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Orthopaedic Surgery Board Exam Review: ABOS Part I & AAOS OITE Prep Questions | Part 22210

Ultimate Orthopedic Board Prep: Interactive MCQs & Study Guide

23 Apr 2026 97 min read 110 Views
Chinese graduating exam

Key Takeaway

Effective Orthopedic Board Exam preparation involves consistent practice with high-yield multiple-choice questions. Utilize platforms offering both study and exam modes, complete with immediate feedback and comprehensive explanations. Focus on critical areas like trauma management (e.g., pelvic fractures and ATLS protocols) to build confidence and enhance retention for exam success.

Comprehensive Exam


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Question 1

A 45-year-old male presents to the emergency department after a high-speed motor vehicle collision. He is hypotensive (BP 80/40 mmHg), tachycardic (HR 130 bpm), and has gross hematuria. Physical examination reveals an unstable open-book pelvic fracture. Initial resuscitation with crystalloids is ongoing. What is the MOST appropriate next step in his management AFTER initial ATLS protocol?





Explanation

In an unstable open-book pelvic fracture, immediate pelvic stabilization with a binder or sheet is crucial to reduce pelvic volume, tamponade venous bleeding, and improve hemodynamic stability. While external fixation is definitive, it takes time. Angiography is typically performed after mechanical stabilization if bleeding persists. Laparotomy is for intra-abdominal organ injury, not primary pelvic hemorrhage control. CT scan should be performed once hemodynamically stable or after initial stabilization.

Question 2

A 3-month-old infant presents for a well-child check. On examination, a positive Ortolani sign is noted on the right hip. Radiographs show a dislocated right hip with a significantly increased acetabular index. What is the MOST appropriate management at this age?





Explanation

For infants aged 0-6 months with developmental dysplasia of the hip (DDH), a Pavlik harness is the gold standard of treatment. It maintains the hips in a flexed and abducted position, allowing for gradual reduction and development of the acetabulum. Open reduction is reserved for failures of conservative treatment or older children. Closed reduction with spica cast is typically for older infants (6-18 months) or failures of Pavlik. Ultrasound is a diagnostic tool, not a treatment.

Question 3

A 60-year-old male with a history of lumbar stenosis presents with acute onset bilateral leg weakness, saddle anesthesia, and urinary retention. Physical examination reveals diminished perianal sensation and loss of anal tone. What is the MOST critical immediate diagnostic and management step?





Explanation

This patient presents with classic signs of Cauda Equina Syndrome (CES), which is a surgical emergency. The critical immediate steps are a STAT MRI of the lumbar spine to confirm the diagnosis and identify the compressive lesion, followed by urgent surgical decompression to prevent permanent neurological deficits. Delay in decompression can lead to irreversible bladder, bowel, and sexual dysfunction. Oral corticosteroids, EMG/NCS, PT, and urology referral are not the primary emergent management.

Question 4

A 7-year-old boy falls off monkey bars and sustains a supracondylar humerus fracture. On presentation, he has a pulseless but warm and pink hand with intact motor function. Radiographs confirm a displaced extension-type supracondylar fracture. What is the MOST appropriate initial management?





Explanation

A pulseless but perfused hand in the setting of a supracondylar humerus fracture, particularly after a traumatic event, often indicates vascular spasm or kinking rather than a complete transection. The initial management is urgent closed reduction and percutaneous pinning (CRPP) to restore anatomical alignment and decompress the brachial artery. If the pulse does not return after successful reduction and pinning, or if signs of ischemia develop, then surgical exploration of the brachial artery becomes necessary. Observation is inappropriate, and ORIF is typically reserved for irreducible fractures. Splinting in extension could worsen the neurovascular status.

Question 5

A 68-year-old patient who underwent total knee arthroplasty six months ago presents with worsening knee pain, swelling, and a low-grade fever. ESR is 70 mm/hr and CRP is 85 mg/L. Joint aspiration reveals a cloudy fluid. Which of the following findings from the aspirate is MOST indicative of periprosthetic joint infection (PJI)?





Explanation

According to the Musculoskeletal Infection Society (MSIS) criteria for defining PJI, a synovial fluid WBC count greater than 3000 cells/µL with a neutrophil percentage greater than 80% is a major criterion for diagnosis, particularly for acute PJI. While other options can be supportive, this specific combination is highly indicative and a strong diagnostic marker for PJI, especially in conjunction with elevated ESR/CRP and clinical symptoms. A WBC count of 1500 with 60% neutrophils is less specific and might be seen in aseptic inflammation.

Question 6

A 35-year-old construction worker sustains an open tibia fracture (Gustilo-Anderson Type IIIB) after a fall. He presents to the ER within 1 hour of injury. What is the MOST appropriate initial surgical management within the first 6-8 hours?





Explanation

For Gustilo-Anderson Type IIIB open tibia fractures, the cornerstone of management is urgent, thorough surgical debridement of all contaminated and non-viable tissue, followed by external fixation for skeletal stabilization, and appropriate broad-spectrum intravenous antibiotics. Delayed primary closure or staged soft tissue reconstruction is then planned. Immediate ORIF is contraindicated due to high infection risk. VAC therapy is a dressing, not a primary surgical debridement. Amputation is typically reserved for unsalvageable limbs (e.g., mangled extremity score, failed reconstruction attempts).

Question 7

A 13-year-old obese male presents with a several-week history of left hip pain and a limping gait. He denies any specific trauma. On examination, he holds his left hip in external rotation and has decreased internal rotation and abduction. What is the MOST likely diagnosis and the IMMEDIATE management?





Explanation

This presentation (obese adolescent, hip pain, limping, external rotation, limited internal rotation/abduction) is classic for Slipped Capital Femoral Epiphysis (SCFE). SCFE is an orthopedic emergency because further slippage can occur. Immediate management involves making the patient strictly non-weight bearing on the affected side and urgent surgical pinning in situ to stabilize the growth plate and prevent further displacement. Legg-Calvé-Perthes typically affects younger children (4-8 years). DDH is infantile. Transient synovitis is self-limiting but less likely with these exam findings. Septic arthritis would present with acute, severe pain and fever.

