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2018 Graduate Professional Course Exam Questions: Pass with Confidence

Orthopedic Board Exam Prep: Comprehensive MCQ Practice & Study Guide

23 Apr 2026 72 min read 120 Views
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Key Takeaway

The most effective way to prepare for the Orthopedic Board Exam is through targeted practice with high-yield multiple-choice questions (MCQs). Utilizing an interactive platform with detailed explanations, simulating exam conditions, and tracking your progress across various orthopedic topics enhances retention and builds confidence. Focus on understanding concepts, not just memorizing answers.

Comprehensive Exam


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Question 1

A 28-year-old competitive athlete presents with acute onset knee pain, swelling, and a 'pop' sensation after a non-contact pivoting injury during soccer. On examination, Lachman test is positive, and there is significant effusion. What is the most sensitive and specific clinical test for an ACL tear?





Explanation

The Lachman test is considered the most sensitive and specific clinical test for an acute anterior cruciate ligament (ACL) tear, especially in the presence of swelling and pain. It assesses anterior translation of the tibia on the femur with the knee in 20-30 degrees of flexion, minimizing hamstring guarding. The pivot shift test is highly specific for ACL tears but can be difficult to perform accurately in an acute, painful knee. The anterior drawer test is less sensitive due to hamstring spasm in acute injuries. The posterior sag sign indicates a PCL injury, and the McMurray test assesses meniscal pathology.

Question 2

A 65-year-old male with a history of osteoporosis sustains a low-energy fall resulting in a subcapital femoral neck fracture. He is active and has no significant comorbidities. What is the most appropriate definitive surgical management?





Explanation

For an active, otherwise healthy elderly patient with a displaced femoral neck fracture, Total Hip Arthroplasty (THA) is often preferred over hemiarthroplasty due to superior functional outcomes and lower reoperation rates, especially in those with pre-existing arthritis or significant activity demands. Cannulated screw fixation is typically reserved for non-displaced or minimally displaced fractures, given the high risk of nonunion and avascular necrosis in displaced fractures. Hemiarthroplasty is a reasonable option for less active elderly patients or those with significant comorbidities. DHS and intramedullary nailing are not indicated for femoral neck fractures.

Question 3

A 7-year-old child presents with a limp, hip pain, and limited internal rotation and abduction of the hip. Radiographs show epiphyseal displacement of the femoral head. What is the most likely diagnosis?





Explanation

Slipped Capital Femoral Epiphysis (SCFE) typically presents in pre-adolescent or adolescent children (around 10-16 years old, though can be younger) with obesity, hip or knee pain, and a characteristic limited internal rotation and obligate external rotation with hip flexion. Radiographs show posterior and inferior displacement of the femoral epiphysis relative to the metaphysis. Legg-Calvé-Perthes disease affects a younger age group (4-8 years) and involves avascular necrosis of the femoral head. DDH is a neonatal/infantile condition. Septic arthritis presents with acute onset of severe pain, fever, and systemic signs. Transient synovitis is a self-limiting inflammatory condition with less severe symptoms.

Question 4

Which of the following describes the most common type of rotator cuff tear and its anatomical location?





Explanation

The supraspinatus tendon is the most commonly torn rotator cuff tendon, and tears most frequently occur at its insertion on the greater tuberosity. This area is vulnerable due to its location under the acromion, making it susceptible to impingement and wear. The other options describe less common sites or different tendons/structures.

Question 5

A 40-year-old construction worker presents with chronic low back pain radiating to his left buttock and posterolateral thigh, worsening with standing and walking, and relieved by sitting. Neurological examination reveals diminished left ankle dorsiflexion and sensation over the dorsum of the foot. What is the most likely level of nerve root compression?





Explanation

Diminished ankle dorsiflexion (weakness of tibialis anterior, extensor hallucis longus) and sensory loss over the dorsum of the foot are classic signs of L4-L5 disc herniation compressing the L5 nerve root. L3-L4 compression affects the L4 nerve root, typically causing weakness in knee extension (quadriceps) and sensory loss over the medial calf. L5-S1 compression affects the S1 nerve root, leading to weakness in plantarflexion and sensory loss over the lateral foot and sole. S1-S2 is less commonly compressed in typical lumbar disc herniations. L2-L3 involves the L3 nerve root, affecting hip flexion and thigh sensation.

Question 6

Which of the following is considered a relative contraindication to total knee arthroplasty (TKA)?





