Journal of Bone and Joint Surgery (British Volume)

CME questions July 2006

These papers have been set on the review articles and aspects of current management papers from the 2006 April, May and June issues of the JBJS-Br.

1. What is the volume of blood that has to be lost from the circulatory system of a healthy 75kg man before hypotension is usually first recordable?
1. 500ml
2. 750ml
3. 1000ml
4. 1500ml
5. 2000ml
2. What investigation is essential before applying a pelvic 'C' clamp to stabilise a pelvic fracture?
1. Pelvic ultrasound
2. AP X Ray of the pelvis
3. Inlet/Outlet views of the Pelvis
4. Judet Views of the Pelvis
5. Pelvic CT scan
3. Which of the following is a requirement before selective arterial embolisation can be considered to treat haemorrhage associated with pelvic fracture?
1. Stable fracture pattern
2. Restoration of circulatory status by initial fluid resuscitation
3. Retroperitoneal haematoma on Ultrasound
4. Associated injury to the liver, kidney or spleen
5. A visible 'blush' on contrast enhanced CT scan
4. A patient has an unstable pelvic fracture with unilateral sacroiliac dislocation visible on plain X rays. An abdominal ultrasound reveals intraperitoneal fluid. The blood pressure normalised after 2 litres of intravenous crystalloid given quickly and the application of a 'C' clamp, but fell again 15 mins later when the rate of fluid administration was reduced to maintenance levels. What is the next appropriate step in management?
1. administer a further 2 litre crystalloid fluid challenge
2. apply an anterior external fixator frame
3. urgent CT scan of the abdomen and pelvis
4. reduction of the dislocation and stabilisation with percutaneous sacroiliac screws
5. urgent laparotomy
5. Which of the following tissues yields the smallest proportion of mesenchymal stem cells when experimentally harvested for culture?
1. umbilical cord
2. bone marrow
3. synovium
4. adipose tissue (fat pad from knee)
5. arterial wall
6. According to experimental calculations, if a tibial nonunion could be treated by generating 6ml of new bone, what volume of bone marrow would have to be injected into the nonunion site to secure this effect?
1. 1ml
2. 6ml
3. 20ml
4. 40ml
5. This volume could not be generated after bone marrow injection
7. When large bone defects were experimentally treated by inserting a scaffold of polymeric microsperes and mesenchymal stem cells, what additional effect did BMP-7 confer?
1. Increased rate of differentiation of stem cells
2. Increased rate of osteoid production by osteoblasts that differentiate from stem cells
3. Improved penetration of the scaffold by stem cells
4. Rapid division of stem cells
5. Increased formation of local capillary buds
8. Bony metastases from which of the following tumours is most likely to be sensitive to radiotherapy
1. breast
2. colon
3. lung
4. kidney (renal cell)
5. soft tissue sarcoma
9. Which of the following is the commonest location for initial growth of a vertebral metastasis
1. Vertebral body (central)
2. Vertebral body (enplate)
3. Posterior elements
4. Epidural space
5. Paravertebral soft tissues
10. Which of the following is the commonest form of metastatic disease of the spine
1. Lumbar metastases in a patient with prostatic cancer
2. Lumbar metastases in a patient with lung cancer
3. Lumbar metastases in a patient with breast cancer
4. Thoracic metastases in a patient with lung cancer
5. Thoracic metastases in a patient with breast cancer
11. According to the classification system of Tomita, which of the following patients should be treated by marginal or intralesional excision for medium term local control of the tumour?
1. Slow growing tumour with no bony or visceral metastases
2. Slow growing tumour with treatable visceral metastases and multiple bone metastases
3. Slow growing tumour with untreatable visceral metastases and multiple bony metastases
4. Moderate rate of tumour growth with treatable visceral metastases and multiple bone metastases
5. Rapidly growing tumour with a solitary bone metastasis and treatable visceral metastases
12. Although current evidence is weak, which of the following has been shown to provide lasting pain relief and improvements in motor power and walking capacity when used to treat spinal metastases
1. Stereotactic radiosurgery
