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1. General Principles & Basic Science MCQs

Practice Set 484 of 789

This practice set contains high-yield board review questions covering key concepts in 1. General Principles & Basic Science. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 9661

Topic: 1. General Principles & Basic Science

What is the primary rationale for advocating for a specific 'safe zone' for distal locking screw placement in the tibia, particularly from a lateral approach?

. A. To minimize damage to the anterior tibial artery.
. B. To avoid injury to the superficial peroneal nerve.
. C. To prevent impingement of the extensor tendons.
. D. To avoid damage to the saphenous nerve.
. E. To prevent comminution of the distal tibia.

Correct Answer & Explanation

. A. To minimize damage to the anterior tibial artery.

Explanation

When placing distal locking screws in the tibia, particularly from a lateral approach, there is a risk of injuring the anterior tibial artery and deep peroneal nerve, which run in the anterior compartment. The 'safe zone' is identified to minimize this risk. The superficial peroneal nerve (B) is typically more lateral and distal, and saphenous nerve (D) more medial. Extensor tendon impingement (C) is less of a concern than neurovascular injury. Preventing comminution (E) is a general goal of careful technique.

Question 9662

Topic: Infection, Pharmacology & VTE

A 60-year-old male with a history of open tibia fracture 5 years ago presents with a draining sinus tract and chronic pain at the fracture site. X-rays show sclerosis, cortical thickening, and a cloaca. MRI confirms chronic osteomyelitis with sequestrum formation. Cultures from the draining sinus have repeatedly grown Pseudomonas aeruginosa. After thorough debridement, what is the most appropriate next step in managing the infection and achieving bone union?

. Long-term oral antibiotic therapy alone.
. Local antibiotic delivery (e.g., antibiotic-loaded cement beads) followed by bone grafting.
. Radical surgical debridement including removal of sequestrum, stabilization with external fixator, and systemic intravenous antibiotics.
. Amputation due to refractory infection.
. Hyperbaric oxygen therapy.

Correct Answer & Explanation

. Radical surgical debridement including removal of sequestrum, stabilization with external fixator, and systemic intravenous antibiotics.

Explanation

The patient has chronic osteomyelitis with a draining sinus, sequestrum, and a difficult-to-treat organism (Pseudomonas aeruginosa). Long-term oral antibiotic therapy alone (A) is insufficient for chronic osteomyelitis with sequestrum. Local antibiotic delivery (B) is a good adjunct butmustbe accompanied by radical debridement; bone grafting before infection control is resolved will also fail. Amputation (D) is a last resort and not indicated here. Hyperbaric oxygen therapy (E) can be an adjunct but is not a primary treatment. The most appropriate and effective approach for chronic osteomyelitis with sequestrum isradical surgical debridement, which includes removal of all necrotic and infected bone (sequestrum), meticulous debridement of soft tissues, obliteration of dead space, followed bystabilizationof the bone defect (often with an external fixator, especially if there's significant bone loss or instability), and a prolonged course ofsystemic intravenous antibioticstailored to the cultured organism (C). This comprehensive approach aims to eradicate the infection, promote bone healing, and prevent recurrence.

Question 9663

Topic: Biology, Genetics & Bone Healing

A 45-year-old woman presents with diffuse bone pain, muscle weakness, and multiple stress fractures. Her history includes a remote gastrectomy for peptic ulcer disease and prolonged use of proton pump inhibitors. Lab results show hypocalcemia, hypophosphatemia, elevated alkaline phosphatase, and elevated parathyroid hormone (PTH). Her 25-hydroxyvitamin D level is significantly low. What is the most likely diagnosis and primary treatment target?

. Primary hyperparathyroidism; parathyroidectomy.
. Osteoporosis; bisphosphonate therapy.
. Renal osteodystrophy; phosphate binders and active vitamin D.
. Oncogenic osteomalacia; tumor localization and resection.
. Acquired osteomalacia due to malabsorption; high-dose vitamin D and calcium supplementation.

Correct Answer & Explanation

. Acquired osteomalacia due to malabsorption; high-dose vitamin D and calcium supplementation.

