A mallet finger is caused by loss of extension at the distal interphalangeal (DIP) joint due to an extensor tendon disruption or bony avulsion off the dorsal aspect of the distal phalanx. Loss of extension at the DIP causes the flexor digitorum profundus tendon to pull the DIP joint into a flexion deformity. Bony avulsion fractures are stable if there is no subluxation of the distal phalanx, less than 50% of the joint surface is involved, and < 2-3 mm of displacement. Treatment of acute mallet injuries (<4 weeks old) involves keeping the DIP joint in an extension splint for 6-8 weeks. Dorsal or volar based splints can both be used as studies have shown no greater extension lag deformity with using one or the another. It is common for the DIP joint to have some permanent flexion of less than 10-20 degrees after treatment, however greater than 25 degrees is considered a poor outcome. 1,2

Answer B.
References
1. Alla SR, Deal ND, Dempsey IJ. Current concepts: mallet finger. Hand. 2014 Jun;9(2):138-44.
2. Pike J, Mulpuri K, Metzger M, Ng G, Wells N, Goetz T. Blinded, prospective, randomized clinical trial comparing volar, dorsal, and custom thermoplastic splinting in treatment of acute mallet finger. The Journal of hand surgery. 2010 Apr 1;35(4):580-8.

Avulsion fractures are common after foot and ankle inversion/eversion injuries. Identifying attachment sites of tendons and ligaments of the foot and ankle helps guide identifying particular avulsion patterns. One of the most common avulsion fractures of the calcaneus is an avulsion of the extensor digitorum brevis muscle off the dorsolateral aspect of the calcaneus. These injuries occur from an inversion ankle injury such as a fall upstairs or a slip on ice. The extensor digitorum brevis is the only muscle that originates on the dorsum of the foot and functions to extend the 4 medial toes. Other avulsion fractures of the calcaneus include an anterior process fracture (due to avulsion of the bifurcate ligament) Achilles, and plantar fascia. Most avulsion fractures heal uneventfully with a period of immobilization, usually in a weightbearing boot for 4-6 weeks. If pain from the avulsion fracture persists beyond 4-6 months excision of the avulsed fragment may be considered. 1,2
Answer A.
References
1. Norfray JF, Rogers LF, Adamo GP, Groves HC, Heiser WJ. Common calcaneal avulsion fracture. AJR Am J Roentgenol. 1980 Jan 1;134(1):119-23.
2. Halm JA, Schepers T. Resection of small avulsion fractures of the anterior process of the calcaneus for refractory complaints. The Journal of Foot and Ankle Surgery. 2017 Jan 1;56(1):135-41.

A mallet finger is a disruption of the terminal extensor tendon at its attachment site on the dorsal distal phalanx. The extensor tendon can avulse a piece of bone off (bony mallet) or be purely a soft tissue avulsion. The injury occurs as a result of a sudden forced flexion to the DIP joint. Treatment of acute injuries includes extension splinting of the DIP joint for 6-8 weeks. Residual extensor lag <20 degrees or less after treatment is considered a satisfactory outcome. Mallet fingers presenting 4 weeks after injury (from either benign neglect or failed treatment) are considered to be a chronic injury. Extension splinting is recommended for treating chronic injuries with a similar success rate to treatment of acute injuries. Surgical repair is reserved after failure of nonoperative treatment. A complication of a mallet deformity may include the formation of a swan neck deformity due to the compensatory hyperextension at the PIP joint. 1,2
Answer B.
References
1. Bendre, Anup A. MD; Hartigan, Brian J. MD; Kalainov, David M. MD. Mallet Finger. Journal of the American Academy of Orthopaedic Surgeons 13(5):p 336-344, September 2005.
2. Okafor B, Mbubaegbu C, Munshi I, Williams DJ. Mallet deformity of the finger: five-year follow-up of conservative treatment. The Journal of Bone and Joint Surgery. British volume. 1997 Jul;79(4):544-7.

Thenar eminence atrophy is a classic physical exam finding of chronic carpal tunnel syndrome. Thenar atrophy is a sign of severe and prolonged medial nerve compression and itself is an indication for surgical carpel tunnel release. Although the most common cause of thenar atrophy is carpel tunnel syndrome, C8/T1 radiculopathy and median neuropathy (in the arm) can also be a cause. Carpal tunnel syndrome is diagnosed by multiple factors including clinical picture, physical exam findings (carpal compression test, positive Tinel’s, Prayer and Phalen signs), and with electrodiagnostic testing. Patients with thenar atrophy who undergo a carpal tunnel release can expect significant improvement in hand strength all the way up to 6 months postop, along with improvement in thenar atrophy. Fernandes et al found a 21 % improvement in grip strength and a 30 % increase in tip pinch strength 6 months postop after carpal tunnel release. 1,2
Answer D.
References
1. Fernandes CH, Meirelles LM, Raduan Neto J, Nakachima LR, Dos Santos JB, Faloppa F. Carpal tunnel syndrome with thenar atrophy: evaluation of the pinch and grip strength in patients undergoing surgical treatment. Hand. 2013 Mar;8:60-3.
2. Hoppe B, LeVan D. Hand Atrophy. JBJS JOPA, 9(1):e20.00022 | Review Articles | January 26, 2021

One infrequent, but not to be missed complication of a distal radius fracture is an extensor pollicis longus (EPL) tendon rupture. The classic presentation is a patient presenting with inability to extend the thumb during or just after treatment of a nondisplaced distal radius fracture. The incidence can vary from 0.2% to 4% of all distal radius fractures and most occur with minimally displaced to non-displaced types. Multiple etiologies have been proposed to explain the rupture, including laceration of the tendon on a spike of bone, a disturbed blood supply to the tendon due to local swelling, and from local adhesions. Tendon rupture occurs on average at 9 weeks after the initial injury (range 3-16 weeks) when treated nonoperatively. Treatment of the tendon rupture includes surgical repair with an extensor indicis proprius to extensor pollicis longus tendon transfer with the goal of restoring thumb extension. 1,2
Answer D.

References
1. Roth KM, Blazar PE, Earp BE, Han R, Leung A. Incidence of extensor pollicis longus tendon rupture after nondisplaced distal radius fractures. The Journal of hand surgery. 2012 May 1;37(5):942-7.
2. White BD, Nydick JA, Karsky D, Williams BD, Hess AV, Stone JD. Incidence and clinical outcomes of tendon rupture following distal radius fracture. The Journal of hand surgery. 2012 Oct 1;37(10):2035-40.

A ganglion cyst is the most common tumor of the hand and is 3 times more likely to occur in women compared to men. Ganglion cysts can occur on tendons by adhering to the outside of the tendon without affecting function. A flexor tendon sheath ganglion can be diagnosed by the presence of a small mass that moves with the tendon. Aspiration of clear gelatinous fluid helps confirm the diagnosis and rule out other causes in the differential such as a giant cell tumor and infection. MRI and x-ray are not indicated when a flexor tendon ganglion cyst is clinically diagnosed. Observation is first recommended in most cases as the cyst will likely resolve with time. This patient has trialed a period of immobilization however, and an aspiration is the most appropriate next step. Aspiration with or without steroid injection can be performed if the cyst fails to resolve. Patients should be warned that skin depigmentation and atrophy can occur with a steroid injection. A single aspiration has a high likelihood of recurrence, while surgical excision is often successful for complete resolution. Surgical excision comes with a higher risk of potential complications (infection, wound healing issues) so an aspiration is recommended before surgery is considered. 1,2
Answer B.
Resources
1. Thornburg, Lacy E. MD. Ganglions of the Hand and Wrist. Journal of the American Academy of Orthopaedic Surgeons: July 1999 – Volume 7 – Issue 4 – p 231-238
2. Jebson PJ, Spencer Jr EE. Flexor tendon sheath ganglions: results of surgical excision. Hand. 2007 Sep;2(3):94-100.

Each finger has a digital nerve that runs on both the radial and ulnar boarders, supplying sensation to their respective sides. Digital nerves provide discriminatory sensation which is critical for hand function and dexterity. Digital nerve injuries are often missed as clinicians often fail to perform simple tests required to make the diagnosis. Nerve injuries treated with surgical repair do better if treated early so making the diagnosis is critical. Two point discrimination of the finger is often used to determine if a digital nerve has been injured and requires repair. The American Society for Surgery of the Hand (ASSH) recommended values for two point discrimination (2PD) includes <6 mm is counted as normal, 6–10 mm as fair, 11–15 mm as poor, and >15 mm as protective. Digital 2PD >6mm is highly predictive of a digital nerve injury. Microsurgical repair is performed within the first several days of injury to provide for optimal nerve regeneration. 1,2
The patient has 2PD over 6 mm on both sides of his ring finger indicating a likely laceration through both digital nerves. He is also unable to flex his DIP indicating a likely FDP tendon laceration but can flex his IP joint indicating an intact FDS tendon. 1,2
Answer A.
References
1. Boesch CE, Medved F, Held M, Bender D, Schaller HE, Fuchsberger T. Analysis of the two-point discrimination test in daily routine practice. European Journal of Plastic Surgery. 2017 Aug;40(4):333-6.
2. Mermans JF, Franssen BB, Serroyen J, Van der Hulst RR. Digital nerve injuries: a review of predictors of sensory recovery after microsurgical digital nerve repair. Hand (N Y). 2012 Sep;7(3):233-41.

Glenoid fractures can occur as a result of a traumatic shoulder dislocation (rim fractures) or fall that impacts the humeral head against the glenoid (glenoid fossa fracture). The small surface area of the glenoid compared to the large radius of the humeral head allows the shoulder joint the most range of motion of any joint in the body. Grashey AP and axillary x-rays are the best views to see obvious glenoid fractures. However, a CT scan is often necessary to determine the amount of displacement, or to confirm subtle fractures. Most glenoid fractures have minimal displacement and can be treated non-operatively. Generally intra-articular fractures with <4mm of displacement and involving less than 25% of the glenoid can be treated with shoulder immobilization. Young athletes with bone loss to the glenoid are at the highest risk of recurrent instability and are more likely to require surgery. Glenoid fractures with significant displacement and involving >25% of the glenoid are generally treated with open reduction and internal fixation (ORIF). 1,2
Answer C.
References
1. Seidl, Adam J. MD; Joyce, Christopher D. MD Acute Fractures of the Glenoid, Journal of the American Academy of Orthopaedic Surgeons: November 15, 2020 – Volume 28 – Issue 22 – p e978-e987
2. Van Oostveen DP, Temmerman OP, Burger BJ, Van Noort A, Robinson M. Glenoid fractures: a review of pathology, classification, treatment and results. Acta Orthop Belg. 2014 Mar 1;80(1):88-98.

Hamstring injuries are common and generally involve proximal muscle tears or tendon avulsions off the ischial tuberosity. Distal hamstring tears and tendon avulsions are far less common. The hamstring muscles include the semitendinosus, semimembranosus, and biceps femoris (which has a long and short head). The distal biceps femoris tendon attaches to the lateral aspect of the knee and is the most common distal hamstring injury, typically associated with a varus hyperextension injury. Semitendinosus injuries occur off the attachment side over the medial knee (at the Pes anserine). The most common exam findings with a semitendinosus injury include pain with knee extension, swelling on the medial knee, and tenderness over the Pes anserine. MRI is the study of choice to identify these injuries. Treatment of these injuries is controversial as they are rarely seen. Given the fact that the semitendinosus is harvested for ACL autografts with little to no clinically significant loss in hamstring strength after, the thought that non-operative treatment is a successful option for avulsion injuries is reasonable. Sekhon et al treated two professional athletes successfully with non-operative treatment and a rapid return to sports (within 1-4 weeks). Adejuwon et al found that full recovery from a semitendinosus avulsion injury was achieved in two elite adult sprinters with non-operative treatment. Full recovery with return to pre-injury level of play occurred at 12 months. Conversely, Cooper et al. found that elite athletes returned to sport sooner when undergoing surgical repair within 4 weeks of injury compared to non-operative treatment. The authors criteria for acute surgical repair include elite athletes who desired an earlier return to play, patients who failed to progress with a non-operative rehabilitation program, and continued knee extension pain. Surgical excision of the semitendinosus tendon is also a reasonable option if patients have continued medial sided knee pain. 1,2,3
Answer D.
References
1. Adejuwon A, McCourt P, Hamilton B, Haddad F. Distal semitendinosus tendon rupture: is there any benefit of surgical intervention?. Clinical Journal of Sport Medicine. 2009 Nov 1;19(6):502-4.
2. Sekhon JS, Anderson K. Rupture of the distal semitendinosus tendon–A report of two cases in professional Athletes. The Journal of Knee Surgery. 2007;20(02):147-50.

Primary arthritis of the distal interphalangeal joint (DIP) and proximal interphalangeal joint (PIP) is a common condition presenting with pain and stiffness of the digits. Heberden’s node at the DIP and Bouchard’s node at the PIP is associated with enlargement of the joints due to arthritis. The patient presents with a Heberden’s node and severe arthritis at the DIP joint. Mucous cysts are fluid filled pea size cysts that commonly grow from an arthritic DIP joint. Mucous cysts are fluid filled and soft whereas Heberden’s and Bouchard’s nodes are a generalized enlargement of the joint. Radiographic findings of finger arthritis include joint space narrowing and osteophyte formation. Treatment is almost always conservative to include ice, oral or topical anti-inflammatories, and splinting. Night time extension splitting has been shown to reduce pain and extension lag from DIP arthritis. Symptoms of finger arthritis are generally mild and intermittent and less commonly severe and unrelenting. In rare cases when the finger arthritis causes severe pain and disability, surgery may be an option. DIP joint arthritis is often treated with fusion. Mucous cysts alone can be treated with mucoid cyst excision with osteophyte resection. Arthritis of the PIP joint can be treated surgically with osteophyte excision, fusion, or arthroplasty. 1,2
Answer C

References
1. Spies CK, Langer M, Hahn P, Müller LP, Unglaub F. The treatment of primary arthritis of the finger and thumb joint. Deutsches Ärzteblatt International. 2018 Apr;115(16):269.
2. Watt FE, Kennedy DL, Carlisle KE, Freidin AJ, Szydlo RM, Honeyfield L, Satchithananda K, Vincent TL. Night-time immobilization of the distal interphalangeal joint reduces pain and extension deformity in hand osteoarthritis. Rheumatology (Oxford). 2014 Jun;53(6):1142-9.

Humeral shaft fractures are generally treated nonoperatively as gravity of the arm helps assist fracture reduction for displaced fractures. Healing rates are as high as 90% with non-operative treatment. Criteria for non-operative treatment includes < 20 degrees of anterior angulation, < 30 degrees of varus/valgus angulation, and < 3 cm of shortening. Humeral bracing is indicated for non-operative fractures to help stabilize the fracture. A Sarmiento brace wraps circumferentially around the humerus and allows mobilization of the shoulder and elbow joint. A coaptation or U-shaped splint should go proximally to the axilla and over the deltoid laterally. A sling takes away some of the gravitational pull of the arm that helps reduce the fracture which is not ideal for humeral shaft fractures. 1,2
Answer A.
References
1.Attum B, Obremskey W. Treatment of Humeral Shaft Fractures. A Critical Analysis Review. JBJS Rev, 3(9):e5 | Review Article with Critical Analysis Component | September 29, 2015
2. Ali E, Griffiths D, Obi N, Tytherleigh-Strong G, Van Rensburg L. Nonoperative treatment of humeral shaft fractures revisited. Journal of shoulder and elbow surgery. 2015 Feb 1;24(2):210-4.