Question 8

A 28-year-old professional athlete sustains an acute knee injury while pivoting during a basketball game, hearing a "pop." He experiences immediate pain and swelling. On examination, a positive Lachman test and pivot shift test are present. Radiographs are normal. What is the MOST likely diagnosis?





Explanation

The classic triad of an acute knee injury involving a 'pop,' immediate swelling (hemarthrosis), and positive Lachman and pivot shift tests is highly indicative of an Anterior Cruciate Ligament (ACL) rupture. Meniscal tears cause mechanical symptoms but less immediate swelling unless associated with ACL. Patellar dislocation is usually obvious with patellar displacement. MCL sprains typically present with valgus instability. PCL ruptures manifest with a positive posterior drawer test and sag sign.

Question 9

A 72-year-old female undergoes an elective total hip arthroplasty for severe osteoarthritis. On postoperative day 2, she develops acute shortness of breath, pleuritic chest pain, and hypoxemia. What is the MOST likely diagnosis?





Explanation

Pulmonary embolism (PE) is a serious and well-recognized complication after total hip arthroplasty, especially within the first few weeks post-op. The symptoms of acute shortness of breath and pleuritic chest pain in a postoperative patient are highly suggestive of PE. While pneumonia, MI, and atelectasis are possibilities, PE must be ruled out urgently. Fat embolism syndrome, though possible after orthopedic trauma, is less common after elective arthroplasty and typically presents with a classic triad of respiratory insufficiency, neurological impairment, and petechial rash.

Question 10

A 50-year-old female administrative assistant reports numbness and tingling in her thumb, index, middle, and radial half of the ring finger, especially at night and with repetitive tasks. Phalen's test and Tinel's sign at the wrist are positive. What is the initial MOST appropriate non-surgical management?





Explanation

This clinical picture is classic for Carpal Tunnel Syndrome (CTS). The initial, conservative management of CTS, particularly for mild to moderate symptoms, involves ergonomic workplace adjustments to reduce repetitive strain and night splinting to maintain the wrist in a neutral position, thereby reducing pressure on the median nerve. While corticosteroid injections can provide temporary relief, they are not the first-line and durable solution. Surgery is for failed conservative management or severe cases. NSAIDs are less effective for nerve compression. NCS/EMG is a diagnostic confirmation tool, not a treatment.

Question 11

A 40-year-old immigrant presents with chronic back pain, low-grade fever, and significant weight loss over several months. Radiographs show vertebral body destruction and paraspinal soft tissue swelling, most prominent at T10-T11. What is the MOST likely diagnosis, and what is the primary diagnostic test?





Explanation

The constellation of chronic back pain, systemic symptoms (fever, weight loss), and radiographic findings of vertebral destruction (especially in a population at risk for TB) strongly points towards Spinal Tuberculosis (Pott's disease). The primary diagnostic test is an MRI to delineate the extent of disease and a biopsy of the affected area (usually percutaneous or open) for histopathological examination and culture for acid-fast bacilli to confirm the diagnosis and guide antitubercular treatment. While pyogenic spondylodiscitis has similar imaging, the chronicity and systemic symptoms favor TB. Other options are less likely given the clinical scenario.

Question 12

A 16-year-old male presents with localized knee pain, worse at night and relieved by aspirin. Radiographs show a small lucent lesion with a central nidus and surrounding sclerotic bone in the proximal tibia. What is the MOST likely diagnosis?





Explanation

The classic clinical presentation of localized pain, worse at night, relieved by aspirin, combined with the radiographic finding of a small lucent lesion with a central nidus and surrounding reactive sclerosis, is pathognomonic for an Osteoid Osteoma. Osteochondroma is an exostosis. Enchondroma is a lucent lesion often in the hand/foot. Osteosarcoma and Ewing's sarcoma are malignant and present differently, without the typical aspirin relief.

Question 13

A 45-year-old "weekend warrior" hears a loud "pop" in his left ankle while playing tennis. He experiences sudden sharp pain and can no longer push off on his toes. On examination, a palpable gap is noted in the Achilles tendon, and he has a positive Thompson test. What is the MOST appropriate management for this acute injury in an active individual?





Explanation

Acute Achilles tendon rupture in an active individual is typically managed with surgical repair to restore strength and reduce the risk of re-rupture. While non-operative treatment can be considered for less active individuals or those with significant comorbidities, surgical repair offers better functional outcomes and a lower re-rupture rate in this demographic. Immobilization and PT alone are less effective for complete ruptures. Corticosteroid injections are contraindicated as they weaken tendons and increase rupture risk.

Question 14

A 25-year-old male is involved in a high-speed frontal motor vehicle collision. He complains of severe right hip pain. On examination, his right leg is shortened, internally rotated, and adducted. What is the MOST likely diagnosis, and what is the IMMEDIATE management priority?





Explanation

The classic presentation of a posterior hip dislocation involves a shortened, internally rotated, and adducted lower extremity, often following a dashboard injury in an MVC. The immediate management priority is urgent closed reduction of the hip, ideally within 6 hours, to minimize the risk of avascular necrosis (AVN) of the femoral head. While associated fractures (femoral head, acetabulum) are common and require further imaging (CT post-reduction), the dislocation itself is the immediate limb-threatening concern due to vascular compromise.

Question 15

Which of the following conditions is MOST likely to impair bone healing (fracture union)?





Explanation

Nicotine use (smoking) is a well-established and significant risk factor for impaired bone healing, delayed union, and non-union. Nicotine causes vasoconstriction, impairs osteoblast function, and reduces blood supply to the fracture site. Young age, high calcium intake, stable fixation, and adequate Vitamin D levels are generally favorable for bone healing.

