CME quEstions January 2009

This month the JBJS introduces a multiple-choice questionnaire that we hope will serve several functions. The questions are based on the review articles, aspects of current management and annotations that have appeared in the journal over the last quarter. Satisfactory completion of the
1. What is the effect of penicillin on bacteriae already present in a sensitive colony to which it is added at a therapeutic concentration? a. It binds bacterial mitochondrial proteins leading to cell death b. It binds ribosomes, interfering with protein production and leading to cell death c. It binds to the cell wall, making it leaky and leading to lysis d. It has no effect on organisms already present e. It interferes with nucleic acid replication and prevents further bacterial division 2. Which of the following best describes a biofilm? a. A film of drug resistant organisms beneath which multiple organisms, drug resistant or not, can grow unchecked on the surface of an implant b. A glycocalyx secreted by a colony of organisms that become sessile on the surface of an implant, which forms a barrier between the organisms and antibiotics in the serum c. A layer of drug resistant organisms that colonise the surface of an implant, providing a reservoir from which bacteria can be released into the circulation d. A layer of infected host tissue with no remaining vascular supply that prevents administered antibiotics reaching the contained organisms e. A protein layer derived from the host circulation into which organisms can incorporate to conceal themselves from the host immune system 3. Which of the following factors correlates best with the occurrence of MRSA infection after operation? a. Age of patient b. Length of hospitalisation c. Nasal carriage of MRSA by patient d. Operative time e. The surgeon involved 4. Which of the following collective characteristics best describe the community acquired MRSA organism? a. Resistant to lactams and quinolones, colonises indwelling vascular catheters b. Sensitive to quinolones, causes necrotising pneumonia, outbreaks can occur in young patients c. Resistant to multiple antibiotics, frequently found on nursing home residents after admission to hospital d. Sensitive to vancomycin, causes wound infections in the elderly after surgical procedures for acute problems e. Carries a collection of genes, the products of which code for proteins making the organism resistant to multiple antibiotics 5. Which of the following is an acceptable practice when mixing antibiotics with bone cement for the fixation of prostheses? a Addition of 5 g of antibiotic powder to 40 g cement b. Addition of antibiotic impregnated albumin c. Addition of cefuroxime powder d. Addition of liquid antibiotics e. Addition of lyophilised vancomycin 6. Which of the following would be the most appropriate management for a patient with an infected fracture after fixation of a humeral shaft fracture with a dynamic compression plate, after drainage of any collection and debridement of the wound? a. Antibiotic treatment, retain metalwork until fracture consolidation b Leave the wound open to heal by secondary intention c. Remove plate with its biofilm and re-plate with antibiotic cover d. Remove plate and replace with intramedullary nail with antibiotic cover d. Remove plate and treat using hanging cast until union 7. Which of the following changes is not characteristic of the nucleus pulposus in disc degeneration? a. Declining keratin sulphate: chondroitin sulphate ratio b. Declining link protein density in proteoglycans c. Declining proteoglycan concentration in nucleus d. Declining size of proteoglycan molecules e. Declining type IX collagen concentration in nucleus 8. What are concentric tears of the annulus fibrosus? a. Areas of delamination of the annulus due to shear stress b. Posterior annular tears caused by increased compressive loading after nuclear decompression c. Tears originating at the degenerate nucleus extending out through annulus d. Tears originating at an endplate compression fracture and radiating outwards through the annulus e. Tears originating peripherally due to torsional overload that propagate inwards

questionnaire provides evidence of a thorough knowledge of the content of these articles. If a reader submits responses that reach a standard that suggests satisfactory assimilation of the material then a certificate will be earned recording the award of five CME points.
18. Which of the following factors would be least likely to suggest that a patient is an ideal candidate for tibial osteotomy according to ISAKOS criteria? a. Age 50 b. BMI 28 c. No cupula d. Varus malalignment of 10 e. Wishes to continue all sports

