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Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC.
A 67-year-old female presents to the ED with right hip pain after standing up from a chair and feeling a pop in her hip. She states she fell to the ground and was unable to bear weight after. Radiographs are shown in Figure A. She has a past medical history of hypertension, coronary artery disease and breast cancer, which was treated with lumpectomy 3 years prior. The fracture is deemed pathologic by the radiologist. What role do matrix metalloproteases play in this type of fracture?
RANK-L activation to aid osteoclastogenesis
Induction of angiogenesis
Acidification of the extracellular matrix to aid in bony destruction
Extracellular matrix degradation to aid cell invasion and metastases
Acts as a chemokine to promote targeting of bone
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Figure A is the AP radiograph of a 51-year-old male who presents to the ED after sustaining a fall in which he landed on his right shoulder. Given the appearance of the proximal humerus, a biopsy was obtained as demonstrated in Figure B. Which of the following is the most appropriate implant to treat this patient’s injury?
Proximal humerus locking plate after curettage and grafting
Proximal humerus locking plate with fibular strut
Antegrade humeral nail
Reverse shoulder arthroplasty
Proximal humerus replacement
A 48-year-old male is referred to your clinic for progressive left hip and thigh pain for the past three weeks. His pain is causing him to walk with a significant limp and he is no longer able to do his job as a carpenter. Two months ago, he found a lump in his neck, however, he never saw his doctor due to concerns about missing work. A radiograph obtained in your office is shown in Figure A. A biopsy slide obtained from the lesion is shown in Figure B. What is this patient's Mirel's score, and what would be the next best step in treatment?
Mirel score 5; Intramedullary nailing
Mirel score 9; Radiation
Mirel score 4; Observation
Mirel score 10; Radiation
Mirel score 12: Intramedullary nailing
A 65-year-old man presents to your clinic as a referral for consideration of prophylactic treatment for an impending pathologic hip fracture. He was diagnosed with metastatic prostate cancer one month ago and most recently had his first course of chemotherapy. Which of the following is associated with this diagnosis as compared to other metastatic carcinomas?
Insensitivity to radiation therapy
Comparable likelihood of pathologic fracture healing
Primarily lytic lesions
Increased skeletal related events (SREs)
Worse median survival
A 65-year-old man with a 20-pack-year tobacco history and a remote history of small cell lung carcinoma presents with thigh pain and radiographs demonstrated in Figure A. He undergoes a full femur MRI and a CT chest, abdomen, and pelvis, both of which reveal no other areas of disease. What is the next best step in management?
Open biopsy using an intermuscular interval
Open biopsy using an intramuscular interval
Antegrade intramedullary nailing with reamings sent to pathology
Proximal femoral replacement
ORIF with plate and screws, followed by radiation
A 78-year-old man presents to your office with new onset right knee pain 3 years after total knee replacement. The pain is worse with weightbearing and he now has to use a cane. Ibuprofen initially gave him pain relief, but he now reports constant pain. Figure A and B represent his 1-year and 3-year (current) radiographs, respectively. ESR is 14, CRP 2.3, and an aspirate reveals 900 nucleated cells with a negative gram stain and negative leukocyte esterase. What is the best next step in management?
Bone scan to evaluate for component loosening
2-stage revision arthroplasty for infection
Revision of tibial component with metaphyseal sleeve and long stem
CT chest, abdomen, and pelvis
Observation of an osteolytic lesion
A 70-year-old man is scheduled to undergo a procedure to address a symptomatic left proximal femur solitary lesion. Plain radiographs are depicted in Figure A and histopathology in Figure B. Which of the following procedures is associated with improved survivorship in this patient?
Wide resection and proximal femoral replacement
Open reduction internal fixation with plates and screws
A 72-year-old 2-pack-per-day smoker presents to your office with increasingly severe right hip pain that is now exacerbated by any weight-bearing. Physical exam is significant an antalgic gait but otherwise a full painless range of motion, good strength, and an absence of neurologic symptoms. A radiograph is shown in Figure A. Metastatic work-up reveals a primary source. The histopathology is shown in Figure B. Which of the following is LEAST associated with the diagnosis?