Proximal humerus fractures are one of the most common fracture types that occur in adults. Proximal humerus fractures represent 20% of all fragility fractures (fall from a standing height in patients with osteoporotic bone). Radiographs are the initial imaging modality and understanding fracture patterns is critical in guiding treatment. Inferior subluxation of the humeral head in relation to the glenoid is a common finding in proximal humerus fractures but can be misdiagnosed as a fracture dislocation. Recognizing this fracture pattern prevents unnecessary closed reduction attempts of the shoulder. Inferior subluxation is seen in less than 20% of proximal humerus fractures and is best seen on a shoulder AP view. Risk factors include advanced age, female gender, osteoporotic bone and obesity. The cause of the inferior subluxation is due to deltoid atony often from an axillary nerve injury. The inferior subluxation resolves spontaneously within 6 weeks in 90% of patients and is rarely seen beyond one year regardless of conservative vs. surgical intervention. 1,2
Answer D.
1. Cirino CM, Kantrowitz DE, Cautela FS, Gao M, Cagle PJ, Parsons BO. Incidence and risk factors for pseudosubluxation of the humeral head following proximal humerus fracture. JSES international. 2022 May 1;6(3):338-42.
2. Mighell MA, Kolm GP, Collinge CA, Frankle MA. Outcomes of hemiarthroplasty for fractures of the proximal humerus. Journal of shoulder and elbow surgery. 2003 Nov 1;12(6):569-77.7.

Lower back pain with radiculopathy is one of the most common complaints seen in a healthcare setting. Most patients can be treated successfully with 2-3 months of conservative treatment such as physical therapy, NSAIDs, oral steroids, chiropractic treatment, and acupuncture, to name a few. When patients fail these conservative treatments, fluoroscopic-guided lumbar spinal injections are often the last resort for pain relief before surgical intervention is considered. Fluoroscopic-guided lumbar steroid injections are the most common injection technique used to treat lumbar spine pain with and without radiculopathy. Steroids relieve pain by targeting inflammation causing chemical irritation on a nerve root. Lumbar epidural injections are generally performed with an interlaminar or transforaminal approach. With the interlaminar approach, the medication is delivered into the posterior epidural space. The lumbar transforaminal approach is more technically demanding as the needle is inserted close to the nerve root as it exits the neuroforamen. The benefit of the transforaminal approach is that the steroid is injected closer to the anterior epidural space where most disc and nerve root pathology occurs. Transforaminal epidural steroid injections (ESI’s) are the treatment of choice for patients with radicular pain worse. Lumbar epidural injections are an effective short- and long-term treatment option for patients. The majority of patients (>75%) who have failed other conservative options will get relief and avoid the need for surgery. 1,2
Answer C.
References
1. Manchikanti L, Knezevic NN, Navani A, Christo PJ, Limerick G, Calodney AK, Grider J, Harned ME, Cintron L, Gharibo CG, Shah S, Nampiaparampil DE, Candido KD, Soin A, Kaye AD, Kosanovic R, Magee TR, Beall DP, Atluri S, Gupta M, Helm Ii S, Wargo BW, Diwan S, Aydin SM, Boswell MV, Haney BW, Albers SL, Latchaw R, Abd-Elsayed A, Conn A, Hansen H, Simopoulos TT, Swicegood JR, Bryce DA, Singh V, Abdi S,

Most posterior malleolar fractures occur in the setting of other fractures such as the trimalleolar fracture pattern (lateral, medial, and posterior malleolus fractures). Isolated posterior malleolar fractures (as with this case) are far less common and easy to miss. The importance of an intact posterior malleolus is to maintain a congruent joint line and provide stability to the ankle joint. AP, lateral and mortise view x-rays should be performed initially to determine the fracture pattern and to look for evidence of a syndesmotic injury. CT is recommended for all posterior malleolar fractures to check for joint space congruity and lateralization of the talus. For isolated, non-displaced posterior malleolar fractures, non-operative treatment with a non-weightbearing boot or cast is recommended. There is no clear consensus on indications for operative treatment but in general a fracture involving >33% of the articular surface and a >2mm articular step off are indications for open reduction and internal fixation. 1,2
Answer A.
References
1. Irwin, Todd A. MD; Lien, John MD; Kadakia, Anish R. MD. Posterior Malleolus Fracture. Journal of the American Academy of Orthopaedic Surgeons 21(1):p 32-40, January 2013. | DOI: dx.doi.org/10.5435/JAAOS-21-01-32
2. Smeeing DPJ, Houwert RM, Kruyt MC, Hietbrink F. The isolated posterior malleolar fracture and syndesmotic instability: A case report and review of the literature. Int J Surg Case Rep. 2017;41:360-365. doi: 10.1016/j.ijscr.2017.10.062. Epub 2017 Nov 13. PMID: 29149741; PMCID: PMC5695917.

The ulnar styloid is a bony projection of the distal ulnar that serves as an attachment site for distal radial and ulnar joint ligaments (DRUJ) and triangular fibrocartilage complex (TFCC). Isolated ulnar styloid fractures are rare as they usually occur in association with distal radius fractures. Although the non-union rate for ulnar styloid fractures can be as high as 77%, rarely due they cause any DRUJ instability or require surgical fixation. Treatment of minimally displaced fractures includes a short arm cast for 6 weeks. The size and amount of displacement of the ulnar styloid fracture is the best predictor of resulting DRUJ instability. Fractures can occur (from smallest to largest) at the tip, base, or the larger fovea. Fractures at the tip are the most common and least likely to cause instability. Fractures with >2mm of displacement are more likely to cause DRUJ instability. Displaced ulnar styloid fractures can increase the likelihood of symptomatic abutment to the carpus. Evidence of DRUJ instability include a positive Ballottement test, widening of the DRUJ on AP x-ray, and radioulnar distance of more than 6mm on lateral view x-ray. 1,2,3
Answer B.
References
1. Maniglio M, Park IJ, Zumstein M, Kuenzler M, McGarry MH, Lee TQ. The critical size of ulnar Styloid Fragment for the DRUJ Stability. Journal of wrist surgery. 2021 Oct;10(05):385-91.
2. Mirghasemi AR, Lee DJ, Rahimi N, Rashidinia S, Elfar JC. Distal Radioulnar Joint Instability. Geriatr Orthop Surg Rehabil. 2015 Sep;6(3):225-9.
3. Logan AJ, Lindau TR. The management of distal ulnar fractures in adults: a review of the literature and recommendations for treatment. Strategies Trauma Limb Reconstr. 2008 Sep;3(2):49-56.

A careful physical exam and knowledge of finger anatomy is essential to prevent missing finger injuries. The main flexor tendons of the finger include the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. The FDS tendon inserts at the volar aspect of the middle phalanx and acts to flex the proximal interphalangeal (PIP) joint. The FDP tendon inserts at the volar base of the distal phalanx and acts to flex the DIP joint. A Jersey Finger is an avulsion of the FDP tendon off its insertion at the at the base of the distal phalanx. The mechanism of injury is a forced extension on a flexed finger such as when a football player grabs a jersey while the player runs away. The middle finger is involved in 75% of cases as the increased length results in a more forceful DIP flexion when grasping. On physical exam patients will have an inability to make a full fist and to flex the DIP joint. X-rays of the finger are critical for identifying a bony avulsion vs. a pure tendon avulsion. FDP avulsion injuries require surgical repair which includes reattaching the tendon back down to the distal phalanx. This should be performed within 3 weeks of injury or the tendon can retract and become irreparable. Avulsion fractures often require open reduction and internal fixation of the fracture fragment. Hand therapy is used postoperatively and return to sports is expected around 3 months post-op. 1,2
Answer D.
References
1. Ruchelsman, David E. MD; Christoforou, Dimitrios MD; Wasserman, Bradley MD; Lee, Steve K. MD; Rettig, Michael E. MD. Avulsion Injuries of the Flexor Digitorum Profundus Tendon. American Academy of Orthopaedic Surgeon: March 2011 – Volume 19 – Issue 3 – p 152-162
2. Bachoura A, Ferikes AJ, Lubahn JD. A review of mallet finger and jersey finger injuries in the athlete. Curr Rev Musculoskelet Med. 2017 Mar;10(1):1-9.

Glenohumeral joint stability is provided by a combination of bony anatomy, joint capsule, glenohumeral ligaments, and labrum. A Bankart lesion, or an avulsion of the anterior labrum and inferior glenohumeral ligament, is the most common cause of traumatic shoulder instability. An arthroscopic Bankart repair is the most common surgical stabilization procedure. Bony Bankarts, or when bone is avulsed from the glenoid, can also create glenohumeral instability. Bony Bankarts are more likely to occur with repetitive dislocations and the bony defects increase in size with increasing number of dislocations. The analogy of a golf ball resting on a golf tee is commonly used to describe bony stability of the glenohumeral joint. If a critical piece of the golf tee surface is removed, the golf ball will no longer rest on top. When the glenoid loses 21%-30% of its bony surface, glenohumeral stability is reduced substantially. In younger athletes, bone loss as low as 13.5% has been associated with unacceptable joint instability. CT scan is the study of choice to quantify the percentage of glenoid bone loss. In patients with chronic instability and significant glenoid bone loss, a procedure to add bone to the glenoid to increase its surface area is often necessary. The most common procedure involves taking a coracoid autograft and attaching it to the glenoid, or a Latarjet procedure. 1,2
Answer C.

References
1. Willemot, Laurent B. MD; Elhassan, Bassem T. MD; Verborgt, Olivier MD, PhD. Bony Reconstruction of the Anterior Glenoid Rim. Journal of the American Academy of Orthopaedic Surgeons: May 15, 2018 – Volume 26 – Issue 10 – p e207-e218
2. Bencardino JT, Gyftopoulos S, Palmer WE. Imaging in anterior glenohumeral instability. Radiology. 2013 Nov;269(2):323-37.

The child is presenting with hip pain, a limp, and collapse of the femoral head on x-rays which is consistent with the diagnosis of Legg-Calve-Perthes Disease (LCPD). LCPD is an idiopathic avascular necrosis of the femoral head that generally occurs between the ages of 5 and 8 years old. The most common presenting symptoms are mild hip pain and a limp. The natural course of the condition starts with sclerosis of the epiphysis, loss of epiphyseal height, fragmentation and fissuring of the epiphysis, followed by maximal collapse and fissuring, and finally new bone formation and healing. The course of symptom onset to resolution can last over a period of 2-4 years. AP and frog leg lateral x-rays can be performed every 3-4 months to ensure the femoral head is contained in the acetabulum and to track the course of the disease. The amount of femoral head collapse correlates with outcome, including the likelihood of developing a hip deformity and secondary osteoarthritis. Age of symptom onset is a significant predictor of outcome as younger patients have more time to grow out of any residual deformities. Age of onset <6 years of age can be treated successful with nonsurgical management (activity modification based on symptoms). Bracing and physical therapy are not necessary or helpful for improving outcomes in patients <6 without severe epiphyseal collapse. Age of onset between 6 and 8 years of age offers a less predictable course and surgical vs. nonsurgical outcomes are comparable in this group. Patients with symptom onset at 8 years of age and older are more prone to femoral head and acetabular abnormalities and poor hip function. Surgery is often performed early in the course of the disease for these patients to minimize the risk of secondary degenerative arthritis. 1,2
Answer A.
References
1. Herring JA, Kim HT, Browne R. Legg-Calvé-Perthes disease: part II: prospective multicenter study of the effect of treatment on outcome. JBJS. 2004 Oct 1;86(10):2121-34.
2. Kim, Harry K. W. MD. Legg-Calvé-Perthes Disease. American Academy of Orthopaedic Surgeon: November 2010 – Volume 18 – Issue 11 – p 676-686

The patient has a Baker’s cyst that is compressing the vessels in the back of the knee resulting in venous obstruction and lower extremity edema. The most common cause of a Baker’s cyst is osteoarthritis of the knee however this patient has already had a total knee replacement. On careful inspection of this patients x-rays you can see metal wear on the medial tibial base plate from the femoral implant. This represents severe wear and failure of the polyethylene liner. Metal debris can be seen on lateral view x-ray which is evidence that the patient likely has synovitis from significant metallosis. Metallosis is an uncommon complication of total joint surgery where metal debris from implant wear infiltrates the surrounding soft tissue causing chronic inflammation. The most common symptoms include pain and swelling in the involved joint. The treatment for patients with metallosis include a non-urgent synovectomy and revision joint replacement. If left untreated, metallosis can cause progressive destruction of the involved joint. Metallosis can also cause systemic toxicity as cobalt and chromium can enter the blood stream and accumulate in organs. 1,2

Answer B.

1. Vivegananthan B, Shah R, Karuppiah AS, Karuppiah SV. Metallosis in a total knee arthroplasty. BMJ Case Rep. 2014 Mar 18;2014:bcr2013202801. doi: 10.1136/bcr-2013-202801. PMID: 24642179; PMCID: PMC3962890.
2. Bradberry SM, Wilkinson JM, Ferner RE. Systemic toxicity related to metal hip prostheses. Clin Toxicol (Phila). 2014 Sep-Oct;52(8):837-47. doi: 10.3109/15563650.2014.944977. Epub 2014 Aug 16. PMID: 25132471.

Metatarsal fractures are one of the most common orthopedic injuries seen in the urgent care setting. Injury mechanism varies from overuse type (stress related), low impact like, twisting of the foot (most common), or a traumatic high energy impact (less common). The 2nd metatarsal is the most common site of stress fractures whereas the 5th metatarsal is the most common for all other types of fractures. Most metatarsal factures can be treated non-operatively with a weight bearing cast or boot with no difference in outcomes between the two. Surgical indications for 1rst metatarsal fractures include angulation greater than 10°, greater than 3 to 4 mm of displacement, articular involvement, and the presence of rotational deformity or shortening. Normal length and alignment of the first metatarsal is critical to prevent weight transfer to the other metatarsals during ambulation. Central metatarsal (2-4) fractures have more stability due to the surrounding soft tissue attachments. Indications for surgery for central fractures include sagittal plane deformity >10 degrees, >4mm of translation and multiple bones involved. Fractures of the proximal fifth metatarsal are broken into Zone 1 (metatarsal base avulsion fractures), zone 2 (metaphyseal-diaphyseal junction or Jones fractures), and Zone 3 as the proximal diaphyseal fractures. Zone 1 fractures account for 95% of proximal 5th metatarsal fractures. A spiral fracture of the distal 5th metatarsal diaphysis is often called a Dancer’s fracture. 1,2

References
1. Sarpong NO, Swindell HW, Trupia EP, Vosseller JT. Metatarsal fractures. Foot & Ankle Orthopaedics. 2018 Aug 9;3(3):2473011418775094.
2. O’Malley MJ, Hamilton WG, Munyak J. Fractures of the Distal Shaft of the Fifth Metatarsal: “Dancer’s Fracture.” The American Journal of Sports Medicine. 1996;24(2):240-243.

The incidence of lower extremity stress fractures is much more common in female athletes compared to males. Metatarsal stress fractures are particular common among female runners and dancers. The second and third metatarsal are the most common metatarsals to have a stress fracture due to their length and relative immobility. Early radiographic findings for a stress fracture may include a subtle radiolucency of the shaft and/or cortex. Subtle periosteal bone formation may be seen as early as 2 weeks from injury and thicker callus formation is usually seen at 4-6 weeks post-injury. Risk factors for stress fractures include inadequate dietary intake (which is associated with athletic amenorrhea), lack of rest to allow for proper bone turnover and healing, and a serum 25(OH)D level <40 ng/mL. Treatment involves resting the foot with an immobilizer weight bearing as tolerated. With a hard soled shoe taking pressure off the metatarsals, non-weight bearing restrictions is unnecessary. 1,2
Answer C.
References
1. Frank RM, Romeo AA, Bush-Joseph CA, Bach BR. Injuries to the Female Athlete in 2017. Part I: General Considerations, Concussions, Stress Fractures, and the Female Athlete Triad. 2017 Oct; JBJS Rev, 5(10):e4
2. Miller JR, Dunn KW, Ciliberti Jr LJ, Patel RD, Swanson BA. Association of vitamin D with stress fractures: a retrospective cohort study. The Journal of Foot and Ankle Surgery. 2016 Jan 1;55(1):117-20.