Explanation

A recent myocardial infarction (within 3 months) is a relative contraindication to elective surgeries like TKA due to the increased risk of perioperative cardiac events. While not an absolute contraindication, it warrants careful cardiac evaluation and optimization. Active systemic infection and Charcot joint are absolute contraindications. Severe obesity (BMI > 40) and extensor mechanism dysfunction (e.g., patella alta, patella baja) are also relative contraindications or factors that increase surgical complexity and complication rates, but a recent MI carries significant immediate life-threatening risks.

Question 7

A 10-year-old girl presents with a progressive painless limp and an antalgic gait. Radiographs show flattening and increased density of the capital femoral epiphysis. What is the most common classification system used for this condition?





Explanation

The Herring classification (also known as the Lateral Pillar classification) is the most common system used for Legg-Calvé-Perthes disease, which is characterized by avascular necrosis of the femoral head in children. It classifies the extent of collapse and involvement of the lateral pillar of the epiphysis, guiding treatment and prognosis. Salter-Harris classifies physeal fractures. Garden and Pauwel's classify femoral neck fractures. Meyer's classification is for congenital pseudarthrosis of the tibia.

Question 8

What is the primary mechanism of action of parathyroid hormone (PTH) on bone?





Explanation

Parathyroid hormone (PTH) primarily acts to increase serum calcium levels. It does this by several mechanisms: 1) indirectly stimulating osteoclast activity (via osteoblasts secreting RANKL) to promote bone resorption, 2) increasing calcium reabsorption in the renal tubules, and 3) stimulating the synthesis of calcitriol (active vitamin D), which in turn increases calcium absorption from the gut. While PTH causes bone resorption (answer 3 is incomplete), the most comprehensive answer regarding its primary physiological effect on calcium homeostasis, including gut and renal actions, is option C. However, option 3 focuses on specific bone action. Revisiting this: The question is 'on bone'. So the effect should be bone-specific. PTH primarily acts on osteoblasts, which then signal osteoclasts to resorb bone. Therefore, indirectly stimulating osteoclast activity via osteoblasts is the most accurate description of its action on bone. Let's reconsider. 'Increases calcium absorption in the gut and renal calcium reabsorption' are systemic effects on calcium, not directly on bone, although they contribute to overall calcium homeostasis. 'Directly stimulates osteoblast activity' is incorrect as it favors resorption in chronic exposure. 'Directly inhibits osteoclast activity' is incorrect. 'Decreases phosphate reabsorption in the kidney' is true but not its primary action on bone. Therefore, 'Indirectly stimulates osteoclast activity via osteoblasts, leading to bone resorption' is the most accurate description of its bone action.

Question 9

A 55-year-old male presents with severe pain and swelling in his great toe metatarsophalangeal (MTP) joint. On examination, the joint is exquisitely tender, erythematous, and warm. Fluid aspiration reveals negatively birefringent, needle-shaped crystals. What is the most appropriate long-term management to prevent recurrent attacks?





Explanation

The patient presents with an acute attack of gout, confirmed by negatively birefringent, needle-shaped urate crystals. While NSAIDs, colchicine, and corticosteroids are used for acute symptom relief, allopurinol is the cornerstone of long-term management to prevent recurrent attacks by decreasing uric acid production. It is a xanthine oxidase inhibitor. NSAIDs, colchicine, and corticosteroids treat the acute inflammation but do not alter the underlying hyperuricemia. A low-purine diet is helpful but usually insufficient alone for long-term control.

Question 10

Which ligament is most commonly injured in an inversion ankle sprain?





Explanation

The anterior talofibular ligament (ATFL) is the most commonly injured ligament in an inversion ankle sprain, often being the first to tear. It is the weakest of the lateral ankle ligaments. If the inversion force continues, the calcaneofibular ligament (CFL) may also be injured. The posterior talofibular ligament (PTFL) is less commonly injured in isolated inversion sprains. The deltoid ligament is on the medial side and is injured in eversion sprains. The AITFL is part of the syndesmosis and is injured in high ankle sprains.

Question 11

A 4-year-old child presents with a high fever, refusal to bear weight, and exquisite pain on hip range of motion. Blood tests show elevated white blood cell count and C-reactive protein. What is the most urgent diagnostic and therapeutic step?





