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

Orthopedic Board Exam Preparation: Interactive MCQ Quizzes & Study Engine

23 Apr 2026 71 min read 134 Views
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Key Takeaway

Our Orthopedic Board Prep platform offers an interactive MCQ engine to simulate exam conditions. Practice in study or timed exam mode, receive immediate feedback, detailed explanations, and track your progress across various orthopedic topics, from spinal conditions like lumbar stenosis to surgical procedures, ensuring comprehensive readiness for your board certification.

Comprehensive Exam


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Question 1

A 65-year-old male presents with chronic low back pain radiating into both calves, exacerbated by standing and walking, and relieved by sitting or leaning forward. Physical examination reveals intact motor strength and sensation, with diminished ankle reflexes bilaterally. What is the most likely diagnosis?





Explanation

This classic presentation of neurogenic claudication (exacerbated by standing/walking, relieved by sitting or leaning forward, often termed the 'shopping cart sign') is highly suggestive of lumbar spinal stenosis. Lumbar disc herniation typically presents with more acute, often unilateral radiculopathy. Spondylolisthesis can contribute to stenosis but the specific activity-dependent pain pattern points directly to stenosis. Piriformis syndrome usually causes buttock pain with radiation, often worsened by hip internal rotation. Facet arthropathy primarily causes axial back pain, potentially with referred pain, but less commonly classic neurogenic claudication.

Question 2

A 30-year-old male involved in a high-speed motor vehicle accident presents with a hemodynamically unstable pelvic fracture. Initial resuscitation is underway. What is the most critical next step in managing hemorrhage from the pelvis after initial ABCs?





Explanation

In a hemodynamically unstable patient with a suspected pelvic ring injury, immediate pelvic binder application (or sheet wrapping) is a critical initial step to reduce the pelvic volume and tamponade venous bleeding, which is the most common source of significant hemorrhage in these injuries. While angiography with embolization is crucial for arterial bleeding, and external fixation provides definitive stabilization, these typically follow immediate mechanical stabilization. Transfusion is supportive, not a definitive hemorrhage control measure. Laparotomy is indicated for suspected intra-abdominal hemorrhage, not primarily pelvic bone bleeding.

Question 3

A 22-year-old soccer player sustains a twisting injury to his knee. He reports immediate pain, swelling, and a 'pop.' On examination, there is a positive Lachman test and pivot shift test. Which of the following associated injuries is most commonly missed on initial MRI or requires arthroscopic evaluation for definitive diagnosis?





Explanation

While MCL tears and meniscal tears (especially lateral) are common with ACL injuries, significant articular cartilage injuries (osteochondral fractures or chondral delamination) are frequently associated with acute ACL ruptures due to the valgus-external rotation or internal rotation impaction mechanisms. These can be difficult to fully appreciate on initial MRI and may only be definitively diagnosed during arthroscopy, often contributing to long-term issues if not addressed. PCL and PLC injuries are distinct and usually evident.

Question 4

A 70-year-old female undergoes a total hip arthroplasty for osteoarthritis. Postoperatively, she develops sudden severe groin pain and a leg length discrepancy with internal rotation and adduction. What is the most appropriate immediate management step?





Explanation

The symptoms (sudden severe groin pain, leg length discrepancy, internal rotation, adduction) are classic for a posterior hip dislocation following total hip arthroplasty. The most appropriate initial management is emergent closed reduction under anesthesia, followed by assessment for stability and identification of predisposing factors. Revision surgery is reserved for recurrent instability or irreducible dislocations. An abduction brace might be used post-reduction, but not as the initial management.

Question 5

A 12-year-old obese male presents with a several-week history of left hip and knee pain, worse with activity and relieved with rest. He walks with an antalgic gait. On examination, there is decreased internal rotation and abduction of the left hip. What is the most appropriate immediate management?





Explanation

This clinical picture (obese adolescent male, hip/knee pain, antalgic gait, decreased internal rotation/abduction) is highly suspicious for Slipped Capital Femoral Epiphysis (SCFE). Prompt diagnosis and management are crucial to prevent further slippage and complications like avascular necrosis. Immediate non-weight-bearing (e.g., crutches or wheelchair) is essential to protect the physis from further shear stress, followed by urgent surgical stabilization (in situ pinning). Physical therapy, steroid injections, or simple observation are contraindicated. While an MRI can confirm the diagnosis, the clinical suspicion warrants immediate protection to prevent progression.