The olecranon is an attachment site for the triceps muscle and a critical component of the elbow extensor mechanism. The most common mechanism of injury causing an olecranon fracture is a direct blow to the elbow. Non operative treatment is recommended for non-displaced fractures whereas surgery is recommended in most cases of displaced fractures. The most common surgical options include both plate fixation and tension band wiring. Fracture fixation is not without potential complications however, which can occur more often in elderly patients with poor skin and osteoporotic bone. Duckworth et al found that in low demand elderly patients, non-operative treatment of displaced olecranon fractures had similar short and long term outcomes compared to operative treatment. Non operative treatment of displaced fractures is the same as for nondisplaced fractures; the elbow is immobilized in 60-90 degrees of flexion for 2-3 weeks, followed by gentle motion, and lifting restrictions until healing is present on x-ray. Weekly x-rays should be taken for the first 2-3 weeks to make sure further displacement doesn’t occur. The mean displacement in the aforementioned Duckworth study was 10 mm and greater displacement was associated with worse outcomes. 1,2
Answer A.
References
1. Duckworth AD, Bugler KE, Clement ND, McQueen MM. Nonoperative management of displaced olecranon fractures in low-demand elderly patients. JBJS. 2014 Jan 1;96(1):67-72.
2. Bailey CS, MacDermid J, Patterson SD, King GJ. Outcome of plate fixation of olecranon fractures. Journal of orthopaedic trauma. 2001 Nov 1;15(8):542-8.

The patient has a lesion at the lateral distal femur consistent with a benign osteochondroma. Osteochondromas are the most common benign bone tumor and most are asymptomatic and found incidentally on x-ray. Malignant transformation of osteochondromas is rare (<1%) so most are left alone. Tumor growth after skeletal maturity raises suspicion of potential malignant transformation. X-ray, MRI, and clinical presentation are more than enough to make the diagnosis of an osteochondroma and a bone biopsy is not indicated. Rarely osteochondromas can cause a mass effect on surrounding nerves, blood vessels, muscle, tendons and other soft tissue. Surgical resection of the osteochondroma is the treatment of choice in symptomatic patients when conservative treatments fail. Resection is a very successful surgery as less than 2% of osteochondromas will reoccur. Resection should be performed after patients reach skeletally maturity to be sure no further growth remains. 1,2
Answer D.

References
1. Heron N. Femoral exostosis causing vastus medialis pain in an active young lady: a case report. BMC Res Notes. 2015 Apr 2;8:119. doi: 10.1186/s13104-015-1077-0. PMID: 25889418; PMCID: PMC4387740.
2. Wodajo FM. Top five lesions that do not need referral to orthopedic oncology. Orthop Clin North Am. 2015 Apr;46(2):303-14. doi: 10.1016/j.ocl.2014.11.012. PMID: 25771324.

This patient sustained a low impact vertebral fracture in the setting of normal bone density which raises suspicion of a pathological fracture. The patient has a normal intact PTH, calcium, and vitamin D levels which rules out primary and secondary hyperparathyroidism. The most common primary bone malignancy and cause of a pathological vertebral fracture is multiple myeloma. Multiple myeloma is an incurable B lymphocyte malignancy characterized by proliferation and expansion of plasma cells in bone marrow. Symptoms can include fatigue and bone pain but many patients are completely asymptomatic and a pathological fracture is the first sign. Multiple myeloma is diagnosed when monoclonal proteins are found in the blood or urine. A serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP) detect these proteins and should be ordered in patients with a suspected pathological fracture of the vertebral spine in the absence of a known cause of metastatic disease. If the SPEP and UPEP are positive then a bone marrow biopsy is performed to confirm plasma cells in the bone marrow. 1,2
Answer A.
References
1. Giorgi PD, Schirò GR, Capitani D, D’Aliberti G, Gallazzi E. Vertebral compression fractures in multiple myeloma: redefining the priorities during the COVID-19 pandemic. Aging Clinical and Experimental Research. 2020 Jul;32(7):1203-6.
2. Angtuaco EJ, Fassas AB, Walker R, Sethi R, Barlogie B. Multiple myeloma: clinical review and diagnostic imaging. Radiology. 2004 Apr;231(1):11-23.

Traumatic elbow dislocations in children are relatively rare injuries. Posterior dislocations are the most common type which are caused by a fall on an outstretched hand with the forearm supinated and the elbow in 15-20 degrees of flexion. The ulnar nerve is the most common nerve injured during a posterior lateral dislocation as the nerve is often stretched as the elbow goes into a valgus position. Asking the patient to perform “rock, paper, scissors” grossly test motor function. Making a fist test the medial nerve, paper tests the radial nerve (finger extension), and scissors test the ulnar nerve (spreading fingers apart). Medial epicondyle fractures can commonly occur in pediatric elbow dislocations as the medial condyle is the last ossification center in the distal humerus to fuse, usually by 15-20 years of age. The medial epicondyle is the attachment site to the flexor pronator mass and the ulnar collateral ligament. Recognizing a displaced medial epicondyle fracture is critical as the bone can block the elbow reduction. Significant displacement often requires open reduction and internal fixation of the medial epicondyle fracture with screw fixation, after closed reduction of the elbow, to prevent long term elbow instability. 1,2
Answer D.
References
1. Gottschalk HP, Eisner E, Hosalkar HS. Medial epicondyle fractures in the pediatric population. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2012 Apr 1;20(4):223-32.
2. Varacallo M, Parikh D, Mody K, Herman MJ. Pediatric Elbow Dislocations: Acute Management. InPediatric Elbow Fractures 2018 (pp. 169-184). Springer, Cham.

Pediatric elbow injuries are one of the most common reasons for emergency room or urgent care visits. There are 6 growth centers around the elbow which can make interpreting x-rays difficult in pediatric age groups. Comparison x-rays of the un-injured elbow are often necessary to distinguish normal and abnormal findings. Supracondylar fractures are the most common fracture around the elbow (60%), followed by lateral and medial condylar fractures, and less common, radial head and olecranon fractures. Non-displaced fractures are treated non-operatively with a 3-4 week period of immobilization. Immobilizing options generally include a long arm cast, removable long arm splint, or a sling. The use of a long arm cast or posterior splint provides improved pain relief over a sling in the first two weeks from injury. Elbow immobilization should not be continued beyond 4 weeks as arthrofibrosis of the elbow can start to set in and could lead to a permanent loss of motion. Silva et al found that the use of a removable long arm soft cast (removable under parent supervision) for non-displaced elbow fractures provides a convenient option for patients while safely maintaining fracture alignment. 1,2
Answer C.
References
1. Lins RE, Simovitch RW, Waters PM. Pediatric elbow trauma. Orthopedic Clinics of North America. 1999 Jan 1;30(1):119-32.
2. Silva M, Sadlik G, Avoian T, Ebramzadeh E. A removable long-arm soft cast to treat nondisplaced pediatric elbow fractures: a randomized, controlled trial. Journal of Pediatric Orthopaedics. 2018 Apr 1;38(4):223-9.

The peroneal tendons include the peroneal brevis and peroneal longus tendons which primary function for foot eversion and pronation. Both tendons run along the lateral fibular and the peroneal brevis attaches to the base of the 5th metatarsal and the peroneal longus inserts on the plantar aspect of the first metatarsal and medial cuneiform. Physical exam signs of peroneal tendonitis include pain to palpation running along the lateral fibular and pain with resisted eversion of the foot. Injury to the peroneal tendons can range from tenosynovitis, tendinosis, and tearing. These injuries can occur from a number of causes such as an ankle sprain, hindfoot varus deformity, and ankle sprains, to name a few. MRI is the best study of choice to distinguish between these injuries and to look for tendon subluxation and tearing. Treatment of peroneal tendon pain starts with immobilization, ice, and anti-inflammatories. A walking boot for 3-4 weeks generally helps reduce inflammation, followed by a slow progression to normal activities. A lateral heel wedge can reduce hindfoot varus taking pressure off the peroneal tendons. 1,2
Answer A.
References
1. Selmani E, Gjata V, Gjika E. Current concepts review: peroneal tendon disorders. Foot & ankle international. 2006 Mar;27(3):221-8.
2. Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2009 May 1;17(5):306-17.

The patient has a displaced intra-articular dorsal base fracture of the distal phalanx. Distal phalanx fractures are the most common type of phalanx fractures. The vast majority of phalangeal fractures can be treated non-operatively, even with some displacement. For dorsal base fractures, if the joint is congruent then the fracture pattern is stable and can be treated with distal interphalangeal joint (DIP) immobilization. If the distal phalanx is subluxed from the middle phalanx and the fracture involves >30% to 40% of the articular surface, then open or closed reduction with percutaneous fixation is generally required. The terminal extensor tendon attaches to the dorsal base of the distal phalanx and acts to extend the DIP joint. Fractures of the dorsal base can cause an extension lag if there is disruption in the terminal extensor mechanism. This patient has full extension at the DIP joint with an intact terminal extensor mechanism. The patient was treated with an alumafoam splint to the DIP joint to keep the joint congruent and in extension. 1,2
Answer B.
1. Henry, Mark. Fractures and Dislocations of the Hand. Rockwood, C. A., Green, D. P., & Bucholz, R. W. (2006). Pg 782-785. Rockwood and Green’s fractures in adults (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
2. Phalanx fractures. http://www.orthobullets.com. Accessed on 5/28/2022.

A tibial pilon fracture (also known as a tibial plafond fracture) is a distal tibial fracture commonly associated with comminution, intra-articular extension, and soft tissue compromise. Pilon fractures are often a result of a high energy axial force on the leg such as a fall from a significant height or a motor vehicle accident. Initial diagnostic work-up includes x-rays to include the entire tibia and foot/ankle. CT is also critical in determining articular involvement and preoperative planning. CT is often performed after an external fixator is placed as pulling the fracture to length can shift the fracture. Pilon fractures frequently have significant soft tissue swelling and injury (fracture blisters, skin breakdown) which leads to high complications rates when these fractures are treated with early open reduction and internal fixation. A common treatment protocol for high energy, comminuted, and displaced pilon fractures includes closed reduction with placement of an external fixator for initial restoration of length and alignment. Once the soft tissue swelling has diminished and all fracture blisters, or open wounds have healed, definitive open reduction and internal fixation can be performed. ORIF performed around the 2 week mark after external fixation results in improved surgical wound complications. 1,2
Answer B.
References
1. Kottmeier, Stephen A. MD; Madison, Randall Drew MD. Pilon Fracture: Preventing Complications. Journal of the American Academy of Orthopaedic Surgeons: September 15, 2018 – Volume 26 – Issue 18 – p 640-651
2. Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 1999 Feb;13(2):78-84.

Heel pain is one of the most common musculoskeletal complaints and up to 81% of cases are caused by plantar fasciitis. A calcaneal heel spur is a common finding on lateral radiographs in patients with plantar fasciitis and often a trigger for an orthopedic referral. However, there is no direct correlation between a heel spur and plantar fasciitis. A plantar heel spur is found is 12% of the population and far fewer ever develop plantar fasciitis. The development of a heel spur is thought to be multifactorial and no caused by plantar fasciitis. Factors such as repetitive stress to the heel, tight plantar fascia, and a genetic predisposition for bone spur formation (patients with osteoarthritis) are thought to play a role. Obesity is a strong risk factor for developing chronic heel pain and calcaneal spurs. Calcaneal heel spurs also increase in frequency with advanced age (98% of patients are over 40), which is thought to be due to the general tendency of ligament ossification with aging. The majority of patients with heel pain and spurs do well with conservative treatment including stretching, ice, NSAIDS, night splints, immobilization, steroid injections, and shock wave therapy (treatment usually progresses in that order). Surgical release of the plantar fascia and excision of the heel spur may be considered in chronic cases, however heel spur excision alone is not a surgical option as the spur is not the etiology of heel pain. 1,2
Answer A.

References
1. Moroney, Paul J., et al. “The conundrum of calcaneal spurs: do they matter?.” Foot & Ankle Specialist 7.2 (2014): 95-101.
2. Kirkpatrick, Joshua, Omid Yassaie, and Seyed Ali Mirjalili. “The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations.” Journal of anatomy 230.6 (2017): 743-751.

Anterior cruciate ligament (ACL) reconstruction is the gold standard treatment option for patients who sustain an ACL tear. The ACL has a poor blood supply and ruptures are unlikely to heal with the same stability as its original form. This is why ACL repair options have failed in the past. The ACL fails to form a provisional scaffold between the two torn ends of the ACL which is critical for wound site healing. The knee joint is lubricated by a continuous flow of synovial fluid which his thought to inhibit ACL healing by getting in-between torn ends preventing healing tissue from forming. Unlike the ACL, the extra-articular MCL forms a scaffold between torn ends resulting in high rates of healing. More recent studies over the last 10 years have started to show primarily ACL repair in select patients may be as effective as ACL reconstruction. The patients age, activity level, and location of the tear are all factors in determining if a patient is a repair candidate. Current data shows that repairs are more likely to fail in patients under 18 compared to patients over 30. Also, patients who are active, particularly in running and cutting sports, are at a much higher risk of failure and repair should be avoided in these patients. Proximal ACL tears seem to be more amenable to repair than midsubstance and distal tears. 1,2
Answer C

References
1. Murray MM. Current status and potential of primary ACL repair. Clinics in sports medicine. 2009 Jan 1;28(1):51-61.
2. Gee, MAJ Shawn M. MD; Peterson, CPT David R. MD; Zhou, MAJ Liang MD; Bottoni, Craig R. MD Anterior Cruciate Ligament Repair: Historical Perspective, Indications, Techniques, and Outcomes, Journal of the American Academy of Orthopaedic Surgeons: December 1, 2020 – Volume 28 – Issue 23 – p 963-971

The patient has an obvious rupture of the proximal biceps tendon consistent with his history and physical exam. The proximal biceps muscle has two attachment sites proximally via the long head and short head: the long head of the biceps tendon attaches inside the shoulder at the superior glenoid and the short head attaches at the coracoid process outside the shoulder joint. The long head of the biceps can be a pain generator as the proximal tendon can degenerate and tear with time and repetitive shoulder motion. Symptoms often start with partial tearing of the tendon and, as the tear increases, the tendon can spontaneously tear of its attachment on the labrum. The muscle belly then retracts distally causing the classic Popeye deformity. It is important to educate patients that rupture of the long head of the biceps does not result in any weakness or disability, despite the deformity. The proximal biceps is still attached via the short head of the biceps tendon on the coracoid. Surgical repair including exploration and tenodesis is only considered for cosmetic reasons and is rarely performed. Some patients may be relieved to hear that John Elway, NFL quarterback for the Denver Broncos won two Superbowl’s AFTER he tore his proximal biceps (he had a Popeye deformity as well and was treated with observation and return to football activities to tolerance). 1,2
Answer A.
References
1. Frank, Rachel M. MD; Cotter, Eric J. BS; Strauss, Eric J. MD; Jazrawi, Laith M. MD; Romeo, Anthony A. MD. Management of Biceps Tendon Pathology: From the Glenoid to the Radial Tuberosity. Journal of the American Academy of Orthopaedic Surgeons: February 15, 2018 – Volume 26 – Issue 4 – p e77-e89
2. Gill TJ. CORR Insights®: Does Biceps Tenotomy or Tenodesis Have Better Results After Surgery? A Systematic Review and Meta-analysis. Clin Orthop Relat Res. 2021 Jul 1;479(7):1574-1576. doi: 10.1097/CORR.0000000000001743. PMID: 34077395; PMCID: PMC8208415.