High rate of complications with intralesional treatment requiring revision surgery
Hypervascularity requiring pre-operative embolization
Sensitivity to radiation and cytotoxic chemotherapy
Variable median life expectancy, potentially as short as 6 months
A 59-year-old women with known metastatic lung cancer presents with acute left hip pain with ambulation, as shown in Figure A. She previously underwent a right lung lobectomy 2 years ago, which has been complicated by chronic chest pain. Her oncologist predicts an estimated life expectancy of 12-18 months. She currently lives independently and walks for 2 hours per day. What would be the most appropriate treatment and rehabilitation plan?
Observation; restrict activities with cane assistance as needed
Radiation therapy; partial weight bearing with crutch assistance
Prophylactic intramedullary nailing; non-weight bearing with crutch assistance
Prophylactic intramedullary nailing; full weight bearing with cane assistance
Long stemmed total hip arthroplasty; full weight bearing with walker assistance and hip precautions
A 65-year-old community-ambulatory patient complains of constant left hip pain that affects her activities of daily living. Staging studies confirm multi-focal disease. Biopsy results are shown in Figure A. Recent radiographs are shown in Figures B and C. Life expectancy is estimated at 1 year. What is the most appropriate treatment option?
Curettage, cemented dynamic hip screw fixation and radiotherapy.
Curettage, cancellous bone grafting, cephalomedullary fixation and radiotherapy.
Proximal femoral resection, replacement with allo-prosthetic composite and radiotherapy.
Cemented hemiarthroplasty and radiotherapy.
A 54-year-old male presents to the emergency department after a sudden onset of pain and inability to use his right arm after pushing himself up from a chair. X-rays are obtained and demonstrated in Figures A & B. The patient denies other medical problems. He is subsequently admitted for continued workup including a CT chest/abdomen/pelvis, which does not demonstrate any relevant abnormalities. What would be the next best step of the options below?
Intramedullary nailing of humerus
Initiate radiation therapy to entire right arm
Plate and screw fixation of fracture
Discussion of hospice care
Core needle biopsy
A 65-year-old male is seen for increasing thigh pain and a new femoral lesion seen by his oncologist. A current radiograph is shown in Figure A. He has a known diagnosis of lung carcinoma, however, the initial diagnostic workup over a year ago did not show any metastatic disease. What is the next most appropriate step in management of this patient?
Intramedullary stabilization and send femoral reamings as biopsy
You are consulted to see a 67-year-old female with a new-onset inability to ambulate due to severe right hip pain. Her past medical history is significant for metastatic breast cancer. Radiographs demonstrate a peritrochanteric lytic lesion involving 40% of the cortical circumferential circumference. She has no radiographic evidence of osteoarthritis, acetabular involvement, or skip lesions. The oncology team feels her life expectancy is > 6 months. Which of the following is the recommended management correctly paired with her Mirel's score?
Hemiarthroplasty; Mirels' score of 11
Total hip arthroplasty; Mirels' score of 9
Radiation and physical therapy; Mirels' score of 7
Continued observation; Mirels' score of 11
Cephalomedullary nail; Mirels' score of 8
All of the following are known steps in the development of a malignant tumor with the ability to metastasize EXCEPT?
Tumor cell intravasation
Avoidance of immune surveillance
Endothelin 1 is known to be involved in which of the following disease processes?
RANK ligand induced tumor lysis
Osteoblastic bone metastases
Physeal bar formation
A 61-year-old female presents with a 6 month history of pain in the left hip and thigh. A hip radiograph is shown in Figure A. Serum protein electrophoresis is normal, and a bone scan shows increased uptake in the left femur only. A biopsy is taken and shown in Figure B. What is the most likely diagnosis?
Primary lymphoma of bone
You are seeing a 53-year-old female for 1 year of increasing knee pain. She is otherwise healthy. Based on the imaging studies below (Figures A-D), what is your diagnosis?
Giant cell tumor
Renal Cell Carcinoma
Metastatic bony lesions that occur distal to the elbows or knees are most likely to originate from which one of the following primary organs?
