Ortho Board Exam Prep: Interactive Spinal Trauma MCQs

Comprehensive Exam

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Question 1

A 45-year-old male presents with acute onset back pain and progressive neurological deficit after a fall from a height. Imaging reveals a burst fracture of L1 with retropulsion into the spinal canal causing cauda equina compression. Neurological exam shows bilateral lower extremity weakness (3/5), saddle anesthesia, and urinary retention. Which of the following is the most appropriate initial management strategy?

Explanation

Immediate posterior decompression and fusion with instrumentation is the most appropriate initial management. The presence of acute neurological deficit (cauda equina syndrome) due to spinal canal compromise warrants urgent surgical intervention. Posterior decompression addresses the canal compromise, and instrumentation provides stability to prevent further neurological deterioration and allow early mobilization. Conservative management is contraindicated due to neurological deficits. Anterior decompression might be considered in some cases but is generally not the initial approach for acute neurological deficits in a burst fracture with posterior element involvement, especially with posterior element injury. Laminectomy alone can destabilize the spine further and is associated with poor outcomes. Steroids are not proven to improve outcomes in cauda equina syndrome.

Question 2

A 68-year-old female undergoes a primary total hip arthroplasty for osteoarthritis. On postoperative day 2, she develops acute onset of severe hip pain and inability to bear weight. X-rays show no dislocation or periprosthetic fracture. Lab work reveals a CRP of 150 mg/L (normal <5 mg/L) and a WBC count of 18,000 cells/µL. Her temperature is 38.8°C. What is the most likely diagnosis and subsequent management?

Explanation

The constellation of acute severe pain, inability to bear weight, systemic inflammatory response (high CRP, WBC, fever), and recent surgery is highly suggestive of acute periprosthetic joint infection (PJI). Urgent irrigation and debridement (I&D) with component retention (DAIR - Debridement, Antibiotics, and Implant Retention) is the preferred initial management for acute PJI, especially if the infection is diagnosed early (within 3-4 weeks of onset) and the components are well-fixed. If DAIR fails or components are unstable, a one-stage or two-stage exchange might be necessary. Aseptic loosening usually presents later and without acute systemic inflammatory signs. Hematoma can cause pain but usually not such a strong systemic response without infection. DVT typically presents with calf swelling and tenderness, not severe hip pain and systemic signs of infection. Nerve palsy would not explain the pain, fever, and inflammatory markers.

Question 3

A 28-year-old professional basketball player presents with chronic anterior knee pain and instability, worsening with activity. He previously sustained a twisting injury to his knee. Examination reveals a positive Lachman test, pivot shift test, and a firm endpoint on anterior drawer. His X-rays are normal. MRI shows a complete tear of the anterior cruciate ligament (ACL) and a horizontal tear of the posterior horn of the medial meniscus. What is the most appropriate management?

Explanation

For a young, active individual with a complete ACL tear and symptomatic instability, ACL reconstruction is indicated. Given the concomitant horizontal tear of the posterior horn of the medial meniscus, and assuming it's a reparable tear (e.g., in the red-red or red-white zone, stable, and of sufficient size), primary repair of the meniscus in conjunction with ACL reconstruction is often the preferred approach. ACL reconstruction provides a stable environment that can promote meniscus healing and reduces the risk of future degenerative changes. Partial meniscectomy, while common, removes meniscal tissue and increases the risk of osteoarthritis, and is generally avoided if repair is feasible, especially in younger patients with concomitant ACL injury. Conservative management is not suitable for a professional athlete with symptomatic instability.

Question 4

A 72-year-old female presents with acute, severe, intractable pain in her right shoulder following a fall. She has significant medical comorbidities including atrial fibrillation on anticoagulation, poorly controlled diabetes, and severe osteoporosis. X-rays reveal a displaced 3-part fracture of the proximal humerus. She has limited active and passive range of motion. What is the most appropriate surgical management option?

Explanation

In an elderly patient with severe osteoporosis, a 3-part displaced proximal humerus fracture, significant comorbidities, and likely poor bone quality, reverse total shoulder arthroplasty (rTSA) has emerged as a favorable option. ORIF often has high complication rates (screw cut-out, avascular necrosis) in this population. Hemiarthroplasty can lead to glenoid erosion and pain. Non-operative management is typically reserved for non-displaced or minimally displaced fractures, or very low-demand patients, and is unlikely to provide adequate pain relief or function for a severe displaced fracture. Total shoulder arthroplasty is not indicated for fracture care in this setting due to rotator cuff compromise.

Question 5

A 6-year-old boy presents with a limp and pain in his right hip. On examination, he has limited abduction and internal rotation of the hip. X-rays show flattening and increased density of the right femoral epiphysis. What is the most likely diagnosis?

Explanation

The clinical presentation of a 6-year-old boy with a limp, limited abduction and internal rotation, and radiographic findings of flattening and increased density (sclerosis) of the femoral epiphysis are classic for Legg-Calvé-Perthes disease (LCPD). SCFE typically occurs in older, often obese, adolescents. DDH presents earlier in infancy/toddlerhood. Transient synovitis is a self-limiting inflammatory condition without radiographic changes of epiphyseal collapse. Septic arthritis would present with acute, severe pain, fever, and systemic signs of infection, and often rapid joint destruction, not chronic epiphyseal changes.

Question 6

A 34-year-old construction worker sustains an open right tibial shaft fracture (Gustilo-Anderson Type IIIA) after being crushed by a steel beam. He is hemodynamically stable. What is the most critical initial management step after addressing life-threatening injuries?

Explanation

For an open fracture, especially Gustilo-Anderson Type IIIA, urgent irrigation and debridement (I&D) within 6-8 hours is paramount to minimize the risk of infection. This is a surgical emergency. Following thorough debridement, stabilization of the fracture (often with external fixation initially for severe open fractures, or intramedullary nailing in less contaminated Type I/II/IIIA fractures, depending on surgeon preference and wound status) is performed. Definitive intramedullary nailing is typically performed after initial debridement and often after several days if the wound requires observation or further debridement. Primary wound closure is generally contraindicated in contaminated open fractures until the wound is clean and infection risk is minimized. Systemic antibiotics are crucial but are adjunctive to surgical debridement.

Question 7

Which of the following statements regarding osteosarcoma is FALSE?

Explanation

Radiation therapy is generally NOT the primary treatment modality for localized osteosarcoma. Surgical resection with wide margins is the cornerstone of local control. Osteosarcoma is relatively radioresistant. Chemotherapy, both neoadjuvant (pre-operative) and adjuvant (post-operative), is critical for controlling micrometastatic disease and improving survival. The other statements are true: osteosarcoma is the most common primary malignant bone tumor in children/adolescents, commonly affects the metaphysis of long bones, and frequently metastasizes to the lungs.

Question 8

A 55-year-old male presents with severe, bilateral knee pain, worse with activity and stair climbing. Radiographs reveal tricompartmental osteoarthritis with significant joint space narrowing, subchondral sclerosis, and osteophytes. He has failed extensive conservative management including NSAIDs, physical therapy, and intra-articular injections. His BMI is 32. He is otherwise healthy. What is the most appropriate next step in management?

Explanation

Given the severe tricompartmental osteoarthritis, failure of conservative management, and the patient's age and activity level, bilateral total knee arthroplasty (TKA) is the most appropriate next step. UKA is only suitable for isolated unicompartmental disease. HTO is typically for younger, more active patients with unicompartmental varus malalignment and good bone stock, not tricompartmental disease. Arthroscopic debridement and lavage have shown limited long-term benefits for advanced osteoarthritis. While weight loss is beneficial, it's unlikely to fully resolve symptoms in severe, end-stage osteoarthritis and should be pursued as an adjunct to TKA, not as a replacement for surgical intervention when conservative measures have failed.

Question 9

A 30-year-old male sustains a high-energy impaction injury to his elbow. Radiographs show a comminuted fracture of the radial head with significant displacement and involvement of the coronoid process (Mason Type III, Regan-Morrey Type II coronoid). He has associated elbow instability. Which of the following is the most appropriate management strategy?

Explanation

This patient has a 'terrible triad' injury of the elbow: comminuted radial head fracture, coronoid fracture, and associated elbow dislocation/instability (implied by high-energy injury and significant displacement). For Mason Type III radial head fractures with instability and coronoid involvement, radial head arthroplasty is often preferred over ORIF, especially if the radial head is irreparable, to restore stability and maintain length. Concomitant repair of the coronoid process (if a significant fragment) and the lateral collateral ligament complex is crucial for restoring elbow stability. Excision of the radial head alone in the presence of elbow instability and coronoid fracture can lead to persistent instability and proximal migration of the radius. ORIF of a comminuted radial head often fails. Closed reduction and casting are inadequate for such a complex, unstable injury.

Question 10

Which factor is most strongly associated with an increased risk of chronic regional pain syndrome (CRPS) Type 1 following an orthopedic injury or surgery?

Explanation

Pre-existing psychological distress, anxiety, depression, and somatization disorders are strongly associated with an increased risk of developing CRPS Type 1. While CRPS can occur at any age, younger to middle-aged adults are more commonly affected than those over 60. Peripheral neuropathy is a risk factor for CRPS Type 2 (causalgia), not typically Type 1. Delayed mobilization can contribute to stiffness but is not as strong a predictor for CRPS as psychological factors. CRPS primarily affects the extremities, not the axial skeleton.

Question 11

A 3-month-old infant presents for a routine check-up. The pediatrician notes asymmetric thigh folds and a positive Ortolani test on the left hip. What is the most appropriate next step in management?

Explanation

A positive Ortolani test in a 3-month-old infant indicates a reducible dislocated hip, which is a definitive sign of developmental dysplasia of the hip (DDH). Given the age and positive clinical finding, immediate orthopedic consultation and Pavlik harness application are the most appropriate steps. The Pavlik harness is highly effective for DDH when initiated early, especially before 6 months of age. Reassurance and observation are inappropriate for a dislocated hip. Plain radiographs are less reliable for cartilaginous hips in infants younger than 4-6 months, where ultrasound is preferred, but the clinical exam is diagnostic here. Physical therapy is not the primary treatment for a dislocated hip. MRI is usually reserved for complex cases or failed harness treatment.

Question 12

A 60-year-old male with a history of intravenous drug use presents with acute onset of severe low back pain, fever, and progressive bilateral leg weakness over 48 hours. He is tachycardic and febrile (39.5°C). Neurological examination reveals bilateral motor weakness (3/5) in L2-S1 distribution and a sensory level at L2. Lab work shows elevated inflammatory markers (ESR 100 mm/hr, CRP 250 mg/L) and leukocytosis. What is the most appropriate urgent diagnostic and therapeutic management?

Explanation

This presentation is highly concerning for an epidural abscess with spinal cord compression, a surgical emergency. The history of IV drug use is a strong risk factor. Acute neurological deficit, fever, and elevated inflammatory markers necessitate urgent investigation and treatment. MRI of the lumbar spine is the gold standard for diagnosing epidural abscess and determining the extent of compression. Empiric broad-spectrum antibiotics should be started immediately after blood cultures are drawn, without waiting for culture results. Lumbar puncture is generally contraindicated in suspected spinal epidural abscess due to the risk of neurological deterioration or spreading the infection. Conservative management is inappropriate. Plain radiographs are typically normal in early infection and will not show an epidural abscess. While neurosurgical consultation for decompression may be needed, MRI is crucial first to localize and confirm the diagnosis.