The pelvis acts as an attachment site for the hip flexor muscles. Hip flexors include the psoas which attaches to the lesser trochanter, the rectus femoris which attaches to the anterior inferior iliac spine (AIIS), and the sartorius which attaches to the anterior superior iliac spine. The muscles of the quadriceps include the rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius. Of the four muscles of the quadriceps, the rectus femoris is the most commonly injured and the only muscle that crosses the hip and knee joints. Avulsion of the AIIS can occur with a sudden forceful contraction of the quadriceps including a fall that hyperextends the hip joint or abrupt kicking motion. Diagnostic work-up includes AP hip x-rays which will show the classic avulsion pattern. MRI may be warranted if there is no obvious bony involvement or concomitant injury is suspected. Rectus femoris avulsion injuries are almost always treated non-operatively with a period of rest by avoiding hip flexion. Pain and function usually improves at 6-8 weeks and patients can often return to sports or heavy labor during this time. 1,2
Answer D.

References
1. Begum FA, Kayani B, Chang JS, Tansey RJ, Haddad FS. The management of proximal rectus femoris avulsion injuries. EFORT Open Rev. 2020 Nov 13;5(11):828-834.
2. Knapik DM, Trasolini NA, Diaz CC, Chahla J, Forsythe B. JBJS Rev, 9(7):e20.00269

This patient presents with right shoulder arthritis and a large, retracted rotator cuff tear. The AP x-ray of the shoulder shows a decreased acromiohumeral interval indicating superior migration of the humeral head. The coronal MRI image shows fatty atrophy of the supraspinatus muscle indicating the rotator cuff is irreparable. Superior migration of the humeral head, glenohumeral arthritis, and an irreparable rotator cuff describe a condition called rotator cuff arthropathy, which is an indication for a reverse total shoulder arthroplasty. A traditional total shoulder arthroplasty requires an intact rotator cuff to function properly. A reverse prosthesis moves the center of rotation inferiorly and medially, which allows the deltoid to provide forward flexion of the shoulder. The benefit of a reverse total shoulder is primary pain relief, and to a lesser extent, improved shoulder abduction, as the deltoid replaces the function of a deficient rotator cuff. 1,2
Answer D.

References
1. Familiari F, Rojas J, Doral MN, Huri G, McFarland EG. Reverse total shoulder arthroplasty. EFORT open reviews. 2018 Feb;3(2):58.
2. Gerber C, Pennington SD, Nyffeler RW. Reverse total shoulder arthroplasty. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2009 May 1;17(5):284-95.

The patient has a zone 1 sacral fracture (fracture lateral to the foramina). Sacral insufficiency and non-displaced fractures are common in older patients with poor bone quality. The initial diagnostic study of choice includes x-ray views of the sacrum. CT is best study if a fracture is unclear on x-ray or to determine the amount of displacement and/or instability. MRI is the study of choice to identify sacral insufficiency fractures. Nondisplaced sacral fractures are inherently stable and can be treated successfully with immediate weight-bearing. Gait assistance with a walker or crutches may be necessary for a short time period but prolonged immobilization should be avoided. Sacral fractures in patients of advanced age or poor quality may take up to 4 months for symptom resolution. Sacral fractures that are associated with >1 cm of displacement or have neurologic deficits require surgical treatment. 1,2
Answer C.
References
1. Mehta S, Auerbach JD, Born CT, Chin KR. Sacral fractures. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2006 Nov 1;14(12):656-65.
2. Sacral fractures. http://www.orthobullets.com. Accessed

The scapholunate (SL) ligament is an interosseous structure that stabilizes and connects the scaphoid and lunate bones during wrist motion. The SL ligament has three parts: the dorsal (strongest part of ligament, intermediary, and volar. Injury to the SL ligament is commonly caused by a fall on an outstretched hand which may cause dorsal wrist pain and swelling. SL ligament tears are often missed as AP radiographs are commonly for the injury. A clench fist view x-ray is a dynamic study to help diagnose an SL injury and will show widening of the SL interval. Bilateral clenched fist views are recommended as they consistently pick up SL gaps (if present) and subtle changes. An SL gap >3mm is considered abnormal and unstable. MRI is the best study to diagnose SL ligament tears, and determine the extent of injury, which can range from partial, complete repairable, and complete irreparable tears. Missed SL ligament injuries can progress from a partial tear to complete tear without timely treatment, leading to wrist instability and progressive arthritis. Non-operative treatment for nondisplaced SL injuries is recommended and may include casting or splinting the wrist. Complete tears on MRI and SL widening seen on dynamic x-ray should be treated operatively. 1,2
Answer A.
References
1. Schmitz MW, Morrell NT, Jacobs RC. Diagnosis and Surgical Treatment of Acute Scapholunate Ligament Injuries. JBJS JOPA, 9(2):e20.00039
2. Pappou IP, Basel J, Deal DN. Scapholunate ligament injuries: a review of current concepts. Hand. 2013 Jun;8(2):146-56.

A detailed neurovascular exam is critical after supracondylar humerus fractures. Radial and ulnar artery pulses should be palpated or found with doppler ultrasound. A pink warm hand can be present in the absence of a pulse which may be a sign of a vascular spasm or entrapment. A cold pale hand with capillary refill >2 seconds represents a poorly perfused hand. Closed reduction and percutaneous fixation in the operating room should be performed urgently in patients with decreased perfusion to avoid an ischemic injury. Closed reduction almost always restores vascular perfusion. Angiography is not indicated as closed reduction successfully restores perfusion. In the case of absent pulses after closed reduction, open exploration of the antecubital fossa may be necessary. The most common nerve to be injured with pediatric supracondylar humerus fractures is the anterior interosseous nerve. Patients with anterior interosseous nerve (AIN) injuries will not be able to flex the thumb IP joint or the DIP of the index finger (can’t make an “OK” sign). AIN injuries almost always recover over time (>90%) with an average of 49 days to complete resolution. 1,2
Answer C.
References
1. Howard, Andrew MD; Mulpuri, Kishore MD; Abel, Mark F. MD; Braun, Stuart MD; Bueche, Matthew MD; Epps, Howard MD; Hosalkar, Harish MD; Mehlman, Charles T. DO, MPH; Scherl, Susan MD; Goldberg, Michael MD; Turkelson, Charles M. PhD; Wies, Janet L. MPH; Boyer, Kevin The Treatment of Pediatric Supracondylar Humerus Fractures, Journal of the American Academy of Orthopaedic Surgeons: May 2012 – Volume 20 – Issue 5 – p 320-327
2. Barrett, Kody K.; Skaggs, David L.; Sawyer, Jeffrey R.; Andras, Lindsay; Moisan, Alice; Goodbody, Christine; Flynn, John M. Supracondylar Humeral Fractures with Isolated Anterior Interosseous Nerve Injuries: Is Urgent Treatment Necessary? J Bone Joint Surg Am, 96(21):1793-1797 | Scientific Articles | November 05, 2014

Benign bone growth that extends outward from normal bone (exostosis) are often seen incidentally on x-ray. The most common exophytic lesion diagnosed incidentally on x-ray is an osteochondroma. The classic findings of an osteochondroma include a pedunculated bony lesion in the metaphyseal region that projects away from the nearby joint. A supracondylar process (or spur) on the anteromedial aspect of the humerus (about 5 cm proximal to the medial epicondyle) has similar radiographic findings and can be confused with an osteochondroma. A fibrous band of tissue known as the ligament of Struthers attaches to the process and can cause symptomatic compression of the of the median nerve and/or brachial artery. The lesion should be differentiated from an osteochondroma. The patient’s images show the exostosis pointing toward the joint whereas an osteochondroma generally points away. The humeral cortex is continuous with an osteochondroma cortex whereas the humeral cortex is intact with a supracondylar process. 1,2
Answer B.
References
1. Mutnuru PC, Perubhotla LM. Rare Mimickers of Exostosis: A Case Series. J Clin Diagn Res. 2016 Jul;10(7):TR06-7. doi: 10.7860/JCDR/2016/18794.8193. Epub 2016 Jul 1. PMID: 27630926; PMCID: PMC5020238.
2. Shivaleela C, Suresh BS, Kumar GV, Lakshmiprabha S. Morphological study of the supracondylar process of the humerus and its clinical implications. Journal of clinical and diagnostic research: JCDR. 2014 Jan;8(1):1.

Steroid induced osteonecrosis is a condition that may occur in patients on long term systemic corticosteroid therapy. The exact pathophysiology is unclear, however steroids can disrupt the blood supply to bone leading to bone matrix and articular cartilage degeneration. Steroid induced osteonecrosis can cause joint destruction which accounts for 10% of all total joints performed annually in the Unites States. The most common location of osteonecrosis is the hips and the talus is actually quite uncommon. Higher dosage of steroids and a longer treatment duration increases the risk of developing osteonecrosis. Most patients with early disease (no talar collapse) are treated conservatively with a period of non-weight bearing (up to 3-6 months in some cases) to, in theory, offload the talus to help revascularize. Bracing and extracorporeal shock wave therapy have been used to help revascularize the talus if conservative treatments fail. Surgical procedures such as a core decompression and bone grafting have been used to salvage the talus before a larger procedure such as a fusion and talus replacement is needed. 1,2
Answer B.
References
1. Gross CE, Haughom B, Chahal J, Holmes Jr GB. Treatments for avascular necrosis of the talus: a systematic review. Foot & ankle specialist. 2014 Oct;7(5):387-97.
2. Powell C, Chang C, Naguwa SM, Cheema G, Gershwin ME. Steroid induced osteonecrosis: An analysis of steroid dosing risk. Autoimmun Rev. 2010 Sep;9(11):721-43. doi: 10.1016/j.autrev.2010.06.007. Epub 2010 Jul 9. PMID: 20621176; PMCID: PMC7105235.

Tarlov cysts, or perineural cysts, are found within the spinal canal generally at the sacral level. The cysts grow within the nerve roots and the cyst walls are made of neural tissue. The cysts communicate with the subarachnoid space and are filled with cerebral spinal fluid (CSF). The general theory is that the cyst has a one way valve that allows CSF to enter but not leave. Most of these cysts will remain small and asymptomatic (they occur in up to 9% of the population) but some can grow large enough to cause local nerve compression. Larger cysts greater than 1.5 cm are more likely to be associated with symptoms of nerve room impingement such as radicular pain, paresthesia’s, and bowel or bladder dysfunction. MRI is the best study to view a Tarlov cyst, followed by CT myelography to help demonstrate communication of the cyst with CSF. The majority of Tarlov cysts are clinically irrelevant and radicular pain is much more likely to be caused by other pathology such as a lumbar disc herniation and lumbar stenosis. Initial treatment is conservative unless the patient presents with bowel or bladder dysfunction. Surgical excision is reserved for patients with have progressive neurological deficits or severe pain that has failed conservative treatment. 1,2
Answer A.

References
1. Langdown AJ, Grundy JR, Birch NC. The clinical relevance of Tarlov cysts. Clinical Spine Surgery. 2005 Feb 1;18(1):29-33.
2. Acosta FL, Quinones-Hinojosa A, Schmidt MH, Weinstein PR. Diagnosis and management of sacral Tarlov cysts: case report and review of the literature. Neurosurgical focus. 2003 Aug 1;15(2):1-7.

A Pellegrini-Stieda lesion is a distinct x-ray finding of ossification within the medial soft tissues adjacent to the medial femoral condyle. Most cases are asymptomatic and found incidentally on x-ray but those that are symptomatic are referred to as Pellegrini-Stieda syndrome. The ossification is thought to be caused by either an MCL avulsion injury, avulsion of the gastrocnemius muscle, or ossification of the adductor magnus insertion. Injury to this area is thought to cause an inflammatory cascade that leads to delayed ossification of the surrounding soft tissues. Symptoms of Pellegrini-Stieda syndrome include pain to palpation over the medial femoral condyle and worsening pain with full knee extension and flexion. The lesion can vary in shape and size, with the larger lesions generally being more symptomatic. Generally conservative treatment with ice, oral anti-inflammatories and rest offers a successfully outcome. Refractory cases can be considered for a local corticosteroid injection or surgical excision. Results of surgical excision vary with some studies showing a high recurrence rate. 1,2

Answer A.
References
1. Weaver M. Pellegrini Stieda Disease. InStatPearls [Internet] 2021 Aug 12. StatPearls Publishing.
2. Wiegerinck JI, Somford MP. Review of Stieda’s article (1908) on the Pellegrini-Stieda lesion. Journal of ISAKOS. 2016 Jul 1;1(4):214-8.

The patient has a dorsally angulated thumb metacarpophalangeal (MCP) joint dislocation. The most common mechanism of injury is a fall on the hand causing hyperextension of the MCP joint. The classic x-ray finding is the proximal phalanx at 90 degrees from the metacarpal head. With an MCP joint dislocation, the volar plate avulses off the metacarpal neck and the collateral ligaments may be injured if rotation of the finger occurs. Thumb MCP joint dislocations can be irreducible if the volar plate, sesamoids, or flexor pollicis longus tendon become interposed dorsally in the joint. The reduction method includes dorsal to volar pressure to the proximal phalanx to push it over the metacarpal head. After a closed reduction is performed assessment of the collateral ligaments should be performed by applying a varus and valgus force to the MCP joint. Straight traction alone should be avoided to prevent entrapping the volar plate. The ideal treatment for reducible, stable dislocations has not been established. A dislocation with a stable reduction can be splinted with the MCP joint in slight flexion for 3-4 weeks. Prolonged immobilization beyond 4 weeks may result in permanent stiffness of the digit. A follow-up x-ray of the thumb in 1-2 weeks post reduction should be performed to confirm continued stability. 1,2
Answer B.
References
1. Kim JS, Hussain K, Higginbotham DO, Tsai AG. Management of thumb carpometacarpal joint dislocations: A systematic review. Journal of Orthopaedics. 2021 May 1;25:59-63.
2. Dinh, Paul MD; Franklin, Adam MD; Hutchinson, Brian MD; Schnall, Stephen B. MD; Fassola, Isabella MD. Metacarpophalangeal Joint Dislocation. Journal of the American Academy of Orthopaedic Surgeons: May 2009 – Volume 17 – Issue 5 – p 318-324

The ulnar collateral ligament (UCL) provides stability at the metacarpophalangeal (MCP) joint during tasks like grasping or pinching objects with the thumb. This patient presents with chronic UCL instability with no evidence of arthritic changes on x-ray. The original injury should have been treated in a thumb spica cast for 6 weeks to allow for UCL healing. UCL tears are generally considered chronic if they present >6 weeks out from injury. In the case of a chronic tear, direct repair is not a viable treatment choice as the quality of the torn UCL tissue deteriorates over time. Ligament reconstruction with a tendon graft is the most common procedure to restore MCP joint stability for chronic UCL tears. Patients return to normal activities 3 months postop from ligament reconstruction with an equal grip strength expected. MCP joint arthritis is a contraindication for a ligament reconstruction procedure. MCP joint fusion is a last resort option for patients who have developed arthritis in the joint and continue to have pain and instability. 1,2
Answer C.