Explanation

The symptoms are highly suggestive of septic arthritis of the hip, which is a surgical emergency. The most urgent diagnostic and therapeutic step is joint aspiration to confirm the diagnosis (cell count, Gram stain, culture) and guide antibiotic therapy. Following aspiration, empiric intravenous antibiotics should be started, and surgical debridement (arthrotomy or arthroscopy) is typically performed urgently to prevent articular cartilage destruction and long-term complications. MRI is useful for diagnosis but less immediate than aspiration. Antibiotics and observation alone are insufficient. Skeletal traction is not primary management. Blood cultures are important, but NSAIDs are not a definitive treatment for infection.

Question 12

What is the most critical anatomical structure to protect during surgical excision of a ganglion cyst from the dorsal aspect of the wrist?





Explanation

Ganglion cysts on the dorsal aspect of the wrist are often in close proximity to the superficial branch of the radial nerve (SBRN). Damage to this nerve during excision can lead to painful neuromas or sensory deficits over the dorsum of the hand and thumb, which can be debilitating. The radial artery is typically on the volar side. The ulnar and median nerves are also volar or medial. The posterior interosseous nerve is a deep motor nerve and is less at risk during superficial ganglion excision.

Question 13

Regarding avascular necrosis (AVN) of the femoral head, which of the following is considered the earliest radiographic sign?





Explanation

The earliest radiographic sign of avascular necrosis (AVN) of the femoral head is the 'crescent sign,' which represents a subchondral fracture. This precedes gross flattening of the femoral head and eventual joint space narrowing. Subchondral collapse is a more advanced stage. Diffuse osteopenia is a non-specific finding. While MRI is more sensitive for early detection of AVN, the crescent sign is the earliest identifiable change on plain radiographs.

Question 14

A patient with a traumatic posterior shoulder dislocation presents. What nerve injury is most commonly associated with this injury?





Explanation

The axillary nerve (C5, C6) is the most commonly injured nerve in association with shoulder dislocations, both anterior and posterior. It innervates the deltoid and teres minor muscles and provides sensation over the 'regimental badge' area. The radial, median, ulnar, and musculocutaneous nerves are less frequently involved in isolated shoulder dislocations.

Question 15

What is the most appropriate initial treatment for a Monteggia fracture-dislocation?





Explanation

A Monteggia fracture-dislocation involves a fracture of the ulna and dislocation of the radial head. The most appropriate initial treatment for adults is open reduction and internal fixation (ORIF) of the ulna fracture. Once the ulna is anatomically reduced and stabilized, the radial head often reduces spontaneously. If not, it must be directly reduced. Closed reduction is rarely successful in adults and is usually reserved for children. External fixation and radial head excision are not first-line treatments.

Question 16

Which of the following is the most sensitive imaging modality for detecting early osteomyelitis?





Explanation

Magnetic Resonance Imaging (MRI) is the most sensitive imaging modality for detecting early osteomyelitis. It can identify bone marrow edema and inflammation even before changes are visible on plain radiographs or CT scans. Bone scintigraphy is also sensitive but less specific than MRI, especially in children or when differentiating from other inflammatory conditions. Plain radiographs show changes only after significant bone destruction (typically 10-14 days). CT is good for cortical bone detail but less sensitive for early marrow changes.

Question 17

A patient undergoes a total knee arthroplasty (TKA). Postoperatively, they develop calf pain, swelling, and a positive Homan's sign. Duplex ultrasound confirms a deep vein thrombosis (DVT). What is the most appropriate initial management?





Explanation

The most appropriate initial management for confirmed deep vein thrombosis (DVT) following TKA is the initiation of therapeutic anticoagulation. Low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) are commonly used. An IVC filter is generally reserved for patients with contraindications to anticoagulation or recurrent pulmonary embolism despite adequate anticoagulation. Aspirin is used for prophylaxis but not treatment of established DVT. Warfarin requires a longer time to reach therapeutic levels, so it's usually started with a bridging agent. Compression stockings are adjunctive, not definitive treatment.

Question 18

Which intrinsic muscle of the hand is primarily responsible for opposition of the thumb?





Explanation

The Opponens Pollicis muscle is solely responsible for the complex motion of opposition of the thumb, bringing the thumb across the palm to touch the fingertips. The Abductor Pollicis Brevis abducts the thumb, and the Flexor Pollicis Brevis flexes it. The Adductor Pollicis adducts the thumb. The First Dorsal Interossei flex and abduct the index finger.

Question 19

A patient with osteoarthritis of the knee is considering total knee arthroplasty. Which of the following factors is most predictive of poor functional outcomes after TKA?