Question 6

A 45-year-old male presents with night pain, particularly in the midshaft of his femur, which is relieved by aspirin. Radiographs show a small lucent nidus surrounded by reactive sclerosis. What is the most likely diagnosis?





Explanation

The classic presentation of an osteoid osteoma includes nocturnal pain, often worse at night, which is characteristically relieved by NSAIDs (like aspirin) due to its prostaglandin-mediated pain. Radiographically, it presents as a small lucent nidus (typically <1.5 cm) surrounded by a zone of reactive sclerosis. Osteosarcoma and Ewing sarcoma are malignant and would not typically be relieved by aspirin in this manner. Chondrosarcoma is a cartilaginous tumor. Fibrous dysplasia has a different radiographic appearance and pain pattern.

Question 7

A 55-year-old right-hand dominant female presents with numbness and tingling in her thumb, index, middle, and radial half of the ring finger, particularly at night. Phalen's test is positive. What is the most likely diagnosis?





Explanation

The symptoms described (numbness and tingling in the median nerve distribution - thumb, index, middle, and radial half of the ring finger, worse at night) along with a positive Phalen's test (flexing wrists for 60 seconds reproduces symptoms) are classic for carpal tunnel syndrome, caused by compression of the median nerve at the wrist. Ulnar nerve entrapment would affect the small finger and ulnar half of the ring finger. Radial nerve palsy affects motor function (wrist drop) and sensation on the dorsal hand. Cervical radiculopathy might have similar dermatomal symptoms but often includes neck pain and upper extremity weakness, and Phalen's test would not be positive. De Quervain's tenosynovitis affects the thumb extensors and abductors.

Question 8

Which of the following describes the characteristic radiographic appearance of a unicameral bone cyst (UBC)?





Explanation

A unicameral bone cyst (UBC), or simple bone cyst, is typically a metaphyseal lesion (often proximal humerus or femur) that appears as a well-circumscribed, lytic lesion. The 'fallen leaf' sign refers to a fragment of cortical bone that has fractured off and fallen into the fluid-filled cavity of the cyst, indicating a pathologic fracture through the cyst. Sunburst reaction and Codman's triangle are associated with osteosarcoma. Ground-glass appearance with shepherd's crook deformity is characteristic of fibrous dysplasia. Eccentric lytic lesion with cortical destruction is more indicative of aggressive tumors like osteosarcoma or giant cell tumor. Onion-skin reaction is seen in Ewing sarcoma.

Question 9

A 4-year-old child presents with an antalgic gait and pain in the right hip. Radiographs show flattening and increased density of the right femoral epiphysis. What is the most appropriate initial management?





Explanation

This presentation is classic for Legg-Calve-Perthes disease (LCPD), an idiopathic avascular necrosis of the femoral head. For a 4-year-old, the primary goal is to maintain containment of the femoral head within the acetabulum to allow for remodeling and prevent deformity. While there are various treatment strategies depending on the extent and stage, in most young children, observation and activity modification (often with protected weight-bearing via crutches) is the initial approach for mild cases or early stages, allowing for revascularization and remodeling. Surgical pinning is for SCFE. Total hip arthroplasty is for end-stage arthritis. Steroid injections are not indicated. Casting in abduction (e.g., Petrie cast) may be used for more severe cases or older children to contain the femoral head, but not as the initial generalized approach for all LCPD.

Question 10

Which surgical approach to the hip is associated with the highest risk of postoperative dislocation, particularly posterior dislocation?





Explanation

The posterior approach (Moore approach) to total hip arthroplasty is classically associated with a higher risk of posterior dislocation compared to anterior or lateral approaches, primarily due to posterior capsule and short external rotator muscle division. While modern techniques for posterior approach often involve repair of these structures, it historically carries the highest risk. The direct anterior approach and direct lateral approaches generally have lower dislocation rates, particularly for posterior dislocation.

Question 11

A 35-year-old male sustains a closed comminuted tibia shaft fracture. What is the most common early complication of this injury requiring urgent intervention?





Explanation

Compartment syndrome is a critical and common early complication of high-energy tibia shaft fractures due to the confined compartments of the lower leg. It requires urgent recognition and surgical intervention (fasciotomy) to prevent irreversible muscle and nerve damage. Nonunion and malunion are late complications. DVT can occur but is not as acutely limb-threatening as compartment syndrome. Infection is a risk, particularly with open fractures, but compartment syndrome is a more immediate concern for closed comminuted fractures.

Question 12

Which of the following ligaments is the primary static stabilizer preventing anterior translation of the tibia on the femur?





