Journal of Bone and Joint Surgery (British Volume)

CME questions April 2006

These papers have been set on the review articles and aspects of current management papers from the 2006 January, February and March issues of the JBJS-Br.

1. Which of the following statements best describes what has been discovered through clinical study concerning the retention of information relevant to their treatment by orthopaedic patients ?
1. Most of the information has been forgotten within the first two weeks.
2. Less than half of the information will be retained for two weeks falling to about 10% retention at final follow-up.
3. About three-quarters of the information will be retained for two weeks, falling to about one quarter at final follow-up.
4. About three quarters of the information will be retained at two weeks and half at final follow up.
5. Most of the information will be retained at two weeks, falling to about three quarters of the initial information at final follow up.
2. In a study designed to determine the factors influencing the rate of medical malpractice claims, what was the only factor found to correlate positively at a significant level?
1. Average social class of patients.
2. Density of lawyers in the geographical area.
3. Length of interval between last outpatient consultation and surgery.
4. Vocabulary of patients.
5. Volume of procedures undertaken by the surgeon concerned.
3. Which of the following statements concerning the management of a patient with metastatic compression of the spinal cord treated by radiotherapy prior to excision best describes the appropriate management.
1. Radiation should be followed by surgical debridement after an interval of two weeks, excising all tissue of poor quality regardless of the size of the resulting defect at a single sitting.
2. Radiation should be followed by surgical debridement after an interval of two weeks, limiting debridement to the tumour plus unhealthy tissue up to a maximum of the size that can be filled with a latissimus dorsi flap.
3. Radiation should be followed by surgical debridement after an interval of six to twelve weeks, excising all tissue of poor quality regardless of the size of the resulting defect in one sitting.
4. Radiation should be followed by surgical debridement after an interval of six to twelve weeks, excising all tissue of poor quality and repeating debridements keeping the size of the resulting defect to a maximum of what can be filled by a latissimus dorsi flap.
5. Radiation should be followed by surgical debridement after an interval of six to twelve weeks, excising all tissue of poor quality and repeating debridements until a perfectly healthy bed is obtained, regardless of the size of the resulting defect.
4. Which of the following flaps is not used to help cover a soft tissue defect at the level of L3?
1. Free flap transfer from a range of donor sites.
2. Gluteus flap.
3. Latissimus dorsi flap.
4. Omental flap.
5. Reverse Latissimus Dorsi flap.
5. Which of the following statements about Vacuum Assisted Closure of spinal wounds is not correct?
1. Experimentally, continuous use increases the formation of granulation tissue.
2. Experimentally, intermittent use increases the formation of granulation tissue.
3. It has been shown to increase the perfusion pressure in local arteries.
4. When operating in the recommended way, the absolute pressure measured in the sponge should be approximately 635mmHg.
5. Wound debridement is still necessary.
6. What is the source of most osteoblasts found in callus around a fracture?
1. Bone marrow of the exposed medulla by local migration.
2. Endothelial and perithelial cells of invading capillaries.
3. Mononuclear white cells in the fracture haematoma.
4. Reticuloendothelial cells present in locally injured connective tissue.
5. Stem cells present in locally injured connective tissue.
7. Which of the following is the most significant contra indication to functional bracing of a fracture?
1. Any involvement of a joint surface whatsoever.
2. Comminution.
3. Overlying open wound.
4. Significant angular instability.
5. Significant axial instability.
8. After total hip or knee replacement in a patient with no medical condition that would itself cause elevated inflammatory markers, how long after normalisation of the CRP does ESR return to normal?
1. Approximately one day.
2. Approximately one week.
3. Approximately one month.
4. Approximately two to three months.
5. Approximately one year.
9. After successful treatment of a periprosthetic infection, which of the following tests will remain specifically positive?
1. Immunofluorescence microscopy.
2. Indium labelled white cell scan.
3. Polymerase chain reaction.
4. Positron Emission Tomography.
5. Radionuclide bone scan.
10. Which test sets the highest standard in the diagnosis of infected total hip replacement?
1. Aspiration, culture and sensitivity.
2. Intra-operative frozen section.
3. Intra-operative gram stain.
4. Intra-operative tissue culture.
5. Polymerase Chain Reaction.
11. What is the recommended course of action if preoperative assessment of a loose prosthesis revealed no evidence of infection but cultures taken from peri-prosthetic tissues at the time of revision surgery are positive?
1. Ensure the patient receives three doses of prophylactic antibiotics in the peri-operative period and monitor inflammatory markers and the state of the wound closely for the next six weeks.
2. Continue peri-operative antibiotics for five days.
3. After routine peri-operative prophylaxis continue oral antibiotics for six weeks.
4. Continue appropriate intravenous antibiotics for six weeks after surgery.
5. Revise the joint, mixing appropriate antibiotics into the cement.