Question 16

A 6-year-old boy presents with a painless limp and restricted hip motion, particularly abduction and internal rotation, for several months. Radiographs show fragmentation and flattening of the femoral epiphysis. What is the primary goal of treatment for Legg-Calvé-Perthes disease?





Explanation

The primary goal of treatment for Legg-Calvé-Perthes disease is to maintain the sphericity of the femoral head and achieve containment within the acetabulum. This helps to prevent femoral head collapse and subsequent premature osteoarthritis. While pain relief and revascularization are aspects of care, they are secondary to the overall goal of preserving the joint's shape and function. Urgent osteotomy is reserved for specific indications or failures of conservative management.

Question 17

A 15-year-old gymnast complains of chronic low back pain, exacerbated by hyperextension activities. Physical examination reveals a palpable 'step-off' at L5-S1. Radiographs show anterior translation of L5 on S1. What is the MOST likely diagnosis?





Explanation

This presentation (adolescent, athlete, low back pain with hyperextension, palpable step-off, anterior translation of L5 on S1) is classic for Isthmic Spondylolisthesis, which is a forward slip of one vertebra over another due to a defect (spondylolysis) in the pars interarticularis. Degenerative spondylolisthesis typically occurs in older adults without a pars defect. Disc herniation, facet arthritis, and stenosis have different pain patterns and lack the step-off sign in adolescents.

Question 18

A 60-year-old female with osteoporosis falls onto an outstretched hand, sustaining a dorsally displaced and angulated distal radius fracture (Colles fracture). Which of the following is the MOST important factor to consider when determining the need for surgical fixation versus closed reduction and casting?





Explanation

The most important factor determining the need for surgical fixation versus closed reduction and casting for a distal radius fracture, especially in osteoporotic patients, is the degree of comminution and intra-articular involvement, and the stability of the reduction. Fractures with significant comminution, intra-articular displacement/gapping, or instability after reduction are more prone to malunion and functional impairment, thus often requiring surgical fixation. While age and dominance are considered, they are secondary to fracture characteristics impacting stability and long-term function.

Question 19

A 55-year-old painter presents with chronic right shoulder pain, especially with overhead activities and at night. He has significant weakness with abduction and external rotation. On examination, a positive Neer's and Hawkins' sign are present, and he has a painful arc of motion. What is the MOST likely diagnosis?





Explanation

The combination of chronic shoulder pain, pain with overhead activities, night pain, and weakness in abduction and external rotation is highly suggestive of a rotator cuff tear, particularly involving the supraspinatus and infraspinatus. Positive Neer's and Hawkins' signs indicate impingement, which often precedes or coexists with cuff tears. Adhesive capsulitis presents with global stiffness. Bicipital tendonitis is anterior shoulder pain. Glenohumeral OA causes diffuse pain and stiffness but often with crepitus. AC joint arthritis causes pain localized to the superior aspect of the shoulder, exacerbated by adduction across the chest.

Question 20

A 4-year-old child presents with acute onset severe right hip pain, refusal to bear weight, and fever. On examination, the hip is held in flexion, abduction, and external rotation, and any attempt at passive range of motion elicits significant pain. ESR and CRP are markedly elevated. What is the MOST critical immediate management step?





Explanation

This clinical scenario is highly concerning for septic arthritis of the hip, which is an orthopedic emergency. The most critical immediate management step is urgent hip aspiration to obtain synovial fluid for cell count, culture, and gram stain. This is essential for definitive diagnosis and guiding antibiotic therapy. Concurrently, broad-spectrum intravenous antibiotics should be initiated immediately after aspiration. Delay in diagnosis and treatment can lead to rapid cartilage destruction and long-term joint damage. Radiographs are often normal early on, and oral antibiotics are insufficient.

Question 21

A 65-year-old male with a history of prostate cancer presents with new-onset severe mid-back pain that is worse at night and not relieved by rest. He reports mild leg weakness. What is the MOST likely cause of his symptoms, and what is the preferred imaging modality?





Explanation

A patient with a known history of prostate cancer presenting with new, severe back pain (especially worse at night and unrelieved by rest – 'red flag' symptoms for malignancy) and neurological symptoms (leg weakness) should be highly suspected of having spinal cord compression from metastatic disease. Urgent MRI of the entire spine is the preferred imaging modality to assess for spinal cord compression and delineate the extent of metastatic lesions, guiding emergent treatment. Lumbar disc herniation rarely causes such severe night pain unrelieved by rest. Epidural abscess is a possibility but less likely than metastasis with a cancer history. X-rays are insufficient to rule out cord compression.

Question 22

A 60-year-old patient who underwent total knee arthroplasty (TKA) 5 years ago presents with insidious onset of anterior knee pain and mild swelling. Radiographs show a thin radiolucent line (<1mm) at the bone-cement interface around the tibial component. What is the MOST likely cause of her symptoms?





Explanation

Insidious onset of pain and a thin radiolucent line (<1mm) at the bone-cement interface around a TKA component, without other signs of infection, is highly suggestive of early aseptic loosening. This is a common mode of failure for cemented components. While infection needs to be ruled out, the absence of overt systemic signs and the specific radiographic finding point to aseptic loosening. Patellofemoral pain often presents differently, and extensor mechanism dysfunction might not show a radiolucent line.

Question 23

A 40-year-old male sustains a severe open tibia fracture with a >10 cm laceration, extensive muscle devitalization, and significant periosteal stripping. There is adequate soft tissue coverage for bony fixation but extensive contamination. According to the Gustilo-Anderson classification, what type of open fracture is this?





Explanation

This description fits a Gustilo-Anderson Type IIIB open fracture. Type IIIB involves extensive soft tissue damage, periosteal stripping, and massive contamination, with associated significant comminution, and typically requires local or free flap coverage. Type IIIA has extensive soft tissue damage but usually allows for primary closure. Type I and II have smaller wounds and less severe soft tissue injury. Type IIIC includes an associated arterial injury requiring repair.

