of the
gastrocnemius. The middle third can be successfully covered by the
soleus myoplasty. Open fractures with soft tissue defects over the
distal third usually require free tissue transfer because of lack of
available local tissue coverage.

27. Prognosis of healing in tibial fractures correlates best with:


A. Energy absorption at the time of fracture.
B. Amount of soft tissue damage.
C. Location of the fracture (i.e., in the proximal, middle, or distal third).
D. Age of patient.
Answer: A

DISCUSSION: The amount of energy absorption and the degree of


bony comminution is the most significant factor in predicting healing
of tibial fractures. Location along the tibia and age are not thought of
as significant factors in healing. The soft tissue damage may
contribute to lack of vascular envelope, but the destruction of soft
tissue is based on the amount of energy absorbed.

28. Management of a III-b tibia fracture is best treated initially by:


A. Plaster immobilization.
B. Immediate plating.
C. Reamed intramedullary nailing.
D. External fixation.
Answer: D

DISCUSSION: Studies by Hansen and others have demonstrated that


open reduction and internal fixation of Grade III-b or Grade III-c
fractures are likely to cause more stripping of soft tissue and
therefore further devascularize an already devascularized tibia. The
external fixator is selected because it is a treatment apparatus that
reduces and holds the bone fragments and provides important
stability for soft tissue healing. Treatment of open wounds with a
plaster cast is impractical and wound care is difficult. Reaming
intramedullary nailing further compromises blood supply to the bone
by destroying the intramedullary blood supply that may be critical to
fracture healing.

29. The most frequent forces acting on the foot that cause ankle
fractures are:
A. External rotation.
B. Internal rotation.
C. Plantar flexion.
D. Dorsiflexion.
Answer: A

DISCUSSION: Fractures most frequently involve external rotation of


the foot and ankle joint, which is usually due to an internal rotation or
twisting of the leg on a foot that is fixed by weight bearing. Axial
loading injuries commonly produce distal tibia fractures.

30. Patients who have abduction injuries to the foot are prone to
injure the following structures:
A. Medial malleolus and deltoid.
B. Lateral malleolus and deltoid ligament.
C. Interosseous ligament.
D. Posterior tibiofibular ligament.
Answer: A

DISCUSSION: If the mechanism of fracture is an abduction force, the


medial malleolus fractures below or at the level of the ankle joint, and
this may include tears of the deltoid ligament. These are usually
accompanied by a fibula fracture as well.

31. Of the following bones in the foot, the tarsal bone that is most
prone to vascular compromise is the:
A. Calcaneus.
B. Navicular.
C. Talus.
D. Cuboid.
Answer: C

DISCUSSION: The blood supply of the talus is somewhat tenuous


because there are no muscles or tendons associated with this bone.

32. A Lisfranc fracture is a fracture-dislocation involving:


A. Calaneocuboid joint.
B. Tarsometarsal joint.
C. Metatarsophalangeal joint.
D. Talocalcaneal dislocation.
Answer: B

DISCUSSION: The fracture can be either divergent, dorsal, or plantar.


It usually involves a significant soft tissue injury that, if unrecognized,
leads to ischemia of the forefoot and gangrene resulting in
amputation.

33. The most common reason for surgical amputation in the general
population is:
A. Trauma.
B. Tumor.
C. Infection.
D. Congenital deformity.
E. Ischemia.
Answer: E

DISCUSSION: Congenital deformities leading to amputation are


relatively rare, as are musculoskeletal tumors. Traumatic amputations
are the most common in the younger population, but the majority of
amputations are of the lower extremity and are caused by ischemia
secondary to peripheral vascular disease. Approximately 50% of the
patients suffering from extremity ischemia also suffer from diabetes.

34. The level of amputation in a dysvascular extremity is determined


by:
A. Clinical inspection.
B. Xenon skin clearance.
C. Doppler systolic blood pressure ratios.
D. Transcutaneous oxygen measurements.
E. Nutritional competence and immunocompetence.
Answer: ABCDE

DISCUSSION: Clinical competence of the extremity with observations


of skin turgor, discoloration, perfusion, sensation, and integrity is the
mainstay of surgical decision making. This can be complemented by
transcutaneous PO2, ankle-arm systolic pressure ratios, xenon skin
clearance, serum albumin levels, and total lymphocyte count.