References
1. Pulos, Nicholas MD1,a; Shin, Alexander Y. MD2,b. Treatment of Ulnar Collateral Ligament Injuries of the Thumb: A Critical Analysis Review. JBJS Reviews 5(2):e3, February 21, 2017.
2. Poggi DS, Massarella M, Piccirilli E. The Treatment of Chronic Ulnar Collateral Ligament of the Thumb Injury Using Extensor Pollicis Brevis: Surgical Technique. J Hand Surg Glob Online. 2020 Nov 10;3(1):56-60. doi: 10.1016/j.jhsg.2020.10.002. PMID: 35415531; PMCID: PMC8991867.

A burst fracture is a severe compression fracture that results in disruption of the vertebral body endplate and posterior cortex of the vertebral body. A severe axial force and flexion moment causes compression of the anterior and middle columns of the spine which can lead to retropulsion of bony fragments into the spinal canal. Stable fractures without neurological compromise can be treated conservatively with or without a TLSO and early mobilization. A burst fracture is considered unstable if the patient has neurological deficits and/or disruption of the posterior column (injury to the pedicles, lamina, facet joints, spinous process and posterior ligament complex). Evidence of a posterior column injury may include displaced fractures through the lamina, pedicles, or facet joints, widening of the interspinous distance, and edema in the posterior ligament complex on MRI. Unstable burst fractures are prone to further vertebral height collapse and bony retropulsion with normal axial loading. Severity of kyphosis, vertebral body compression, and the amount of canal compromise also play a roll in surgical decision making. This patient has a posterior column involvement with a pedicle fracture and injury to the posterior ligament complex (with T12 spinous process fracture). He underwent a T11-L 3 posterior instrumented fusion (2 levels above and below the fracture). 1,2
Answer D.
References
1. Mikles, Mark R. MD; Stchur, Robert P. MD; Graziano, Gregory P. MD. Posterior Instrumentation for Thoracolumbar Fractures. Journal of the American Academy of Orthopaedic Surgeons: November 2004 – Volume 12 – Issue 6 – p 424-435
2. Woo JH, Lee HW, Choi HJ, Kwon YM. Are “Unstable” Burst Fractures Really Unstable? J Korean Neurosurg Soc. 2021 Nov;64(6):944-949. doi: 10.3340/jkns.2021.0080. Epub 2021 Oct 25. PMID: 34689477; PMCID: PMC8590911.

The patient has started to develop posterior tibial tendon dysfunction (PTTD) as noted by the collapse of his medial arches and planovalgus deformity. Early PTTD is characterized by tendon inflammation without a change in foot shape (stage 1). As the condition progresses, the posterior tibial tendon elongates and the medial arch starts to collapse (stage 2 of 4). Obesity is one of the largest risk factors for progressive posterior tibial tendon dysfunction. The main function of the posterior tibial tendon is plantar flexion and inversion of the hindfoot. Single and double heel rises test the functional strength of the posterior tibial tendon. Early in the disease, when the tendon is inflamed, repetitive heel rises can become weak and painful with increasing attempts. As the condition progresses, many patients can’t perform a heel rise at all. This patient presents with early disease as there is no evidence of forefoot abduction or loss of talar head coverage on AP x-ray. Treatment for early PTTD is conservative with medial arch supports orthotics, stiff soled shoes, and/or a period of immobilization. 1,2

Answer A.

References

1. Jackson, J. Benjamin III MD, MBA; Pacana, Matthew J. MD; Gonzalez, Tyler A. MD, MBA. Adult Acquired Flatfoot Deformity. Journal of the American Academy of Orthopaedic Surgeons 30(1):p e6-e16, January 1, 2022.
2. Abousayed M, Alley M, Shakked R, Rosenbaum AJ. Adult Acquired Flatfoot Deformity: etiology, diagnosis, and management. JBJS REVIEWS 2017;5(8):e7.

Pediatric elbow fractures can be a challenge to diagnosis as the ossification centers of the elbow appear and close at varying ages. The capitellum is the first ossification center to appear at 1-2 years of age followed by the radial heat at 3-4, medial epicondyle at 5-6, the trochlea at 7-8, the olecranon at 9-10, and finally the lateral condyle at 11-12. The mnemonic CRITOE can be used to remember this sequence, capitellum, radial head, internal (medial) condyle, trochlea, olecranon, and external (lateral) epicondyle. Knowing this chronological sequence of ossification can help identify fractures and displacement. For instance, this patient’s olecranon ossification center has appeared so the medial epicondyle should be present. If there is any question of fracture, an x-ray of the contralateral elbow is useful for comparison. The medial epicondyle apophysis is the last growth plate to fuse in the elbow, generally between the ages of 15 and 20. The medial epicondyle is an attachment site for the forearm flexor-pronator mass and the ulnar collateral ligament. 1,2

Answer D.

References

1. Gottschalk, Hilton P. MD; Eisner, Eric MD; Hosalkar, Harish S. MD. Medial Epicondyle Fractures in the Pediatric Population. Journal of the American Academy of Orthopaedic Surgeons 20(4):p 223-232, April 2012. | DOI: 10.5435/JAAOS-20-04-223
2. Bolander S, Post G. Prompt Recognition. 5 Pediatric Elbow Fractures not to Miss. JBJS JOPA 2023; 11(2):

The differential diagnosis for hip pain in an athletic adolescent can be broad. Coxa saltans, otherwise known as “snapping hip syndrome”, can include a tight IT band snapping over the greater trochanter and catching of the iopsoas tendon at the iliopectineal eminence or on the femoral head. Other common diagnoses may include tight hip flexors, hip dysplasia, acetabular labral tear, and femoroacetabular impingement. Hip dysplasia generally produces symptoms of hip instability (popping sensation, pain with activities) and is associated with chronic symptoms for years. Radiographs of the hip will show decreased femoral head coverage with a lateral center-edge angle (LCEA) <20 degrees. Femoroacetabular impingement (FAI) causes pain with hip flexion and rotation and patients may describe their pain using a C sign by cupping the anterior lateral aspect of the hip with the thumb and forefingers. FAI is opposite to hip dysplasia as the condition is caused by over coverage of the femoral head by the acetabulum. FAI usually has an increased LCEA >40 degrees. Conservative treatment is initially recommended for all adolescent patients presenting with athletic related hip pain. A period of rest and NSAIDS can usually settle down an inflammatory condition like tendinitis or hip joint synovitis. Physical therapy is also important to stretch tight muscles and tendons and to strengthen the hip joint for athletic performance. 1,2

Answer A.

References

1. Schmitz, Matthew R. MD; Murtha, Andrew S. MD;  The ANCHOR Study Group; Clohisy, John C. MD. Developmental Dysplasia of the Hip in Adolescents and Young Adults. Journal of the American Academy of Orthopaedic Surgeons 28(3):p 91-101, February 1, 2020.
2. Allen, William C. MD; Cope, Ray MD. Coxa Saltans: The Snapping Hip Revisited. Journal of the American Academy of Orthopaedic Surgeons 3(5):p 303-308, September 1995.

The patient has an avulsion fracture of the less trochanter. Avulsion fractures are commonly seen in the pediatric population at secondary ossification centers including the ischial tuberosity, anterior superior iliac spine, and anterior inferior iliac spine, and less often in the tibial tubercle, calcaneus, and greater and lesser trochanters. Secondary ossification centers act as attachment sites for tendons and ligaments and don’t contribute to the length of bone. Secondary ossification centers generally fuse by 17 years of age so the most common age group for avulsion fractures are adolescent athletes. In adolescents the tendon attachment is stronger than the growth plate so sudden contraction of the attached tendon/muscle can result in an avulsion injury. Avulsion injuries are diagnosed radiographically in most cases and advanced imaging is not necessary unless the diagnosis is in question. Isolated lesser trochanter avulsion fractures occur with a sudden contraction of the iliopsoas muscle (hip flexor). Patients present with groin pain, difficulty ambulating, and inability to flex the hip. Lesser trochanter avulsion fractures are treated non-operatively with a 3-4 week period of rest and crutches for support, followed by a gradual rehab back into athletic activities. Sports should be resumed when the patient is asymptomatic and there are radiographic signs of healing, which may take 2-3 months. The prognosis for lesser trochanter avulsion injuries is excellent and surgery is only considered if patients develop a symptomatic nonunion and/or a painful exostosis. Surgery involves removal of the painful nonunion with reattachment of the iliopsoas to the proximal femur. 1,2

Answer C.

References

1. Tahir T, Manzoor QW, Gul IA, Bhat SA, Kangoo KA. Isolated Avulsion Fractures of Lesser Trochanter in Adolescents – A Case Series and Brief Literature Review. J Orthop Case Rep. 2019 Jan-Feb;9(1):11-14.
2. Schiller, Jonathan MD; DeFroda, Steven MD, ME; Blood, Travis MD. Lower Extremity Avulsion Fractures in the Pediatric and Adolescent Athlete. Journal of the American Academy of Orthopaedic Surgeons 25(4):p 251-259, April 2017.

The ulnar collateral and radial collateral ligaments provide stability to the MCP joint of the thumb and are critical structures for thumb function. The ulnar collateral ligament on the ulnar side of the thumb is particularly important for grasping objects and is 10 times more likely to be injured than the radial collateral ligament. UCL injuries represent 86% of all athletic thumb injuries. Treatment of bony avulsion injuries is controversial but general guidelines include conservative treatment if the fracture is displaced <2mm. Larger fragments (involving >30% of the joint space) and >2mm of displacement tend to have more thumb instability with conservative treatment. Fracture rotation can also lead to a nonunion so x-rays should be critically reviewed for alignment of the fracture fragment.  Treatment of nondisplaced, and <2mm displaced, bony UCL injuries involves immobilization with a thumb spica cast for 6 weeks. 1,2

Answer A

References

1. Thumb collateral ligament injuries. http://www.orthobullets.com. Accessed on 4/30/23
2. Chang, Andy L. MD; Merkow, David B. MD; Bookman, Jared S. MD; Glickel, Steven Z. MD. Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injuries: Management and Biomechanical Evaluation. Journal of the American Academy of Orthopaedic Surgeons 31(1):p 7-16, January 1, 2023. | DOI: 10.5435/JAAOS-D-22-00112

The cauda equina consists of peripheral nerve roots (L1-S5) that continue from the spinal cord (picture a horse tail leaving the spinal cord) and is surrounded by a dural sac within the lumbar spinal canal. Lumbar disc herniations that compress peripheral roots can cause a number of symptoms including lower back pain, leg pain, and numbness and weakness in the lower extremities. A large disc herniation that occupies the central canal can compress the cauda equina causing severe motor and sensory impairment, or cauda equina syndrome (CES). Symptoms of CES may vary and include lower extremity pain and weakness, saddle anesthesia, and loss of bowel or bladder function. Loss of bladder function is a required element of CES and can vary from difficulty initiating a urinary stream to full incontinence. If symptoms of CES exist an urgent MRI must be performed to confirm the diagnosis and prepare for surgery. Neurological deficits can progress rapidly and become permanent with CES unless the disc herniation is removed and pressure is taking off the nerve roots. Emergent surgical decompression should be performed within 24-48 hours of symptom onset to improve neurological recovery. 1,2

Answer D.

References

1. Spector, Leo R. MD; Madigan, Luke MD; Rhyne, Alfred MD; Darden, Bruce II MD; Kim, David MD. Cauda Equina Syndrome. Journal of the American Academy of Orthopaedic Surgeons 16(8):p 471-479, August 2008.
2. Gitelman A, Hishmeh S, Morelli BN, Joseph Jr SA, Casden A, Kuflik P, Neuwirth M, Stephen M. Cauda equina syndrome: a comprehensive review. Am J Orthop (Belle Mead NJ). 2008 Nov 1;37(11):556-62.

The prevalence of meniscus tears increases with age and patients over 70 years old more common than not will have an asymptomatic meniscus tear. In fact, male patients over 50 were found to have a 32% prevalence of a meniscal tear and a 56% prevalence in patients over 70. The prevalence of meniscus tears increases dramatically in the presence of arthritis. Among patients with moderate to severe arthritis (grades 3 and 4 changes on x-ray) 95% had meniscus damage. The take home message to this is the incidental finding of a meniscus tear in patients with knee arthritis is very common. Patients over 50 years of age should understand the high likelihood of finding an asymptomatic meniscus tear when ordering an MRI and when interpreting the results. Surgical treatment with an arthroscopic meniscectomy in the presence of knee arthritis has poor outcomes as the arthroscopy treats the meniscus tear but not the underling arthritis. The degenerative pattern of a meniscus tear in patients over 50 with underlying arthritis should be treated with a focus on the arthritis and not with an arthroscopic meniscectomy. 1,2

Answer B.

References

1. Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M, Felson DT. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. New England Journal of Medicine. 2008 Sep 11;359(11):1108-15.
2. Buchbinder R, Harris IA, Sprowson A. Management of degenerative meniscal tears and the role of surgery. Bmj. 2015 Jun 4;350.

Quervain (stenosing tenosynovitis) is a condition where the tendons become inflamed and swollen which causes friction and pain at the first dorsal compartment during thumb motion. The Finkelstein test is a reliable test to make the diagnosis and includes tucking the thumb in a clenched fist and ulnar deviating the wrist. X-rays of the thumb can help rule out carpometacarpal (base of the thumb) arthritis. A period of rest and immobilization with a thumb spica splint is recommended initially to help reduce the friction of the tendons gliding under the fibrous tissue of the first dorsal compartment. Corticosteroid injections offer a very successful treatment option should more conservative treatments fail. Many patients get complete relief after one injection. Nearly all patients will have relief of symptoms with a combination of an injection and intermittent immobilization at 6 months. If patients fail two injections and continue to have pain surgical treatment with an open release of the first dorsal compartment is a successful option. 1,2

Answer C.

References

1. Ilyas, Asif M. MD; Ast, Michael MD; Schaffer, Alyssa A. MD; Thoder, Joseph MD. de Quervain Tenosynovitis of the Wrist. Journal of the American Academy of Orthopaedic Surgeons 15(12):p 757-764, December 2007.
2. Larsen C, Fitzgerald M, Nellans K, Lane L. Management of de Quervain Tenosynovitis: A Critical Analysis Review. JBJS Rev, 9(9):e21.00069

Patients that present with a suspected scaphoid injury with negative x-rays create a treatment dilemma for providers. Treating the injury as a suspected occult fracture or obtaining immediate advanced imaging is the controversial next step. Up to 30% to 40% of scaphoid fractures are missed with clinical exam and initial x-rays and a missed diagnosis can lead to long term complications. Anatomical snuffbox tenderness is the most sensitive physical exam finding for identifying scaphoid fractures. Many providers treat patients with snuffbox tenderness with wrist immobilization due to a suspected fracture. However, treating all suspected scaphoid fractures as true fractures can result in unnecessary immobilization, lost time from sports and/or work, and potentially post-immobilization stiffness. Obtaining immediate advanced imagining is favored in most cost and outcome models as a negative MRI avoids the expense of further follow-up visits and repeat x-rays. If an immediate MRI is not available or unaffordable, a reasonable approach would be to repeat a physical exam and x-rays 2 weeks after the initial office visit. 1,2

Answer C

References

1. Karl JW, Swart E, Strauch RJ. Diagnosis of Occult Scaphoid Fractures: A Cost-Effectiveness Analysis. J Bone Joint Surg Am, 97(22):1860-1868 | Scientific Articles | November 18, 2015
2. Stirling PH, Strelzow JA, Doornber JN, White TO, McQueen MM, Duckworth AD. Diagnosis of Suspected Scaphoid Fractures. JBJS Rev, 9(12):e20.00247 | Review Articles | December 08, 2021

The sternoclavicular (SC) joint consists of the medial clavicle that articulates with the sternum in a shallow saddle type joint. Much of the stability of the SC joint is provided by the surrounding ligaments. The SC joint is just beneath the subcutaneous tissue and therefore even mild swelling of the joint can be visible. Many patients present with asymptomatic swelling of the SC joint with concerns of malignancy or joint instability. Swelling from the joint without a history of trauma is most likely from degenerative arthritis. A history of IV drug abuse with an acutely red and swollen SC joint should raise concern of septic arthritis. The diagnosis is often made by clinical exam and radiographs. Subtle findings of joint space narrowing and sclerosis can be difficult to see with overlapping bone. Treatment is almost always conservative with ice and NSAIDs to help bring down the swelling. A local steroid injection should be considered with caution as critical vascular structures lie just beneath the SC joint. In rare cases an SC joint resection is a surgical option that could be considered if conservative treatments fail. 1,2

Answer B.