Question 24

A new mother complains of pain along the radial side of her wrist and at the base of her thumb, exacerbated by lifting her baby. Finkelstein's test is positive. What tendons are primarily affected?





Explanation

De Quervain's tenosynovitis is an inflammatory condition affecting the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons, as they pass through the first dorsal compartment of the wrist. Finkelstein's test specifically exacerbates pain by stretching these tendons. This condition is common in new mothers due to repetitive lifting with wrist ulnar deviation and thumb abduction.

Question 25

A newborn is diagnosed with idiopathic clubfoot (talipes equinovarus). What is the gold standard, non-surgical treatment approach?





Explanation

The Ponseti method of serial manipulation and casting is the universally accepted gold standard non-surgical treatment for idiopathic clubfoot. It involves a specific sequence of gentle manipulations and plaster cast applications, typically weekly, followed by a percutaneous Achilles tenotomy and then bracing with a foot abduction orthosis. Surgical correction is reserved for failed Ponseti treatment or severe, rigid deformities. Other options are ineffective or not primary treatment.

Question 26

A 14-year-old girl is diagnosed with adolescent idiopathic scoliosis with a 35-degree thoracic curve (Cobb angle). She is still skeletally immature (Risser 0). What is the MOST appropriate initial management?





Explanation

For adolescent idiopathic scoliosis, the management depends on the curve magnitude and skeletal maturity. For curves between 25-40 degrees in a skeletally immature patient (Risser 0-2), bracing (e.g., Boston brace or TLSO) is the most appropriate initial treatment to prevent progression. Observation is for smaller curves (<25 degrees) or skeletally mature patients. Spinal fusion is typically reserved for curves >45-50 degrees or progressive curves despite bracing. Milwaukee brace is generally outdated compared to modern TLSOs.

Question 27

A 48-year-old male sustains a high-energy Schatzker Type VI tibial plateau fracture. He has an open wound over the medial aspect of the knee and a tense calf compartment with diminished distal pulses. What is the IMMEDIATE priority in management?





Explanation

This scenario describes a severe tibial plateau fracture with signs of both an open injury and impending compartment syndrome/vascular compromise. The IMMEDIATE priority is an urgent surgical debridement of the open wound to prevent infection, and fasciotomy of the calf compartments to relieve pressure and restore perfusion, given the tense calf and diminished pulses. External fixation provides temporary stability but doesn't address the acute soft tissue/vascular emergency. A CT angiogram may be needed but follows fasciotomy if pulses don't improve. Delayed ORIF is appropriate for definitive fixation, but not initially.

Question 28

A 10-year-old boy presents with a 2-week history of worsening right tibia pain, fever, and refusal to bear weight. Blood tests show elevated ESR and CRP. Radiographs show subtle periosteal reaction. What is the MOST sensitive imaging modality for early diagnosis of acute osteomyelitis?





Explanation

Magnetic Resonance Imaging (MRI) is the MOST sensitive imaging modality for early diagnosis of acute osteomyelitis, especially in children. It can detect bone marrow edema and early changes before they are visible on plain radiographs or CT scans. Bone scintigraphy can also detect early changes but is less specific than MRI. Plain radiographs often lag behind clinical symptoms by 10-14 days. CT is good for cortical bone but less for marrow changes.

Question 29

A 30-year-old active male complains of intermittent catching and locking sensation in his knee, particularly after twisting injuries. He also experiences pain along the medial joint line. What is the MOST likely diagnosis?





Explanation

Intermittent catching and locking sensations, especially after twisting injuries, combined with pain along the joint line, are classic symptoms of a meniscal tear. Mechanical symptoms like catching and locking are highly indicative of meniscal pathology. ACL tears present with instability. MCL sprains with valgus instability. Patellofemoral pain is typically anterior knee pain, worse with stairs. Osteoarthritis causes diffuse pain and stiffness, usually without acute locking.

Question 30

A 58-year-old female complains of her ring finger catching or locking in a flexed position, especially in the morning. She often has to manually extend it, sometimes with a painful snap. What is the MOST appropriate initial treatment for this condition?





Explanation

This patient has classic symptoms of trigger finger (stenosing tenosynovitis). The initial treatment of choice is typically a corticosteroid injection into the flexor tendon sheath at the A1 pulley, which often provides significant and sometimes permanent relief. If conservative measures fail, or if symptoms recur, surgical release of the A1 pulley is highly effective. Oral NSAIDs and hand therapy are generally less effective as standalone treatments. Night splinting and observation are also less likely to resolve the mechanical catching.

Question 31

A 75-year-old female with a previous right total hip arthroplasty falls and sustains a Vancouver Type B2 periprosthetic femoral fracture. Which of the following describes the fracture pattern and typical management?





Explanation

A Vancouver Type B2 periprosthetic femoral fracture is characterized by a fracture around the femoral stem with evidence of a loose or unstable femoral component. The typical management involves revision total hip arthroplasty with a longer, often distally fixed, femoral stem to bypass the fracture and achieve stable fixation. Type B1 is around a stable stem, managed with ORIF. Type B3 involves significant bone loss and a loose stem, often requiring extensive reconstruction.

Question 32

A 2-year-old child presents with refusal to use her left arm after being pulled up by the hand. The arm is held in slight flexion and pronation. There is no swelling or ecchymosis. What is the MOST likely diagnosis and treatment?





Explanation

This is a classic presentation of Nursemaid's elbow, or radial head subluxation, common in young children after a sudden pull on the arm. The typical presentation is a child holding the arm in slight flexion and pronation, unwilling to use it. The treatment is a simple closed reduction maneuver (either supination-flexion or hyperpronation technique), which is usually successful and immediately relieves symptoms. The other options are incorrect based on the mechanism and presentation.