12. A patient is found to have a methicillin sensitive staphylococcal infection of their hip replacement but there is significant bone loss on the pelvic side and they have developed life threatening comorbidities. A decision is therefore taken to simply suppress the infection with antibiotics, aiming to avoid surgery altogether. Assuming no contraindications to any of the antibiotics that follow, which agent or combination has the greatest chance of actually eradicating the infection?
1. Cefuroxime and metronidazole.
2. Ciprofloxacin.
3. Ciprofloxacin and rifampicin.
4. Linezolid.
5. Methicillin.
13. Which of the following was noted by the Lower Extremity Assessment Project (LEAP)?
1. If there is loss of plantar sensation in the foot of a mangled extremity, initial amputation is indicated.
2. If there is loss of plantar sensation in the foot of a mangled extremity skeletal stabilisation should always be accompanied by posterior tibial nerve repair.
3. If there is loss of plantar sensation in the foot of a mangled extremity but the capillary refill time is less than 5 seconds the prognosis for return of sensation is excellent.
4. If there is loss of sensation in the foot of a mangled extremity this will be due to neuropraxia of the posterior tibial nerve in a significant number of cases and will ultimately recover.
5. If there is loss of sensation in the foot of a mangled extremity, assessment and decision making with respect to management are unaffected, depending much more strongly on other factors.
14. Which of the following organisms is a particular risk for infection of open fractures exposed to river or stream water?
1. Clostridium perfringens
2. Mycobacterium marinum
3. Pseudomonas aeruginosa
4. Staphylococcus epidermidis
5. Treponema sp.
15. An open fracture is swabbed in the emergency room and cultures from the swabs grow organisms. The fracture subsequently develops signs of overt infection. What is the chance that organisms cultured from the infected fracture will also have been cultured from the swabs taken in the emergency room?
1. Less than one in twenty cases.
2. About one in every ten cases.
3. About one in every three cases.
4. About two in every three cases.
5. More than nine in every ten cases.
16. What is the appropriate antibiotic regime to accompany surgical treatment of a grade III open fracture exposed to soil contamination?
1. Penicillin G, a second generation cephalosporin and an aminoglycoside continued for at least one week.
2. Penicillin G, a second generation cephalosporin and an aminoglycoside for three days.
3. A second generation cephalosporin and an aminoglycoside and continued for at least one week.
4. A second generation cephalosporin and an aminoglycoside and continued for three days.
5. A first generation cephalosporin and metronidazole continued for at least one week.
17. What is the approximate risk of chronic osteomyelitis when open tibial fractures are managed by external fixation using non-circular frames?
1. 2%
2. 4%
3. 6%
4. 10%
5. 25%
18. What has been estimated as the proportion of infected open fractures in which the offending organism is acquired in hospital?
1. Almost half of all cases.
2. About a quarter.
3. About one tenth.
4. About one twentieth.
5. Around one in a hundred.
19. Which of the following is the strongest predictive factor for compartment syndrome in open tibial fracture?
1. Location – shaft, plateau or pilon.
2. Interval between injury and debridement.
3. Presence of farmyard or river water contamination.
4. The grade of injury according to Gustillo.
5. The degree of bone comminution.
20. Which of the following variables is not assessed in calculating the Mangled Extremity Severity Score?
1. Age of the patient.
2. Limb ischaemia time.
3. Nerve injury.
4. Skeletal and soft tissue injury.
5. Shock.
21. Which of the following was not a conclusion of the LEAP study?
1. Reconstruction and limb salvage improved the two year outcomes for Gustillo grade IIIB and IIIC injuries distal to the femur.
2. There was no difference in the scores on the sickness impact profile between patients who underwent below knee and those who underwent above knee amputation.
3. Patients with a through knee amputation had a slower self-selected walking speed than those with above knee amputation.
4. Patient with an above knee amputation had better regression-adjusted sickness impact scores than those with a through knee amputation
5. Patients with a below knee amputation had a faster self selected walking speed and better regression-adjusted sickness scores than those with through the knee amputation.
22. Which of the following is the commonest pattern of upper limb nerve involvement seen in leprosy?
1. Combined lesions of the proximal or distal ulnar nerve and the distal median nerve.
2. Distal median nerve.
3. Proximal or distal ulnar nerve.
4. Radial nerve.
5. Triple nerve lesion of median, ulnar and radial nerves.
23. Which of the following is not a prerequisite for elective hand reconstructive surgery in leprosy?
1. Hand therapy to restore flexibility.
2. Multidrug therapy regime must have been completed.
3. No evidence of acute neuritis.
4. Recent steroid course to suppress neural inflammation.
5. Skin smears negative.
24. Which of the following is the least suitable insertion site for a motor tendon transfer being used to correct a claw hand?
1. Central slip of the extensor tendon.
2. Interosseous tendon.
3. Lateral band of the dorsal extensor expansion.
4. Proximal annular pulleys of the flexor tendon sheath.
5. Proximal phalanx.
25. Which of the following motors is least suitable for use in opponensplasty?
1. Extensor carpi ulnaris.
2. Extensor digiti minimi.
3. Extensor indicis.
4. Palmaris longus.

Here are the answers to the April 2006 CME test paper.