References

1. Higginbotham, Thomas O. MD; Kuhn, John E. MD. Atraumatic Disorders of the Sternoclavicular Joint. Journal of the American Academy of Orthopaedic Surgeons 13(2):p 138-145, March 2005.
2. Robinson CM, Jenkins PJ, Markham PE, Beggs I. Disorders of the sternoclavicular joint. The Journal of Bone & Joint Surgery British Volume. 2008 Jun 1;90(6):685-96.

Ulnar sided wrist pain is a common presenting symptom but can be difficult to determine a cause. Common causes may include TFCC tears, a ligament sprain, distal radial ulnar joint (DRUJ) arthritis and instability, fractures and tendinitis. The triangular fibrocartilage complex (TFCC) is a ligament structure that supports the carpus and DRUJ. TFCC injuries can occur with a traumatic fall or degenerate over time. TFCC injuries present with ulnar sided wrist pain when opening a door knob or turning a key. The most common mechanism of injury is a fall with the wrist in extension and the forearm in pronation. On physical exam patients will have pain over the soft spot between the ulnar styloid and flexi carpi ulnaris tendon (fovea sign). X-rays will be negative with TFCC injuries and an MRI is the study of choice to confirm the diagnosis. Diagnostic wrist arthroscopy with repair or debridement is the recommended surgical approach when conservative treatments have failed. 1,2

Answer B.

References

1. DaSilva, Manuel F. MD; Goodman, Avi D. MD; Gil, Joseph A. MD; Akelman, Edward MD. Evaluation of Ulnar-sided Wrist Pain. Journal of the American Academy of Orthopaedic Surgeons 25(8):p e150-e156, August 2017. | DOI: 10.5435/JAAOS-D-16-00407
2. Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand clinics. 2011 Aug 1;27(3):263-72.

Ankle fractures are a very common pediatric injury, only behind distal radius and finger injuries as the most common fracture locations involving growth plates. The distal tibial physis contributes to 40% growth of the tibia so an ankle injury that causes growth arrest can be devastating. Distal tibial physis closure generally occurs by 16 years of age for boys and 14 for girls. Before this time the surrounding ligament structures can be stronger than the growth plates, which leads to a tendency for growth plate fractures over ankle sprains in this age group. Over a period of 18 months, the distal tibial physis closes first in the middle of the physis, then the medial part, and lastly the lateral side. A Tillaux fracture is a Salter-Harris III fracture of the anterolateral portion of the distal tibia, which results from an epiphyseal avulsion at the attachment site of the anterior talofibular ligament. Triplane fractures have fracture lines in 3 planes which involve the metaphyseal fragment posteriorly and an epiphyseal fragment which is more often lateral than medial. The patients fracture appears to involve the epiphysis and physis which is characteristic of a Salter-Harris Type III fracture. 1,2

Answer D

References

1. Kay, Robert M. MD; Matthys, Gary A. MD. Pediatric Ankle Fractures: Evaluation and Treatment. Journal of the American Academy of Orthopaedic Surgeons 9(4):p 268-278, July 2001.
2. Blackburn EW, Aronsson D, Rubright J, Lisle J. Current Concepts Review: Ankle fractures in Children. J Bone Joint Surg Am. 2012;94:1234-44

The scaphoid bone is a difficult one to fracture given its tenuous blood supply and its predilection for not healing. The blood supply to the scaphoid flows from a distal to proximal direction which causes scaphoid waist and proximal pole fractures to be more likely to form a non-union. Treatment of scaphoid waist fractures remains controversial but in general <2mm of displacement can be considered for conservative treatment with cast immobilization. Casting for a minimum of 8 weeks is generally recommended for scaphoid waist fractures. CT can be performed at 8 weeks to see if bridging callus is present. If there is significant bridging callus present then mobilization of the wrist may begin. Practically speaking, not every patient can get a CT so factors such as anatomical snuffbox tenderness and interval healing on x-ray are important factors. High risk patients such as those who work construction or athletes generally require 12-14 weeks of immobilization. Immobilization and serial x-rays every 3 weeks or so should be continued until radiographic signs of healing, which may take up to 4-6 months in some cases.  Bone resporption is common to see in scaphoid waist fractures at 4-6 weeks but this generally improves 4-6 weeks later on repeat x-rays. Concerning signs on x-ray that the fracture may be going on to a non-union include lack of interval healing, sclerosis of the fracture, cystic changes, increasing bone resorption on subsequent x-rays, and further displacement. 1,2

Answer B.

References

1. Li, Neill Y. MD; Dennison, David G. MD; Shin, Alexander Y. MD; Pulos, Nicholas A. MD. Update to Management of Acute Scaphoid Fractures. Journal of the American Academy of Orthopaedic Surgeons ():10.5435/JAAOS-D-22-01210, June 16, 2023.
2. Fan S, Suh N, Grewal R. Observation of bony resorption during scaphoid fracture healing: a case series. Journal of Hand Surgery (European Volume). 2020 Oct;45(8):874-6.

Acute carpel tunnel syndrome (ACTS) can occur after a distal radius fracture due to elevated compartment pressures in the wrist from swelling and compression from a displaced fracture. A carpel tunnel contusion can be differentiated from ACTS by worsening symptoms over time in ACTS. Generally symptoms are watched over a few days to follow symptom progression and wait for swelling to subside prior to surgery. Failing to recognize ACTS can lead to permanent injury to the medial nerve. ACTS is diagnosed clinically with pain and paresthesia in the medial nerve distribution or thumb, index, and middle fingers. Fracture translation >35% and female patients less than 48 years of age are at higher risk of developing persistent carpel tunnel syndrome. Patients with persistent or worsening ACTS symptoms should have a prophylactic carpel tunnel release at the time of open reduction and internal fixation (ORIF). A closed reduction of a displaced fracture and splinting may also help ACTS symptoms before definitive surgery. The incidence of ACTS after a distal radius fracture is around 9% and the symptoms are severe enough in 5% of patients to require a carpel tunnel release. A carpel tunnel release can be performed with a separate incision at the time of ORIF of a distal radius fracture. 1,2

Answer D.

References

1. Leow, J.M., Clement, N.D., McQueen, M.M. et al. The rate and associated risk factors for acute carpal tunnel syndrome complicating a fracture of the distal radius. Eur J Orthop Surg Traumatol 31, 981–987
2. Dyer G, Lozano-Calderon S, Gannon C, Baratz M, Ring D. Predictors of acute carpal tunnel syndrome associated with fracture of the distal radius. The Journal of hand surgery. 2008 Oct 1;33(8):1309-13.

Adhesive capsulitis is characterized by functional loss of both passive and active shoulder range of motion due to a fibroplastic proliferation of the joint capsule. Adhesive capsulitis most commonly occurs in middle-aged women and has a high association with hypothyroidism and diabetes. Most cases will resolve with conservative treatment within 6 months. The key to treatment is continued shoulder motion with physical therapy and a home stretching program. The focus should be a gentle and progressive stretching program. An intra-articular corticosteroid injection has been shown to improve passive motion and shorten the overall duration of symptoms.  Functional deficits after >6 months of physical therapy warrant discussion about surgical options which may include a manipulation under anesthesia or an arthroscopic capsular release. Sling immobilization is contraindicated because it likely will promote further joint contracture and prolonged recovery. 1,2

Answer B.

References

1. Redler, Lauren H. MD; Dennis, Elizabeth R. MS, MD. Treatment of Adhesive Capsulitis of the Shoulder. Journal of the American Academy of Orthopaedic Surgeons 27(12):p e544-e554, June 15, 2019. | DOI: 10.5435/JAAOS-D-17-00606
2. Wang W, Shi M, Zhou C, Shi Z, Cai X, Lin T, Yan S. Effectiveness of corticosteroid injections in adhesive capsulitis of shoulder: a meta-analysis. Medicine. 2017 Jul;96(28).

The patient has a bunionette deformity, also known as a Tailors bunion, which is characterized by a prominence of the lateral aspect of the 5^th metatarsal head. Bunionettes are often seen in adolescents and adults and are more common in females. The deformity results from compression of the forefoot and can lead to forefoot pain and callus formation over the prominence. Nonoperative management is the first line treatment of bunionette deformities and includes NSAIDS, shoe wear modification to increase the toe box and semi rigid soles, orthotics, keratosis padding, and/or callous shaving. Non-operative treatment is generally successful, but should symptoms become persistent and severe, surgical options are available including a lateral condylectomy and osteotomy procedures. 1,2

Answer B.

References

1. Shi, Glenn Guangyu MD; Humayun, Ammar MD; Whalen, Joseph L. MD, PhD; Kitaoka, Harold B. MD. Management of Bunionette Deformity. Journal of the American Academy of Orthopaedic Surgeons 26(19):p e396-e404, October 1, 2018. | DOI: 10.5435/JAAOS-D-17-00345
2. Koti M, Maffulli N. Bunionette. J Bone Joint Surg Am. 2001 Jul;83(7):1076-82. doi: 10.2106/00004623-200107000-00016. PMID: 11451980.

The patient presents with a pathological fracture to the proximal radius. After calling the nursing facility where she resides, it was determined she has a history of breast cancer diagnosis 10 years ago but was in remission. Bone is the most common site for first distant relapse of breast cancer. Most pathological fractures are due to metastatic disease with lung, breast, thyroid, renal and prostate being the most common primary sources. In patients over 40, metastatic disease is 500 times more likely than a primary bone sarcoma. Aggressive features on this patient’s bone lesion that indicates a pathological fracture include cortical disruption and periosteal reaction. X-ray is the best modality in characterizing a pathological fracture. Pathological fractures have altered healing biology due to destructive cancer cells and may be slow to heal, or may never heal, depending on life expectancy. External beam radiation therapy may be used to treat pathological fractures from spreading and help relieve pain. Most impending or pathological fractures of the upper extremity can be treated in a sling for comfort. 1,2

Answer D.

References

1. Rizzo SE, Kenan S. Pathologic Fractures. [Updated 2023 Jan 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
2. Hamaoka T, Madewell JE, Podoloff DA, Hortobagyi GN, Ueno NT. Bone imaging in metastatic breast cancer. Journal of Clinical Oncology. 2004 Jul 15;22(14):2942-53.

Osteoporosis related lumbar compression fractures are a common injury in the aging population. Patients can often be treated conservatively with a corset brace, NSAIDs, and if necessary, narcotic pain medication. Pain associated with lumbar compression fractures can last much longer than other fracture types, in some cases lasting up to 4-6 months. Cement augmentation with kyphoplasty is another treatment option that can help relieve lower back pain and preserve vertebral height in patients who have failed at least 2-3 weeks of conservative treatment. MRI should be performed if a kyphoplasty is considered. MRI is critical in determining the age of fracture, with bony edema signaling an acute or subacute process. The absence of bony edema on MRI indicates a chronic fracture which is not amenable to kyphoplasty. Time to kyphoplasty is controversial with most agreeing non-operative treatment should be trialed for 2-3 weeks after onset of symptoms. The average time to kyphoplasty after onset of symptoms in one large meta-analysis was 10 weeks, with the same study showing improved outcomes with surgery over conservative care. Kyphoplasty has not been shown to increase the risk of adjacent, or secondary, vertebral fractures. Relative contraindications for kyphoplasty include bone retropulsion, the presence of radiculopathy, and greater than 70% vertebral height loss. 1,2

Answer A.

References

1. Halvachizadeh S, Stalder AL, Bellut D, Hoppe S. Systematic Review and Meta-Analysis of 3 Treatment Arms for Vertebral Compression Fractures. A Comparison of Improvement in Pain, Adjacent-Level Fractures, and Quality of Life Between Vertebroplasty, Kyphoplasty, and Nonoperative Management. JBJS Rev, 9(10):e21.00045
2. Savage JW, Schroeder GD, Anderson PA. Vertebroplasty and kyphoplasty for the treatment of osteoporotic vertebral compression fractures. J Am Acad Orthop Surg. 2014 Oct;22(10):653-64.

The patient presents with a congenital vertebral synostosis (CVS) at L1-L2.  A congenital lumbar synostosis is caused by failure of lumbar spine segmentation resulting in inappropriate vertebral fusion. CVS is generally found incidentally on x-ray as patients are often symptom free. Symptoms can arise if patients develop adjacent segment degeneration or lumbar stenosis. The amount of fusion can vary from partial or complete fusion of the vertebral endplates, facet joints, laminae, and spinous processes. Complete vs partial fusion depends on early or late failure of normal development. Complete vertebral fusion suggests early developmental failure. The majority of congenital fusions occur in the cervical spine, where they are often associated with Klippel-Feil syndrome. The patient was advised to perform core strengthening at home and monitor symptoms. 1,2

Answer A.

References

1. Volk AM, Mathkour M, Iwanaga J, Dumont AS, Tubbs RS. A Comprehensive Review of Congenital Lumbar Synostosis and Associated Findings. Cureus. 2021 Oct 24;13(10):e19013. doi: 10.7759/cureus.19013. PMID: 34824930; PMCID: PMC8610779.
2. Paraskevas GK, Noussios G, Koutsouflianiotis KN, Iliou K. Congenital synostosis of cervical vertebrae: an osteological study and review of the literature. Cureus. 2019 Oct 28;11(10).

The patient presents with a congenital vertebral synostosis (CVS) at L1-L2.  A congenital lumbar synostosis is caused by failure of lumbar spine segmentation resulting in inappropriate vertebral fusion. CVS is generally found incidentally on x-ray as patients are often symptom free. Symptoms can arise if patients develop adjacent segment degeneration or lumbar stenosis. The amount of fusion can vary from partial or complete fusion of the vertebral endplates, facet joints, laminae, and spinous processes. Complete vs partial fusion depends on early or late failure of normal development. Complete vertebral fusion suggests early developmental failure. The majority of congenital fusions occur in the cervical spine, where they are often associated with Klippel-Feil syndrome. The patient was advised to perform core strengthening at home and monitor symptoms. 1,2

Answer A.

References

1. Volk AM, Mathkour M, Iwanaga J, Dumont AS, Tubbs RS. A Comprehensive Review of Congenital Lumbar Synostosis and Associated Findings. Cureus. 2021 Oct 24;13(10):e19013. doi: 10.7759/cureus.19013. PMID: 34824930; PMCID: PMC8610779.
2. Paraskevas GK, Noussios G, Koutsouflianiotis KN, Iliou K. Congenital synostosis of cervical vertebrae: an osteological study and review of the literature. Cureus. 2019 Oct 28;11(10).