Explanation

While factors like severe obesity can increase complication rates, psychological factors such as depression and anxiety are increasingly recognized as strong predictors of poor functional outcomes and patient satisfaction after total knee arthroplasty, even more so than age or severity of osteoarthritis. These conditions can influence pain perception, motivation for rehabilitation, and overall recovery. High preoperative pain and functional limitation are indications for surgery and often improve after TKA. Prior arthroscopy does not typically predict poor TKA outcomes.

Question 20

A 30-year-old active female sustains a Salter-Harris Type II fracture of the distal tibia. What is the characteristic feature of a Salter-Harris Type II fracture?





Explanation

A Salter-Harris Type II fracture is the most common type of physeal fracture and involves a fracture line that extends through the physis and then exits through the metaphysis, sparing the epiphysis. This typically leaves a triangular metaphyseal fragment attached to the epiphysis (Thurston-Holland sign). Type I is through the physis only. Type III is through the physis and epiphysis. Type IV is through the metaphysis, physis, and epiphysis. Type V is a crush injury of the physis.

Question 21

What is the most common cause of osteonecrosis of the femoral head?





Explanation

While all listed options are known causes of osteonecrosis of the femoral head (ONFH), the most common cause is considered idiopathic, meaning no clear underlying etiology can be identified. However, prolonged corticosteroid use and excessive alcohol intake are the most frequent identifiable non-traumatic causes, and trauma is a significant cause. Sickle cell disease is a known cause but less prevalent overall than idiopathic or steroid/alcohol-induced ONFH.

Question 22

Which nerve is at greatest risk of injury during anterior surgical approaches to the hip (e.g., direct anterior approach for THA)?





Explanation

The lateral femoral cutaneous nerve (LFCN) is particularly vulnerable during direct anterior approaches to the hip, as it crosses the iliac crest and lies superficial within the surgical field. Injury can lead to meralgia paresthetica (numbness, tingling, or burning pain in the lateral thigh). The sciatic nerve is at risk with posterior approaches. The femoral, obturator, and superior gluteal nerves are deeper and less frequently injured during anterior approaches.

Question 23

A 45-year-old male sustains a distal radius fracture after a fall onto an outstretched hand. Radiographs show dorsal displacement and angulation of the distal fragment. Which eponymous fracture does this describe?





Explanation

A Colles' fracture is a distal radius fracture with dorsal displacement and dorsal angulation of the distal fragment, typically occurring from a fall onto an outstretched hand. A Smith's fracture (or reverse Colles') has volar displacement and angulation. A Barton's fracture is an intra-articular distal radius fracture with either dorsal or volar displacement of the carpus with the associated rim of the radius. A Galeazzi fracture involves a distal radial shaft fracture with associated dislocation of the distal radioulnar joint (DRUJ). An Essex-Lopresti fracture is a radial head fracture with concomitant dislocation of the DRUJ and disruption of the interosseous membrane.

Question 24

What is the primary function of the menisci in the knee joint?





Explanation

The menisci serve multiple functions, but their primary role is to improve the congruence between the incongruent femoral condyles and tibial plateau, thereby increasing the stability of the knee joint. They also act as secondary shock absorbers and play a role in load transmission and joint lubrication. While they contribute to shock absorption and load transmission, 'increasing stability by deepening the articular surface' is their fundamental anatomical contribution to joint mechanics.

Question 25

A 60-year-old female presents with progressive difficulty with overhead activities and external rotation of her left shoulder. She reports chronic dull pain exacerbated by movement. On examination, she has severe pain and weakness with resisted external rotation and abduction. What is the most likely diagnosis?





Explanation

The combination of progressive difficulty with overhead activities, weakness with resisted external rotation and abduction, and chronic pain is highly suggestive of a rotator cuff tear, particularly affecting the supraspinatus and/or infraspinatus. Adhesive capsulitis presents with global restriction of both active and passive range of motion. Subacromial impingement syndrome typically causes pain with overhead activities but not necessarily profound weakness in resisted movements. Biceps tendinopathy causes pain in the anterior shoulder. Glenohumeral osteoarthritis would present with crepitus and restricted passive range of motion, often with significant pain.

Question 26

Which surgical approach for total hip arthroplasty (THA) is most commonly associated with a higher risk of postoperative dislocation?





Explanation

The posterior approach for total hip arthroplasty (THA) has traditionally been associated with a higher risk of postoperative dislocation, primarily due to the necessary division of the short external rotator muscles and posterior capsule. While surgical techniques and repair of the capsule have reduced this risk, it remains a concern compared to anterior or lateral approaches. Direct anterior and lateral approaches are generally considered to have lower dislocation rates, although each approach has its own unique set of potential complications.