2. Intensity modulated radiotherapy
3. Radiofrequency ablation
4. Vertebroplasty
5. Endoscopic vertebrectomy
13. From a synthesis of the available literature on tibial nailing, what is the approximate incidence of anterior knee pain at the end of follow up in patients who have undergone tibial intramedullary nailing.
1. < 10%
2. 10%
3. 25%
4. 50%
5. 75%
14. Concerning retrograde femoral nailing, which of the following describes the reported effect of surgical approach on the incidence of knee pain
1. Knee pain is not a reported complication of retrograde femoral nailing
2. The incidence of knee pain is not affected by the surgical approach used
3. The incidence of knee pain is greatest when a paratendinous approach is used
4. The incidence of knee pain is greater when a transtendinous approach is used
5. All patients experience anterior knee pain, making comparison of approaches impossible
15. To which super family of molecules do the Bone Morphogenetic Proteins belong?
1. Interferons
2. TGF-beta
3. Collagens
4. PDGF
5. VEGF
16. Which of the following is a potential advantage of gene therapy when used to deliver growth factors to a fracture site?
1. Prolonged expression of the protein
2. Immunosensitisation
3. Variation of gene expression
4. Ectopic bone formation
5. Extent of host immune response
17. According to currently available randomised trials, what is the outcome when comparing autograft with BMP7 in a collagen carrier for tibial nonunions?
1. Ultimately both groups have the same outcome, though the BMP group achieve union quicker
2. The autograft group has a significantly greater union rate at 9 months
3. The BMP group had a significantly greater union rate at 9 months
4. Union rates at 9 months were similar but morbidity differed, with more infections in the BMP group
5. Union rates at 9 months were similar but morbidity differed, with 20% incidence of donor site pain in the autograft group
18. On EUA of a knee dislocation the anterior and posterior drawer tests, Lachmann and Dial tests are all positive. No fracture lines are apparent on plain films or CT scans. How would this injury be classified according to the system initially proposed by Schenk?
1. KD-II
2. KD-III
3. KD-IV
4. KD-V3L
5. KD-V4
19. What direction of knee dislocation is typically produced by knee hyperextension
1. anterior
2. posterior
3. lateral
4. medial
5. rotatory
20. In which of the following patterns of knee dislocation is common peroneal nerve injury most likely?
1. KD-I
2. KD-II
3. KD-V1
4. KD-V2
5. KD-V3L
21. Which of the following injuries is most commonly associated with knee dislocation
1. popliteal artery rupture
2. common peroneal nerve injury
3. fracture of the distal femur
4. fracture of the tibial plateau
5. Segond fracture
22. If urgent vascular repair has been necessary to restore distal perfusion after a knee dislocation, which of the following is the appropriate next step.
1. Plaster backslab immobilisation until the anastamosis has healed and nonoperative management of the knee ligament injury.
2. Plaster backslab immobilisation until the anastamosis has healed followed by reconstruction of all injured ligaments.
3. Bridging external fixator for 8 weeks then assess ligaments
4. Repair or reconstruct lateral ligaments then assess - if inadequate apply bridging external fixator
5. Graft the ACL to restore initial stability with delayed reconstruction of other components
23. How long should definitive reconstruction be delayed after popliteal artery repair to allow the vascular anastamosis to mature sufficiently that a torniquet can be applied to the lower limb?
1. No delay necessary
2. 6 weeks
3. 3 to 6 months
4. 6 to 12 months
5. At least 12 months
24. Reconstruction of which ligamant is key to reducing the subluxed knee after dislocation without associated fracture?
1. MCL
2. LCL
3. ACL
4. PCL
5. Posterolateral corner
25. What is the most appropriate remedial management for a patient found to have a 10cm deficit in the common peroneal nerve at exploration of a knee dislocation.
1. Direct repair
2. Immediate nerve graft
3. Delayed nerve graft at 3 months
4. Delayed nerve graft once knee ROM restored after ligament reconstruction
5. Tibialis posterior transfer

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