Question 13

Which biomechanical principle is most critical for the successful healing of an articular cartilage defect treated with microfracture?

Explanation

Microfracture aims to stimulate the growth of fibrocartilaginous repair tissue from mesenchymal stem cells (MSCs) released from subchondral bone. Controlled, cyclic loading (e.g., non-weight bearing range of motion or continuous passive motion) is crucial post-microfracture. This mechanical stimulation helps guide the differentiation of MSCs towards a chondrogenic lineage and promotes the production of a more organized and resilient repair matrix. While a stable interface is important, it's not the primary biomechanical principle guiding microfracture healing itself. The repair tissue formed (fibrocartilage) is generally inferior to native hyaline cartilage in wear properties, but the goal is to improve upon the defect. Eliminating all weight-bearing for 6 months is overly restrictive and detrimental to cartilage formation. Low friction is a characteristic of healthy cartilage, but the principle for healing involves stimulating cell differentiation.

Question 14

A 22-year-old male sustains a spiral fracture of the middle third of the humerus after an arm wrestling injury. He presents with wrist drop and sensory deficit over the dorsum of the hand. X-rays confirm the fracture. What is the most appropriate initial management?

Explanation

A spiral fracture of the middle third of the humerus with wrist drop is classic for radial nerve palsy, which is the most commonly injured nerve in humeral shaft fractures. Most radial nerve palsies associated with closed humeral shaft fractures are neuropraxias or axonotmesis in continuity and recover spontaneously (up to 90%). Therefore, the initial management is closed reduction and functional bracing of the fracture, with close observation for neurological recovery. Surgical exploration is generally reserved for open fractures, failure of nerve recovery after 3-6 months, or if the nerve is clearly entrapped. EMG/NCS are useful for prognosticating recovery but are not immediate management steps; they are typically performed at 3-6 weeks or later to assess denervation. Nerve transfer is for irreversible nerve damage, not initial management. External fixator is usually for open or highly comminuted unstable fractures.

Question 15

Which of the following is the most sensitive imaging modality for detecting early avascular necrosis (AVN) of the femoral head?

Explanation

Magnetic resonance imaging (MRI) is the most sensitive and specific imaging modality for detecting early avascular necrosis (AVN) of the femoral head. It can demonstrate changes in bone marrow signal before any changes are visible on plain radiographs or CT scans. Plain radiographs are typically normal in the early stages. CT scans are good for bone detail but less sensitive for early marrow changes. Bone scintigraphy can show areas of decreased uptake, but MRI is superior for specific diagnosis and staging. Ultrasound has no role in diagnosing AVN of the femoral head.

Question 16

A 16-year-old female cheerleader reports sudden onset of sharp anterior knee pain during practice. She describes her kneecap 'moving out of place' and then 'moving back in.' On examination, she has a large hemarthrosis, patellar apprehension, and tenderness along the medial patellar facet. Her X-rays are normal, but an MRI shows edema within the medial patellofemoral ligament (MPFL) and a small osteochondral defect on the lateral femoral condyle. What is the most appropriate initial treatment?

Explanation

This is a classic presentation of acute patellar dislocation, with spontaneous reduction. The presence of hemarthrosis, patellar apprehension, and MPFL edema on MRI confirms the diagnosis. Initial treatment for a first-time patellar dislocation, even with an osteochondral defect, is typically conservative. This involves rest, ice, compression, elevation (RICE), pain control, and early protected range of motion, followed by a structured physical therapy program focusing on quadriceps (especially vastus medialis obliquus) and hip abductor strengthening. Surgical MPFL reconstruction is usually reserved for recurrent dislocations or persistent instability after failed conservative treatment. Long-leg casting is often avoided to prevent stiffness. Diagnostic arthroscopy might be considered if the osteochondral defect is large, displaced, or causes mechanical symptoms, but it's not the immediate first step. Quadriceps strengthening is part of rehab, not the sole initial treatment.

Question 17

In total hip arthroplasty, what is the primary purpose of using highly cross-linked polyethylene?

Explanation

Highly cross-linked polyethylene is primarily used in total hip arthroplasty to significantly reduce polyethylene wear. The cross-linking process modifies the molecular structure of polyethylene, making it more resistant to abrasion and oxidative degradation. This reduction in wear debris is crucial because polyethylene wear particles are the main cause of periprosthetic osteolysis, which can lead to aseptic loosening and the need for revision surgery. It does not directly improve initial fixation, reduce dislocation risk (though larger heads made possible by thinner liners can help), enhance osseointegration, or increase infection resistance.

Question 18

A 48-year-old male presents with worsening pain and numbness in his left hand, especially the thumb, index, and middle fingers, worse at night. Phalen's test and Tinel's sign at the wrist are positive. He also reports occasional weakness when gripping objects. What is the most accurate diagnostic test to confirm the diagnosis and guide management?

Explanation

The patient's symptoms are classic for carpal tunnel syndrome (CTS), caused by compression of the median nerve at the wrist. While clinical examination (Phalen's, Tinel's) is highly suggestive, electromyography (EMG) and nerve conduction studies (NCS) are the most accurate diagnostic tests to confirm CTS, assess the severity of median nerve compression, rule out other neuropathies (e.g., cervical radiculopathy), and provide a baseline for monitoring. Plain radiographs are typically normal in CTS. MRI of the cervical spine would be considered if a cervical radiculopathy was suspected as a differential. Ultrasound can show median nerve swelling but is not as definitive for confirming nerve compression severity as EMG/NCS. Blood tests are not specific for CTS.

Question 19

A 70-year-old female sustains a comminuted, intra-articular fracture of the distal radius (AO type C3) after falling from standing height. She has severe osteoporosis and multiple comorbidities. What is the most appropriate definitive management strategy to optimize functional outcome?

Explanation

For a comminuted, intra-articular distal radius fracture in an osteoporotic elderly patient, volar locking plate fixation has become the preferred treatment. It allows for rigid internal fixation, early mobilization, and better maintenance of reduction compared to casting or external fixation alone. Closed reduction and casting are often insufficient for maintaining reduction in highly comminuted, unstable fractures, especially in osteoporotic bone. External fixation can provide indirect reduction but may not fully restore articular congruity and has issues with pin-site care and stiffness. Dorsal plating is an option but volar plating is biomechanically superior for distal radius fractures, allowing for easier fixation of volar fragments and better restoration of volar tilt. Wrist fusion is reserved for salvage in failed attempts or severe arthritis, not primary fracture treatment.

Question 20

Regarding the management of non-unions, which of the following statements is TRUE?

Explanation

The 'diamond concept' for non-union treatment emphasizes four key factors: adequate stability (mechanical environment), healthy biology (vascularity, tissue viability), growth factors (e.g., bone morphogenetic proteins), and local bone graft. This holistic approach is crucial for successful healing. Hypertrophic non-unions demonstrate sufficient biology but lack stability; therefore, they primarily require stable fixation without the need for additional bone graft. Atrophic non-unions lack both stability and biology, thus requiring rigid fixation AND bone grafting. Infection is a common cause and significant complication of non-unions, and it must be addressed (debridement, antibiotics) before or concurrently with definitive non-union surgery, not a contraindication to intervention. Electrical stimulation is an adjunctive treatment, usually considered after surgical attempts, not a first-line for all non-unions, especially atrophic types.

Question 21

A 40-year-old male presents with worsening right foot pain, particularly around the medial longitudinal arch, radiating to the heel. He describes a 'too many toes' sign on clinical examination. On weight-bearing radiographs, there is a collapse of the medial longitudinal arch, talonavicular sag, and forefoot abduction. What is the most likely diagnosis?

Explanation

The patient's symptoms (medial arch pain, radiating to heel), clinical sign ('too many toes' indicating forefoot abduction), and radiographic findings (arch collapse, talonavicular sag) are classic for adult acquired flatfoot deformity (AAFD), most commonly caused by progressive posterior tibial tendon dysfunction (PTTD). Plantar fasciitis is typically heel pain. Achilles tendinitis is posterior heel/calf pain. Haglund's deformity is posterior heel pain with retrocalcaneal bursitis. Navicular stress fractures cause localized navicular pain and often edema.

Question 22

Which of the following is an absolute contraindication to performing a knee arthroplasty?

Explanation

Active infection in the knee joint is an absolute contraindication to knee arthroplasty. Proceeding with arthroplasty in an infected joint significantly increases the risk of periprosthetic joint infection, which is a devastating complication often requiring multiple surgeries and prolonged antibiotic treatment. Age, obesity, severe osteoporosis, and history of DVT are relative contraindications or risk factors that need to be managed and discussed, but they do not absolutely preclude surgery. Active infection must be eradicated before arthroplasty can be considered.

Question 23

A 65-year-old male with a history of prostate cancer (diagnosed 5 years ago, currently in remission) presents with new onset, severe lower back pain radiating down his left leg. He denies any recent trauma. On examination, he has tenderness over the L4 spinous process and mild weakness (4/5) in left ankle dorsiflexion. What is the most critical diagnostic test to perform first?

Explanation

Given the patient's history of prostate cancer, new onset severe back pain, and neurological deficit (even mild), metastatic disease to the spine causing potential cord compression or nerve root involvement must be ruled out urgently. An MRI of the entire spine is the most critical diagnostic test as it can identify metastatic lesions, differentiate them from degenerative changes, and assess for spinal cord compression. Plain radiographs are often normal in early metastatic disease. EMG assesses nerve function but doesn't identify the cause. Bone scan is good for detecting bony metastases but doesn't show soft tissue involvement or cord compression as well as MRI. Lumbar discography is an invasive procedure used for diagnosing discogenic pain and is not appropriate here.

Question 24

Which of the following describes a 'stress-shielding' phenomenon in the context of orthopedic implants?

Explanation

Stress shielding is the phenomenon where bone resorbs due to a reduction in mechanical stress, as described by Wolff's Law. In the context of orthopedic implants, a stiff implant (e.g., a femoral stem in total hip arthroplasty) can bear a significant portion of the load, 'shielding' the adjacent bone from normal physiological stresses. This leads to a reduction in bone density (osteopenia or bone loss) in the shielded areas, which can potentially weaken the bone and lead to complications like periprosthetic fracture or aseptic loosening. It's distinct from osteolysis due to wear particles or infection.

Question 25

A 10-year-old girl sustains a Salter-Harris Type II fracture of the distal tibia. What is the most important concern regarding long-term complications?

Explanation

Salter-Harris fractures involve the growth plate (physis). Type II fractures involve the physis and the metaphysis. The most important long-term complication concern for any Salter-Harris fracture, especially in a growing child, is growth arrest. This can lead to limb length discrepancy (shortening) or angular deformity, particularly if the fracture is displaced, involves a significant portion of the physis, or if repeated attempts at reduction cause further physeal damage. Avascular necrosis is a risk in some physeal fractures (e.g., Type IV, or specific locations like femoral neck), but less common in Type II distal tibia. Ankle dislocation is not a typical long-term complication. Osteoarthritis is a long-term risk of intra-articular fractures (Type III, IV). Non-union is rare for physeal fractures.