35. Knee disarticulation has the following advantages over above-knee


amputation:
A. Longer lever arm.
B. Better cosmetic result.
C. Easier prosthetic fitting.
D. End-bearing stump.
E. Supracondylar suspension.
Answer: ADE

DISCUSSION: Patients with knee disarticulations have a slightly worse


cosmetic appearance due to an inequality of knee heights particularly
noticeable when sitting. Additionally, prosthetic fitting is significantly
more difficult and requires the involvement of a prosthetist familiar
with the specific considerations. On the other hand, the increase in
lever arm, the end-bearing stump, and the use of supracondylar
suspension far outweigh the disadvantages when such an amputation
is possible from an anatomic standpoint.

36. Hematogenous osteomyelitis most frequently affects:


A. The diaphysis of long bones.
B. The epiphysis.
C. The metaphysis of long bones.
D. Flat bones.
E. Cuboidal bones.
Answer: C

DISCUSSION: Hematogenous osteomyelitis occurs most frequently in


children and involves the metaphyseal ends of long bones. The cause
is thought to relate to the pattern of blood flow in the metaphysis
wherein arterioles empty into numerous sinusoidal veins with
sluggish blood flow favoring the lodgement of bacteria.
37. A 5-year-old child presents with a 2-day history of the atraumatic
onset of pain, erythema, and swelling of the right knee joint. The child
is febrile with an elevated white blood cell count. The differential
diagnosis includes:
A. Acute rheumatic fever.
B. Leukemia.
C. Scurvy.
D. Acute septic arthritis.
E. Acute juvenile rheumatoid arthritis.
Answer: ABCDE

DISCUSSION: All of the above conditions may present with the clinical
and laboratory findings described above. Aspiration of the joint and
examination of the synovial fluid is required to rule out pyogenic
arthritis. Ancillary laboratory testing for juvenile rheumatoid arthritis
and acute rheumatic fever may be required.

38. Skeletal tuberculosis is:


A. Of historical interest only.
B. Increasing in association with patients with human
immunodeficiency virus (HIV) infection.
C. Most frequently encountered at the thoracolumbar junction.
D. Seen in the absence of visceral tubercular infection.
Answer: BC

DISCUSSION: Skeletal tuberculosis is still present and is occurring with


increased frequency in patients with HIV infection. The thoracolumbar
junction is most frequently affected. Skeletal tuberculosis is a sequel
to pulmonary or gastrointestinal tuberculosis.

39. A radical margin in the resection of a musculoskeletal tumor


removes:
A. The entire limb.
B. A 5-cm. margin of normal tissue around the neoplasm.
C. The anatomic compartment in which the tumor arises.
D. The joint adjacent to the neoplasm.
E. The reactive capsule around the tumor.
Answer: C

DISCUSSION: A radical resection defines removal of the anatomic


compartment in which the tumor arises and does not necessarily
mandate an amputation.
40. The appropriate surgical procedure for the treatment of an
osteosarcoma is based on:
A. Staging information.
B. The age of the patient.
C. The response of the lesion to neoadjuvant chemotherapy.
D. The radiographic aggressiveness of the lesion.
Answer: AC

DISCUSSION: The surgical treatment of an osteosarcoma is either


amputation or wide excision with limb salvage. The decision to do a
limb-salvage operation is based on the staging information and on the
response of the lesion to chemotherapy. If staging studies indicate
involvement of vital structures or if the response to neoadjuvant
chemotherapy is inadequate, amputation may be selected rather than
limb salvage. The age of the patient and the radiographic appearance
of the lesion are not factors in this decision.

41. Which of the following statements about selection of an


amputated part for replantation is/are correct?
A. A good choice for replantation is an amputated thumb at the level
of the proximal phalanx of the dominant hand of a 35-year-old
salesman.
B. The index finger should be replanted in an adult male if the
amputation is at the base of the proximal phalanx.
C. In a 12-year-old child with an arm amputated above the elbow by
an avulsion injury, replantation should be attempted.
D. In a 42-year-old male accountant with a complete amputation of
the leg just below the knee, replantation should be attempted.
E. Replantation is advisable for a 20-year-old male with a complete
amputation at the proximal forearm with 11 hours of warm ischemic
time.
Answer: AC