Question 27

A 14-year-old male football player sustains a valgus stress injury to his knee. Examination reveals pain and laxity with valgus stress at 30 degrees of knee flexion, but stability at 0 degrees. What structure is most likely injured?





Explanation

Laxity with valgus stress at 30 degrees of knee flexion, with stability at 0 degrees, is the classic presentation for an isolated medial collateral ligament (MCL) injury (Grade I or II). The MCL is the primary restraint to valgus stress. If there were laxity at 0 degrees, it would suggest a more severe injury involving the posterior oblique ligament and/or ACL. LCL is injured with varus stress. ACL and PCL injuries cause anteroposterior instability. The medial meniscus can be injured with valgus forces, but the primary instability described points to the MCL.

Question 28

Which of the following conditions is most accurately diagnosed with a bone scan (technetium-99m methylene diphosphonate)?





Explanation

A bone scan (technetium-99m methylene diphosphonate) is highly sensitive for detecting areas of increased bone turnover, making it particularly useful for diagnosing stress fractures, which involve micro-trauma and increased osteoblastic activity. While it can detect osteosarcoma (as it's metabolically active bone), MRI is superior for characterizing bone tumors. Disc herniation and soft tissue tumors are not directly evaluated by bone scans. Gout is a joint inflammation, not a primary bone pathology best seen on a bone scan.

Question 29

A patient with a traumatic brachial plexus injury presents with a 'waiter's tip' posture (shoulder adducted and internally rotated, elbow extended, forearm pronated, wrist flexed). Which nerve roots are most likely affected?





Explanation

The 'waiter's tip' posture is characteristic of an Erb's palsy, which results from injury to the upper trunk of the brachial plexus, primarily involving the C5 and C6 nerve roots. This affects muscles innervated by these roots, including the deltoid, supraspinatus, infraspinatus, biceps, and brachialis, leading to the described posture. C8-T1 injuries cause Klumpke's palsy, affecting intrinsic hand muscles.

Question 30

Which type of collagen is primarily found in hyaline articular cartilage?





Explanation

Type II collagen is the predominant collagen type found in hyaline articular cartilage, providing its characteristic strength and elasticity. Type I collagen is found in bone, tendons, ligaments, and fibrous cartilage. Type III collagen is found in reticular fibers, skin, and blood vessels. Type IV collagen is found in basement membranes. Type V collagen is found in hair and cell surfaces.

Question 31

What is the most common primary malignant bone tumor in children and young adults?





Explanation

Osteosarcoma is the most common primary malignant bone tumor in children and young adults (typically 10-30 years old), often affecting the metaphysis of long bones (e.g., distal femur, proximal tibia, proximal humerus). Ewing's sarcoma is the second most common, often affecting diaphyseal regions. Chondrosarcoma is more common in older adults. Multiple myeloma is a malignant proliferation of plasma cells, primarily affecting older adults, and is the most common primary bone malignancy overall. Fibrosarcoma is rare.

Question 32

A patient presents with a painful, swollen index finger. On examination, the finger is held in slight flexion, and there is tenderness along the flexor tendon sheath, particularly at the A1 pulley. Passive extension of the finger is painful. What is the most likely diagnosis?





Explanation

The description (finger held in slight flexion, uniform tenderness along the flexor sheath, pain with passive extension, fusiform swelling) matches Kanavel's cardinal signs of flexor tenosynovitis, a surgical emergency due to infection. Mallet finger is a disruption of the extensor tendon at the DIP joint. Trigger finger involves catching/locking of a digit due to a nodule in the flexor tendon at the A1 pulley. De Quervain's tenosynovitis affects the abductor pollicis longus and extensor pollicis brevis at the radial styloid. Gamekeeper's thumb is an injury to the ulnar collateral ligament of the thumb MCP joint.

Question 33

What is the primary role of vitamin D in bone metabolism?





Explanation

The primary role of active vitamin D (calcitriol) in bone metabolism is to increase calcium absorption from the gut. It also directly promotes bone mineralization and works synergistically with PTH to maintain calcium and phosphate homeostasis. While it has some effects on osteoblasts and osteoclasts, its most prominent and direct role in calcium homeostasis relevant to bone is intestinal calcium absorption.

Question 34

A 25-year-old male sustains a high-energy femoral shaft fracture. What is the most appropriate definitive treatment in an otherwise healthy adult?