Question 26

A 50-year-old male undergoes arthroscopic rotator cuff repair. Postoperatively, he develops progressive shoulder stiffness and pain, disproportionate to the expected recovery. He has limited active and passive range of motion, particularly external rotation and abduction. What is the most likely complication, and what is its typical management?

Explanation

The clinical picture of progressive shoulder stiffness, pain, and limited active and passive range of motion after shoulder surgery is highly suggestive of adhesive capsulitis, commonly known as frozen shoulder. It can occur as a complication of rotator cuff repair or other shoulder procedures. Initial management involves aggressive physical therapy, NSAIDs, and potentially corticosteroid injections. If conservative treatment fails, manipulation under anesthesia (MUA) or arthroscopic capsular release may be considered. A re-tear would typically present with pain and weakness, but usually not profound global stiffness. Infection would present with systemic signs (fever, elevated inflammatory markers) and severe localized pain. Deltoid dehiscence would present with deltoid weakness and possibly a palpable defect. Neurovascular injury would have distinct neurological or vascular signs.

Question 27

Which of the following is the most effective method for preventing heterotopic ossification (HO) after total hip arthroplasty (THA), particularly in high-risk patients?

Explanation

Indomethacin or other non-steroidal anti-inflammatory drugs (NSAIDs), administered post-operatively for 7-14 days, are highly effective in preventing heterotopic ossification (HO) after THA, especially in high-risk patients (e.g., history of HO, ankylosing spondylitis, hypertrophic osteoarthritis). The mechanism involves inhibiting prostaglandin synthesis, which plays a role in osteoblast differentiation. Radiation therapy (either single dose pre- or post-op) is also highly effective but generally reserved for patients who cannot tolerate NSAIDs or have an extremely high risk. Systemic corticosteroids are not standard for HO prevention. Calcium and vitamin D are for bone health, not HO. Early mobilization is generally beneficial but not a primary preventative measure for HO itself.

Question 28

A 35-year-old female presents with chronic lateral elbow pain, worsened by gripping and wrist extension. Examination reveals tenderness over the lateral epicondyle and pain with resisted wrist extension and forearm supination. X-rays are normal. What is the most appropriate initial management?

Explanation

This is a classic presentation of lateral epicondylitis, also known as 'tennis elbow,' which is a tendinopathy of the common extensor origin (primarily ECRB). The initial management is almost always conservative, focusing on activity modification (rest), non-steroidal anti-inflammatory drugs (NSAIDs), a counterforce brace to offload the tendon, and physical therapy, with a strong emphasis on eccentric strengthening exercises for the wrist extensors. Corticosteroid injections can provide short-term pain relief but have been shown to have worse long-term outcomes and may lead to tendon degeneration. Surgical release is reserved for cases refractory to at least 6-12 months of conservative treatment. PRP is a newer treatment with mixed evidence and is not typically first-line. Diagnostic arthroscopy is not indicated for this diagnosis.

Question 29

Which complication is most characteristic of a posterior hip dislocation?

Explanation

Sciatic nerve injury is the most common and characteristic neurological complication of a posterior hip dislocation, occurring in 10-20% of cases. The sciatic nerve is anatomically vulnerable as it passes posterior to the hip joint. Femoral head avascular necrosis is also a significant complication, especially with delayed reduction, but sciatic nerve injury is more immediately characteristic. DVT is a general complication of trauma/immobility. Trochanteric non-union is relevant to hip fractures, not dislocations. Femoral artery injury is rare in posterior dislocation and more common in anterior dislocations.

Question 30

A 38-year-old male presents with chronic insidious onset of groin pain, worse with activity and prolonged sitting. He denies trauma. Physical exam reveals pain with FADIR (flexion-adduction-internal rotation) and FABER (flexion-abduction-external rotation) tests. Radiographs show a prominent anterior inferior iliac spine (AIIS) and an alpha angle of 70 degrees. What is the most likely diagnosis?

Explanation

The clinical presentation of chronic groin pain, positive FADIR and FABER tests, and a high alpha angle (70 degrees) are classic for femoroacetabular impingement (FAI), specifically the cam type. A cam deformity describes an aspherical femoral head-neck junction that abuts the acetabular rim during hip flexion and internal rotation. A prominent anterior inferior iliac spine (AIIS) can contribute to a form of extra-articular impingement (subspine impingement) which sometimes coexists with pincer or cam morphology, but the elevated alpha angle is the defining radiographic feature of cam-type FAI. Osteoarthritis is typically a consequence of long-standing FAI, not the primary diagnosis in a 38-year-old with these specific findings. Sports hernia is an athletic pubalgia, which presents differently, primarily with lower abdominal or adductor pain. Stress fractures usually have a more acute onset and distinct radiographic findings.

Question 31

What is the primary goal of surgical treatment for adolescent idiopathic scoliosis (AIS) with curves greater than 45-50 degrees?

Explanation

The primary goal of surgical treatment for adolescent idiopathic scoliosis (AIS) with significant curves (typically >45-50 degrees in skeletally immature or >50 degrees in mature patients) is to correct the cosmetic deformity and, most importantly, prevent further curve progression. Curves exceeding 50 degrees in adults tend to progress throughout life and can eventually lead to significant back pain and pulmonary compromise. While pain improvement can occur, it is not the primary indication for surgery. Complete normalization of spinal alignment is generally not achievable or necessary. Pulmonary function improvement is a secondary benefit, especially in very severe curves. Prevention of neurological deficits is a concern during surgery, but not the primary indication for elective correction of AIS.

Question 32

A 25-year-old male sustains a traumatic rupture of the Achilles tendon during a recreational basketball game. Clinical examination reveals a palpable gap in the tendon, a positive Thompson test, and inability to perform a single heel raise. What is the most appropriate management, considering his age and activity level?

Explanation

For a young, active individual with a complete Achilles tendon rupture, surgical repair (either open or percutaneous) is generally recommended to restore tendon length and tension, reduce the risk of re-rupture, and facilitate a quicker return to high-level activity. While non-operative treatment is an option, it is associated with higher rates of re-rupture, especially in active individuals. Open surgical repair allows for direct visualization of the tear and stronger repair. Percutaneous repair is a less invasive option with similar re-rupture rates to open repair but may have a higher risk of sural nerve injury. Physical therapy alone is insufficient for a complete rupture. PRP injections are investigational and not a standalone treatment for complete ruptures.

Question 33

Which of the following describes a key advantage of dual-mobility articulations in total hip arthroplasty?

Explanation

Dual-mobility articulations in total hip arthroplasty are designed to reduce the risk of dislocation. They feature a small femoral head articulating within a larger polyethylene liner, which in turn articulates within a polished metal acetabular shell. This 'ball-within-a-ball' design provides a larger jump distance before dislocation, offering greater stability, especially in patients at high risk for dislocation (e.g., those with neuromuscular disorders, revision cases, or previous dislocations). It does not eliminate wear (though wear characteristics can differ), improve bone ingrowth directly, or necessarily provide enhanced pain relief compared to other stable designs. The surgical technique is generally more involved than traditional designs.

Question 34

A 5-year-old boy presents with a painful swelling over his proximal tibia. He has a low-grade fever and appears unwell. X-rays show periosteal reaction and lucency in the metaphysis of the tibia. Blood tests reveal an elevated ESR and CRP. What is the most likely diagnosis?

Explanation

The constellation of painful swelling, fever, malaise, elevated inflammatory markers (ESR, CRP), and radiographic findings of periosteal reaction and metaphyseal lucency in a child is highly suggestive of acute osteomyelitis. This is an infection of the bone, most commonly hematogenous in children, affecting the highly vascular metaphysis. Ewing's sarcoma can also present with pain, swelling, and periosteal reaction ('onion skin'), but usually with more aggressive bone destruction and often a soft tissue mass. Osteoid osteoma is a benign bone tumor causing nocturnal pain relieved by NSAIDs, typically without systemic signs. Stress fractures are related to activity and usually lack systemic signs. Non-ossifying fibroma is a benign, often asymptomatic, cortical bone lesion.

Question 35

Which of the following approaches to total hip arthroplasty is associated with the highest rate of posterior dislocation during the early postoperative period?

Explanation

The posterior approach to total hip arthroplasty, while providing excellent exposure, is traditionally associated with the highest rate of posterior dislocation in the early postoperative period. This is because it typically involves a capsulotomy and detachment of the short external rotators (piriformis, gemelli, obturator internus), which contribute significantly to posterior hip stability. While modern techniques emphasize capsular repair and meticulous soft tissue handling to mitigate this risk, it remains a characteristic complication of this approach compared to others that preserve the posterior capsule and external rotators (e.g., direct anterior, direct lateral). Minimally invasive approaches refer to incision size, not necessarily the specific muscle interval, and thus don't universally predispose to dislocation in one direction.

Question 36

A 28-year-old male sustains a Gustilo-Anderson Type IIIB open tibia fracture. After initial irrigation and debridement and external fixation, the soft tissue defect is significant. What is the most appropriate next step for soft tissue coverage?

Explanation

A Gustilo-Anderson Type IIIB open tibia fracture involves extensive soft tissue damage and periosteal stripping, exposing bone and requiring complex soft tissue reconstruction. Delayed primary closure and secondary intention are insufficient for such large, complex defects with exposed bone. A split-thickness skin graft requires a well-vascularized bed, which is typically absent over exposed bone or tendon. Local rotational flaps may be an option for smaller defects but are often inadequate for the significant defects seen in Type IIIB fractures of the tibia. Free tissue transfer (free flap) is often the reconstructive method of choice for Type IIIB open tibia fractures, providing robust, vascularized tissue that can cover exposed bone, achieve primary wound healing, and allow for eventual definitive fracture fixation. This is a critical principle in open fracture management.

Question 37

Which of the following statements about clubfoot (congenital talipes equinovarus) is FALSE?

Explanation

The statement that 'Correction involves serial casting with gentle manipulation, primarily addressing hindfoot equinus first' is FALSE. The Ponseti method, the gold standard for clubfoot correction, addresses the components of the deformity in a specific sequence: first correcting the cavus and adduction, then the varus, and finally the equinus. The hindfoot equinus is usually the last deformity addressed, often requiring a percutaneous Achilles tenotomy. If equinus is corrected first, it can lead to a 'rocker-bottom' foot. The other statements are true: clubfoot has characteristic deformities, Ponseti is the gold standard, Achilles tenotomy is common, and surgery is reserved for failures.

Question 38

A 60-year-old male presents with sudden, excruciating pain in his left knee, accompanied by erythema, swelling, and warmth. He has a history of hypertension and hyperuricemia but has never had a prior attack like this. Aspiration of the knee joint reveals negatively birefringent needle-shaped crystals under polarized light microscopy. What is the most appropriate acute management?