DISCUSSION: The thumb is a prime choice for replantation. If the


patient is healthy replantation of the thumb is advisable at just about
any level and any age. Amputations of fingers proximal to the flexor
superficialis tendon insertion (middle phalanx) generally result in poor
active digital motion, and in most adults isolated finger amputations
at this level are not replanted. In general, in children replantation
should be attempted at any level. Replantation of lower extremity
amputations is seldom indicated in adults because of leg-length
discrepancy, pain, and poor function. Prosthetic replacement usually
results in a more functional gait. Replantation of a forearm amputated
at the proximal forearm level is difficult because of the large amount
of muscle mass and the multiple nerves entering the muscle.
Additionally, over 6 hours of warm ischemia time at this level will most
likely cause massive myonecrosis and replantation failure.

42. Which of the following statements about preservation of a


completely amputated digit is/are correct?
A. The amputated digit should be wrapped in a sterile, dry cloth and
kept at body temperature.
B. The amputated digit should be wrapped in a cloth moistened with
saline or Ringer's lactate solution and kept at body temperature.
C. The amputated digit should be wrapped in a clean cloth and placed
directly on ice.
D. The amputated digit should be placed in a plastic bag containing
Ringer's lactate or saline solution, and the plastic bag placed on ice.
E. The amputated digit should be wrapped in a cloth or sponge
moistened with Ringer's lactate or saline solution and placed in a
plastic bag to rest on ice.
Answer: DE

DISCUSSION: The amputated part must be kept cool (4‫ ؛‬C or less) but
not frozen. Cooling lowers the metabolic needs of the severed part,
which allows replantation for up to 12 to 14 hours for major limb
amputations and 24 to 36 hours for major digital amputations. The
amputated part is preserved by one of the two following methods: (1)
Place the amputated part in a plastic bag containing lactated Ringer's
or saline solution and place the bag on ice or (2) wrap the amputated
part in a cloth and place it in a plastic bag to be put on ice.

43. Which of the statements about major limb replantations


(amputation proximal to the hand or foot) is/are correct?
A. Bone shortening is usually necessary.
B. If the amputation occurred more than 6 hours before arrival in the
operating room some type of temporary vascular shunting is
indicated.
C. Primary closure of all of the skin is generally recommended.
D. Myonecrosis is a common cause of failure of the replantation.
E. There are few indications for replantation of the lower extremity in
adults.
Answer: ABDE

DISCUSSION: Bone shortening of at least 2 cm. is critical in most major


limb replantations, to allow thorough débridement of injured
structures and approximation of normal tissue to normal tissue (e.g.,
nerve, vessel, and tendon repair). If the anticipated cold ischemic time
for an amputated limb will exceed 6 hours before circulation can be
re-established, a temporary silicone shunt should be applied. This is
usually the setting, for rarely can the artery be reconnected within 6
hours of the amputation. Primary closure of all of the skin is rarely
recommended. Because of the edema associated with reperfusion of
the ischemic limb, tight skin closure can compromise the circulation.
Skin grafts and/or delayed closure is indicated. Some degree of
myonecrosis occurs in all major limb replantations. Thorough surgical
excision of damaged muscle tissue diminishes the amount of
necrosis. Excessive myonecrosis leads to infection and failure. There
are few indications for replantation of lower extremities in adults. The
amount of débridement and shortening that is necessary to obtain a
viable lower extremity replantation results in excessive leg length
discrepancy. Prosthetic replacement can result in a nearly normal gait,
especially when the amputation is below the knee.

44. The most crucial elements of the flexor retinacular or pulley


system needed for full digital flexion include which annular pulleys?
A. A 1.
B. A 2.
C. A 3.
D. A 4.
E. A 5.
Answer: BD

DISCUSSION: The flexor retinacular system from the


metacarpophalangeal joint to the distal interphalangeal joint
maintains the flexor tendons against the digit during flexion,
preventing bow stringing and allowing the digital tip to flex to the
distal palmar crease. Division of the A 1, A 3, or A 5 pulleys minimally
compromises this function; however, division of the A 2 or A 4 pulleys
can significantly limit digital excursion.