Explanation

For most diaphyseal femoral shaft fractures in adults, intramedullary nailing is the gold standard for definitive treatment. It provides excellent biomechanical stability, allows for early weight-bearing, and has high union rates with lower complication rates compared to other methods. Skeletal traction followed by casting is largely historical for adults. External fixation is primarily used for temporary stabilization in polytrauma or open fractures. Plate osteosynthesis is an option but generally considered inferior to IMN for femoral shaft fractures. A dynamic hip screw is used for intertrochanteric hip fractures.

Question 35

Which nerve is typically involved in Carpal Tunnel Syndrome?





Explanation

Carpal Tunnel Syndrome (CTS) results from compression of the median nerve as it passes through the carpal tunnel at the wrist. This leads to characteristic symptoms of numbness, tingling, and pain in the thumb, index finger, middle finger, and radial half of the ring finger, often worse at night. The radial and ulnar nerves pass outside the carpal tunnel.

Question 36

What is the most common site for osteochondroma?





Explanation

Osteochondroma is the most common benign bone tumor and typically arises from the metaphysis of long bones, especially around the knee (distal femur, proximal tibia) or proximal humerus. It grows away from the joint. It is characterized by a cartilage cap and continuity of the medullary canal with the underlying bone.

Question 37

A 70-year-old active male presents with chronic insidious onset groin pain, worse with weight-bearing and internal rotation. Radiographs show joint space narrowing, subchondral sclerosis, and osteophytes in the hip. What is the most appropriate non-operative management strategy?





Explanation

The patient's symptoms and radiographic findings are consistent with hip osteoarthritis. The most appropriate initial non-operative management typically involves a combination of oral NSAIDs for pain and inflammation, along with physical therapy to maintain range of motion, strengthen surrounding muscles, and improve function. Corticosteroid injections can provide temporary relief but are not a long-term solution. Total hip arthroplasty is a surgical option reserved for failed non-operative management. Opioids are generally avoided for chronic non-cancer pain, and bed rest is detrimental.

Question 38

Which tendon is most commonly involved in 'tennis elbow' (lateral epicondylitis)?





Explanation

Lateral epicondylitis, or 'tennis elbow,' is a degenerative condition affecting the common extensor origin at the lateral epicondyle, with the Extensor Carpi Radialis Brevis (ECRB) tendon being most commonly involved. Repetitive wrist extension and supination contribute to its development. The other tendons listed are either flexors or less commonly involved in this specific condition.

Question 39

What is the most common type of nonunion in a scaphoid fracture?





Explanation

Scaphoid fractures have a high propensity for nonunion due to their precarious blood supply, especially in the proximal pole. When nonunion occurs, it is most commonly an atrophic nonunion, characterized by a lack of healing potential and a 'pencil-point' appearance on radiographs, often requiring bone grafting. Hypertrophic nonunions show exuberant callus formation but fail to bridge the fracture gap. Infected nonunion is rare in scaphoid fractures. Delayed union means it eventually heals, just slowly. Malunion implies healing in an unsatisfactory position.

Question 40

A 6-month-old infant is diagnosed with developmental dysplasia of the hip (DDH). The Ortolani and Barlow tests are negative. Ultrasonography shows acetabular dysplasia but a reducible hip. What is the most appropriate initial treatment?





Explanation

For infants diagnosed with developmental dysplasia of the hip (DDH) that is reducible and not dislocated (Graf Type IIa or IIb), the Pavlik harness is the most appropriate initial treatment. It maintains the hip in a position of flexion and abduction, promoting acetabular development. A spica cast or open reduction is used for irreducible or dislocated hips, or when Pavlik harness fails. Observation is inappropriate for a diagnosed reducible DDH. Traction is rarely used as primary treatment for DDH.

Question 41

Which of the following ligaments is considered the primary static stabilizer against posterior translation of the tibia on the femur?





Explanation

The Posterior Cruciate Ligament (PCL) is the strongest ligament in the knee and serves as the primary static stabilizer against posterior translation of the tibia on the femur, as well as providing some secondary restraint to varus, valgus, and rotational forces. The ACL is the primary restraint to anterior translation. The MCL and LCL provide valgus and varus stability, respectively. The posterior oblique ligament is part of the posteromedial corner and contributes to valgus stability and external rotation.

Question 42

What is the most common site of metastatic bone disease in the spine?