Explanation

The clinical presentation (acute, excruciating monoarticular arthritis with erythema, swelling, warmth) and the finding of negatively birefringent needle-shaped crystals on joint fluid analysis are diagnostic of acute gouty arthritis. The most appropriate acute management involves NSAIDs (e.g., indomethacin), colchicine, or systemic corticosteroids. Intra-articular corticosteroid injection is an alternative for monoarticular attacks if systemic agents are contraindicated or ineffective. Systemic antibiotics are for septic arthritis (which is in the differential but ruled out by crystal analysis and lack of bacteria). Joint lavage and debridement are for septic arthritis. Allopurinol is a uric acid-lowering therapy used for long-term prevention of gout attacks, not for acute attack management (and can sometimes worsen acute attacks if initiated during one).

Question 39

What is the primary mechanism of action of bone morphogenetic proteins (BMPs) in promoting fracture healing?

Explanation

Bone morphogenetic proteins (BMPs) are powerful osteoinductive proteins. Their primary mechanism of action in promoting fracture healing is the induction of mesenchymal stem cells (MSCs) to differentiate into osteoblasts (bone-forming cells) and chondroblasts (cartilage-forming cells), thereby initiating and accelerating the bone repair process. They also recruit undifferentiated mesenchymal cells to the site. BMPs do not primarily inhibit osteoclast activity, stimulate osteoblast apoptosis, enhance vascular permeability, or directly structurally bridge fracture gaps; rather, they stimulate the biological cascade that leads to new bone formation.

Question 40

A 4-year-old child presents with a 'toddler's fracture' of the tibia. What is the characteristic radiographic finding?

Explanation

A 'toddler's fracture' is a common, non-displaced or minimally displaced, spiral or oblique fracture of the distal or mid-tibial shaft in ambulatory young children (typically 9 months to 3 years old). It often occurs with minimal or unrecognized trauma. Radiographs can sometimes be subtle, showing only a hairline lucency or just periosteal reaction after a week or two. The other options describe different fracture patterns that are not characteristic of a toddler's fracture.

Question 41

In the context of anterior cervical discectomy and fusion (ACDF), what is the primary biomechanical advantage of using an anterior plate?

Explanation

The primary biomechanical advantage of using an anterior plate in ACDF is to provide immediate stability to the construct and to reduce the risk of graft extrusion or migration. The plate compresses the bone graft or cage between the vertebral bodies, preventing dislodgement and promoting fusion. While it does contribute to stability allowing earlier mobilization, the main goal is preventing graft failure and pseudarthrosis by optimizing the mechanical environment for fusion. It does not prevent dysphagia (which can be a complication of ACDF itself), nor does it increase pseudarthrosis (it aims to decrease it). It doesn't directly facilitate posterior fusion or necessarily allow full activity without bracing (which depends on surgeon preference and patient factors).

Question 42

Which of the following is the most common cause of painful hardware after ankle fracture fixation?

Explanation

The most common cause of painful hardware after ankle fracture fixation is prominent hardware causing soft tissue irritation. The ankle joint has relatively thin soft tissue coverage, making plates, screws, and wires easily palpable and susceptible to irritation from shoes, socks, or movement. While infection, aseptic loosening, non-union, and CRPS can all cause pain, prominent hardware is by far the most frequent reason for symptomatic hardware removal following ankle fracture surgery. Aseptic loosening is less common with ankle hardware compared to arthroplasty components.

Question 43

Which organism is the most common causative agent of acute hematogenous osteomyelitis in healthy children?

Explanation

Staphylococcus aureus is by far the most common causative organism of acute hematogenous osteomyelitis in healthy children across all age groups. While other organisms can cause osteomyelitis (e.g., Kingella kingae in infants/toddlers, Pseudomonas in puncture wounds through athletic shoes, E. coli in neonates or immunocompromised), S. aureus remains predominant in the general pediatric population.

Question 44

A 55-year-old male undergoes a revision total knee arthroplasty for aseptic loosening of both components. During surgery, significant bone loss is noted in both the distal femur and proximal tibia. What type of implant or technique is most appropriate to address this bone loss and provide stable fixation?

Explanation

For revision total knee arthroplasty with significant bone loss in both the distal femur and proximal tibia, a hinged knee prosthesis with intramedullary stems and augments is often the most appropriate choice. Intramedullary stems provide enhanced stability in compromised bone. Augments (metal wedges or blocks) are used to fill bone defects and restore joint line. A hinged prosthesis provides greater intrinsic stability, which is crucial when soft tissue constraints are deficient or bone loss is severe. Standard primary components are insufficient for significant bone loss. Unicompartmental and patellofemoral arthroplasties are for isolated compartment disease. Osteochondral allografts are for cartilage defects, not widespread bone loss in revision arthroplasty.

Question 45

What is the most accurate predictor of success for anterior cruciate ligament (ACL) reconstruction using a hamstring autograft?

Explanation

Compliance with a comprehensive postoperative rehabilitation protocol is arguably the most critical and accurate predictor of success following ACL reconstruction, regardless of graft type. While patient age, quadriceps strength, graft tunnel widening, and fixation type all play a role, consistent and appropriate rehabilitation (including early range of motion, gradual strengthening, proprioception training, and sport-specific drills) is essential for achieving good functional outcomes, restoring stability, and reducing the risk of re-injury. Without proper rehab, even a perfectly executed surgery can result in a poor outcome.

Question 46

A 68-year-old male with a history of prostate cancer and severe degenerative scoliosis presents with new onset severe back pain and bilateral leg weakness. MRI reveals a compression fracture at T10 with severe spinal canal stenosis and epidural tumor involvement. What is the most appropriate management approach?

Explanation

This patient has metastatic spinal cord compression (MSCC) from prostate cancer. The presence of new or worsening neurological deficits (bilateral leg weakness) combined with severe spinal canal stenosis necessitates urgent surgical decompression and stabilization. Surgical intervention provides immediate relief of neural element compression. Following surgical decompression and stabilization, radiation therapy is typically administered to target residual tumor and provide long-term local control. Conservative management is contraindicated due to neurological compromise. Radiation therapy alone may be considered for patients without neurological deficits or with minimal compression, but not for severe stenosis and neurological compromise. Chemotherapy is systemic but won't provide urgent decompression. Vertebroplasty/kyphoplasty is for pain relief in stable compression fractures, not for fractures with neurological deficits and canal compromise.

Question 47

Which specific ligament is most commonly injured in an isolated high ankle sprain (syndesmotic injury)?

Explanation

In an isolated high ankle sprain, also known as a syndesmotic injury, the anterior inferior tibiofibular ligament (AITFL) is the most commonly injured ligament. The syndesmosis consists of the AITFL, posterior inferior tibiofibular ligament (PITFL), interosseous ligament, and transverse tibiofibular ligament. The ATFL, CFL, and PTFL are components of the lateral ankle collateral ligaments, typically injured in inversion ankle sprains. The deltoid ligament is on the medial side of the ankle.

Question 48

Which of the following describes the most accurate interpretation of a positive Trendelenburg sign?

Explanation

A positive Trendelenburg sign indicates weakness of the hip abductor muscles (primarily gluteus medius and minimus) on the stance leg side. When the patient stands on the affected leg, the pelvis drops on the unsupported (contralateral) side because the weak abductors cannot adequately stabilize the pelvis. This classic sign can be seen in conditions like superior gluteal nerve palsy, avascular necrosis of the femoral head, hip dysplasia, or severe osteoarthritis leading to abductor dysfunction. It is not directly related to adductor weakness, IT band tightness, or pain (though pain can cause an antalgic gait, the Trendelenburg sign is specifically about pelvic drop due to abductor weakness).

Question 49

A 6-month-old infant is diagnosed with congenital muscular torticollis. What is the most appropriate initial management?

Explanation

Congenital muscular torticollis (CMT) is a common musculoskeletal condition in infants characterized by sternocleidomastoid muscle shortening and head tilt. The most appropriate initial management is non-operative, primarily consisting of passive stretching exercises and physical therapy to lengthen the affected sternocleidomastoid muscle and encourage symmetrical head posture. This is highly effective, especially when started early (before 6 months of age). Surgical release is reserved for cases that fail extensive non-operative treatment (e.g., after 12-18 months of therapy, or with significant facial asymmetry). Botulinum toxin injections are rarely used and not first-line. Cervical collar immobilization is contraindicated. Waiting for spontaneous resolution is not recommended as it can lead to permanent facial and skull asymmetry.

Question 50

Which type of fracture is most commonly associated with a high incidence of non-union due to its inherently poor blood supply?

Explanation

The scaphoid waist fracture is classically associated with a high incidence of non-union and avascular necrosis (AVN) due to its retrograde blood supply. The blood supply to the proximal pole of the scaphoid enters distally, meaning a fracture through the waist can compromise the blood supply to the proximal fragment. This makes scaphoid waist fractures notoriously slow to heal and prone to complications. Other fractures listed have better inherent blood supplies and lower non-union rates.

Question 51

A 70-year-old female presents with a new onset of severe, unremitting back pain and tenderness over T12 after a minor fall. She has a history of diffuse osteopenia on DXA scan. Neurological exam is normal. What is the most appropriate initial diagnostic study?

Explanation

While plain radiographs would typically be the initial imaging for a suspected vertebral compression fracture, given the patient's age, history of osteopenia, and new onset of severe unremitting pain after even minor trauma, it is crucial to rule out a pathological fracture due to malignancy or primary tumor, even with a normal neurological exam. An MRI of the thoracic spine with contrast is the most appropriate initial diagnostic study because it can differentiate between benign osteoporotic fractures and pathological fractures (tumor, infection), and can identify spinal cord or nerve root compression more definitively than plain films or CT. Bone scans are sensitive for metastases but not specific for the underlying cause of fracture, and don't show soft tissue/neural compression. EMG is for nerve function assessment.

Question 52

In the setting of a calcaneal fracture (Böhler's angle < 20 degrees), what is the most significant long-term functional complication, even after surgical fixation?

Explanation

Subtalar arthritis and pain are the most significant and common long-term functional complications following intra-articular calcaneal fractures, even after optimal surgical fixation. The Böhler's angle (normal 20-40 degrees) is a measure of the posterior facet's inclination; a reduced angle indicates collapse and comminution of the subtalar joint. Despite anatomic reduction and fixation, residual articular incongruity, damage to the cartilage, and altered biomechanics often lead to post-traumatic subtalar arthritis, stiffness, and chronic pain. Achilles tendinitis, ankle instability, plantar fasciitis, and toe deformities are less common or less significant complications compared to subtalar joint issues.

Question 53

Which of the following growth factors is most commonly used in clinical practice to enhance bone healing, particularly in non-union scenarios?

Explanation

Bone Morphogenetic Protein-2 (BMP-2), often delivered in a collagen sponge (e.g., Infuse Bone Graft), is currently the most commonly used growth factor in clinical orthopedic practice to enhance bone healing, particularly in treating recalcitrant non-unions, open tibial fractures, and lumbar spinal fusions. BMPs are potent osteoinductive agents. While other growth factors like FGF, VEGF, TGF-β, and IGF-1 play roles in bone healing, they are not as widely used or approved for direct clinical application as an osteoinductive agent for fracture healing/fusion augmentation as BMP-2 (and BMP-7).