45. Continuous passive mobilization following flexor tendon repair of


Zone II injuries produces:
A. Increased total arc of digital range of motion.
B. Decreased incidence of poor results.
C. Increased incidence of postoperative tendon rupture.
D. Increased incidence of infection.
Answer: AB

DISCUSSION: Continuous passive mobilization (CPM) causes a 16%


improvement in range of digital motion compared to intermittent
mobilization. The incidence of poor results is much lower (3% versus
26%) despite no postoperative ruptures or infections. Continuous
passive mobilization appears to be a more effective yet safe means of
improving postoperative function following flexor tendon injury.
46. Isolated flexor digitorum superficialis tendon function is
determined by assessing:
A. Flexion of the metacarpophalangeal joint.
B. Flexion of the proximal interphalangeal joint with the adjacent
digits held in extension.
C. Flexion of the distal interphalangeal joint.
D. Flexion of the proximal interphalangeal joint.
Answer: B

DISCUSSION: Metacarpophalangeal joint flexion is effected by intrinsic


flexor digitorum profundus or flexor digitorum superficialis
contraction and therefore cannot be utilized to assess isolated flexor
digitorum superficialis integrity. The flexor digitorum superficialis
tendon, by inserting on the middle phalanx, acts to flex the proximal
interphalangeal joint. Since the flexor digitorum profundus tendon
inserts distal to this level, it may also flex this joint. To negate this
influence of the flexor digitorum profundus, the adjacent digits should
be passively maintained in full extension to isolate flexor digitorum
superficialis function in the digit. Distal interphalangeal flexion is the
isolated function of the flexor digitorum profundus. The proximal
interphalangeal joint may be flexed by the flexor digitorum profundus
or flexor digitorum superficialis.

47. The zone of flexor tendon injury that carries the poorest prognosis
following injury and repair is:
A. Zone I.
B. Zone II.
C. Zone III.
D. Zone IV.
E. Zone V.
Answer: B

DISCUSSION: Zone I extends from the distal margin of the flexor


digitorum superficialis insertion to the flexor digitorum profundus
insertion. Injury at this level involves only the profundus tendon. Zone
II is defined as the proximal edge of the first annular pulley to the
distal margin of the flexor digitorum superficialis insertion. At this
level both the superficialis and profundus tendons are contained in a
rigid fibroosseous canal. The smooth gliding required at the interfaces
at this level may be compromised by adhesions following injury, thus
making this the level with the poorest functional prognosis after
injury. Injuries in Zones III, IV, and V, at the level of the palm, carpal
canal, and distal forearm, respectively, may injure both or either of
the flexor tendons to a digit. However, because of a less constrictive
environment at the levels, adhesions that limit motion are less likely
and the prognosis better than with Zone II injuries.

48. The contraindications to primary repair of a flexor tendon injury


are:
A. Contaminated wound.
B. Severe soft tissue trauma.
C. Inexperienced surgeon.
D. Compromised general condition of the patient prohibiting
prolonged anesthetic.
Answer: ABCD

DISCUSSION: The prerequisites for primary repair (within 24 hours of


injury) of a flexor tendon injury are (1) a clean wound or one that may
be débrided to a clean status, (2) minimal soft tissue injury providing a
relatively stable soft tissue environment, (3) a surgeon experienced in
flexor tendon repair, (4) adequate anesthetic condition of the patient,
and (5) appropriate supportive staff (operating room personnel). If all
of these conditions are met, primary repair may be performed
allowing accurate anatomic alignment and quicker rehabilitation.
Delayed repair is indicated if one or more of these prerequisites are
not met.

49. Principles to be considered when using open reduction and


internal fixation include which of the following ?

a. Anatomic reduction and fixation stability


b. Maintenance of maximal soft tissue coverage and interposition
between the device and skin surface
c. Creation of fixation constructs that minimize load shielding of the
underlying bone
d. Maximal maintenance of periosteal and vascular tissue without
compromising stability
Answer: a, b, c, d

When open reduction and internal fixation treatment are chosen, the
following principles should be considered: 1) maximal maintenance of
periosteal and vascular tissues without compromising stability; 2)
anatomic reduction and fixation stability; 3) the use of high strength
biocompatable implants; 4) the creation of fixation constructs that
minimize load shielding of the underlying bone; and 5) maintenance
of maximal soft tissue coverage and interposition between the device
and skin surface.
50. Serum proteins that have been demonstrated to influence bone
induction include:

a. Platelet-derived growth factor


b. Transforming growth factor-b
c. Osteogenin
d. Fibroblast growth factor
Answer: a, b, c, d