Explanation

The Anterior Cruciate Ligament (ACL) is the primary static stabilizer preventing anterior translation of the tibia on the femur. The Posterior Cruciate Ligament (PCL) prevents posterior translation. The Medial Collateral Ligament (MCL) resists valgus stress, and the Lateral Collateral Ligament (LCL) resists varus stress. The meniscofemoral ligament (Humphry and Wrisberg ligaments) are secondary stabilizers and attachments to the menisci.

Question 13

A patient undergoing an anterior cervical discectomy and fusion (ACDF) develops hoarseness postoperatively. Which nerve is most likely to have been injured?





Explanation

Hoarseness after an ACDF is most commonly due to injury or irritation of the recurrent laryngeal nerve, which is closely associated with the surgical field. This nerve innervates most of the intrinsic muscles of the larynx. The phrenic nerve innervates the diaphragm. The spinal accessory nerve innervates the sternocleidomastoid and trapezius muscles. The vagus nerve supplies the recurrent laryngeal nerve, but direct injury to the vagus itself is less common than to its recurrent branch. The long thoracic nerve innervates the serratus anterior muscle.

Question 14

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





Explanation

Osteosarcoma is the most common primary malignant bone tumor in children and adolescents, typically presenting in the metaphysis of long bones (e.g., distal femur, proximal tibia, proximal humerus). Ewing sarcoma is the second most common, often affecting the diaphysis of long bones and flat bones. Chondrosarcoma and fibrosarcoma are less common in this age group, and multiple myeloma is a malignancy of plasma cells typically seen in older adults.

Question 15

A 60-year-old female presents with severe pain and progressive stiffness in her shoulder, limiting both active and passive range of motion. Radiographs show diffuse osteopenia but no acute fracture or significant degenerative changes. What is the most likely diagnosis?





Explanation

The key features pointing to adhesive capsulitis (frozen shoulder) are severe pain and a progressive global limitation of both active and passive range of motion. Rotator cuff tears primarily limit active range of motion, often with preserved passive motion (unless severe chronic tear leading to stiffness). Glenohumeral osteoarthritis would show significant joint space narrowing and osteophytes on radiographs. Biceps tendinopathy and calcific tendinitis are usually more localized and less restrictive of global motion, though they cause significant pain.

Question 16

Which of the following is considered an absolute contraindication to closed reduction for a fracture-dislocation?





Explanation

An open fracture is an absolute contraindication to closed reduction of a fracture-dislocation. Open fractures require urgent surgical debridement and stabilization to prevent infection. While neurovascular compromise is an emergency requiring prompt reduction, it is not a contraindication to attempted closed reduction; rather, it's an indication for it. Severe comminution might make closed reduction difficult or unstable, but it's not an absolute contraindication. Pathologic fractures and associated ligamentous injuries generally don't contraindicate closed reduction.

Question 17

A 28-year-old construction worker presents with pain, swelling, and redness over the olecranon bursa, with no history of trauma. He reports a low-grade fever. Aspiration reveals cloudy fluid with elevated white blood cell count and positive Gram stain for Staphylococcus aureus. What is the most appropriate initial management?





Explanation

The presence of signs of infection (redness, swelling, fever, cloudy fluid with elevated WBCs and positive Gram stain for S. aureus) indicates septic olecranon bursitis. The most appropriate initial management is oral antibiotics targeting S. aureus (e.g., a first-generation cephalosporin or clindamycin if MRSA is suspected locally). NSAIDs, rest, and corticosteroid injections are for aseptic bursitis. Surgical excision is reserved for chronic, recurrent, or refractory septic bursitis. Repeated aspiration alone without antibiotics is insufficient for infection.

Question 18

In the setting of a complete Achilles tendon rupture, what is the most sensitive physical examination test?





Explanation

The Thompson test (calf squeeze test) is the most sensitive and widely used physical examination test for a complete Achilles tendon rupture. A positive test is the absence of plantarflexion of the foot when the calf muscle is squeezed, indicating a complete tear. The Matles test is another useful test (prone, knee flexed to 90 degrees, no plantarflexion when foot allowed to relax). O'Brien's and Crossover tests are for shoulder pathology. Gait analysis would show weakness but is not as specific as the Thompson test for a complete rupture.

Question 19

Which of the following is a classic radiographic sign of Developmental Dysplasia of the Hip (DDH) in an infant older than 3 months?