Question 33

A 45-year-old male complains of right arm pain, numbness in his thumb and index finger, and weakness in wrist extension. Reflexes are diminished at the brachioradialis. Which cervical nerve root is MOST likely compressed?





Explanation

This constellation of symptoms (thumb and index finger numbness, wrist extensor weakness, diminished brachioradialis reflex) is classic for C6 radiculopathy. C5 involves deltoid weakness. C7 affects the middle finger, triceps, and wrist flexors. C8 affects the small finger and finger flexors. C4 involves shoulder shrug and sensation over the trapezius.

Question 34

A 20-year-old male falls onto an outstretched hand while snowboarding. He complains of radial wrist pain. Physical examination reveals tenderness in the anatomical snuffbox and pain with scaphoid compression. Initial X-rays are negative for fracture. What is the MOST appropriate next step in management?





Explanation

Given the classic mechanism of injury and physical exam findings suggestive of a scaphoid fracture, even with negative initial X-rays, the risk of misdiagnosis and subsequent non-union is high. The MOST appropriate next step is to immobilize the wrist in a thumb spica cast and repeat X-rays in 10-14 days, at which point a fracture line may become visible due to bone resorption. Alternatively, if definitive diagnosis is desired sooner, an MRI is highly sensitive for occult scaphoid fractures. Discharging the patient or just a wrist splint is inadequate for suspected scaphoid fracture.

Question 35

What is the MOST effective single prophylactic measure to reduce the risk of periprosthetic joint infection (PJI) in total joint arthroplasty?





Explanation

Intravenous prophylactic antibiotics administered within 60 minutes prior to surgical incision are consistently shown to be the single most effective measure in reducing the risk of periprosthetic joint infection (PJI). While all listed options contribute to infection prevention, the timing and administration of antibiotics are paramount. Laminar flow, chlorhexidine showers, antibiotic cement, and normothermia are all important adjunctive measures but less impactful than appropriate antibiotic prophylaxis.

Question 36

A 16-year-old male presents with progressively worsening knee pain and swelling. Radiographs show a destructive lesion in the distal femur with a "sunburst" periosteal reaction and Codman's triangle. What is the MOST likely diagnosis?





Explanation

This classic radiographic presentation of a destructive lesion with "sunburst" periosteal reaction and Codman's triangle in the metaphysis of a long bone (distal femur is common) in an adolescent is highly characteristic of Osteosarcoma, the most common primary malignant bone tumor in this age group. Ewing's sarcoma often has an "onion-skin" reaction and is typically diaphyseal. Chondrosarcoma presents differently. Fibrous dysplasia and enchondroma are benign.

Question 37

A 50-year-old female presents with a painful bunion deformity. Examination reveals a lateral deviation of the great toe and medial prominence of the first metatarsal head. What is the primary deformity that characterizes hallux valgus?





Explanation

Hallux valgus is primarily characterized by adduction (varus) of the first metatarsal and abduction (valgus) of the hallux (great toe) at the metatarsophalangeal (MTP) joint, leading to the prominent bunion deformity. While other foot deformities may coexist, these are the fundamental angular deformities. Excessive pronation can be associated, but it's not the primary deformity.

Question 38

A 22-year-old long-distance runner complains of bilateral lower leg pain, tightness, and cramping that consistently develops at the same point during his runs, forcing him to stop. The pain resolves with rest. Physical examination is normal at rest. What is the MOST appropriate diagnostic test?





Explanation

This presentation is classic for chronic exertional compartment syndrome (CECS). The definitive diagnostic test for CECS is intracompartmental pressure measurement performed before and after exercise. A significant elevation in pressure after exercise, which fails to normalize within a few minutes, confirms the diagnosis. Imaging (X-rays, MRI) is typically normal and is used to rule out other pathology but not to diagnose CECS directly.

Question 39

A 78-year-old female sustains a displaced femoral neck fracture. She is otherwise healthy and active. What is the MOST appropriate definitive surgical treatment?





Explanation

For an active, otherwise healthy elderly patient (typically >60-65 years old) with a displaced femoral neck fracture, Total Hip Arthroplasty (THA) is generally considered the preferred treatment option over hemiarthroplasty. THA offers better functional outcomes and a lower re-operation rate for acetabular erosion compared to hemiarthroplasty, especially in active individuals with healthy acetabular cartilage. Hemiarthroplasty is often preferred for less active or cognitively impaired patients. Closed reduction and pinning or DHS are typically for non-displaced or impacted femoral neck fractures.

Question 40

Which of the following biomaterials is known for its excellent biocompatibility and is commonly used for the acetabular liner in total hip arthroplasty due to its low wear characteristics?





Explanation

Ultra-High Molecular Weight Polyethylene (UHMWPE) is the most commonly used material for the acetabular liner in total hip arthroplasty. It is valued for its excellent wear resistance and biocompatibility, minimizing particulate debris which can lead to osteolysis and aseptic loosening. Cobalt-chromium and titanium alloys are used for the femoral head and acetabular shell, respectively. Stainless steel is less common now. PMMA is bone cement.

Question 41

A 14-year-old boy, active in sports, presents with anterior knee pain and tenderness over the tibial tubercle, exacerbated by jumping and kneeling. There is a palpable bump at the site. What is the MOST likely diagnosis?





Explanation

The classic presentation of Osgood-Schlatter disease is anterior knee pain, localized tenderness, and a palpable bump over the tibial tubercle in an active adolescent, particularly during growth spurts. It is an apophysitis caused by repetitive traction of the patellar tendon on the tibial tubercle. Patellofemoral pain is diffuse anterior knee pain. Patellar tendonitis is pain at the inferior pole of the patella. Sinding-Larsen-Johansson is similar but affects the inferior pole of the patella. Osteochondritis dissecans involves articular cartilage and subchondral bone, usually in the femoral condyle.