A number of proteins have been demonstrated to directly or indirectly


influence bone induction. Platelet-derived growth factor from
platelets and macrophages has been shown to induce migration and
mitosis of mesenchymal cells in wounds and to enhance cartilage and
bone formation in adult rats. Fibroblast growth factors is a mitogenic
and angiogenic protein that favors new bone formation, particularly if
neo-ascularization is required. Transforming growth factor-b is
secreted from bone cell cultures. This protein appears to be naturally
released from platelets at the time of a fracture and stimulates
proliferation of osteoblasts and increases their production of collagen.
Finally, a purified and partially sequenced regulator from bovine bone
matrix termed osteogenin has been isolated. This substance has the
ability to induce cartilage and bone formation and to play a major
controlling role in the development of de novo bone in muscle and
subcutaneous tissues.

51. Which of the following statement(s) is/are true concerning the


treatment of diaphyseal fractures?

a. The use of intramedullary rods allows early weight bearing and


minimal immobilization
b. The infection rate using intramedullary fraction fixation devices is
minimal
c. Results for the use of intramedullary rods are better for fractures of
the femoral shaft than the tibia
d. Loss of limb length is inevitable with segmented or comminuted
fractures
Answer: a, b, c

Treatment for diaphyseal fractures (particularly tibial, femoral, and


humeral fractures) uses intramedullary fracture fixation devices. The
use of intramedullary rods allows early weight bearing and requires
minimal immobilization of the joints above and below the fracture.
Little long-term remodeling (loss of bone) has been documented.
Rehabilitation is rapid, and blood loss is minimized. For simple
transverse or oblique closed fractures, the infection rate is nearly
zero. When used to treat segmented or comminuted fractures or
other unstable fractures with proximal and distal bone loss, the
interlocking allows for surgical reestablishment of the bone
compartment and therefore limb length. The device can maintain
length until the fracture is healed. Although this technique is the
optimal treatment for most fractures of the femoral shaft, application
of these same principles to the tibia has not resulted in such
dependable results.

52. Which of the following statement(s) is/are true concerning the


biologic mechanisms of fracture repair?

a. The mechanisms involved depend primarily on the stability of the


fracture
b. The first material formed by osteoblasts at the fracture site is
woven bone
c. Callus increases the cross-sectional area of the injury therefore
weakening the structure
d. Woven bone provides a permanent microstructure in the area of a
fracture
Answer: a, b

After initial inflammation and neovascularization of an area fracture,


the repair continues by a combination of mechanisms: endochondral
ossification, direct bone apposition, and primary healing involving an
acceleration of the normal remodeling process directed across a
stable, securely reduced fracture line. The occurrence and distribution
of these mechanisms depends primarily on the stability of the
fracture during the treatment and secondarily on the fracture
location. The more unstable the fracture, the more endochondral the
repair process and the greater the cross-sectional area of the callus.
The biologic processes are driven by the need to establish mechanical
integrity as quickly as possible. The first material formed by osteoblast
at the fracture site is woven bone. Although woven bone has inferior
mechanical properties when compared to lamellar bone, it can be laid
down rapidly and at high density. The laws of mechanics dictate that
an increase in the cross-sectional area as produced by surrounding
callus, greatly increases the resistance of the structure to bending or
torsional loads. An increase in unit diameter of the cross-section
raises the strength of the structure by the fourth power of the
diameter change. Therefore, even if callus is made of an inferior
material, the cross-sectional attributes more than compensate for the
inferior substance. Once the fracture is stabilized by the initial woven
bone proliferation, secondary remodeling occurs.

53. The most important structural component of connective tissue is


collagen. Which of the following statement(s) is/are true concerning
types of collagen?

a. All collagen is fiber forming


b. Type 1 collagen is the most abundant in the human body
c. Type 2 collagen is found in cartilage
d. The basement membrane collagens, type 4 and 5, do not form
regular fibers
Answer: b, c, d

At least 15 separate collagen molecules have been identified, each


with a specific confirmation associated with a unique kinetic or
mechanical property. The collagens can be categorized into two major
groups—fiber-forming collagens and collagens that do not form
regular fibers. The fiber-forming collagens include Type 1, Type 2, and
Type 3. Type 1 collagen is the most abundant in the human body and
is the dominant constituent in tendons, ligaments, bone, skin, vessel
walls, and scar and granulation tissues. Type 2 collagen is found in the
cartilage and Type 3 collagen is found in tendon and ligament
sheaths, as well as in muscle, skin, blood vessel walls, and scar tissue.
The remaining collagens do not form regular fibers and include the
basement membrane collagens, Types 4 and 5.