Explanation

Shenton's line (a curved line formed by the medial aspect of the femoral neck and the inferior border of the superior pubic ramus) disruption is a classic radiographic sign of hip dislocation or subluxation in DDH. An increased acetabular index (angle formed by the acetabular roof and a horizontal line through the triradiate cartilage) indicates acetabular dysplasia. Lester's sign is not a recognized orthopedic sign. Ossification of the femoral head typically begins around 3-6 months and is not a direct sign of DDH, although delayed ossification can be associated. Perkins' line (vertical line from the lateral aspect of the acetabulum) helps define quadrants for femoral head position, but disruption of Shenton's line is a direct indicator of subluxation/dislocation.

Question 20

A 50-year-old male with a history of long-term corticosteroid use presents with insidious onset of left hip pain, worse with weight-bearing. Radiographs are initially normal, but an MRI reveals diffuse low signal intensity on T1-weighted images and high signal intensity on T2-weighted images with a characteristic 'double-line sign' in the femoral head. What is the most likely diagnosis?





Explanation

The clinical history (corticosteroid use, insidious pain) and characteristic MRI findings ('double-line sign' on T2-weighted images representing the reactive interface between viable and necrotic bone, and T1 hypointensity/T2 hyperintensity indicative of bone marrow edema and necrosis) are diagnostic of avascular necrosis (osteonecrosis) of the femoral head. Femoral head osteomyelitis, transient regional osteoporosis, stress fracture, and septic arthritis have different clinical and imaging presentations.

Question 21

What is the primary function of the deltoid ligament complex in the ankle?





Explanation

The deltoid ligament complex (medial collateral ligament of the ankle) is a strong ligamentous structure composed of several bands that primarily resists eversion stress and limits external rotation of the talus. The lateral collateral ligaments (anterior talofibular, calcaneofibular, posterior talofibular) resist inversion stress. The anterior talofibular ligament is the primary restraint to anterior drawer of the talus. The distal tibiofibular syndesmosis is stabilized by the anterior and posterior inferior tibiofibular ligaments and the interosseous membrane.

Question 22

In the management of chronic osteomyelitis, what is the most important factor for successful treatment?





Explanation

Surgical debridement of infected and necrotic (non-viable) bone is the cornerstone of successful treatment for chronic osteomyelitis. Antibiotics alone are often insufficient due to poor penetration into avascular necrotic tissue and biofilm formation. While long-term antibiotics are crucial post-debridement, they are ineffective without source control. Hyperbaric oxygen therapy can be an adjunctive treatment but is not primary. Bone grafting and external fixation are reconstructive or stabilizing procedures performed after successful debridement.

Question 23

A 40-year-old male presents with lateral elbow pain exacerbated by gripping and resisted wrist extension. Examination reveals tenderness over the lateral epicondyle and pain with Cozen's test. What is the most likely diagnosis?





Explanation

The symptoms (lateral elbow pain, exacerbated by gripping and resisted wrist extension) and examination findings (tenderness over the lateral epicondyle, positive Cozen's test - pain with resisted wrist extension with the elbow extended) are classic for lateral epicondylitis, commonly known as 'tennis elbow.' This condition involves degeneration of the common extensor origin, primarily the extensor carpi radialis brevis. Medial epicondylitis ('golfer's elbow') involves the common flexor origin. Olecranon bursitis involves the bursa. Radial tunnel syndrome involves compression of the posterior interosseous nerve, causing more vague forearm pain. Biceps tendinopathy causes pain in the anterior elbow/shoulder.

Question 24

Which of the following conditions is most strongly associated with adolescent idiopathic scoliosis progression?





Explanation

The most significant factors for progression of adolescent idiopathic scoliosis are curve magnitude at presentation (curves > 20 degrees are more likely to progress than smaller curves), skeletal immaturity (lower Risser sign), and premenarchal status in females. Female gender is associated with higher progression rates and need for intervention. Risser sign 5 indicates skeletal maturity, at which point progression risk is minimal. Younger age and pre-menarche are risk factors for progression.

Question 25

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





Explanation

Congenital muscular torticollis is typically managed initially with physical therapy, which includes gentle stretching of the affected sternocleidomastoid muscle and strengthening of the contralateral neck muscles. This is highly effective, especially when initiated early. Surgical release is reserved for cases refractory to conservative management after 6-12 months. Cervical collars are not typically used. Observation alone is insufficient. Botulinum toxin injections are rarely used in infants for this condition.

Question 26

What is the most common cause of acute hematogenous osteomyelitis in children?