Proximal phalanx fractures of the hand can be unstable fractures due to the deforming forces placed on the bone. The interosseous muscles insert on the base of the proximal phalanx and can flex the proximal fracture fragment while the flexor and extensor tendons apply a shortening force to the fracture. The most stable nondisplaced transverse fractures can withstand these deforming forces, however, the unstable displaced, comminuted, or oblique fracture patterns tend to displace. Non displaced fractures can be treated with immobilization with the metacarpophalangeal (MCP ) joint in 70-90 degrees of flexion which reduces the displacing forces of the surrounding soft tissue. A removeable boxer fracture splint is a good option for reliable patients otherwise a ulnar gutter cast may be required. Immobilization for 3 weeks is recommended or until fracture healing is found on x-ray, at which time buddy tapping can be resumed for another 3 weeks. Buddy taping can also help with initial immobilization to help with rotational stability. Fractures that are displaced, shortened and unstable often require surgery. Relative indications for surgery include fractures that are angulated, malrotated, or shortened by more than 5 mm. Shortened fractures can result in an extension lag to the finger. Percutaneous fixation is often performed for displaced proximal third fractures where middle and distal third fractures are often treated with open reduction and internal fixation. Because displaced fractures are so unstable, closed reduction and casting is usually not an option unless patients have a contraindication to surgery. 1,2

Answer C.

References

1. Lögters TT, Lee HH, Gehrmann S, Windolf J, Kaufmann RA. Proximal Phalanx Fracture Management. Hand (N Y). 2018 Jul;13(4):376-383. doi: 10.1177/1558944717735947. Epub 2017 Oct 27. PMID: 29078727; PMCID: PMC6081790.
2. Kozin, Scott H. MD; Thoder, Joseph J. MD; Lieberman, Glenn MD. Operative Treatment of Metacarpal and Phalangeal Shaft Fractures. Journal of the American Academy of Orthopaedic Surgeons 8(2):p 111-121, March 2000.

An interdigital (Morton’s) neuroma is an entrapment neuropathy of the interdigital nerve of the foot. The interdigital nerve at the 3^rd webspace  (between the 3^rd and 4^th metatarsal heads) is the most commonly affected followed by the 4^th webspace. The cause is thought to be from the nerve being compressed by the intermetatarsal ligament, metacarpal heads, and/or the tissues surrounding the MTP joints. Walking in tight shoe ware compresses the intermetatarsal joint and usually worsens symptoms of pain and/or feeling like there is a pebble in the shoe. Symptoms can be reproduced by compressing the metatarsal heads together. A palpable click when squeezing the metatarsals together is considered a positive Mulder sign. MRI and US have equal sensitivity in diagnosing Morton’s neuroma but are only used if the clinical picture is unclear. An interdigital injection should be performed to make the most accurate diagnosis. 1,2

Answer A.

References

1. Pomeroy, Gregory MD; Wilton, James DPM; Anthony, Steven DO. Entrapment Neuropathy About the Foot and Ankle: An Update. Journal of the American Academy of Orthopaedic Surgeons 23(1):p 58-66, January 2015. | DOI: 10.5435/JAAOS-23-01-58
2. Bignotti B, Signori A, Sormani MP, Molfetta L, Martinoli C, Tagliafico A. Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. European radiology. 2015 Aug;25:2254-62.

Knowing how to differentiate stable and unstable ankles fractures is critical in determining which injuries would do better with surgical treatment. Ankle stability is provided by the bones of the ankle and the surrounding ligament structures. The lateral ligaments include the anterior talofibular (ATFL), calcaneofibular (CFL) and posterior talofibular (PTFL).  The medial side of the ankle is stabilized by the deltoid ligament and the syndesmosis between the fibula and tibia is stabilized by the anterior and posterior inferior tibiofibular ligaments (AITFL and PITFL) and the interosseus ligament. Fracture patterns help dictate if a fracture is stable and if ligament structures have been injured. For instance, the more proximal that a fibular fracture occurs the more likely it is unstable. Medial sided deltoid tenderness on physical exam was once thought to indicate an unstable injury, however tenderness may indicate a superficial deltoid injury only and the stronger deep fibers may remain intact. A complete deltoid rupture will show medial clear space widening and lateral talar shift on mortise view x-ray indicating a unstable injury. If a complete deltoid injury is suspected (high fibular fracture, syndesmosis tenderness, normal initial x-rays) a weight bearing x-ray can be obtained 7-10 days after the injury to the stress the joint. MRI has not been shown to reliably, or accurately, determine a partial vs. complete deltoid rupture and is not recommended for ankle fractures.

Answer A.

References

1. Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures: diagnosis and treatment. EFORT open reviews. 2018 May;3(5):294.
2. Nortunen S, Lepojärvi S, Savola O, Niinimäki J, Ohtonen P, Flinkkilä T, Lantto I, Kortekangas T, Pakarinen H. Stability assessment of the ankle mortise in supination-external rotation-type ankle fractures: lack of additional diagnostic value of MRI. JBJS. 2014 Nov 19;96(22):1855-62.

The primary soft tissue restraint to a valgus force to the elbow includes the flexor pronator mass, the ulnar collateral ligament (UCL), and the joint capsule. The most common presentation of a UCL injury is medial elbow pain in an overhead throwing athlete. Repetitive throwing causing attritional wear of the UCL which tears over time. In non throwing athletes, the UCL is more likely to be injured by an acute traumatic event that causes a valgus load to the elbow such as gymnastics and mixed martial arts. If a UCL tear is suspected, MRI is the study of choice to confirm the diagnosis and determine if the tear is partial vs. complete. In overhead athletes, the results of nonoperative treatment are poor with less than half of pitchers able to return to throwing at a preinjury level. UCL injuries in non-throwing athletes can usually be managed with nonoperative treatment including a period of activity restrictions, bracing, and rehab.  Platelet rich plasma injections into the UCL with a structured rehab program has shown promising results for improved stability and earlier return to play. Partial tears may return to sports as early as 4-6 weeks whereas complete tears may require 3-4 months and are more likely to require surgery.  Surgery is generally reserved for patients with persistent valgus instability despite > 6 months of non-surgical management. 1,2

Answer B.

References

1. Swindell, Hasani W. MD; Trofa, David P. MD; Alexander, Frank J. MS, ATC; Sonnenfeld, Julian J. MD; Saltzman, Bryan M. MD; Ahmad, Christopher S. MD. Nonsurgical Management of Ulnar Collateral Ligament Injuries. JAAOS: Global Research and Reviews 5(4):e20.00257, April 2021. | DOI: 10.5435/JAAOSGlobal-D-20-00257
2. Erickson B, Romeo A. The Ulnar Collateral Ligament Injury Evaluation and Treatment. J Bone Joint Surg Am, 99(1):76-86 | Current Concepts Review | January 04, 2017

A hip dislocation is one of the most common complications seen after total hip arthroplasty. Most hip dislocations occur within 3 weeks post op due to inadequate soft tissue healing whereas late dislocations generally occur from failure of implants. Patients who sustain a hip dislocation usually report a pop or clunk sensation and an inability to bear weight on the affected extremity. On physical exam of a posterior hip dislocation the affected extremity is usually shortened, adducted and internally rotated. An anterior hip dislocation presents with a flexed, abducted and externally rotated extremity. Treatment of a total hip dislocation includes a closed reduction under sedation if there is no periprosthetic fracture. The reduction maneuver is guided by the direction of the dislocation on radiographs. A posterior dislocation is reduced with the patient supine and traction and internal rotation is initially placed, followed by external rotation when the femoral head has cleared the acetabular rim. Reducing an anterior dislocation is the opposite; initial traction and externally rotation followed by internal rotation when the head clears the cup. 1,2

Answer A

References

1. Saiz AM, Lum ZC, Pereira GC. Etiology, evaluation, and management of dislocation after primary total hip arthroplasty. JBJS reviews. 2019 Jul 1;7(7):e7.
2. Soong M, Rubash HE, Macaulay W. Dislocation after total hip arthroplasty. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2004 Sep 1;12(5):314-21.

Distal clavicle fractures represent the minority of clavicle fractures (most common is midshaft) and can be prone to nonunion. The conoid (medial) and trapezoid (lateral) ligaments are known as the CC ligaments (coracoclavicular ligaments) and provide resistance to superior migration of the lateral clavicle. Disruption of these ligaments can cause an unstable fracture pattern. Fractures that occur lateral to the CC ligaments and outside of the AC joint are stable type 1 injuries. Fractures that occur between or at the attachment sites of the CC ligaments (type 2) are prone to poor healing with non-union rates between 28% and 44%, with most nonunions described as lack of bone bridging 12 months from injury. Nondisplaced and minimally displaced type 2 fractures (presence of cortical contact between bone ends of the fracture) can be treated nonoperatively with a sling for 2 weeks and lifting restrictions for 6-8 weeks. Nonunion is more common with displaced type II fractures and in patients with advanced age. Often times patients who do go on to non-union with distal clavicle fractures with be asymptomatic which further advocates for non-operative treatment. The risk of nonunion and displacement should be discussed with patients at their initial visit and followed closely with serial radiographs through 6-8 weeks. 1,2

Answer A.

References

1. Van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: current concepts review. Journal of shoulder and elbow surgery. 2012 Mar 1;21(3):423-9.
2. Banerjee R, Waterman B, Padalecki J, Robertson W. Management of distal clavicle fractures. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2011 Jul 1;19(7):392-401.

The wedge-shaped triquetrum is in the proximal row of the carpus and articulates with the lunate, hamate, and pisiform. Triquetral fractures are the second most common type of carpal fracture behind scaphoid fractures. The most common form of fracture is a dorsal avulsion fracture as the strong dorsal ligaments of the wrist can pull a sleave of bone off the triquetrum. The most common mechanism of injury is a fall on an outstretched hand with the wrist in extension and ulnar deviation. Triquetral fractures are often difficult to detect on radiographs but given the benign nature of the injury, advanced imaging such as MRI or CT are rarely used unless other injuries are suspected. On physical exam patients will have pain and swelling on the ulnar side of the wrist. Treatment involves a wrist splint or cast for 3-4 weeks followed by early motion. Wrist pain should subside by 6-8 weeks. Repeat x-rays are usually not helpful in guiding treatment as many dorsal avulsion fractures will go on to an asymptomatic fibrous non-union (doesn’t look healed on x-ray). 1,2

Answer C.

References

1. Guo RC, Cardenas JM, Wu CH. Triquetral fractures overview. Current Reviews in Musculoskeletal Medicine. 2021 Apr;14:101-6.
2. Hopkins A, Bowman SR, Preketes AP, Dowd MB. Triquetral fractures—a retrospective, multi-centre study of management and outcomes. Australasian Journal of Plastic Surgery. 2020 Mar 23;3(1):11-5.

Ankle injuries are very common in the pediatric population and can be a challenge to determine the cause of pain. Differentiating a Salter Harris (SH) I fracture of the distal fibula vs. a lateral ankle sprain is the most common diagnostic dilemma as both have a similar injury mechanism, physical exam, and radiographic findings. Boutis et al. performed an MRI one week after injury in pediatric patients (mean age of 8) who were diagnosed with SH I fractures and found that over 80% had a ligament injury. A repeat ankle x-ray taken 4 weeks after injury showing periosteal new bone formation is one of the few ways to confirm a SH I fracture.  An ankle sprain and a SH I fracture can both be treated with a walking boot, an air stirrup brace, or a cast for 3-4 weeks with activity modification for 1-2 weeks thereafter. An air stirrup ankle brace offered an earlier return to activities and was preferred over casting by most kids with stable ankle fractures. 1,2

Answer B.

References

1. Shirley, Eric D. MD; Maguire, Kathleen Joan MD; Mantica, Abigail Louise MD; Kruse, Richard Wayne DO, MBA. Alternatives to Traditional Cast Immobilization in Pediatric Patients. Journal of the American Academy of Orthopaedic Surgeons 28(1):p e20-e27, January 1, 2020. | DOI: 10.5435/JAAOS-D-18-00152
2. Hofsli M, Torfing T, Al-Aubaidi Z. The proportion of distal fibula Salter–Harris type I epiphyseal fracture in the paediatric population with acute ankle injury: a prospective MRI study. Journal of Pediatric Orthopaedics B. 2016 Mar 1;25(2):126-32.

Most tibial plateau fractures occur on the lateral side and often result from a high energy fall or motor vehicle accident. CT can be helpful if an occult fracture is suspected, or for pre-operative planning, but is not necessary in patients with non-displaced or minimally displaced fractures who qualify for non-operative care. The goal of treatment is to prevent articular step offs that can lead to eventual arthritis. Preventing the need for a future knee replacement is the ultimate goal. Common indications for surgery include > 2mm of articular depression, > 1mm of fracture gap, and condylar widening >5mm. However, Vaartjes et al found that fracture gaps and step-offs of up to 4mm can result in a good functional outcome without the need for an eventual total knee replacement. In general, the greater an articular depression is the more motion loss is expected, leading to a worse functional outcome. This patient has pre-existing arthritis which further makes the argument for non-operative treatment. Non-operative treatment involves a non-weight bearing hinged knee brace or knee immobilizer for 8-12 weeks. 1,2

Answer C.

References

1. Vaartjes, Thijs P. BSc1; Assink, Nick MSc1; Nijveldt, Robert J. MD, PhD2; van Helden, Svenhjalmar H. MD, PhD2; Bosma, Eelke MD, PhD3; El Moumni, Mostafa MD, PhD1; Duis, Kaj ten MD1; Hogervorst, Mike MD1; Doornberg, Job N. MD, PhD1; de Vries, Jean-Paul P. M. MD, PhD4; Hoekstra, Harm MD, PhD5; IJpma, Frank F. A. MD, PhD1. Functional Outcome After Nonoperative Management of Tibial Plateau Fractures in Skeletally Mature Patients: What Sizes of Gaps and Stepoffs Can be Accepted?. Clinical Orthopaedics and Related Research 480(12):p 2288-2295, December 2022. | DOI: 10.1097/CORR.0000000000002266

2. Pean, Christian A. MD, MS; Driesman, Adam BA; Christiano, Anthony MD; Konda, Sanjit R. MD; Davidovitch, Roy MD; Egol, Kenneth A. MD. Functional and Clinical Outcomes of Nonsurgically Managed

Spondylolysis is a defect, or stress fracture, of the pars articularis which is part of the posterior vertebral arch. Spondylolysis is a common sports related injury with one study finding a 48% incidence in young athletes with back pain. All of these athletes had negative x-rays and the spondylolysis was found on MRI.  A common presentation includes a history of activity related chronic back pain without radiculopathy and hamstring tightness of physical exam. High risk sports include football, gymnastics, and diving where there is a lot of repetitive lumbar extension and rotation. Standard AP and lateral radiographs should be taken initially but are often negative. Treatment involves bracing with a lumbar corset brace (to restrict extension and rotation) until the patient achieves painless flexion and extension of the lumbar spine. Physical therapy is then initiated with a gradual increase back into activities. Physical therapy focuses on hamstring stretching, core strengthening, and avoidance of lumbar hyperextension. In early spondylolysis, signal intensity on MRI can take an average of 4-6 months to resolve with conservative treatment. The goal of early spondylolysis is to prevent fracture progression, spinal instability, and spondylolisthesis. 1,2

Answer D.

References

1. Cavalier, Ralph MD; Herman, Martin J. MD; Cheung, Emilie V. MD; Pizzutillo, Peter D. MD. Spondylolysis and Spondylolisthesis in Children and Adolescents: I. Diagnosis, Natural History, and Nonsurgical Management. Journal of the American Academy of Orthopaedic Surgeons 14(7):p 417-424, July 2006.
2. Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976). 2009 Jan 15;34(2):199-205. doi: 10.1097/BRS.0b013e31818edcfd. PMID: 19139672; PMCID: PMC3793342.