Question 54

A 12-year-old boy, overweight, presents with a 3-week history of right hip and knee pain, particularly when walking. Examination shows a painful limp, limited internal rotation, and abduction of the hip. What is the most appropriate initial diagnostic imaging?

Explanation

This clinical scenario (overweight adolescent with hip and knee pain, painful limp, limited internal rotation) is highly suspicious for Slipped Capital Femoral Epiphysis (SCFE). SCFE requires urgent diagnosis and treatment to prevent further slip and complications. The most appropriate initial diagnostic imaging is AP and frog-leg lateral radiographs of BOTH hips. This is crucial because SCFE can be bilateral (even if asymptomatic on the other side) and a frog-leg lateral view is essential to visualize the slip, which may not be obvious on the AP view. MRI is more sensitive but often not needed initially for diagnosis. Ultrasound and CT are typically not first-line for SCFE diagnosis. Plain radiographs of the knee would likely be normal given the hip pathology, but hip pain often refers to the knee.

Question 55

Which of the following surgical procedures is considered the gold standard for treating severe, symptomatic hallux valgus (bunion deformity) in a young, active patient with a high intermetatarsal angle and hallux valgus angle?

Explanation

For severe, symptomatic hallux valgus in a young, active patient with a high intermetatarsal (IM) angle (>15 degrees) and hallux valgus angle, a proximal metatarsal osteotomy (such as Ludloff or Scarf) or a Lapidus procedure (fusion of the first metatarsal-cuneiform joint) is often considered the gold standard. These procedures address the proximal metatarsal malalignment, which is the primary driver of the deformity in these cases, providing powerful correction and stability. Bunionectomy alone is insufficient. Keller arthroplasty is a resection arthroplasty reserved for elderly, low-demand patients. Distal metatarsal osteotomies (Chevron, Weil) are typically for mild-to-moderate deformities. Arthrodesis of the first MTP joint is a salvage procedure for severe arthritis or failed previous surgeries, not usually primary for bunion correction in a young patient without arthritis.

Question 56

Which classification system is primarily used to assess the severity of acetabular fractures and guide surgical approach?

Explanation

The Letournel and Judet classification system is the universally recognized and most commonly used system to assess the severity and morphology of acetabular fractures. It divides fractures into elementary patterns (e.g., anterior wall, posterior column, transverse) and associated patterns (e.g., T-type, posterior column and wall). This classification guides the choice of surgical approach and predicts prognosis. Gustilo-Anderson is for open fractures. AO/OTA is a general system for all fractures but less specific for acetabulum. Mason is for radial head fractures. Denis is for thoracolumbar spine fractures.

Question 57

A 40-year-old active male presents with chronic plantar heel pain, worse with the first steps in the morning and after periods of rest. Physical examination reveals tenderness at the origin of the plantar fascia on the medial calcaneal tuberosity. What is the most important long-term conservative management strategy?

Explanation

The patient presents with classic symptoms of plantar fasciitis. While all options except surgery are conservative treatments, custom or over-the-counter orthotics with adequate arch support and heel cushioning, along with appropriate footwear, are crucial long-term management strategies. They help to offload the plantar fascia, correct biomechanical imbalances, and reduce repetitive stress. Corticosteroid injections provide temporary relief but are associated with complications. ESWT and night splints are also conservative treatments, often used in conjunction with orthotics, but orthotics address the underlying biomechanics more fundamentally long-term. Surgical release is reserved for recalcitrant cases after extensive failed conservative management.

Question 58

Which of the following statements regarding osteomyelitis of the spine (spondylodiscitis) in adults is TRUE?

Explanation

MRI with contrast is indeed the gold standard for diagnosing spondylodiscitis, as it can accurately identify infection in the vertebral bodies and disc spaces, assess for epidural or paraspinal abscess formation, and detect spinal cord compression. Spondylodiscitis primarily affects the vertebral bodies and intervertebral disc spaces, not typically the posterior elements first. Staphylococcus aureus is the most common causative organism, not S. epidermidis (which is more common in implant-related infections). Patients often present with axial back pain and fever, but neurological deficits are present in a minority of cases, typically indicating more advanced disease or epidural extension. While antibiotics are crucial, surgical debridement and stabilization are often required for patients with neurological deficits, significant spinal instability, or persistent infection despite adequate antibiotic therapy.

Question 59

What is the most significant disadvantage of a unicompartmental knee arthroplasty (UKA) compared to total knee arthroplasty (TKA)?

Explanation

The most significant disadvantage of unicompartmental knee arthroplasty (UKA) compared to total knee arthroplasty (TKA) is a higher rate of revision surgery. While UKA offers advantages like less bone resection, faster recovery, and better range of motion for carefully selected patients, it has a higher cumulative revision rate, often due to progression of osteoarthritis in the unreplaced compartments, aseptic loosening, or technical issues. The other options (blood loss, DVT, pain, recovery time) are generally either comparable or often better with UKA in the short term.

Question 60

A 4-year-old child presents with a limp, fever, and refusal to bear weight on the left leg. On examination, the left hip is held in flexion, abduction, and external rotation. Passive range of motion is severely painful, especially internal rotation. Blood tests show a WBC count of 75,000 cells/µL, 90% neutrophils, and positive Gram stain for Gram-positive cocci in clusters. What is the most appropriate management?

Explanation

This is a clear case of septic arthritis of the knee, an orthopedic emergency in children. The presentation (limp, fever, swollen/warm/painful joint), and particularly the synovial fluid analysis (high WBC count, high neutrophils, positive Gram stain) confirms the diagnosis. Urgent surgical irrigation and debridement (arthrotomy or arthroscopy) of the knee is the most appropriate management to remove purulent material, reduce bacterial load, and prevent cartilage destruction. This should be combined with intravenous antibiotics. While aspiration is part of diagnosis, surgical washout is definitive for septic arthritis of a large joint. Immediate IV antibiotics alone without surgical debridement are insufficient to treat severe septic arthritis. Corticosteroid injection is contraindicated. Synovectomy is not the primary goal; debridement and irrigation are.

Question 61

Which nerve is most at risk of injury during surgical exposure of the anterior column of the acetabulum through an ilioinguinal approach?

Explanation

During an ilioinguinal approach for anterior column acetabular fractures, the femoral nerve is most at risk of injury. It lies within the middle window of the ilioinguinal approach, deep to the iliopsoas muscle and lateral to the femoral artery. The sciatic nerve is posterior. The obturator nerve is more medial within the pelvis. The lateral femoral cutaneous nerve is also at risk, but femoral nerve injury can be more devastating. The superior gluteal nerve is superior and lateral, typically associated with posterior approaches.

Question 62

A 58-year-old male with a history of chronic alcoholism and pancreatitis develops progressive bilateral hip pain. Radiographs reveal patchy sclerosis and lucency in both femoral heads, with a subchondral crescent sign. What is the most appropriate treatment at this stage?

Explanation

The patient's history (chronic alcoholism, pancreatitis) and radiographic findings (patchy sclerosis/lucency, subchondral crescent sign) are classic for osteonecrosis (avascular necrosis, AVN) of the femoral head. The presence of a subchondral crescent sign indicates collapse of the femoral head, which signifies a Ficat Stage III or IV lesion. At this stage, the joint surface has collapsed, and total hip arthroplasty (THA) is typically the most appropriate treatment to relieve pain and restore function. Core decompression is effective for pre-collapse (Ficat I/II) stages. Non-operative management is unlikely to provide lasting relief with collapse. Intertrochanteric osteotomy is a joint-preserving procedure for early-stage AVN, but less effective once collapse occurs. Hemiarthroplasty is less commonly used for AVN than THA.

Question 63

Which of the following is the most effective intervention to reduce the risk of surgical site infection (SSI) in orthopedic surgery, specifically related to the operating room environment?

Explanation

Strict control of operating room traffic and minimizing door openings is considered one of the most effective and easily implemented strategies to reduce the risk of surgical site infection (SSI). Each door opening can introduce airborne contaminants into the sterile field. While laminar flow operating rooms can be beneficial, their routine use is debated and expensive. Prophylactic antibiotics are crucial but should be discontinued shortly after surgery (typically within 24 hours). Topical antibiotics have limited evidence for reducing SSI in orthopedic surgery, and increasing povidone-iodine concentration beyond standard recommendations does not confer additional benefit and may cause irritation. Environmental control through traffic restriction is a high-yield intervention.

Question 64

A 14-year-old competitive gymnast presents with chronic, diffuse lower back pain, exacerbated by hyperextension. Radiographs reveal bilateral spondylolysis at L5. Neurological exam is normal. What is the most appropriate initial management?

Explanation

The patient's symptoms (back pain, worsened by hyperextension) and radiographic findings (bilateral L5 spondylolysis) are typical for this condition. In adolescents, especially athletes, the initial management is almost always conservative. This involves activity modification (rest from aggravating activities, particularly hyperextension), bracing (to limit extension and allow healing of the pars), and a focused physical therapy program to strengthen core and hamstring muscles. Most patients respond well to conservative care. Surgical repair or fusion is reserved for those who fail prolonged conservative management, have persistent debilitating pain, or demonstrate progression to spondylolisthesis with instability. Epidural injections are not typically indicated for spondylolysis in adolescents. Vertebroplasty is for compression fractures.

Question 65

Which of the following conditions is an indication for surgical management of an acute rotator cuff tear?

Explanation

Surgical repair of an acute rotator cuff tear is strongly indicated in a young, active patient who sustains a full-thickness tear (especially greater than 1 cm) from acute trauma and experiences significant weakness. In this demographic and tear pattern, surgical repair offers the best chance for restoring function, preventing tear enlargement, and avoiding future degenerative changes. Small, partial tears, or tears in elderly/sedentary patients, or chronic asymptomatic/degenerative tears are often managed conservatively first. Impingement syndrome without a tear is also managed conservatively.

Question 66

A patient undergoing an anterior total hip arthroplasty is positioned supine. Which nerve is most susceptible to injury during positioning or retraction, especially with hyperextension and external rotation of the hip?

Explanation

The lateral femoral cutaneous nerve (LFCN) is particularly susceptible to injury during positioning and retraction in the direct anterior approach to total hip arthroplasty. It is a sensory nerve that exits the pelvis near the anterior superior iliac spine (ASIS) and can be compressed or stretched with hip hyperextension, external rotation, or direct pressure from retractors, leading to meralgia paresthetica (numbness/pain in the lateral thigh). The sciatic nerve is posterior. The femoral and obturator nerves are more medial and deep, though still at risk. The peroneal nerve is typically at risk around the fibular head.

Question 67

In patients with osteosarcoma, what is the most significant prognostic factor?

Explanation

The presence of metastatic disease at the time of diagnosis is the single most significant prognostic factor for osteosarcoma. Patients who present with metastatic disease have a significantly worse prognosis than those with localized disease. While patient age, tumor size, and location all influence prognosis, and response to neoadjuvant chemotherapy is crucial for treatment planning and also prognostic, the presence of macroscopic metastases at initial presentation remains the most powerful predictor of poor outcome.