Question 42

A 70-year-old male complains of bilateral leg pain and numbness that is worse with standing and walking, but relieved by sitting or leaning forward (shopping cart sign). He has no focal motor weakness. What is the MOST likely diagnosis?





Explanation

The characteristic symptoms of bilateral leg pain and numbness, exacerbated by standing/walking and relieved by sitting or leaning forward (the 'shopping cart sign'), are classic for neurogenic claudication caused by lumbar spinal stenosis. This is due to compression of the cauda equina nerve roots in the narrowed spinal canal. Vascular claudication is also worse with activity but typically relieved by standing still, not necessarily by sitting, and is associated with diminished pulses. Lumbar disc herniation usually causes unilateral, radicular pain, not typically bilateral positional symptoms. Peripheral neuropathy and piriformis syndrome have different presentations.

Question 43

A 30-year-old male presents to the emergency department after falling directly onto his shoulder. His arm is held in slight abduction and external rotation, and there is a palpable void beneath the acromion. What is the MOST likely type of shoulder dislocation?





Explanation

The classic presentation of an anterior glenohumeral dislocation (the most common type, accounting for >95%) is the arm held in slight abduction and external rotation, with a palpable anterior shoulder prominence and a 'square shoulder' deformity (void under the acromion). Posterior dislocations typically present with the arm internally rotated and adducted. Luxatio erecta is rare with the arm locked overhead. AC joint dislocation is at the AC joint, not glenohumeral.

Question 44

A 40-year-old tennis player complains of lateral elbow pain that radiates down his forearm, exacerbated by gripping and lifting objects. Examination reveals tenderness over the lateral epicondyle and pain with resisted wrist extension. What is the MOST likely diagnosis?





Explanation

This presentation is classic for lateral epicondylitis, commonly known as 'Tennis Elbow.' It is a tendinopathy of the common extensor origin at the lateral epicondyle, primarily involving the extensor carpi radialis brevis (ECRB) tendon. Pain with resisted wrist extension is a hallmark sign. Medial epicondylitis (Golfer's Elbow) affects the common flexor origin. Radial tunnel syndrome is nerve entrapment, not typically isolated to the epicondyle. Olecranon bursitis is swelling at the tip of the elbow. Ulnar nerve entrapment causes medial elbow pain and small finger numbness.

Question 45

A 55-year-old diabetic male with a history of open tibia fracture 10 years ago presents with a chronic draining sinus tract in his lower leg. Radiographs show sclerotic bone and a sequestrum. What is the definitive management for chronic osteomyelitis with a sequestrum?





Explanation

Chronic osteomyelitis with a sequestrum (a piece of dead, infected bone) requires surgical debridement and sequestrectomy (removal of the sequestrum) for definitive treatment. The sequestrum acts as a nidus for infection and cannot be eradicated by antibiotics alone. Antibiotics are adjunctive to surgery. Long-term oral antibiotics alone will not cure it. Amputation is a last resort. Bone grafting should be performed after infection eradication.

Question 46

Which of the following cells is primarily responsible for bone resorption during bone remodeling?





Explanation

Osteoclasts are specialized multinucleated cells primarily responsible for bone resorption. They secrete acids and enzymes to break down bone matrix. Osteoblasts are responsible for bone formation. Osteocytes are mature bone cells embedded in the matrix. Chondrocytes form cartilage. Fibroblasts form fibrous connective tissue.

Question 47

A 85-year-old female sustains an intertrochanteric hip fracture after a fall. She has multiple comorbidities. Which surgical implant is generally preferred for stable intertrochanteric fractures, offering good stability and allowing early weight-bearing?





Explanation

For stable intertrochanteric fractures, the Dynamic Hip Screw (DHS) is a widely used and effective implant, providing compression across the fracture site and allowing controlled collapse, which promotes union and permits early weight-bearing. Cephalomedullary nails are often preferred for unstable intertrochanteric and subtrochanteric fractures. Arthroplasty is typically for femoral neck fractures. Cannulated screws are usually for non-displaced femoral neck fractures or certain acetabular fractures.

Question 48

A 75-year-old female with severe osteoporosis presents with acute onset severe back pain after a minor fall. Radiographs show a new T12 compression fracture. She has failed conservative management with pain medication and bracing. What is a minimally invasive surgical option to alleviate pain and stabilize the fracture?





Explanation

For painful osteoporotic vertebral compression fractures that fail conservative management, Kyphoplasty is a minimally invasive surgical option. It involves inflating a balloon within the vertebral body to restore some height, creating a cavity, and then injecting bone cement (PMMA) to stabilize the fracture and relieve pain. Vertebroplasty (without balloon) is similar but just injects cement without height restoration. Spinal fusion, laminectomy, and discectomy are more extensive procedures typically for instability or neurological compression.

Question 49

A 4-year-old child presents with a sudden onset of hip pain and a limp. He has a low-grade fever but is otherwise well. Labs show mild elevation of ESR/CRP. Hip range of motion is mildly restricted, but he is able to bear some weight. What is the MOST likely diagnosis?





Explanation

This presentation (sudden onset limp and hip pain, low-grade fever, mild lab elevations, ability to bear some weight) is classic for Transient Synovitis of the hip, which is a benign, self-limiting inflammatory condition. Septic arthritis would present with much more severe pain, inability to bear weight, and higher inflammatory markers. Perthes and SCFE have more insidious onset and different age groups (Perthes 4-8, SCFE adolescent). JIA is a chronic condition.

Question 50

A 35-year-old male jams his finger while playing basketball, resulting in an inability to actively extend the distal interphalangeal (DIP) joint of his right ring finger. The finger appears to be in slight flexion at the DIP joint. What is the MOST likely diagnosis and initial management?