9. Which of the following is not a consequence of ageing in the intervertebral disc? a. Collagen in the nucleus changes from type II to type ! b. Diminished capacity for cell proliferation c. Disc space narrowing d. Increased non-collagenous protein in the nucleus e. Loss of distinction between the annulus and nucleus 10. Which bacterium has been implicated in the process of intervertebral disc degeneration? a. Erysipelothrix rhusiopathiae b. Mycobacterium tuberculosis c. Propionibacterium acnes d. Staphylococcus albus e. Staphylococcus aureus 11. Which of the following has the most direct role in disc degeneration? a. Basic fibroblast growth factor b. Cartilage intermediate layer protein c. Insulin-like growth factor d. Matrix metalloproteinase e. Transforming growth factor 12. What, on average, is the expected outcome after hemiarthroplasty for fracture or fracture dislocation of the shoulder? a. Constant score 36, elevation 90, abduction 60, external rotation 0 b. Constant score 36, elevation 60, abduction 90, external rotation 10 c. Constant score 56, elevation 90, abduction 105, external rotation 30 d. Constant score 56, elevation 105, abduction 90, external rotation 30 e. Constant score 76, elevation 105, abduction 60, external rotation 10 13. Overall, which of the following is the most commonly reported complication following hemiarthroplasty for fracture or fracture dislocation of the shoulder? a. Deep infection b. Heterotopic ossification c. Inadequate tuberosity fixation or healing d. Proximal migration of the head e. Superficial infection 14. Which of the following factors is least predictive of instability in fractures of the distal radius? a. Age > 60 b. Dorsal angulation of > 20 c. Dorsal comminution d. Intra-articular fracture e. Prior diagnosis of osteoporosis 15. Concerning dorsal plating for fractures of the distal radius, which of the following is incorrect? a. Dorsal scars are less well tolerated than volar scars b. Early metalwork removal does not prevent the complications of dorsal plating c. Extensor tendon irritation and attrition rupture are common complications d. Fracture reduction is less perfect when compared with volar plating e. Loss of palmar flexion can occur 16. What is the `watershed line of the distal radius? a. Junction between bone supplied by nutrient artery and bone supplied by capsular vessels b. Landmark identified by the proximal extent of the distal radioulnar joint c. Line marking the site of the epiphyseal scar d. Line that volar plates must cross to have an efficient hold on dorsal fragments e. Line where volar cortex turns dorsally and gives attachment to ligaments and capsule 17. Which of the following is not a perceived advantage of volar locking plate fixation for fractures of the distal radius? a. Anatomical reduction of fracture lines is easier b. Inspection of the joint surface is facilitated c. It allows a range of pegs or screws to be used to secure or buttress fragments d. There is a mechanical advantage in osteoporotic bone e. There is less tendency to cause tendon irritation

19. The weight-bearing axis is checked after high tibial osteotomy for medial compartment arthrosis. Which of the following is the best position for the axis as it crosses the tibial plateau as a percentage of the width of the plateau when measured from the medial side? a. 50% b. 60% c. 70% d. 80% e. 90%

20. A tibial osteotomy is carried out for posteromedial cartilage damage in an ACL deficient knee. What combination of corrections would best address the combined pathology? a. Varus with a flexion osteotomy of proximal tibia b. Varus with an extension osteotomy of proximal tibia c. Valgus with flexion osteotomy of proximal tibia d. Valgus with extension osteotomy of proximal tibia e. Varus with osteotomy and lateral transposition of tibial tubercle

21. In approximately what proportion of patients can common peroneal nerve compromise be detected on nerve conduction studies after high tibial osteotomy? a. 2% b. 5% c. 10% d. 15% e. 25% 22. Which of the following correctly describes a hormonal influence on the human growth plate? a. Growth hormone diminishes cytoplasmic proliferation b. Growth hormone triggers closure of the physis after longitudinal growth c. Oestrogens decrease the number of cells in the physeal columns d. Thyroid hormone potentiates cytoplasmic proliferation e. Thyroid hormone increases the number of cells in the physeal columns 23. Which of the following could increase rather than decrease physeal growth? a. Chemotherapy b. Division of the sympathetic supply c. Meningococcal septicaemia d. Thalassaemia e. Vitamin A intoxication

24. Which of the following features of chondrocyte death at the proximal end of cell columns in the growth plate does not fit with the classic description of apoptosis? a. Cell death appears to be programmed b. It occurs to a greater extent in infancy than in later childhood c. Nuclear chromatin condenses d. Rough endoplasmic reticulum proliferates e. The process appears to be very tightly controlled 25. Which of the following factors contributes most to the increase in bone length? a. Deposition of calcium into the matrix laid down by chondrocytes b. Division of cells in the proliferative zone c. Division of cells in the hypertrophic zone d. Laying down of matrix between chondrocytes in the cell columns e. The volume of individual chondrocytes increases in hypertrophic zone

The next CME will be available online from April 2009 Submit your responses online at www.jbjs.org.uk