A 56-year-old female is referred for a second opinion after placement of an intramedullary nail through a presumed metastatic lesion in her proximal femur. Final biopsy results from the lesion show a high-grade chondrosarcoma and staging studies show this to be an isolated site of disease. What treatment should be recommended?
Intramedullary nail removal and radiotherapy to the limb
Systemic chemotherapy and keep nail in place to prevent fracture
Wide proximal femoral resection and hemiarthroplasty followed by radiotherapy
Wide resection including hip disarticulation
A 69-year-old man with known metastatic lung cancer presents with a pathological fracture after a fall from standing height (Figure A). Which of the following options is the best choice for treating this fracture?
Total hip arthroplasty
Sliding hip screw
Dynamically locked cephalomedullary nail
Statically locked cephalomedullary nail
What is the most common cause for an aggressive lytic bone lesion in a patient above 40-years-old?
Metastatic bone disease
All of the following are necessary steps in bony metastasis of a malignant cell EXCEPT?
Target tissue localization
Direct stimulation of osteoclasts
A 65-year-old woman presents with elbow pain. Her radiograph is shown in the Figure A. The patient had a history of non-metastatic breast cancer 10 years ago which was treated successfully. Repeat mammogram, bone scan and CT scan of the chest, abdomen and pelvis demonstrate this to be an isolated lesion. What is the next most appropriate action in treatment?
Biopsy of lesion
Total elbow arthroplasty
Currettage and bone grafting
Percutaneous cement injection
A 53-year-old woman with a history of Paget's disease and bilateral total hip arthroplasties presents with left hip pain and dysuria. An AP pelvic radiograph and CT scan are shown in Figure A and B. What is the next most appropriate step in management?
Revise the left hip total arthroplasty with a cemented stem
Open reduction and internal fixation of the acetabular fracture
Rest, IV bisphosphanates and follow-up in 6 weeks
Technetium Tc 99 and CT of the chest, abdomen and pelvis
What is the most appropriate treatment for a 65-year-old female with a 100-pack-year tobacco history who presents with a new painful lytic lesion in her femoral diaphysis?
Antegrade femoral nailing with reamings sent to pathology for analysis
Antegrade femoral nailing with adjuvant radiotherapy to the lesion
Minimally invasive plating of the femur for stabilization and open cementation of the lesion
Referral to medical oncology for chemo-radiotherapy
Lesion biopsy with further treatment based on the results of the biopsy
A 51-year-old female with known metastatic breast cancer presents with acute right thigh pain and inability to bear weight. A radiograph is shown in Figure A. A biopsy is performed that confirms metastatic breast cancer. What is the next step in management?
Local radiation therapy
Intramedullary nailing only
Intramedullary nailing and chemotherapy
Intramedullary nailing, radiation therapy to the tumor site, and chemotherapy
Intramedullary nailing, radiation therapy to the entire femur, and chemotherapy
A 70-year-old man with a history of esophageal cancer presents to the emergency department with pain in his right femur. His right hip xray is shown in Figure A and B. His medical oncologist has estimated he has a life expectancy of less than 6 months. His activities are limited to walking around his house. Which of the following management options is most appropriate?
Proximal femoral locking plate
A 62-year-old male with a 50-pack-year history of tobacco use presents with complaints of productive cough and increasing leg pain for the past 6 months. Proximal tibial radiographs are shown in Figures A and B, and are concerning for an impending pathologic fracture. CT of the chest, abdomen, and pelvis, and staging blood work are negative. MRI of the tibia shows a multi-focal cortically based lesion without significant soft tissue mass and whole body technetium bone scan shows this to be an isolated lesion. What is the next most appropriate step in management of this patient?
Intramedullary nailing of the tibia and send canal reamings to pathology
Radiotherapy for palliative pain control as the risk for pathological fracture is very small
Open incisional biopsy
Chemotherapy and surgical stabilization with intramedullary nailing of the tibia
Radiotherapy and surgical stabilization with intramedullary nailing of the tibia