Explanation

Staphylococcus aureus is by far the most common causative organism of acute hematogenous osteomyelitis in children across all age groups. While other organisms can cause osteomyelitis (e.g., Kingella kingae in infants/toddlers, Pseudomonas in puncture wounds through sneakers), S. aureus remains the predominant pathogen.

Question 27

A patient presents with a wrist drop following a humeral shaft fracture. Which nerve is most likely to be injured?





Explanation

A 'wrist drop' is the classic sign of radial nerve palsy, which commonly occurs with humeral shaft fractures due to the proximity of the radial nerve to the humeral shaft in the spiral groove. The radial nerve innervates the extensors of the wrist and fingers. Median nerve injury would affect wrist and finger flexion and thumb opposition. Ulnar nerve injury would affect intrinsic hand muscles and sensation to the small and ulnar half of the ring finger. Axillary nerve injury affects the deltoid, leading to shoulder abduction weakness. Musculocutaneous nerve injury affects biceps and brachialis.

Question 28

Which type of Salter-Harris fracture classification involves a fracture through the physis and metaphysis, but spares the epiphysis?





Explanation

Salter-Harris Type II fractures involve a fracture through the physis and extend into the metaphysis, sparing the epiphysis. This is the most common type. Type I is a separation through the physis only. Type III is a fracture through the physis and epiphysis. Type IV is a fracture through the metaphysis, physis, and epiphysis. Type V is a crush injury to the physis.

Question 29

What is the primary goal of surgical management for unstable intertrochanteric hip fractures in an elderly patient?





Explanation

For unstable intertrochanteric hip fractures in elderly patients, the primary goal of surgical management (typically with an intramedullary nail or sliding hip screw) is to provide stable fixation that allows for early mobilization and weight-bearing. This helps to prevent complications associated with prolonged immobility, such as pneumonia, DVT, and decubitus ulcers. While anatomic reduction is desired, it is often secondary to stability for early mobilization in this population. Preservation of femoral head viability is more critical for femoral neck fractures. Total hip arthroplasty is generally not indicated for intertrochanteric fractures unless there is pre-existing severe arthritis or nonunion.

Question 30

A 25-year-old male sustains a high-energy knee dislocation. After reduction, pulses are palpable, and sensation is intact. What is the most critical next step in management?





Explanation

Knee dislocations, even if reduced and with initially palpable pulses, carry a high risk of popliteal artery injury due to the tethering of the artery by the adductor hiatus proximally and the soleus arch distally. Therefore, a vascular assessment, typically involving an Ankle-Brachial Index (ABI) or urgent angiography, is mandatory to rule out occult vascular injury, even if pulses are initially present. Delayed presentation of vascular compromise can lead to limb loss. MRI is for assessing ligamentous injuries, which would be addressed later. Immediate ligament repair is not always indicated and should follow vascular assessment. Discharge is contraindicated.

Question 31

Which of the following is the most common primary benign bone tumor?





Explanation

Osteochondroma (exostosis) is the most common primary benign bone tumor. It is a cartilage-capped bony projection on the external surface of bone, arising from the metaphysis. Enchondroma is common but less frequent than osteochondroma. Osteosarcoma is malignant. Giant cell tumors and aneurysmal bone cysts are less common benign tumors.

Question 32

In the context of a tibial plateau fracture, a 'sagging' posterior displacement of the proximal tibia on lateral radiographs suggests injury to which structure?





Explanation

A 'sagging' posterior displacement of the proximal tibia relative to the femur on a lateral radiograph (especially when the patient is supine and the knee is flexed) is a classic sign of Posterior Cruciate Ligament (PCL) insufficiency. This often occurs with bicondylar tibial plateau fractures or high-energy trauma affecting the posterior structures. ACL injury would result in anterior translation. MCL and LCL injuries involve valgus and varus stability, respectively. Meniscal injuries do not cause this specific radiographic sign of instability.

Question 33

A patient presents with pain and swelling around the distal radius after a fall onto an outstretched hand. Radiographs show a fracture of the distal radius with dorsal displacement and angulation. Which eponymous fracture does this describe?





Explanation

A Colles fracture is a fracture of the distal radius with dorsal displacement and dorsal angulation, typically resulting from a fall onto an outstretched hand (FOOSH) with the wrist in extension. A Smith fracture (reverse Colles) involves volar displacement and angulation. A Galeazzi fracture involves a distal radial shaft fracture with associated distal radioulnar joint (DRUJ) dislocation. A Monteggia fracture involves a proximal ulnar shaft fracture with associated radial head dislocation. A Barton's fracture is an intra-articular fracture of the distal radius with dislocation of the carpus, either dorsally or volarly.