54. Which of the following statement(s) is/are true concerning soft


tissue repair?

a. The first stage involves a formation of granulation tissue


b. The initial pattern of collagen fibers and the degrees of waviness is
random and therefore not as functional as the normal structure
c. Early immobilization, regulated physical stimuli, and good vascular
supply are beneficial to healing
d. Normal physiologic loading conditions impair wound remodeling
Answer: a, b, c

The healing of soft tissue occurs in stages. The first stage involves a
granulation tissue, in which the collagen fibers are oriented in a
random pattern and the degree of waviness is likewise random. This
tissue is not as functional as the more optimal normal structure. In
time, the soft tissue is remodeled to produce an architecture more
nearly that of normal intact tissue. Factors associated with beneficial
effects on healing include early immobilization, regulated physical
stimuli, and good vascular supply. Remodeling or adaptation of soft
tissues has also been shown to occur under normal physiologic
loading conditions. There are reports of training effects increasing the
properties of tissues and metabolically active cells incorporated within
the matrix.
55. Which of the following statement(s) is/are true concerning types of
bone found in the human body?

a. Trabecular and cortical bone differ in their chemical, molecular and


cellular components
b. Primary bone must be formed on existing surfaces
c. Woven bone reflects a highly organized microstructural
organization
d. Secondary osteonal bone is the primary constituent of adult
cortices
Answer: b, d

Two major types of bone are found in the human body: trabecular
and cortical. Although the chemical, molecular and cellular
components are similar, the organization of these components at the
ultrastructural and microstructural level leads to significant
differences in their mechanical and metabolic activities. The
microstructural organization of bone can be classified into three
types: primary bone, secondary bone, and woven bone. The most
important characteristic of primary bone is that it must be formed on
existing surfaces. The surfaces can be cartilaginous or preexisting
bone. This bone is highly organized and exhibits excellent mechanical
properties. Secondary osteonal bone is the primary constituent of
adult cortices. The final microstructural type of bone is woven bone.
Although the collagen matrices in lamellar and osteonal bone are
precisely organized, providing maximal mechanical properties with
minimal material, woven bone is composed of disorganized yet highly
mineralized tissue and is expressed in the course of fracture or
damage repair. It has the advantage of being quickly deposited but
the disadvantage of significantly reduced mechanical properties when
compared to a highly ordered primary and secondary bone.

56. Which of the following statement(s) is/are true concerning


operative arthroscopy?

a. Arthroscopy is unquestionably the most effective method for


diagnosis and treatment of knee ligament injuries
b. Arthroscopic repair allows almost immediate rehabilitation
c. Despite advances an anterior cruciate ligament tear will essentially
end any high level sports activity
d. The presence of loose osteochondral fragments requires open
arthrotomy
Answer: a, b
Arthroscopy is unquestionably the most effective method for the
diagnosis and treatment of knee ligament injuries. Previously there
was not certainty that there was a torn ligament, or how many, or
whether the tears were complete. With arthroscopy, ligament injuries
can be diagnosed with certainty on the day of injury or shortly
thereafter and reparative surgical treatment initiated. Complete tears
of the anterior cruciate ligament of the knee are devastating injuries.
The arthroscope allows immediate and certain diagnosis of an
anterior cruciate ligament tear and is a valuable tool in operative
reconstruction of function. Using small external incisions, special
drilling guides, and the arthroscope, strong bone-ligament-bone grafts
may be placed in an anatomic location. Considerable increased
stability is often achieved, allowing patients to return to a high-level
sports activity. The small size of the incision, the clear visualization of
the interior of the joint, and the ability to perform definitive surgical
corrections with minimal damage to other structures often allows
immediate rehabilitation. Muscular atrophy due to extensive
immobilization and nonweight bearing is prevented. Loose fragments
from minuscule injuries can easily be removed by the arthroscope. If
they are too large for removal using the standard small, delicate
athroscopy instruments, a small direct arthrotomy can be performed
and arthroscopically directed open loose body removal easily
accomplished. Similarly, loose bodies that have previously required
open arthrotomy for removal are more easily treated with
arthroscopic instrumentation.