Femur fractures in the pediatric population are relatively uncommon. Femur fractures that occur in children under 3 years of age should be worked up for potential child abuse. Treatment of these fractures is very much age dependent with ages 0-6 months generally treated with a Pavlik harness, ages 6 months to 4-5 years with a spica cast, and 4 to 11 years with surgery. Children 5 and under generally heal quickly have a thick periosteum which provides additional fracture stability. Surgical fixation of patients 4-5 years and older generally includes either flexible intramedullary nails, submuscular bridge plate fixation, or less commonly, external fixation. Intramedullary nails are ideal for transverse midshaft fractures without distal or proximal extension. Patients with length unstable fractures and proximal or distal extension are good candidates for submuscular bridge plate fixation. The plate is placed at least 2 cm from the physis when possible to avoid growth disturbance and is generally removed when full healing is present. 1,2

Answer D.

References

1. Greenhill, Dustin A. MD; Herman, Martin J. MD, FAAOS. Treatment of Pediatric Femoral Shaft Fractures. Journal of the American Academy of Orthopaedic Surgeons 30(22):p e1443-e1452, November 15, 2022. | DOI: 10.5435/JAAOS-D-22-00415
   2. Li, Ying MD; Hedequist, Daniel J. MD. Submuscular Plating of Pediatric Femur Fracture. Journal of the American Academy of Orthopaedic Surgeons 20(9):p 596-603, September 2012. | DOI: 10.5435/JAAOS-20-09-596

Knee dislocations can be caused by a variety of mechanisms from sports related to, to high energy motor vehicle accidents, to lower energy falls in the morbidly obese. The biggest concern after a knee dislocation is injury to the vascular structures around the knee which could lead to irreversible distal tissue ischemia. A closed reduction should be performed as soon as possible in all knee dislocations, and if irreducible, proceed to an open reduction. Patients with diminished or absent distal pulses should have an immediate CT angiogram to rule out popliteal artery injury. Patients with intact distal pulses may have serial physical exams, and if normal after 48 hours, are unlikely to have a vascular injury. Part of the physical exam should include measurement of the ankle brachial index (normal is ABI >.9). Knee dislocations generally have some degree of multi-ligament injury including ACL, PCL, LCL and MCL disruptions. Surgical repair is often performed in a two stage procedure. The MCL is often surgically repaired acutely as delay can cause tendon retraction and scar tissue. Conversely, when the ACL is reconstructed acutely patients tend to have more complications with postoperative motion than with delayed reconstruction. 1,2

Answer B.

References

1. Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G Jr, Robinson JT, Volgas DA. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. 2004 May;86(5):910-5. PMID: 15118031.
2. Mook WR, Miller MD, Diduch DR, Hertel J. et al. Multiple-ligament Knee Injuries: A Systematic Review of the Timing of Operative Intervention and Postoperative Rehabilitation. J Bone Joint Surg Am, 2009 Dec; 91(12); 2946-5

The criteria for surgical fixation of midshaft clavicles fractures is well established in the adult population with >15 mm of shortening, 100% displacement, and/or significant comminution. Criteria for the adolescent population is controversial as there is more healing potential with open growth plates. Rarely do adolescent clavicles fractures go on to nonunion, even with significant displacement. Most adolescent patients can be treated in a sling for a few weeks followed by a return to activities when the shoulder has full painless range of motion, which is generally 6 weeks. Significant clavicle shortening can change the dynamics of shoulder motion potentially causing a change in long term shoulder function. Specifically weakness with shoulder external rotation and abduction have been found after clavicle fractures that have healed shortened. Fractures that are completely displaced (no corticol contact) are prone to nonunion and often benefit from open reduction and internal fixation, which is the most common form of fixation. 1,2

Answer B.

References

1. Scott ML, Baldwin KD, Mistovich RJ. Operative Versus Nonoperative Treatment of Pediatric and Adolescent Clavicular Fractures. A Systematic Review and Critical Analysis. JBJS Rev, 7(3):e5 | Evidence-Based Systematic Reviews | March 19, 2019
2. Pandya, Nirav K. MD; Namdari, Surena MD, Msc; Hosalkar, Harish S. MD. Displaced Clavicle Fractures in Adolescents: Facts, Controversies, and Current Trends. Journal of the American Academy of Orthopaedic Surgeons 20(8):p 498-505, August 2012. | DOI: 10.5435/JAAOS-20-08-498

The patient has a Jones Fracture of the diaphyseal-metaphyseal junction which is notoriously prone to nonunion due to a poor vascular supply in that area. Conservative treatment includes 8+ weeks of non weight bearing in a cast or boot which is often difficult for athletes and laborers. Surgical treatment is recommended in younger active patients as time to union is significantly less with surgery compared to conservative treatment.  Attia et al found an average return to play in athletes at 9.6 weeks after intramedullary screw fixation compared to 13.1 weeks in a nonoperative group. Time to union in the surgical group was 8.2 weeks and 13.7 weeks in the non operative group. The union rate in the operative group was 93.7% and 71.4% in the nonoperative group. For this patient, surgical fixation with a percutaneous screw fixation offers him an earlier to return to weightbearing and work and an increased likelihood of fracture union.

Answer D.

References

1. Metzl, Joshua A. MD; Bowers, Mark W. MD; Anderson, Robert B. MD. Fifth Metatarsal Jones Fractures: Diagnosis and Treatment. Journal of the American Academy of Orthopaedic Surgeons 30(4):p e470-e479, February 15, 2022. | DOI: 10.5435/JAAOS-D-21-00542
2. Yates J, Feeley I, Sasikumar S, Rattan G, Hannigan A, Sheehan E. Jones fracture of the fifth metatarsal: Is operative intervention justified? A systematic review of the literature and meta-analysis of results. The Foot. 2015 Dec 1;25(4):251-7.
3. Attia AK, Taha T, Kong G, Alhammoud A, Mahmoud K, Myerson M. Return to play and fracture union after the surgical management of Jones fractures in athletes: a systematic review and meta-analysis. The American Journal of Sports Medicine. 2021 Oct;49(12):3422-36.

Legg-Calvé-Perthes disease is caused by a loss of blood flow to the femoral head in a skeletally immature patient with 4-8 years of age being the most common ages of presentation. The condition typically follows a predictable radiographic course of bone necrosis, bone resorption, and reossification.  Reossification is typically evident 6 months from onset of symptoms. Radiographs are the preferred imaging modality to diagnose, stage, a follow Perthes. Serial radiographs follow the sphericity of the femoral head and stability of the hip joint. Collapse of the lateral femoral head represents an unstable pattern that can cause hip instability. Age is also a predictor of outcome with the diagnosis made before the age of 6 years of age offering a better prognosis. Serial radiographs should be taken every 3-4 months until reossification to follow femoral head changes, with the ultimate goal of preventing premature hip arthritis. Patients who present <6 years of age can be treated with observation with weight bearing as tolerated and activity restrictions if the hip is symptomatic. Patients who present at age >6-8 years of age with significant femoral head collapse may require bracing, nonweight bearing and/or surgical fixation. 1,2

Answer A.

References

1. Laine JC, Martin BD, Novotny SA, Kelly DM. Role of advanced imaging in the diagnosis and management of active Legg-Calve-Perthes disease. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2018 Aug 1;26(15):526-36.
2. Kim, Harry K. W. MD. Legg-Calvé-Perthes Disease. American Academy of Orthopaedic Surgeon 18(11):p 676-686, November 2010.

Scaphoid fracture is a common injury but can be missed on original x-rays in up to 15% of cases. A common treatment plan with an occult scaphoid fracture and negative x-rays includes a thumb spica cast or brace with follow x-rays in 2 weeks. Continued pain on follow-up exam, or changes on x-ray, will help confirm the diagnosis. CT or MRI can diagnose early occult fractures but cost can prohibit their use in early cases. Between the two, MRI is more sensitive over CT for scaphoid fractures and generally the preferred option. In adults who present with occult fractures, MRI may be more cost effective than immobilization alone due to lost work wages with restrictions. Occult scaphoid fractures that are missed can lead to higher nonunion rates and potential disability. Cast treatment can still be an effective treatment option when scaphoid fractures are missed. Grewal et al found a 96% healing rate with cast treatment when the diagnosis of a nondisplaced scaphoid fracture was delayed past 6 weeks. Generally these fractures can take 10-12 weeks to unite with cast treatment. 1,2

Answer B.

References

1. Karl JW, Swart RJ. Diagnosis of Occult Scaphoid Fractures. A Cost-Effectiveness Analysis. J Bone Joint Surg Am, 97(22):1860-1868 | Scientific Articles | November 18, 2015
2. Grewal R, Suh N, MacDermid JC. The missed scaphoid fracture–outcomes of delayed cast treatment. Journal of Wrist Surgery. 2015 Nov;4(04):278-83.

Phalanx fractures are the most common hand fractures and are frequently seen in the urgent care, emergency room, and orthopedic settings. Most of the fractures can be treated with short term immobilization (1-2 weeks) with an alumafoam and fiberglass splint followed by early range of motion. It is critical for close follow-up and repeat xrays of these fractures, however, as these fractures can displace, become unstable, and fingers can get stiff quickly. Unstable fractures include displaced intra-articular fractures, fracture dislocations, and fractures causing finger rotation or shortening. Fractures of the volar plate causing joint subluxation (this patient’s fracture pattern) can be treated initially with a closed reduction and dorsal extension block splinting. Extension block splinting doesn’t allow the PIP joint to fully extend which would cause further subluxation but allows for PIP flexion so the joint doesn’t become stiff. If a closed reduction and splinting fails, closed reduction with percutaneous pinning or open reduction and internal fixation is recommended. 1,2

Answer C.

References

1. Carpenter S, Rohde RS. Treatment of phalangeal fractures. Hand Clinics. 2013 Nov 1;29(4):519-34.
2. Henry, Mark H. MD. Fractures of the Proximal Phalanx and Metacarpals in the Hand: Preferred Methods of Stabilization. Journal of the American Academy of Orthopaedic Surgeons 16(10):p 586-595, October 2008.

A trimalleolar ankle fracture involves 3 critical components of the ankle joint: the lateral, medial and posterior malleolus. Trimalleolar fractures represent just 7% of all ankle fractures and are unstable injuries and prone to displacement. Nonoperative treatment may be attempted in low demand patients with non-displaced fractures. However, in healthy active patients the risk of ankle instability and post traumatic arthritis is too high with non-operative treatment and surgery is recommended. Surgical treatment typically involves open reduction and internal fixation of the lateral malleolus with a plate and screws and percutaneous screw fixation of the medial malleolus fracture. If the posterior malleolus fragment involves >25% of the joint space, open reduction and internal fixation is recommended. This usually involves a posterior surgical approach to the ankle with plate and screw fixation. This patient’s posterior malleolus fragment is small, or involving approximately 5% of the joint space, so it doesn’t need to be fixed. The medial and lateral malleolus are displaced and should be fixed. 1,2

Answer C.

References

1. Stead TS, Pomerantz LH, Ganti L, Leon L, Elbadri S. Acute Management of Trimalleolar Fracture. Cureus. 2021 Jan 6;13(1):e12536. doi: 10.7759/cureus.12536.
2. Hong CC, Nashi N, Roy SP, Tan KJ. Impact of trimalleolar ankle fractures: how do patients fare post-operatively?. Foot and Ankle Surgery. 2014 Mar 1;20(1):48-51.

The suprascapular nerve arises from the brachial plexus and travels along the posterior superior scapular and through the suprascapular notch where it then begins to innervate the rotator cuff muscles. The nerve can be injured with repetitive overhead motion (volleyball, tennis, and baseball pitchers in particular) and by space occupying lesions (generally from a large paralabral cyst that arises from a labral tear). Symptoms often include pain and weakness with shoulder abduction and external rotation as the nerve supply to the rotator cuff is impaired. Physical exam findings will typically show weakness to the supraspinatus and infraspinatus muscles. MRI is the study of choice to determine if there is a rotator cuff tear, mass occupying lesion, or other soft tissue pathology. Initial treatment involves activity modification (avoidance of overhead activities), anti-inflammatories, and physical therapy to focus on scapular stabilization and shoulder mechanics. Paralabral cysts formed from labral tears are generally treated with arthroscopic decompression and labral repair or debridement. The labral tear is a known cause of inflammation and cyst formation, and without debridement or repair, the cyst is unlikely to go away. Aspiration of the cyst alone has a high recurrence rate as this doesn’t address the cause of the cyst. 1,2

Answer D.

References

1. Boykin RE, Friedman DJ, Higgins LD, Warner JP. Current Concepts Review: Suprascapular Neuropathy. J Bone Joint Surg Am, 92(13):2348-2364
2. Strauss, Eric J. MD; Kingery, Matthew T. MD; Klein, David DO; Manjunath, Amit K. MD. The Evaluation and Management of Suprascapular Neuropathy. Journal of the American Academy of Orthopaedic Surgeons 28(15):p 617-627, August 1, 2020. | DOI: 10.5435/JAAOS-D-19-00526

An osteochondral fracture of the talus involves the articular cartilage and subchondral bone. The injury occurs when the lateral talar dome compresses on the adjacent tibia when the ankle is in dorsiflexion and inversion (typically ankle sprain mechanism). CT scan is often used when a fracture is identified on xray to determine the size and displacement of the subchondral bone. MRI is often used when xrays are normal and patients continue to have persistent ankle pain. This patients osteochondral fracture appears to be a complete nondisplaced fragment on CT. Initial treatment typically involves 6 weeks of non-weight bearing in an immobilizer or short leg cast. Acute osteochondral fractures often heal slow and can take patients up to 12-16 weeks to regain full mobility. Osteochondral fractures are prone to not healing as 45% of nondisplaced complete fractures will fail nonsurgical treatment. In general, non-displaced osteochondral fractures are managed non-operatively for up to a year before surgery is considered. Surgery is considered for patients with higher-grade lesions, patients not responding to non-operative management, displaced lesions, or loose bodies. 1,2

Answer A.

References

1. McGahan PJ, Pinney SJ. Current concept review: osteochondral lesions of the talus. Foot & ankle international. 2010 Jan;31(1):90-101.
2. Schachter, Aaron K. MD; Chen, Andrew L. MD, MS; Reddy, Ponnavolu D. MD; Tejwani, Nirmal C. MD. Osteochondral Lesions of the Talus. Journal of the American Academy of Orthopaedic Surgeons 13(3):p 152-158, May 2005.

Calcific tendonitis is a common condition in which the body deposits calcium hydroxyapatite crystals within tendons. The condition is slightly more common in women and the condition generally occurs in patients between 30 and 60 years of age. Calcific tendonitis can occur in any tendon insertion in the body but the shoulder and hips are the most common sites. The presentation includes a rapid onset of severe pain in a tendon insertion in the absence of trauma of precipitation event. In many cases calcific tendonitis can be found on xray incidentally in asymptomatic patients while others may have severe pain. The natural course of the condition is calcium deposition followed by spontaneous resorption and improvement of clinical symptoms. Calcific tendonitis is often painful during the resorptive phase when the calcium appears cloudy on xray. The pathogenesis of calcific tendonitis remains unclear without any one theory widely accepted. Treatment is first conservative with a period of rest, NSAIDS, and gentle range of motion exercises to preserve joint motion. Symptoms often resolve in 2-3 months as the calcium deposit is slowly absorbed.  If conservative treatments fail other treatments such as extracorporeal shockwave lithotripsy, needle aspiration and steroid injection, and surgery are options. 1,2

Answer A.

References

1. Siegal DS, Wu JS, Newman JS, Del Cura JL, Hochman MG. Calcific tendinitis: a pictorial review. Canadian Association of Radiologists Journal. 2009 Dec;60(5):263-72.
2. Nikci, Valdet MD; Doumas, Christopher MD. Calcium Deposits in the Hand and Wrist. Journal of the American Academy of Orthopaedic Surgeons 23(2):p 87-94, February 2015. | DOI: 10.5435/JAAOS-D-14-00001