Explanation

The thoracic spine is the most common site for metastatic bone disease in the spine, accounting for about 60-70% of spinal metastases. This is followed by the lumbar spine (20-25%) and then the cervical spine (10-15%). The rich vascularity of the thoracic vertebral bodies and their proximity to the venous plexus of Batson contribute to this predilection.

Question 43

A patient presents with a chronically painful, stiff ankle following a severe pilon fracture treated with ORIF. Radiographs show significant post-traumatic arthritis. What is the most appropriate surgical management for end-stage ankle arthritis in an active patient?





Explanation

For end-stage ankle arthritis in an active patient, total ankle arthroplasty (TAA) is increasingly considered a viable option. It aims to relieve pain while preserving motion, which is desirable for active individuals. Ankle arthrodesis (fusion) is a reliable pain-relieving procedure but sacrifices motion, which can lead to increased stress on adjacent joints. Distraction arthroplasty is for early to mid-stage arthritis. Debridement is for early stages. Supramalleolar osteotomy is for correction of malalignment with early arthritis.

Question 44

Which clinical finding is most indicative of a complete tear of the Achilles tendon?





Explanation

A positive Thompson test (absence of plantarflexion of the foot when the calf muscle is squeezed) is the most reliable clinical sign for a complete rupture of the Achilles tendon. While a palpable gap and difficulty with heel raises are often present, the Thompson test specifically demonstrates the functional loss of the gastrocnemius-soleus complex's connection to the calcaneus. Pain and swelling are non-specific, and limited passive dorsiflexion is not typically associated with an Achilles rupture unless there's concomitant injury.

Question 45

What is the most appropriate initial treatment for a stress fracture of the fifth metatarsal (Jones fracture) in an athlete?





Explanation

A Jones fracture (fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal) is known for its high risk of nonunion due to compromised blood supply. In athletes, especially, early surgical intervention with intramedullary screw fixation is often recommended to ensure union and facilitate a quicker return to sport, especially when compared to prolonged non-weight-bearing immobilization. Non-weight-bearing cast immobilization is an option but has higher nonunion rates in athletes. Plate and screw fixation or percutaneous pinning are not typically used for Jones fractures.

Question 46

Which of the following describes the anatomical landmark used to locate the neurovascular bundle during a posterior approach to the knee for meniscal repair or PCL reconstruction?





Explanation

The popliteal fossa is the anatomical landmark containing the neurovascular bundle (popliteal artery, vein, and tibial nerve) that must be carefully protected during a posterior approach to the knee. These vital structures are located in the deep aspect of the fossa. The adductor tubercle and medial epicondyle are on the medial aspect of the femur. Gerdy's tubercle is on the lateral tibia. The fibular head is on the lateral aspect of the knee.

Question 47

What is the most common cause of septic arthritis in adults?





Explanation

Staphylococcus aureus is by far the most common causative organism for septic arthritis in adults (and children). It accounts for 70-80% of cases. Staphylococcus epidermidis is common in prosthetic joint infections but less so in native joint septic arthritis. Neisseria gonorrhoeae is a common cause in young, sexually active individuals but not overall the most common. Streptococcus pneumoniae and E. coli are less frequent causes in general.

Question 48

A 50-year-old male presents with severe pain and limited range of motion of the elbow after a fall onto an outstretched hand. Radiographs show a fracture of the radial head with associated dislocation of the distal radioulnar joint (DRUJ) and disruption of the interosseous membrane. Which eponymous injury is this?





Explanation

The description perfectly matches an Essex-Lopresti lesion: a comminuted radial head fracture, rupture of the interosseous membrane, and dislocation of the distal radioulnar joint (DRUJ). This is a severe forearm injury that can lead to significant instability and chronic wrist pain if not recognized and treated appropriately. Monteggia involves an ulna fracture and radial head dislocation. Galeazzi involves a distal radial shaft fracture and DRUJ dislocation. Colles' is a distal radius fracture. Mason classification describes radial head fractures but does not encompass the entire Essex-Lopresti lesion.

Question 49

What is the primary indication for surgical treatment of scoliosis in adolescents?





Explanation

The primary indication for surgical correction of adolescent idiopathic scoliosis (AIS) is a progressive curve greater than 45-50 degrees in a skeletally immature patient, or a curve greater than 50-60 degrees in a skeletally mature patient. This threshold is chosen because curves of this magnitude are likely to progress even after skeletal maturity and can lead to significant pulmonary compromise or trunk imbalance. While progression despite bracing and refractory pain are considerations, the specific Cobb angle threshold in an immature patient is a critical surgical indication. Cosmetic deformity alone is not a primary medical indication for surgery unless it is associated with a severe curve.

