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A 14-year-old immigrant from a developing country had complained of pain playing soccer 4 months prior. Radiographs at that time were read as normal and he was given a prescription for NSAIDs. More recently, his parents noticed he is limping and complaining of pain after playing games. He has had some intermittent fevers and swelling around his thigh. A complete blood workup is performed. Current radiographs and MRI are seen in Figures A and B respectively. What is the next step in treatment
Genetic screening for EXT1 and EXT2 gene mutations
NSAIDS and single-dose radiation therapy
Select Answer to see Preferred Response
An 11-year-old male presents with left forearm swelling and pain after getting kicked while playing soccer. Figures A through E are the radiographs, bone scan and MRI scan of the forearm and biopsy results. What is the most likely diagnosis?
Giant cell tumor
An 11-year-old boy presents with knee pain, warmth and swelling after a fall. Radiographs, MRI, bone scan and biopsy of the knee are seen in Figures A through E. What is the most appropriate treatment plan?
Curettage and targeted intravenous antibiotics for 6 weeks.
Curettage, cancellous bone grafting, non-weightbearing until visible callus is seen on follow-up radiographs.
Curettage, placement of antibiotic beads, intravenous antibiotics for 6 weeks, removal of beads and placement of bone graft substitute at 6 weeks.
Neoadjuvant chemotherapy, physeal-sparing resection, intercalary bone allograft, locked plate fixation, postoperative adjuvant chemotherapy.
Neoadjuvant chemotherapy, wide resection of the distal one-third of the femur, reconstruction with a custom implant, postoperative adjuvant chemotherapy.
A 13-year-old presents with persistent leg pain. Representative radiographs are shown in Figures A and B. A biopsy is subsequently obtained and is shown in Figure C. What is the most likely diagnosis?
A 13-year-old boy presents with left leg pain for 10 weeks. He reports a remote history of trauma while falling off of a trampoline 12 weeks ago. He reports constitutional symptoms for the past 4 weeks. The patient's serum LDH and alkaline phosphatase are elevated. A radiograph of the left knee is shown in Figures A and B. A bone scan is displayed in Figure C. Magnetic resonance imaging (MRI) is shown in Figure D and E. A biopsy specimen is shown in Figure F. What is the most appropriate next step in management?
Neoadjuvant chemotherapy, surgical excision, adjuvant radiation therapy
Surgical irrigation and debridridement followed by 6 weeks of culture directed intravenous antibiotics
Surgical excision followed by adjuvant chemotherapy and radiation therapy
Neoadjuvant chemotherapy, surgical excision, adjuvant chemotherapy
Surgical irrigation and debridridement with antibiotic cement spacer placement followed by 6 weeks of culture directed intravenous antibiotics
A 8-year-old boy presents with knee pain and an effusion. Biopsy and staging studies show a distal femoral osteosarcoma with contamination of the knee joint. Which of the following treatment options will provide this child with the best chance of local control and the highest level of function?
Through knee amputation
Above knee amputation
Extra-articular resection, endoprosthetic reconstruction, and free flap coverage
Extra-articular resection, allograft prosthetic composite, and free flap coverage
A 16-year-old boy presents with a 6-month history of increasing knee pain and swelling. He is otherwise healthy, but the child has a known retinoblastoma gene mutation. A mass is found on the posterior aspect of his knee, and a biopsy is taken. A radiograph is shown in Figure A. Which of the following biopsy specimens in Figures B through F most likely fits with this patient's history, exam, and radiograph?
Which of the following most accurately lists the most common location of osteosarcoma in decreasing frequency?
axial skeleton > distal femur > proximal tibia > proximal humerus
distal femur > proximal tibia > proximal humerus > axial skeleton
distal femur > axial skeleton > proximal tibia > proximal humerus
distal femur > proximal tibia > axial skeleton > proximal humerus
proximal tibia > distal femur > axial skeleton > proximal humerus
You are asked to consult on a 8-year-old child in the emergency department with the pathologic fracture seen in Figure A. In preparation for transfer to a sarcoma center for treatment, all of the following are correct steps in the child's management EXCEPT?
Hanging arm sling
Tumor staging, including bone scan, CT of chest, MRI of the entire bone
Consultation with pediatric oncology
Tumor biopsy performed by interventional radiology
A 19-year-old woman presents with dull right thigh pain for the past 2 months. Radiographs and a biopsy specimen are shown in Figures A-C. What is the most appropriate definitive treatment?
Nonsteroidal anti-inflammatory drugs with follow-up x-ray in 6 months
Preoperative chemotherapy, wide resection, and postoperative chemotherapy
In patients with an extremity-based osteosarcoma without metastasis, all of the following are risk factors for disease progression and poor outcomes EXCEPT?
High histologic grade
Low serum level of alkaline phosphatase at diagnosis
Large tumor volume
Inadequate surgical margins following resection
70% histologic tumor necrosis after pre-operative chemotherapy
A 13-year-old girl presents with right thigh pain and constitutional symptoms for 8 weeks. The patient's serum LDH and alkaline phosphatase are elevated. A radiograph of the right femur is shown in Figure A. Computed tomography (CT) of the chest reveals no pulmonary metastases. Magnetic resonance imaging (MRI) of the right femur shows erosion of the tumor through the cortex into the adjacent soft tissue, but no skip lesions are seen. A biopsy specimen is shown in Figures B and C. What stage does this patient's case most appropriately represent using the Enneking Staging System for Musculoskeletal Tumors?
What is the most common site of metastasis for osteosarcoma?
A 17-year-old male presents with increasing right shoulder pain and swelling. There is no history of trauma and he is otherwise healthy. Representative clinical photograph, radiograph, bone scan, MRI, and histology are shown in Figures A through E. What is the most appropriate treatment for this patient?
Chemotherapy and radiation therapy
Surgery and chemotherapy
Surgery and radiation therapy
A 13-year-old boy is diagnosed with osteosarcoma of his distal femur. The treating surgeon samples the bone marrow from the resection margin of the femur during definitive limb salvage surgery and finds microscopic evidence of tumor. Assuming no change in the resection level, what type of resection would this be considered?
A 14-year-old child presents to your office with 6 months of worsening knee pain. Figures A through D show the respective radiographs, bone scan, MRI, and histology. What treatment protocol has been shown to maximize survival in patients with this diagnosis?
Neoadjuvant chemotherapy followed by surgical excision
Neoadjuvant chemotherapy, surgical excision, adjuvant chemotherapy
Surgical excision followed by radiation therapy
Neoadjuvant chemotherapy, surgical excision, radiation therapy
Surgical excision followed by adjuvant chemotherapy
A 10-year-old boy has 2 months of right knee pain that started at summer camp. The patient denies constitutional symptoms. There is no lymphadenopathy present. CT of the chest shows no signs of metastatic disease. Imaging studies and biopsy results are shown in Figures A-E. What is the most likely diagnosis?
Malignant fibrous histiocytoma
A 30-year-old man has had leg pain for 6 months. A lesion is identified in the proximal femur and biopsy it taken. Histology is shown in Figure A and is consistent with a low-grade intramedullary osteogenic sarcoma. Additional imaging studies confirm that this is an isolated lesion with no metastasis. What is the standard treatment for this type of lesion?
chemotherapy and surgery
radiation and surgery