Explanation

This is a classic presentation of a mallet finger, which is a rupture or avulsion of the extensor tendon at its insertion on the distal phalanx, resulting in an inability to actively extend the DIP joint. The initial management is typically continuous splinting of the DIP joint in extension (without hyperextension of the PIP joint) for 6-8 weeks to allow the tendon to heal. Surgical repair is reserved for specific cases like large bony avulsions or failed conservative management. Boutonniere and Swan neck deformities are different and chronic. Jersey finger involves the flexor digitorum profundus.

Question 51

A 70-year-old patient with severe osteoarthritis of the shoulder presents with chronic pain and limited range of motion, significantly impacting daily activities. Rotator cuff function is intact. What is the MOST appropriate surgical treatment?





Explanation

For severe glenohumeral osteoarthritis with an intact rotator cuff, Anatomic Total Shoulder Arthroplasty (TSA) is the gold standard surgical treatment. It involves replacing both the humeral head and the glenoid with prosthetic components, offering excellent pain relief and restoration of function. Reverse TSA is indicated for rotator cuff deficient arthropathy. Arthroscopic debridement is for less severe cases. Resection arthroplasty is for salvage or infection. Partial resurfacing is for very early-stage disease.

Question 52

A 6-month-old infant is diagnosed with a dislocated hip due to Developmental Dysplasia of the Hip (DDH). After successful closed reduction, what is the MOST appropriate next step in management?





Explanation

After successful closed reduction of a dislocated hip in DDH (typically for infants aged 6-18 months, or older infants where Pavlik harness failed), the hip is immobilized in a spica cast for typically 6-12 weeks to maintain the reduction and allow for acetabular remodeling. This is crucial for long-term stability. Long-term bracing might follow the cast, but cast immobilization is the immediate next step post-reduction. Open reduction is for irreducible dislocations.

Question 53

A 50-year-old male with chronic low back pain and left leg radiculopathy extending into the foot (dermatomal pattern L5) has failed 6 weeks of conservative treatment. Neurological exam reveals weakness in dorsiflexion of the ankle. What is the MOST likely cause of his symptoms?





Explanation

Chronic low back pain with radiculopathy in an L5 dermatomal pattern (lateral leg, dorsum of foot, weakness in ankle dorsiflexion, affecting tibialis anterior) is highly suggestive of L5 nerve root compression, most commonly due to an L4-L5 disc herniation. Facet arthropathy and SI joint dysfunction typically do not cause radicular pain with motor weakness. Piriformis syndrome affects the sciatic nerve but usually presents with gluteal pain and less specific dermatomal symptoms.

Question 54

Which of the following describes the mechanism of injury for a 'dashboard injury' that commonly results in a posterior hip dislocation?





Explanation

A 'dashboard injury' typically involves an axial load on a flexed knee with the hip adducted. This forces the femoral head posteriorly out of the acetabulum, resulting in a posterior hip dislocation, which is the most common type of hip dislocation. A direct blow to the greater trochanter usually results in a trochanteric fracture. Other mechanisms are for different injuries.

Question 55

A 25-year-old female presents with recurrent anterior knee pain, particularly with stair climbing and prolonged sitting. Physical examination reveals tenderness along the medial patellar facet and a positive patellar apprehension test. What is the MOST likely diagnosis?





Explanation

Recurrent anterior knee pain, exacerbated by stair climbing, prolonged sitting ('theater sign'), and tenderness along the patellar facets, particularly with a positive patellar apprehension test (indicating patellar instability), is classic for patellofemoral pain syndrome, or patellar instability if the apprehension is severe. Meniscal and ACL tears present differently with mechanical or instability symptoms. Patellar tendonitis is pain at the inferior patellar pole. Osteochondritis dissecans is less common and localized bone/cartilage lesion.

Question 56

What is the primary goal of non-surgical management for Achilles tendon rupture?





Explanation

The primary goal of non-surgical management for Achilles tendon rupture (often performed with functional bracing and early range of motion) is to allow the tendon to heal in a controlled, slightly lengthened position, which minimizes the risk of re-rupture and optimizes functional recovery. The tendon needs to heal, and a cast maintaining equinus initially, followed by gradual dorsiflexion, is often used. Immediate full return to activity is unsafe. Surgical repair is a different treatment modality. Allowing healing in a shortened position is not ideal for function.

Question 57

A 60-year-old female presents with severe pain and progressive stiffness in her left shoulder. She has significantly limited active and passive range of motion in all planes, with radiographs showing only mild degenerative changes. What is the MOST likely diagnosis?





Explanation

The hallmark of adhesive capsulitis, or 'frozen shoulder,' is a global restriction of both active and passive range of motion, often severe, with radiographs that are typically normal or show only mild changes. Rotator cuff tears usually have intact passive range of motion. Glenohumeral osteoarthritis would show significant degenerative changes on X-ray. Calcific tendonitis is acute and painful but doesn't cause global stiffness. AC joint arthritis pain is localized superiorly and not global stiffness.

Question 58

In the management of chronic osteomyelitis, which of the following is considered the MOST crucial aspect of surgical intervention?





Explanation

The MOST crucial aspect of surgical intervention for chronic osteomyelitis is thorough debridement of all necrotic and infected bone and soft tissue. Without complete removal of the infected and non-viable tissue, antibiotics alone are unlikely to eradicate the infection. While antibiotics, stabilization, and soft tissue management (like VAC) are important adjunctive therapies, debridement is paramount. Bone grafting is typically performed after infection eradication and soft tissue coverage have been achieved.

Question 59

A 10-year-old boy presents with a painful right wrist and limited pronation/supination after a fall. Radiographs show a fracture of the distal radius with intact ulna but significant widening of the distal radioulnar joint (DRUJ) and disruption of the interosseous membrane proximally. What is the MOST likely diagnosis?





Explanation

This describes an Essex-Lopresti injury, which is a rare but severe injury involving a comminuted radial head fracture, disruption of the interosseous membrane, and dislocation of the distal radioulnar joint (DRUJ). The key is the radial head involvement with distal radioulnar joint instability. Galeazzi fracture-dislocation involves a distal radius fracture with DRUJ dislocation. Monteggia involves a proximal ulna fracture with radial head dislocation. Colles and Smith are distal radius fractures without such extensive DRUJ/interosseous membrane involvement.