Question 34

What is the hallmark radiographic finding in osteonecrosis of the lunate (Kienböck's disease)?





Explanation

Kienböck's disease is avascular necrosis of the lunate bone. The hallmark radiographic findings progress through stages but typically involve increasing sclerosis, fragmentation, and collapse of the lunate, leading to loss of carpal height. Cystic changes in the scaphoid might be seen in degenerative conditions, but not specific to Kienböck's. Increased joint space is atypical. Fracture of the triquetrum is a separate injury. Increased ulnar variance (ulna longer than radius) is a potential predisposing factor but not a direct sign of lunate osteonecrosis itself.

Question 35

Which factor is most crucial in determining the need for operative fixation in a displaced intra-articular calcaneal fracture?





Explanation

For displaced intra-articular calcaneal fractures, the extent of articular surface depression (specifically, the depression of the posterior facet) and the involvement of the Böhler's angle are crucial for surgical decision-making. Significant articular depression warrants surgical reduction and fixation to restore joint congruity and minimize post-traumatic arthritis. Skin tenting is an indication for immediate reduction but not the primary factor for internal fixation decision. Calcaneal widening and associated fractures are important but secondary to articular involvement for surgical indications.

Question 36

A 72-year-old male with severe osteoarthritis of the knee is undergoing total knee arthroplasty. During exposure, the surgeon notes a tight lateral compartment, making balanced soft tissue release necessary. Which structure should be considered for release to address lateral tightness in flexion?





Explanation

During total knee arthroplasty, a tight lateral compartment in flexion often requires release of the popliteus tendon. The popliteus muscle and its tendon are dynamic stabilizers of the posterolateral corner and restrict external rotation and posterior translation of the tibia. Releasing the popliteus tendon can help balance the lateral compartment in flexion. The pes anserinus and MCL are medial structures. The posterior oblique ligament is part of the deep MCL, also a medial structure.

Question 37

Which of the following is the most sensitive test for subacromial impingement syndrome?





Explanation

The Hawkins-Kennedy test is considered one of the most sensitive tests for subacromial impingement syndrome. It involves internally rotating the arm with the shoulder flexed to 90 degrees and the elbow flexed to 90 degrees, which causes the supraspinatus tendon to impinge under the coracoacromial arch. The Empty Can test and Drop Arm test are more specific for rotator cuff tears, particularly the supraspinatus. Speed's test is for biceps pathology. Cross-body adduction test is for AC joint pathology.

Question 38

A 6-year-old child presents with a painful limp and swelling over the proximal tibia after a fall. Radiographs show a fracture through the proximal tibial physis, involving the metaphysis and extending laterally into the epiphysis. According to the Salter-Harris classification, what type is this fracture?





Explanation

This describes a Salter-Harris Type IV fracture, which involves a fracture line extending through the metaphysis, physis, and epiphysis. This type of fracture is intra-articular and can lead to growth arrest or angular deformity if not anatomically reduced, especially due to damage to the germinal cells of the growth plate and disruption of the articular surface. Type II involves physis and metaphysis. Type III involves physis and epiphysis.

Question 39

What is the most appropriate initial management for acute calcific tendinitis of the rotator cuff?





Explanation

Acute calcific tendinitis is often intensely painful due to an inflammatory reaction around the calcium deposits. The most appropriate initial management is conservative, focusing on pain and inflammation control. This typically involves NSAIDs and often a subacromial corticosteroid injection, which can provide significant pain relief. Surgical debridement or arthroscopic removal of deposits are reserved for chronic, refractory cases. ESWT is often used for chronic calcific tendinitis, not typically for the acute phase. Aggressive strengthening physical therapy is often painful in the acute phase and contraindicated.

Question 40

Which of the following describes the characteristic radiographic appearance of fibrous dysplasia?





Explanation

Fibrous dysplasia is characterized by a 'ground-glass' appearance on radiographs due to immature woven bone within a fibrous stroma. When affecting the proximal femur, severe forms can lead to bowing and deformity known as a 'shepherd's crook deformity.' Sunburst reaction is osteosarcoma. Onion-skin reaction is Ewing sarcoma. Lytic lesions with 'soap bubble' appearance can be seen in aneurysmal bone cysts or giant cell tumors. Dense sclerosis with a central nidus is characteristic of osteoid osteoma.

Question 41

A 3-year-old child presents with a progressive valgus deformity of the tibia. Radiographs show irregular widening and medial sloping of the proximal tibial physis. What is the most likely diagnosis?