Question 68

A 5-year-old child sustains a supracondylar humerus fracture (Gartland Type III) after a fall. Examination reveals a pale, pulseless hand. What is the most appropriate emergent management?

Explanation

A supracondylar humerus fracture with signs of vascular compromise (pale, pulseless hand) is an orthopedic emergency. The most appropriate emergent management is immediate closed reduction of the fracture and percutaneous pinning. Often, reduction of the fracture itself can restore arterial flow by relieving mechanical compression of the brachial artery. If the pulse does not return after successful reduction and pinning, then further investigation (e.g., Doppler ultrasound, formal angiography) and vascular exploration would be necessary. Observation is contraindicated in an ischemic limb. Open reduction and vascular exploration are secondary steps if closed reduction fails to restore perfusion. Administering fluids and heparin is supportive but not definitive.

Question 69

Which of the following is considered the most common early complication of cervical spine fusion surgery?

Explanation

Dysphagia (difficulty swallowing) is the most common early complication of anterior cervical spine fusion surgery, occurring in up to 50% of patients acutely, though it is usually transient. It is thought to be due to direct surgical trauma, retractor pressure, edema, or nerve irritation. While CSF leak is a possible complication, it's less common than dysphagia. Spinal cord injury is rare but devastating. Pseudarthrosis and adjacent segment disease are considered later complications (failure of fusion, or degenerative changes at adjacent levels).

Question 70

A 62-year-old female presents with chronic shoulder pain and weakness. MRI reveals a massive, irreparable rotator cuff tear with superior migration of the humeral head and glenohumeral arthritis (cuff tear arthropathy). She has limited active elevation but preserved passive range of motion. What is the most appropriate surgical intervention?

Explanation

The patient's presentation (massive, irreparable rotator cuff tear, superior humeral head migration, glenohumeral arthritis - cuff tear arthropathy, limited active elevation but preserved passive ROM) is a classic indication for reverse total shoulder arthroplasty (rTSA). rTSA reverses the ball-and-socket anatomy, medializes the center of rotation, and tensions the deltoid, allowing the deltoid to effectively elevate the arm in the absence of a functional rotator cuff. Arthroscopic debridement or partial repair would be ineffective for an irreparable tear with established arthropathy. Total shoulder arthroplasty requires an intact rotator cuff. Hemiarthroplasty might address pain but not active elevation. Latissimus dorsi transfer is an option for younger, active patients with irreparable posterosuperior tears and good deltoid function, but less effective with established arthropathy and superior migration.

Question 71

Which of the following is the most common cause of non-traumatic amputation in adults globally?

Explanation

Globally, peripheral vascular disease (PVD) and diabetes mellitus are by far the most common causes of non-traumatic amputations in adults. These conditions lead to critical limb ischemia, diabetic foot ulcers, and infection, ultimately necessitating amputation. While trauma is a significant cause of amputation, it is typically traumatic. Malignancy, chronic osteomyelitis, and neurological disorders also lead to amputation but are less common than PVD/diabetes combined.

Question 72

A 3-year-old child presents with a limp, fever, and refusal to bear weight on the left leg. On examination, the left hip is held in flexion, abduction, and external rotation. Passive range of motion is severely painful, especially internal rotation. Blood tests show cloudy fluid with a WBC count of 75,000 cells/µL, 90% neutrophils, and positive Gram stain for Gram-positive cocci in clusters. What is the most appropriate management?

Explanation

Question 73

Which of the following describes the most common long-term complication after anterior cruciate ligament (ACL) reconstruction, despite a successful surgery?

Explanation

Despite successful ACL reconstruction, the most common long-term complication is the development of osteoarthritis of the knee. Even with anatomical reconstruction and restoration of stability, the initial injury itself, associated meniscal or cartilage damage, and altered joint kinematics contribute to an accelerated degenerative process, leading to osteoarthritis in a significant percentage of patients over time. While graft re-rupture, patellofemoral pain, infection, and arthrofibrosis are all possible complications, osteoarthritis remains the most prevalent long-term issue impacting joint health and function.

Question 74

A 30-year-old male sustains a severe open pilon fracture (distal tibia intra-articular) with significant soft tissue compromise. After initial debridement and external fixation, the soft tissue condition remains precarious. What is the optimal timing for definitive internal fixation of the fracture?

Explanation

For severe open pilon fractures with significant soft tissue compromise, the optimal timing for definitive internal fixation is when the soft tissue envelope has recovered. This often means waiting 7-21 days (or even longer) after the initial injury and external fixation, until the 'wrinkle sign' is present (indicating decreased soft tissue edema and skin laxity). Operating too early in the presence of severe soft tissue swelling significantly increases the risk of wound complications, infection, and non-union. Immediate fixation is reserved for pristine soft tissues, and 3-5 days is still too early for severe compromise. Waiting 6 weeks might risk malunion. While external fixation can be definitive, internal fixation is generally preferred for optimal articular reconstruction if soft tissues allow.

Question 75

Which classification system is used to assess the severity of proximal humerus fractures?

Explanation

The Neer classification system is the most widely recognized and commonly used system for classifying proximal humerus fractures. It categorizes fractures based on the number of displaced 'parts' (anatomical neck, surgical neck, greater tuberosity, lesser tuberosity) by more than 1 cm displacement or 45 degrees angulation. Gustilo-Anderson is for open fractures. AO/OTA is a general fracture classification. Hawkins is for talar neck fractures. Salter-Harris is for physeal (growth plate) fractures in children.

Question 76

In the management of pediatric femoral shaft fractures, what is the generally accepted threshold for surgical intervention (e.g., intramedullary nailing) in a school-aged child (6-12 years old)?

Immediate definitive intramedullary nailing.
Application of a cast and delayed definitive fixation.
Urgent irrigation and debridement within 6 hours, followed by stabilization.
Administration of systemic antibiotics and observation.
Primary closure of the wound.

Correct Answer: Urgent irrigation and debridement within 6 hours, followed by stabilization.

Explanation:

Question 7:

Which of the following statements regarding osteosarcoma is FALSE?

Options:

It is the most common primary malignant bone tumor in children and adolescents.
The most common sites are the metaphysis of long bones (distal femur, proximal tibia, proximal humerus).
Chemotherapy is an essential part of treatment, both neoadjuvantly and adjuvantly.
Pulmonary metastasis is the most common site of metastatic disease.
Radiation therapy is the primary treatment modality for localized disease.

Correct Answer: Radiation therapy is the primary treatment modality for localized disease.

Explanation:

Question 8:

Options:

Continue with conservative management including weight loss and consider repeat injections.
Perform bilateral unicompartmental knee arthroplasties (UKA).
Proceed with bilateral total knee arthroplasties (TKA).
High tibial osteotomy (HTO).
Arthroscopic debridement and lavage.

Correct Answer: Proceed with bilateral total knee arthroplasties (TKA).

Explanation:

Question 9:

Options:

Excision of the radial head and immobilization.
Open reduction and internal fixation of the radial head and coronoid with lateral collateral ligament repair.
Radial head arthroplasty with coronoid fixation and lateral collateral ligament repair.
Radial head arthroplasty alone.
Closed reduction and casting for 6 weeks.

Correct Answer: Radial head arthroplasty with coronoid fixation and lateral collateral ligament repair.

Explanation:

Question 10:

Which factor is most strongly associated with an increased risk of chronic regional pain syndrome (CRPS) Type 1 following an orthopedic injury or surgery?

Options:

Patient age over 60 years.
Presence of pre-existing peripheral neuropathy.
Delayed mobilization after injury.
Pre-existing psychological distress or anxiety.
Fracture location in the axial skeleton.

Correct Answer: Pre-existing psychological distress or anxiety.

Explanation:

Question 11:

A 3-month-old infant presents for a routine check-up. The pediatrician notes asymmetric thigh folds and a positive Ortolani test on the left hip. What is the most appropriate next step in management?

Options:

Reassure the parents and observe for 3 months.
Order a plain radiograph of the pelvis.
Refer for immediate orthopedic consultation and likely Pavlik harness application.
Start physical therapy exercises for hip strengthening.
Obtain an MRI of the hip.

Correct Answer: Refer for immediate orthopedic consultation and likely Pavlik harness application.

Explanation:

Question 12:

Options:

Empiric broad-spectrum antibiotics and MRI of the lumbar spine.
Lumbar puncture and cerebrospinal fluid analysis.
Conservative management with bed rest and analgesia.
Plain radiographs of the lumbar spine and blood cultures.
Neurosurgical consultation for immediate laminectomy.

Correct Answer: Empiric broad-spectrum antibiotics and MRI of the lumbar spine.

Explanation:

Question 13:

Which biomechanical principle is most critical for the successful healing of an articular cartilage defect treated with microfracture?

Options:

Maintenance of a stable bone-cartilage interface through rigid fixation.
Creation of a low-friction surface that resists shear forces.
Formation of a fibrocartilaginous repair tissue with improved wear properties.
Controlled, cyclic loading to stimulate chondrocyte differentiation and matrix production.
Elimination of all weight-bearing for at least 6 months post-operatively.

Correct Answer: Controlled, cyclic loading to stimulate chondrocyte differentiation and matrix production.

Explanation:

Question 14:

Options:

Immediate surgical exploration and nerve repair.
Closed reduction and functional bracing with close observation of nerve recovery.
Open reduction and internal fixation with nerve transfer.
Electromyography (EMG) and nerve conduction studies (NCS) to confirm nerve injury.
Placement of an external fixator and delayed nerve exploration.

Correct Answer: Closed reduction and functional bracing with close observation of nerve recovery.

Explanation:

Question 15:

Which of the following is the most sensitive imaging modality for detecting early avascular necrosis (AVN) of the femoral head?

Options:

Plain radiograph (AP pelvis and frog-leg lateral).
Computed tomography (CT) scan.
Magnetic resonance imaging (MRI).
Bone scintigraphy (bone scan).
Ultrasound.

Correct Answer: Magnetic resonance imaging (MRI).

Explanation:

Question 16:

Options:

Immediate surgical MPFL reconstruction.
Long-leg casting for 6 weeks.
Conservative management with RICE, pain control, and early protected range of motion, followed by physical therapy.
Diagnostic arthroscopy with loose body removal and debridement.
Quadriceps strengthening exercises only.

Correct Answer: Conservative management with RICE, pain control, and early protected range of motion, followed by physical therapy.

Explanation:

Question 17:

In total hip arthroplasty, what is the primary purpose of using highly cross-linked polyethylene?

Options:

To improve initial fixation of the acetabular component.
To reduce the risk of dislocation.
To enhance osseointegration of the implant.
To decrease polyethylene wear and osteolysis.
To increase the implant's resistance to infection.

Correct Answer: To decrease polyethylene wear and osteolysis.

Explanation:

Question 18:

Options:

Plain radiographs of the wrist.
MRI of the cervical spine.
Electromyography (EMG) and nerve conduction studies (NCS).
Ultrasound of the median nerve.
Blood tests for inflammatory markers.

Correct Answer: Electromyography (EMG) and nerve conduction studies (NCS).