Question 60

Which of the following is a common complication specific to the surgical management of congenital muscular torticollis?





Explanation

The most common specific complication following surgical correction (e.g., sternocleidomastoid release) for congenital muscular torticollis is recurrence of the deformity, particularly if not adequately addressed or if postoperative stretching/physical therapy is not maintained. While other surgical complications are possible, recurrence is directly related to the condition and its treatment. Facial nerve palsy is not typically associated. Brachial plexus or phrenic nerve injuries are rare and usually associated with more extensive neck dissections or prolonged retraction.

Question 61

A 65-year-old male with a history of recurrent gout presents with acute onset severe pain, swelling, and redness in his left knee. Arthrocentesis reveals a cloudy synovial fluid with negatively birefringent, needle-shaped crystals. What is the MOST appropriate initial medical treatment?





Explanation

The presence of negatively birefringent, needle-shaped crystals in the synovial fluid is pathognomonic for gout (monosodium urate crystal arthropathy). The MOST appropriate initial medical treatment for an acute gout flare includes colchicine and NSAIDs (such as indomethacin) to reduce inflammation and pain. Intra-articular corticosteroids can be used as an alternative if NSAIDs/colchicine are contraindicated or ineffective. Allopurinol is a long-term urate-lowering therapy and is typically not initiated during an acute attack. Antibiotics are for septic arthritis.

Question 62

Which of the following growth plate fractures, classified by Salter-Harris, carries the HIGHEST risk of growth arrest and angular deformity?





Explanation

Salter-Harris Type V fractures involve a crush injury to the epiphyseal growth plate. Due to the complete destruction of the growth plate cartilage, they carry the HIGHEST risk of premature growth arrest and subsequent angular deformity, often with an unpredictable outcome. Type IV fractures (epiphysis and metaphysis) also have a high risk if not anatomically reduced, but Type V is considered the most severe in terms of growth plate damage.

Question 63

A 30-year-old male sustains a high-energy Pilon fracture of the tibia (distal tibia intra-articular fracture). He has significant soft tissue swelling. What is the MOST appropriate initial approach to definitive surgical management?





Explanation

Pilon fractures are high-energy intra-articular distal tibia fractures often associated with severe soft tissue swelling. The MOST appropriate initial approach to definitive surgical management is usually a staged protocol: initial management with external fixation to restore length and alignment and allow the soft tissues to recover, followed by delayed (typically 7-14 days) open reduction and internal fixation once the soft tissue envelope has improved and the 'wrinkle sign' is present. Immediate ORIF risks wound complications and infection. Casting is inadequate for these unstable, articular fractures. Arthrodesis and amputation are salvage procedures.

Question 64

Which of the following factors is considered the MOST significant determinant of prognosis in patients with osteosarcoma?





Explanation

The presence of metastatic disease at presentation is by far the MOST significant determinant of prognosis in patients with osteosarcoma. Patients with metastatic disease have a significantly worse prognosis than those with localized disease. While tumor size, location, and response to chemotherapy are important prognostic indicators for localized disease, metastasis is the overriding factor for overall survival.

Question 65

A 45-year-old male, a keen recreational basketball player, complains of progressive pain, swelling, and instability in his ankle after multiple sprains. Radiographs show mild ankle degenerative changes and chronic lateral ankle instability. He has failed a comprehensive course of physical therapy. What is the MOST appropriate surgical management?





Explanation

Given the history of recurrent sprains, chronic lateral ankle instability, and failure of conservative treatment in an active, middle-aged individual with mild degenerative changes, lateral ankle ligament reconstruction (such as the Broström procedure or its modifications) is the MOST appropriate surgical management. This aims to restore stability and prevent further cartilage damage and progression of osteoarthritis. Ankle arthrodesis or arthroplasty are reserved for more severe, advanced osteoarthritis. Arthroscopic debridement might be adjunctive but not address instability. Achilles lengthening is for equinus contracture.

Question 66

A 5-year-old child presents with a high-riding scapula and limited abduction of the shoulder. Radiographs reveal an omovertebral bone connecting the scapula to the cervical spine. What is the MOST likely diagnosis?





Explanation

This is a classic description of Sprengel's deformity, which is congenital elevation of the scapula, often associated with an omovertebral bone connecting the scapula to the cervical spine, leading to a cosmetically high-riding scapula and limited shoulder motion. Klippel-Feil syndrome involves congenital fusion of cervical vertebrae and is often associated with Sprengel's but is not the primary diagnosis here. Congenital pseudoarthrosis of the clavicle and cleidocranial dysostosis affect the clavicle primarily.

Question 67

Which of the following is the MOST accurate statement regarding avascular necrosis (AVN) of the femoral head?





Explanation

MRI is the most sensitive imaging modality for early detection of avascular necrosis (AVN) of the femoral head, often showing marrow edema and the characteristic 'double line sign' before radiographic changes appear. AVN can be asymptomatic initially. Corticosteroid use and alcohol abuse are significant non-traumatic risk factors, alongside trauma (e.g., femoral neck fracture). Plain radiographs are often normal in early AVN. Core decompression is typically indicated for pre-collapse or early-stage AVN to prevent collapse, not advanced stages.

Question 68

In patients undergoing total knee arthroplasty, what is the MOST common cause of revision surgery within the first 5-10 years?





Explanation

While all options are potential complications, infection is historically one of the most common causes for early revision surgery following total knee arthroplasty (within the first few years and up to 5-10 years). Polyethylene wear leading to aseptic loosening becomes more prevalent in the later stages (10+ years), but infection often necessitates earlier intervention. Periprosthetic fractures and extensor mechanism ruptures are less common overall reasons for revision.

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