Explanation

The description of a progressive valgus deformity of the tibia with irregular widening and medial sloping of the proximal tibial physis is characteristic of Blount's disease (tibia vara), particularly the infantile form. Blount's disease is a growth disturbance of the medial part of the proximal tibial physis leading to progressive varus deformity. Physiological genu valgum usually resolves spontaneously by age 7-8 and has a symmetric, non-pathological appearance of the physis. Rickets would present with more generalized physeal widening and metaphyseal fraying. Osgood-Schlatter is apophysitis of the tibial tubercle. Fibrous dysplasia has a different radiographic appearance.

Question 42

What is the most common ligament injured in an ankle inversion sprain?





Explanation

The anterior talofibular ligament (ATFL) is the most commonly injured ligament in an ankle inversion sprain. It is the weakest of the lateral ankle ligaments and the first to be stretched or torn with excessive inversion and plantarflexion. The calcaneofibular ligament (CFL) is injured secondarily with more severe inversion. The posterior talofibular ligament (PTFL) is rarely injured in isolation. The anterior inferior tibiofibular ligament is part of the syndesmosis. The deltoid ligament is on the medial side.

Question 43

Which of the following is an absolute indication for surgical intervention in a patient with a scaphoid fracture?





Explanation

A displaced scaphoid fracture (typically defined as >1mm displacement, angulation >10-15 degrees, or significant humpback deformity) is an absolute indication for surgical intervention due to the high risk of nonunion and avascular necrosis. Non-displaced fractures of the distal pole or stable waist fractures are often treated non-operatively in a cast. Fracture of the tubercle is usually treated symptomatically. Positive snuffbox tenderness indicates suspicion but not a definitive need for surgery alone.

Question 44

What is the most reliable imaging modality for early detection of avascular necrosis of the femoral head?





Explanation

Magnetic Resonance Imaging (MRI) is the most sensitive and specific imaging modality for the early detection of avascular necrosis (AVN) of the femoral head. It can detect changes in bone marrow signal before they are visible on plain radiographs or CT scans. Plain radiographs are often normal in early AVN. CT scans are good for assessing bone architecture but less sensitive than MRI for early marrow changes. Bone scans can show increased uptake but are less specific. Ultrasound has limited utility for this condition.

Question 45

Which type of orthosis is most commonly used to manage developmental dysplasia of the hip (DDH) in an infant up to 6 months of age?





Explanation

The Pavlik harness is the most commonly used and effective orthosis for managing developmental dysplasia of the hip (DDH) in infants up to 6 months of age (and sometimes up to 9 months). It holds the hips in flexion and abduction, allowing for gradual reduction and development of the acetabulum. A hip spica cast is typically used for older infants or those who fail Pavlik harness treatment. Abduction braces are used for older children or after cast removal. KAFOs and Scottish Rite braces are for different orthopedic conditions.

Question 46

A patient presents with acute, severe pain, swelling, and exquisite tenderness of the great toe metatarsophalangeal joint. Aspiration reveals negatively birefringent, needle-shaped crystals. What is the most likely diagnosis?





Explanation

The classic presentation of acute, severe pain, swelling, and exquisite tenderness of the great toe MTP joint (podagra), combined with the finding of negatively birefringent, needle-shaped crystals on synovial fluid analysis, is pathognomonic for gout. Pseudogout involves positively birefringent, rhomboid-shaped crystals. Septic arthritis would have pus and bacteria. Rheumatoid arthritis typically affects smaller joints symmetrically and has specific serologic markers. Osteoarthritis is a degenerative condition and does not present with acute inflammation or crystal findings like gout.

Question 47

Which muscle is primarily responsible for the initiation of shoulder abduction in the first 15-30 degrees?





Explanation

The supraspinatus muscle is primarily responsible for initiating shoulder abduction (first 15-30 degrees) before the deltoid muscle takes over for the remainder of the range. The deltoid is a powerful abductor but is less efficient at initiation. Pectoralis major and latissimus dorsi are adductors and internal rotators. Teres major is an adductor and internal rotator.

Question 48

What is the most common complication of a high-energy Pilon fracture of the distal tibia?





Explanation

Pilon fractures (distal tibia intra-articular fractures) are high-energy injuries involving the weight-bearing surface of the ankle. The most common and devastating long-term complication, despite optimal surgical management, is post-traumatic arthritis due to the severe articular damage and often irreparable chondral injury. While nonunion, malunion, and infection can occur, post-traumatic arthritis is the most frequent and significant cause of long-term disability. Compartment syndrome is an acute complication.