Explanation:

Question 19:

Options:

Closed reduction and casting.
External fixation alone.
Dorsal plating with bone graft.
Volar locking plate fixation.
Wrist fusion.

Correct Answer: Volar locking plate fixation.

Explanation:

Question 20:

Regarding the management of non-unions, which of the following statements is TRUE?

Options:

Hypertrophic non-unions typically require bone grafting.
Atrophic non-unions usually heal with rigid fixation alone.
Infection is a contraindication to surgical intervention for non-union.
The diamond concept for non-union treatment includes stability, biology, growth factors, and mechanical environment.
Electrical stimulation is the first-line treatment for all types of non-unions.

Correct Answer: The diamond concept for non-union treatment includes stability, biology, growth factors, and mechanical environment.

Explanation:

Question 21:

Options:

Plantar fasciitis.
Achilles tendinitis.
Haglund's deformity.
Adult acquired flatfoot deformity (AAFD) due to posterior tibial tendon dysfunction (PTTD).
Stress fracture of the navicular.

Correct Answer: Adult acquired flatfoot deformity (AAFD) due to posterior tibial tendon dysfunction (PTTD).

Explanation:

Question 22:

Which of the following is an absolute contraindication to performing a knee arthroplasty?

Options:

Patient age greater than 80 years.
Obesity (BMI > 40).
Active infection in the knee joint.
Severe osteoporosis.
History of deep vein thrombosis (DVT).

Correct Answer: Active infection in the knee joint.

Explanation:

Question 23:

Options:

Plain radiographs of the lumbar spine.
Electromyography (EMG).
MRI of the entire spine.
Bone scan (technetium-99m).
Lumbar discography.

Correct Answer: MRI of the entire spine.

Explanation:

Question 24:

Which of the following describes a 'stress-shielding' phenomenon in the context of orthopedic implants?

Options:

Increased bone density around a prosthetic implant due to enhanced load transfer.
Resorption of bone due to reduced mechanical stress in areas protected by a stiff implant.
The body's immune response to foreign material causing osteolysis.
The protective effect of soft tissue surrounding an implant preventing fracture.
Overgrowth of callus around a fracture site due to excessive motion.

Correct Answer: Resorption of bone due to reduced mechanical stress in areas protected by a stiff implant.

Explanation:

Question 25:

A 10-year-old girl sustains a Salter-Harris Type II fracture of the distal tibia. What is the most important concern regarding long-term complications?

Options:

Avascular necrosis of the epiphysis.
Recurrent dislocation of the ankle.
Growth arrest leading to limb length discrepancy or angular deformity.
Osteoarthritis of the ankle joint.
Non-union of the metaphysis.

Correct Answer: Growth arrest leading to limb length discrepancy or angular deformity.

Explanation:

Question 26:

Options:

Re-tear of the rotator cuff; revision surgery.
Adhesive capsulitis (frozen shoulder); physical therapy and potentially manipulation under anesthesia.
Infection; surgical debridement and antibiotics.
Deltoid dehiscence; surgical repair.
Neurovascular injury; neurosurgical consultation.

Correct Answer: Adhesive capsulitis (frozen shoulder); physical therapy and potentially manipulation under anesthesia.

Explanation:

Question 27:

Which of the following is the most effective method for preventing heterotopic ossification (HO) after total hip arthroplasty (THA), particularly in high-risk patients?

Options:

Administration of systemic corticosteroids.
Pre-operative calcium and vitamin D supplementation.
Indomethacin or other NSAIDs administered post-operatively.
Targeted intraoperative radiation therapy.
Early and aggressive mobilization.

Correct Answer: Indomethacin or other NSAIDs administered post-operatively.

Explanation:

Question 28:

Options:

Corticosteroid injection into the extensor tendon origin.
Surgical release of the common extensor origin.
Platelet-rich plasma (PRP) injection.
Rest, NSAIDs, counterforce bracing, and physical therapy focusing on eccentric strengthening.
Diagnostic arthroscopy of the elbow.

Correct Answer: Rest, NSAIDs, counterforce bracing, and physical therapy focusing on eccentric strengthening.

Explanation:

Question 29:

Which complication is most characteristic of a posterior hip dislocation?

Options:

Femoral head avascular necrosis.
Sciatic nerve injury.
Deep vein thrombosis.
Trochanteric non-union.
Vascular injury to the femoral artery.

Correct Answer: Sciatic nerve injury.

Explanation:

Question 30:

Options:

Osteoarthritis of the hip.
Femoroacetabular impingement (FAI), cam type.
Femoroacetabular impingement (FAI), pincer type.
Sports hernia (athletic pubalgia).
Stress fracture of the femoral neck.

Correct Answer: Femoroacetabular impingement (FAI), cam type.

Explanation:

Question 31:

What is the primary goal of surgical treatment for adolescent idiopathic scoliosis (AIS) with curves greater than 45-50 degrees?

Options:

Elimination of all back pain.
Correction of cosmetic deformity and prevention of curve progression.
Complete normalization of spinal alignment.
Improvement of pulmonary function only.
Prevention of neurological deficits.

Correct Answer: Correction of cosmetic deformity and prevention of curve progression.

Explanation:

Question 32:

Options:

Non-operative management with cast immobilization and gradual weight-bearing.
Open surgical repair of the Achilles tendon.
Percutaneous surgical repair of the Achilles tendon.
Physical therapy focusing on strengthening and stretching.
Platelet-rich plasma (PRP) injection and immobilization.

Correct Answer: Open surgical repair of the Achilles tendon.

Explanation:

Question 33:

Which of the following describes a key advantage of dual-mobility articulations in total hip arthroplasty?

Options:

Elimination of wear particle generation.
Reduced risk of dislocation.
Improved bone ingrowth to the acetabular component.
Enhanced pain relief compared to traditional designs.
Simpler surgical technique.

Correct Answer: Reduced risk of dislocation.

Explanation:

Question 34:

Options:

Ewing's sarcoma.
Osteomyelitis.
Osteoid osteoma.
Stress fracture.
Non-ossifying fibroma.

Correct Answer: Osteomyelitis.

Explanation:

Question 35:

Which of the following approaches to total hip arthroplasty is associated with the highest rate of posterior dislocation during the early postoperative period?

Options:

Direct anterior approach.
Direct lateral approach.
Anterolateral approach.
Posterior approach.
Minimally invasive approach (irrespective of muscle interval).

Correct Answer: Posterior approach.

Explanation:

Question 36:

Options:

Delayed primary closure.
Secondary intention healing with daily wound care.
Split-thickness skin graft.
Local rotational flap.
Free tissue transfer (free flap).

Correct Answer: Free tissue transfer (free flap).

Explanation:

Question 37:

Which of the following statements about clubfoot (congenital talipes equinovarus) is FALSE?

Options:

It is characterized by hindfoot equinus, hindfoot varus, forefoot adduction, and forefoot supination.
The Ponseti method is the gold standard for initial non-operative treatment.
Correction involves serial casting with gentle manipulation, primarily addressing hindfoot equinus first.
Percutaneous Achilles tenotomy is often performed as part of the Ponseti method.
Surgical release is typically reserved for failed Ponseti treatment or recurrence.

Correct Answer: Correction involves serial casting with gentle manipulation, primarily addressing hindfoot equinus first.

Explanation:

Question 38:

Options:

Intra-articular corticosteroid injection.
Systemic antibiotics.
NSAIDs, colchicine, or systemic corticosteroids.
Joint lavage and debridement.
Allopurinol.

Correct Answer: NSAIDs, colchicine, or systemic corticosteroids.

Explanation:

Question 39:

What is the primary mechanism of action of bone morphogenetic proteins (BMPs) in promoting fracture healing?

Options:

Inhibition of osteoclast activity.
Stimulation of osteoblast apoptosis.
Induction of mesenchymal stem cell differentiation into osteoblasts and chondroblasts.
Enhancement of vascular permeability at the fracture site.
Direct structural bridging of fracture gaps.

Correct Answer: Induction of mesenchymal stem cell differentiation into osteoblasts and chondroblasts.

Explanation:

Question 40:

A 4-year-old child presents with a 'toddler's fracture' of the tibia. What is the characteristic radiographic finding?

Options:

Transverse fracture of the distal tibial metaphysis.
Oblique or spiral non-displaced fracture of the tibial shaft.
Comminuted intra-articular fracture of the proximal tibia.
Salter-Harris Type I fracture of the distal tibia.
Complete diaphyseal fracture with significant displacement.

Correct Answer: Oblique or spiral non-displaced fracture of the tibial shaft.

Explanation:

Question 41:

In the context of anterior cervical discectomy and fusion (ACDF), what is the primary biomechanical advantage of using an anterior plate?

Options:

To prevent dysphagia.
To increase the rate of pseudarthrosis.
To provide immediate stability and reduce graft extrusion.
To facilitate posterior cervical fusion at a later stage.
To allow for earlier return to full activity without bracing.

Correct Answer: To provide immediate stability and reduce graft extrusion.

Explanation:

Question 42:

Which of the following is the most common cause of painful hardware after ankle fracture fixation?

Options:

Infection.
Aseptic loosening of screws.
Non-union of the fracture.
Prominent hardware causing soft tissue irritation.
Complex regional pain syndrome (CRPS).

Correct Answer: Prominent hardware causing soft tissue irritation.

Explanation:

Question 43:

Which organism is the most common causative agent of acute hematogenous osteomyelitis in healthy children?

Options:

Pseudomonas aeruginosa.
Staphylococcus aureus.
Streptococcus pyogenes.
Kingella kingae.
Escherichia coli.

Correct Answer: Staphylococcus aureus.

Explanation:

Question 44:

Options:

Standard primary knee components with cement augmentation.
Unicompartmental knee arthroplasty.
Hinged knee prosthesis with intramedullary stems and augments.
Patellofemoral arthroplasty.
Osteochondral allograft transplantation.

Correct Answer: Hinged knee prosthesis with intramedullary stems and augments.

Explanation:

Question 45:

What is the most accurate predictor of success for anterior cruciate ligament (ACL) reconstruction using a hamstring autograft?

Options:

Patient age.
Quadriceps strength at 6 months post-surgery.
Postoperative graft tunnel widening.
Compliance with postoperative rehabilitation protocol.
Type of fixation used for the graft.

Correct Answer: Compliance with postoperative rehabilitation protocol.

Explanation:

Question 46:

Options:

Conservative management with pain medication and bracing.
Radiation therapy alone to the T10 lesion.
Surgical decompression and stabilization, followed by radiation therapy.
Chemotherapy alone.
Vertebroplasty or kyphoplasty.

Correct Answer: Surgical decompression and stabilization, followed by radiation therapy.

Explanation:

Question 47:

Which specific ligament is most commonly injured in an isolated high ankle sprain (syndesmotic injury)?

Options:

Anterior talofibular ligament (ATFL).
Calcaneofibular ligament (CFL).
Posterior talofibular ligament (PTFL).
Anterior inferior tibiofibular ligament (AITFL).
Deltoid ligament.

Correct Answer: Anterior inferior tibiofibular ligament (AITFL).

Explanation:

Question 48:

Which of the following describes the most accurate interpretation of a positive Trendelenburg sign?