57. Which of the following statement(s) is/are true concerning bone


remodeling?

a. Remodeling can occur only on the surface of trabeculi


b. The remodeling process takes approximately 120 days in an adult
c. Trabecular bone remodeling occurs up to 10 times faster than
cortical bone remodeling
d. Bone modeling involves bone formation without resorption
Answer: b, c, d

After the initial development and deposition of bone, it is remodeled


in an effort to produce a more optimally aligned and constructed
structure. This process involves the resorption by osteoclasts followed
by deposition of nonmineralized matrix (osteoid) by osteoblasts.
During mineralization, the osteoblasts become entrapped in their
matrix, thereby serving as the resulting bone cells (osteocytes). This
remodeling can occur on the surface of trabeculi, on the surface of
cortical bone, and intercortically. It precedes as a method of normal
turnover, providing access to minerals needed for normal
homeostasis. Under normal circumstances, the process takes about
120 days in an adult. Trabecular bone remodels at a rate 5 to 10 times
that of cortical bone remodeling, probably because of its porosity and
greater surface/volume ratio.
It is important to differentiate bone remodels from modeling. Bone
remodeling involves the resorption of existing bone followed by
formation within the resorption cavity. Modeling describes the
phenomenon of bone formation without resorption. This modeling
can occur only through the deposition of woven bone and occurs
during fracture healing.

58. Which of the following statement(s) is/are correct concerning total


joint replacement arthroplasty?

a. Total knee and hip prostheses have a life expectancy of


approximately 10 years
b. The major failure of total joint arthroplasty is aseptic mechanical
loosening at the interface between the bone, cement, and implant
c. Biologic tissue ingrowth into a prosthesis worsens long-term results
d. Rigid fixation at the time of implantation is important to secure
tissue ingrowth
Answer: b, d

Significant technological advances in both the biomaterial and


manufacturing process have lead to dramatic improvement in total
joint replacement surgery during the last 20 years. These advances
have significantly improved the longevity of artificial joints, particularly
hip and knee prostheses, which are by far the most common. Despite
these advances the procedure is still considered primarily for elderly
patients. Total knee and hip prostheses have a fixation life expectancy
of about 15 years or more in many patients. The major failure of total
joint arthroplasty is aseptic mechanical loosening at the interface
between the bone, cement, and implant. Factors which contribute to
loosening include excessive weight, high activity level, component
misalignment, and breakdown of the cement interface. An important
potential advance, and one that has demonstrated some clinical
success already, is the use of porous surface coated prostheses that
promotes biological tissue ingrowth and fixation of the implants.
These implants are designed to be inserted surgically into carefully
prepared bone under conditions of interference fit (tight intimate
contact). It is proposed that significant bone tissue infiltration into the
porous surface will begin within 8 to 12 weeks and that after an
appropriate amount of time (perhaps 1 year) long-term equilibrium
bone remodeling will result in a well-fixed bone ingrowth phase that
will last for years. Two factors are important to secure fixation. First,
the implant must be fixed rigidly within the bone during the initial
ingrowth period. Secondly, the local mechanical environment must
promote a positive remodeling response of the supporting trabecular
bone.

MedCosmos at 7:06 PM

3 comments:

Charisma Combestra June 16, 2011 at 4:38 PM


This book has been divided in various sections, according to different
subspecialities of the field; this is likely to make reading smooth and
memorising a bit easier.