Question 49

A 5-year-old child presents with a progressive idiopathic scoliosis measuring 45 degrees, with a high risk of progression. What is the most appropriate management?





Explanation

For progressive idiopathic scoliosis in a 5-year-old with a curve measuring 45 degrees, surgical spinal fusion is generally indicated. Bracing is typically used for curves between 25-45 degrees in skeletally immature patients to prevent progression, but it is less effective for very young children with large curves, or those with significant growth remaining where fusion may be necessary to control severe deformity. Observation is for small, non-progressive curves. Physical therapy and chiropractic manipulation have not been shown to halt curve progression in idiopathic scoliosis. Early fusion in very young children typically involves growth-friendly techniques to allow for continued spinal and thoracic development.

Question 50

Which of the following is the most important radiographic measurement for assessing the severity of hallux valgus?





Explanation

The Hallux Valgus Angle (HVA) and the Intermetatarsal Angle (IMA) are the two most important radiographic measurements for assessing the severity of hallux valgus. The HVA specifically measures the degree of lateral deviation of the great toe, while the IMA measures the angle between the first and second metatarsals, reflecting the splayfoot deformity. DMAA assesses joint congruity. Tibial sesamoid position reflects subluxation of the sesamoids, which accompanies the deformity. Talar tilt is for ankle stability.

Question 51

Which of the following is considered the gold standard for diagnosing a nonunion of a long bone fracture?





Explanation

While plain radiographs are the initial imaging modality for fracture assessment, a CT scan is considered the gold standard for diagnosing a nonunion. It provides detailed cross-sectional images, allowing for precise assessment of fracture callus formation, the presence of a fracture gap, bone remodeling, and the extent of any sclerotic bone, which are crucial for determining if healing is truly stalled. Plain radiographs can be suggestive but may be difficult to interpret definitively. MRI is excellent for soft tissue and bone marrow edema but less precise for cortical bone healing. Bone scans show metabolic activity but are not specific for nonunion. Clinical examination is essential but needs imaging confirmation.

Question 52

A 28-year-old female presents with pain, numbness, and weakness in her shoulder and arm. Examination reveals atrophy of the intrinsic hand muscles (e.g., thenar eminence) and a positive Adson's test. What is the most likely diagnosis?





Explanation

The constellation of symptoms including pain, numbness, weakness in the arm, intrinsic hand muscle atrophy, and a positive Adson's test (diminished radial pulse with arm abduction, extension, and external rotation, and head rotation towards the affected side) is highly suggestive of Thoracic Outlet Syndrome (TOS), specifically the neurogenic type affecting the brachial plexus. Rotator cuff tears cause shoulder pain and weakness, but not typically hand atrophy or positive Adson's. Cervical radiculopathy (C8/T1) can cause similar neurological symptoms, but Adson's test is specific for TOS. Carpal tunnel syndrome affects the median nerve at the wrist. Ulnar nerve entrapment affects the ulnar nerve distribution.

Question 53

Which metabolic bone disease is characterized by generalized decreased bone mineral density and normal bone mineralization, leading to increased fracture risk?





Explanation

Osteoporosis is characterized by a reduction in bone mineral density and microarchitectural deterioration of bone tissue, leading to increased bone fragility and fracture risk, but with normal bone mineralization. Osteomalacia and rickets (in children) are characterized by defective bone mineralization. Paget's disease involves abnormal bone remodeling with localized areas of increased bone turnover. Hyperparathyroidism causes bone resorption due to elevated PTH, leading to osteopenia but is a distinct etiology.

Question 54

Which of the following is the most common cause of painful pes planus (flatfoot) in an adult?





Explanation

Posterior tibial tendon dysfunction (PTTD), often progressing to adult acquired flatfoot deformity, is the most common cause of painful pes planus in adults. It results from a progressive attenuation and eventual failure of the posterior tibial tendon, leading to collapse of the medial longitudinal arch. While congenital pes planus, ligamentous laxity, tarsal coalition, and accessory navicular can cause flatfoot, PTTD is the predominant cause of adult-onset painful progressive flatfoot.

Question 55

What is the most common direction of shoulder dislocation?





Explanation

Anterior shoulder dislocation is by far the most common type of glenohumeral dislocation, accounting for over 95% of cases. It typically occurs due to an abduction-external rotation force. Posterior dislocations are much less common and often associated with seizures or electrocution. Inferior and superior dislocations are rare. Luxatio erecta is a specific type of inferior dislocation.

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