Options:

Weakness of the hip adductor muscles, causing the pelvis to drop on the affected side.
Weakness of the hip abductor muscles, causing the pelvis to drop on the unsupported (contralateral) side during single-leg stance.
Tightness of the iliotibial band, leading to a compensatory gait pattern.
Pain in the hip joint, causing an antalgic gait.
Leg length discrepancy, resulting in pelvic tilt.

Correct Answer: Weakness of the hip abductor muscles, causing the pelvis to drop on the unsupported (contralateral) side during single-leg stance.

Explanation:

Question 49:

A 6-month-old infant is diagnosed with congenital muscular torticollis. What is the most appropriate initial management?

Options:

Immediate surgical release of the sternocleidomastoid muscle.
Referral for botulinum toxin injection.
Passive stretching exercises and physical therapy.
Cervical collar immobilization.
Wait until the child is older to assess for spontaneous resolution.

Correct Answer: Passive stretching exercises and physical therapy.

Explanation:

Question 50:

Which type of fracture is most commonly associated with a high incidence of non-union due to its inherently poor blood supply?

Options:

Distal radius fracture.
Humeral shaft fracture.
Scaphoid waist fracture.
Tibial shaft fracture.
Proximal humerus fracture.

Correct Answer: Scaphoid waist fracture.

Explanation:

Question 51:

Options:

Plain radiographs of the thoracic spine.
MRI of the thoracic spine with contrast.
CT scan of the thoracic spine.
Bone scan.
Electromyography (EMG).

Correct Answer: MRI of the thoracic spine with contrast.

Explanation:

Question 52:

In the setting of a calcaneal fracture (Böhler's angle < 20 degrees), what is the most significant long-term functional complication, even after surgical fixation?

Options:

Achilles tendinitis.
Ankle instability.
Subtalar arthritis and pain.
Plantar fasciitis.
Toe deformities.

Correct Answer: Subtalar arthritis and pain.

Explanation:

Question 53:

Which of the following growth factors is most commonly used in clinical practice to enhance bone healing, particularly in non-union scenarios?

Options:

Fibroblast Growth Factor (FGF).
Vascular Endothelial Growth Factor (VEGF).
Transforming Growth Factor-beta (TGF-β).
Bone Morphogenetic Protein-2 (BMP-2).
Insulin-like Growth Factor-1 (IGF-1).

Correct Answer: Bone Morphogenetic Protein-2 (BMP-2).

Explanation:

Question 54:

Options:

MRI of the hip to rule out avascular necrosis.
AP and frog-leg lateral radiographs of both hips.
Ultrasound of the hip to check for effusion.
CT scan of the pelvis.
Plain radiographs of the knee.

Correct Answer: AP and frog-leg lateral radiographs of both hips.

Explanation:

Question 55:

Options:

Bunionectomy (exostectomy) alone.
Keller arthroplasty.
Distal metatarsal osteotomy (e.g., Chevron, Weil).
Proximal metatarsal osteotomy (e.g., Ludloff, Scarf) or Lapidus procedure.
Arthrodesis of the first metatarsophalangeal (MTP) joint.

Correct Answer: Proximal metatarsal osteotomy (e.g., Ludloff, Scarf) or Lapidus procedure.

Explanation:

Question 56:

Which classification system is primarily used to assess the severity of acetabular fractures and guide surgical approach?

Options:

Gustilo-Anderson classification.
AO/OTA classification.
Letournel and Judet classification.
Mason classification.
Denis classification.

Correct Answer: Letournel and Judet classification.

Explanation:

Question 57:

Options:

Corticosteroid injections.
Extracorporeal shockwave therapy (ESWT).
Custom orthotics with arch support and heel cushioning.
Night splints to maintain ankle dorsiflexion.
Surgical release of the plantar fascia.

Correct Answer: Custom orthotics with arch support and heel cushioning.

Explanation:

Question 58:

Which of the following statements regarding osteomyelitis of the spine (spondylodiscitis) in adults is TRUE?

Options:

It primarily affects the posterior elements of the vertebrae.
Staphylococcus epidermidis is the most common causative organism.
Patients typically present with severe neurological deficits at diagnosis.
MRI with contrast is the gold standard for diagnosis.
Antibiotics alone are usually sufficient for treatment, even with neurological compromise.

Correct Answer: MRI with contrast is the gold standard for diagnosis.

Explanation:

Question 59:

What is the most significant disadvantage of a unicompartmental knee arthroplasty (UKA) compared to total knee arthroplasty (TKA)?

Options:

Increased blood loss.
Higher risk of deep vein thrombosis.
Greater postoperative pain.
Higher rate of revision surgery.
Longer recovery time.

Correct Answer: Higher rate of revision surgery.

Explanation:

Question 60:

Options:

Immediate intravenous antibiotics and observation.
Aspiration, culture, and non-weight bearing.
Urgent surgical irrigation and debridement of the knee.
Intra-articular corticosteroid injection.
Arthroscopy with synovectomy.

Correct Answer: Urgent surgical irrigation and debridement of the knee.

Explanation:

Question 61:

Which nerve is most at risk of injury during surgical exposure of the anterior column of the acetabulum through an ilioinguinal approach?

Options:

Femoral nerve.
Sciatic nerve.
Obturator nerve.
Lateral femoral cutaneous nerve.
Superior gluteal nerve.

Correct Answer: Femoral nerve.

Explanation:

Question 62:

Options:

Core decompression of the femoral head.
Total hip arthroplasty (THA).
Non-operative management with crutches and NSAIDs.
Intertrochanteric osteotomy.
Hemiarthroplasty.

Correct Answer: Total hip arthroplasty (THA).

Explanation:

Question 63:

Which of the following is the most effective intervention to reduce the risk of surgical site infection (SSI) in orthopedic surgery, specifically related to the operating room environment?

Options:

Administration of prophylactic broad-spectrum antibiotics for 7 days post-operatively.
Use of laminar flow operating rooms with ultra-clean air.
Strict control of operating room traffic and door openings.
Routine application of topical antibiotics to surgical wounds.
Increased concentration of povidone-iodine in surgical skin prep.

Correct Answer: Strict control of operating room traffic and door openings.

Explanation:

Question 64:

Options:

Surgical repair of the pars defects with instrumentation.
Spinal fusion at L5-S1.
Bracing (e.g., LSO or TLSO), activity modification, and physical therapy.
Epidural steroid injections.
Percutaneous vertebroplasty.

Correct Answer: Bracing (e.g., LSO or TLSO), activity modification, and physical therapy.

Explanation:

Question 65:

Which of the following conditions is an indication for surgical management of an acute rotator cuff tear?

Options:

Small, partial-thickness tear in an elderly, sedentary patient.
Full-thickness tear (>1 cm) in a young, active patient with acute trauma and significant weakness.
Chronic, asymptomatic full-thickness tear.
Degenerative full-thickness tear with minimal pain and good function.
Impingement syndrome without a documented tear.

Correct Answer: Full-thickness tear (>1 cm) in a young, active patient with acute trauma and significant weakness.

Explanation:

Question 66:

Options:

Sciatic nerve.
Femoral nerve.
Obturator nerve.
Lateral femoral cutaneous nerve.
Peroneal nerve.

Correct Answer: Lateral femoral cutaneous nerve.

Explanation:

Question 67:

In patients with osteosarcoma, what is the most significant prognostic factor?

Options:

Patient age at diagnosis.
Tumor size.
Location of the primary tumor.
Presence of metastatic disease at diagnosis.
Response to neoadjuvant chemotherapy (histologic necrosis).

Correct Answer: Presence of metastatic disease at diagnosis.

Explanation:

Question 68:

A 5-year-old child sustains a supracondylar humerus fracture (Gartland Type III) after a fall. Examination reveals a pale, pulseless hand. What is the most appropriate emergent management?

Options:

Immediate closed reduction and percutaneous pinning.
Observation and repeat vascular assessment in 1 hour.
Open reduction and internal fixation with vascular exploration.
Angiography to localize the vascular injury.
Administer IV fluids and heparin.

Correct Answer: Immediate closed reduction and percutaneous pinning.

Explanation:

Question 69:

Which of the following is considered the most common early complication of cervical spine fusion surgery?

Options:

Spinal cord injury.
Cerebrospinal fluid (CSF) leak.
Pseudarthrosis.
Dysphagia.
Adjacent segment disease.

Correct Answer: Dysphagia.

Explanation:

Question 70:

Options:

Arthroscopic debridement and partial repair.
Total shoulder arthroplasty.
Hemiarthroplasty.
Reverse total shoulder arthroplasty (rTSA).
Latissimus dorsi transfer.

Correct Answer: Reverse total shoulder arthroplasty (rTSA).

Explanation:

Question 71:

Which of the following is the most common cause of non-traumatic amputation in adults globally?

Options:

Trauma.
Malignancy (e.g., osteosarcoma).
Peripheral vascular disease and diabetes.
Chronic osteomyelitis.
Neurological disorders (e.g., severe spasticity).

Correct Answer: Peripheral vascular disease and diabetes.

Explanation:

Question 72:

Options:

Immediate intravenous antibiotics and observation.
Aspiration, culture, and non-weight bearing.
Urgent surgical irrigation and debridement of the knee.
Intra-articular corticosteroid injection.
Arthroscopy with synovectomy.

Correct Answer: Urgent surgical irrigation and debridement of the knee.

Explanation:

Question 73:

Which of the following describes the most common long-term complication after anterior cruciate ligament (ACL) reconstruction, despite a successful surgery?

Options:

Graft re-rupture.
Chronic patellofemoral pain.
Development of osteoarthritis.
Infection.
Arthrofibrosis.

Correct Answer: Development of osteoarthritis.

Explanation:

Question 74:

Options:

Immediately after external fixation, within 24 hours.
Within 3-5 days, once the swelling has subsided.
When the soft tissue envelope has recovered, often 7-21 days later (the 'wrinkle sign').
After 6 weeks, once partial healing has occurred.
Never, always treat with external fixation for open pilon fractures.

Correct Answer: When the soft tissue envelope has recovered, often 7-21 days later (the 'wrinkle sign').

Explanation:

Question 75:

Which classification system is used to assess the severity of proximal humerus fractures?

Options:

Neer classification.
Gustilo-Anderson classification.
AO/OTA classification.
Hawkins classification.
Salter-Harris classification.

Correct Answer: Neer classification.

Explanation:

Question 76:

In the management of pediatric femoral shaft fractures, what is the generally accepted threshold for surgical intervention (e.g., intramedullary nailing) in a school-aged child (6-12 years old)?

Options:

All displaced femoral shaft fractures.
Fractures with less than 1 cm shortening.
Fractures with less than 15 degrees angulation.
Age-dependent guidelines, but typically above 6 years old for unstable or displaced fractures.
Only open fractures or polytrauma patients.

Correct Answer: Age-dependent guidelines, but typically above 6 years old for unstable or displaced fractures.

Orthopedic Spine Review | Dr Hutaif Spine Surgery Revie -...

Orthopedic Surgery Board Exam Prep: Interactive Spinal Trauma MCQs

Key Takeaway

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