Question 50

Which of the following ligaments provides the most significant restraint to external rotation of the tibia on the femur?





Explanation

The anterior cruciate ligament (ACL) is the primary restraint to anterior translation of the tibia on the femur, but it also provides a significant secondary restraint to internal and external rotation, particularly preventing excessive external rotation. The PCL restrains posterior translation. The MCL and LCL primarily resist valgus and varus forces, respectively. The oblique popliteal ligament is part of the posteromedial corner and contributes to posterior stability.

Question 51

What is the most characteristic radiographic finding in osteoid osteoma?





Explanation

Osteoid osteoma is a benign bone tumor characterized radiographically by a small, radiolucent nidus (typically less than 1.5 cm) surrounded by a zone of dense, reactive sclerotic bone. This appearance, especially with an identifiable nidus, is pathognomonic. Sunburst pattern, onion-skinning, and Codman's triangle are associated with malignant bone tumors (e.g., osteosarcoma, Ewing's sarcoma). Ground-glass matrix is seen in fibrous dysplasia.

Question 52

Which of the following is an absolute contraindication to open reduction and internal fixation (ORIF) of a fracture?





Explanation

Active infection at the fracture site is an absolute contraindication to immediate open reduction and internal fixation (ORIF) with implants, as it carries a very high risk of implant contamination, osteomyelitis, and treatment failure. The infection must be aggressively treated and eradicated before definitive internal fixation. Osteoporosis, poor patient compliance, multiple comorbidities, and advanced age are all relative contraindications or factors that increase surgical risk, but they do not absolutely preclude ORIF.

Question 53

A patient with suspected avascular necrosis of the lunate (Kienböck's disease) presents. Which classification system is commonly used to stage this condition?





Explanation

The Lichtman classification is the most commonly used staging system for Kienböck's disease (avascular necrosis of the lunate). It categorizes the disease into four stages based on radiographic findings, including sclerosis, collapse, fragmentation, and secondary degenerative changes, guiding treatment decisions. Watson classification is for scapholunate dissociation. Mayo classification is for elbow instability. Herbert classification is for scaphoid fractures. Garcia-Elias is not a widely recognized orthopedic classification.

Question 54

What is the appropriate management for a stable burst fracture of the thoracolumbar spine with no neurological deficit?





Explanation

For a stable burst fracture of the thoracolumbar spine without neurological deficit, non-operative management with brace immobilization (e.g., thoracolumbosacral orthosis, TLSO) is often the preferred treatment. Surgical intervention is typically reserved for unstable fractures, those with neurological deficits, or significant kyphosis. Vertebroplasty or kyphoplasty are mainly used for osteoporotic compression fractures, not acute traumatic burst fractures. Emergent surgical decompression and fusion are for unstable fractures with neurological compromise.

Question 55

Which of the following describes the anatomical defect in a direct inguinal hernia?





Explanation

A direct inguinal hernia protrudes directly through the posterior wall of the inguinal canal, specifically through Hesselbach's triangle, and is located medial to the inferior epigastric vessels. It does not pass through the deep inguinal ring. An indirect inguinal hernia protrudes through the deep inguinal ring, lateral to the inferior epigastric vessels. A femoral hernia passes through the femoral canal. An obturator hernia passes through the obturator foramen.

Question 56

Which bone is most commonly affected by osteomyelitis in IV drug users?





Explanation

Intravenous drug users (IVDU) are particularly susceptible to hematogenous osteomyelitis of the vertebral bodies, often caused by Staphylococcus aureus or Pseudomonas aeruginosa. This is due to direct inoculation of bacteria into the bloodstream and subsequent spread to the highly vascular vertebral bodies. While long bones can be affected, the spine is a notably common site in this population.

Question 57

What is the most appropriate initial treatment for acute compartment syndrome of the forearm?





Explanation

Acute compartment syndrome is a surgical emergency characterized by increased pressure within a confined fascial compartment, leading to impaired blood flow and potential irreversible muscle and nerve damage. The definitive treatment is emergent fasciotomy to decompress the compartment and restore perfusion. Delay in treatment can lead to Volkmann's ischemic contracture. Ice, elevation, analgesics, observation, splinting, rest, and compression bandages are all inappropriate and potentially harmful interventions.

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Dr. Mohammed Hutaif
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