Orthopedics Las Vegas


Reply

Leo Voisey April 11, 2012 at 12:21 AM


Stem cells are “non-specialized” cells that have the potential to form
into other types of specific cells, such as blood, muscles or nerves.
They are unlike "differentiated" cells which have already become
whatever organ or structure they are in the body. Stem cells are
present throughout our body, but more abundant in a fetus.
Medical researchers and scientists believe that stem cell therapy will,
in the near future, advance medicine dramatically and change the
course of disease treatment. This is because stem cells have the
ability to grow into any kind of cell and, if transplanted into the body,
will relocate to the damaged tissue, replacing it. For example, neural
cells in the spinal cord, brain, optic nerves, or other parts of the
central nervous system that have been injured can be replaced by
injected stem cells. Various stem cell therapies are already practiced,
a popular one being bone marrow transplants that are used to treat
leukemia. In theory and in fact, lifeless cells anywhere in the body, no
matter what the cause of the disease or injury, can be replaced with
vigorous new cells because of the remarkable plasticity of stem cells.
Biomed companies predict that with all of the research activity in
stem cell therapy currently being directed toward the technology, a
wider range of disease types including cancer, diabetes, spinal cord
injury, and even multiple sclerosis will be effectively treated in the
future. Recently announced trials are now underway to study both
safety and efficacy of autologous stem cell transplantation in MS
patients because of promising early results from previous trials.
History
Research into stem cells grew out of the findings of two Canadian
researchers, Dr’s James Till and Ernest McCulloch at the University of
Toronto in 1961. They were the first to publish their experimental
results into the existence of stem cells in a scientific journal. Till and
McCulloch documented the way in which embryonic stem cells
differentiate themselves to become mature cell tissue. Their
discovery opened the door for others to develop the first medical use
of stem cells in bone marrow transplantation for leukemia. Over the
next 50 years their early work has led to our current state of medical
practice where modern science believes that new treatments for
chronic diseases including MS, diabetes, spinal cord injuries and
many more disease conditions are just around the corner. For more
information please visit http://www.neurosurgeonindia.org/
Reply

Leo Voisey June 12, 2012 at 9:19 PM


David Summers, a 37 year old MS patient from Murfreesboro,
Tennessee was a score of 8.0 on the Expanded Disability Status Scale
(EDSS) when he had the Combination Liberation Therapy and Stem
Cell Transplantation at CCSVI Clinic in March of 2012. Having been
diagnosed in 1996 he had been in a wheelchair for the past decade
without any sensation below the waist or use of his legs.
“It was late 2011 and I didn’t have much future to look forward to”
says David. “My MS was getting more progressive and ravaging my
body. I was diagnosed as an 8.0 on the EDSS scale; 1 being mild
symptoms, 10 being death. There were many new lesions on my optic
nerves, in my brain and on my spinal cord. My neurologist just told
me: ‘be prepared to deteriorate’. I knew that he was telling me I didn’t
have much time left, or at least not much with any quality.” David had
previously sought out the liberation therapy in 2010 and had it done
in a clinic in Duluth Georgia. “The Interventional Radiologist who did it
told me that 50% of all MS patients who have the jugular vein-clearing
therapy eventually restenose. I didn’t believe that would happen to
me if I could get it done. But I have had MS for 16 years and
apparently my veins were pretty twisted up”. Within 90 days, David’s
veins had narrowed again, and worse, they were now blocked in even
more places than before his procedure.
“I was so happy after my original procedure in 2010. I immediately
lost all of the typical symptoms of MS. The cog fog disappeared, my
speech came back, the vision in my right eye improved, I was able to
regulate my body temperature again, and some of the sensation in
my hands came back. But as much as I wanted to believe I felt
something, there was nothing below the waist. I kind of knew that I
wouldn’t get anything back in my legs. There was just way too much
nerve damage now”. But any improvements felt by David lasted for
just a few months.
After his relapse, David and his family were frustrated but
undaunted. They had seen what opening the jugular veins could do
to improve him. Because the veins had closed so quickly after his
liberation procedure, they considered another clinic that advocated
stent implants to keep the veins open, but upon doing their due
diligence, they decided it was just too risky. They kept on searching
the many CCSVI information sites that were cropping up on the
Internet for something that offered more hope. Finding a suitable
treatment, especially where there was no known cure for the disease
was also a race against time. David was still suffering new attacks and
was definitely deteriorating. Then David’s mother Janice began
reading some patient blogs about a Clinic that was offering both the
liberation therapy and adult autologous stem cell injections in a
series of procedures during a hospital stay. “These patients were
reporting a ‘full recovery’ of their neurodegenerative deficits” says
Janice, “I hadn’t seen anything like that anywhere else”. She contacted
CCSVI Clinic in late 2011 and after a succession of calls with the
researchers and surgeons they decided in favor of the combination
therapies.For more information please visit http://www.ccsviclinic.ca
/?p=904
Reply

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