Explanation

The patient's clinical presentation (diffuse bone pain, muscle weakness, stress fractures) and lab findings (hypocalcemia, hypophosphatemia, elevated PTH, elevated alkaline phosphatase, low 25-hydroxyvitamin D) are classic for osteomalacia. The history of gastrectomy and prolonged PPI use strongly suggests malabsorption. Primary hyperparathyroidism (A) would typically present with hypercalcemia. Osteoporosis (B) would not typically cause hypophosphatemia or such elevated alkaline phosphatase. Renal osteodystrophy (C) would show kidney dysfunction, and the primary cause here points to the gut. Oncogenic osteomalacia (D) typically presents with isolated hypophosphatemia but normal calcium and PTH. Therefore, the most likely diagnosis isacquired osteomalacia due to malabsorption, and the primary treatment target is to correct the vitamin D deficiency and calcium balance (E). This involves high-dose vitamin D supplementation (often calciferol followed by cholecalciferol) and calcium supplementation to address the malabsorption caused by gastrectomy and PPI use.

Question 9664

Topic: Biomechanics & Biomaterials
Which of the following statements regarding the biological response and mechanical properties of orthopedic implants is most accurate?
. Cobalt-chromium alloys are primarily chosen for their excellent osseointegration properties.
. Ultra-high molecular weight polyethylene (UHMWPE) wear particles typically induce an osteolytic response leading to aseptic loosening.
. Titanium alloys possess a higher Young's modulus compared to stainless steel, making them stiffer and less prone to elastic deformation.
. Bone cement (PMMA) acts primarily as a biological adhesive, promoting bone ingrowth into the implant.
. Hydroxyapatite coatings on metallic implants primarily function by increasing the coefficient of friction for immediate mechanical stability.

Correct Answer & Explanation

. Ultra-high molecular weight polyethylene (UHMWPE) wear particles typically induce an osteolytic response leading to aseptic loosening.

Explanation

A. Cobalt-chromium alloys are chosen primarily for their high strength, hardness, and corrosion resistance, not for osseointegration (which is a property of titanium). B. UHMWPE wear particles are a major cause of aseptic loosening in arthroplasty. These particles elicit an inflammatory response in periprosthetic tissues, leading to a cascade of events that includes osteoclast activation and subsequent periprosthetic osteolysis, causing the implant to loosen. C. Titanium alloys have a lower Young's modulus (closer to bone) compared to stainless steel, making them more flexible and less prone to stress shielding. D. Bone cement (PMMA) functions as a mechanical interlock, providing immediate fixation by filling spaces; it does not promote biological bone ingrowth. E. Hydroxyapatite (HA) coatings promote osseointegration by providing a bioactive surface that encourages bone apposition and ingrowth for biological fixation. They do not primarily increase the coefficient of friction for immediate mechanical stability.

Question 9665

Topic: Infection, Pharmacology & VTE

A 50-year-old diabetic male develops chronic osteomyelitis in his right tibia following an open fracture 2 years ago. He has a persistent draining sinus tract and imaging shows a large segmental bone defect (6 cm) with surrounding sclerotic bone and sequestrum. What is the most appropriate surgical treatment?

. Debridement and chronic antibiotic suppression.
. Sequestrectomy and local antibiotic bead placement.
. Segmental resection of the infected bone, debridement, and bone transport using an Ilizarov frame.
. Amputation below the knee.
. Open wound care with daily dressings.

Correct Answer & Explanation

. Segmental resection of the infected bone, debridement, and bone transport using an Ilizarov frame.

Explanation

For chronic osteomyelitis with a large segmental bone defect, draining sinus tract, sequestrum, and extensive infection, aggressive surgical debridement including segmental resection of all infected and non-viable bone is essential. This creates a significant bone defect that must be addressed for limb salvage. Bone transport using an Ilizarov frame (or other external fixator) is a well-established technique for reconstructing large segmental bone defects after infection eradication, allowing for new bone formation and limb lengthening. Debridement with antibiotic suppression or local beads alone is often insufficient for large defects and chronic infection with sequestrum. Amputation is a last resort. Open wound care is supportive but not curative for this extensive infection.

Question 9666

Topic: Surgical Anatomy & Approaches

A 45-year-old male sustains a posterior column and posterior wall acetabular fracture in a motor vehicle accident. CT scan confirms significant displacement and a large posterior wall fragment. The ideal surgical approach for this specific fracture pattern, considering the need for direct visualization and reduction, is typically:

. Ilioinguinal approach
. Kocher-Langenbeck approach
. Modified Stoppa approach
. Extended iliofemoral approach
. Trochanteric flip osteotomy approach

Correct Answer & Explanation

. Kocher-Langenbeck approach

Explanation

The Kocher-Langenbeck approach provides excellent exposure to the posterior column and posterior wall of the acetabulum, making it the workhorse approach for fractures involving these components. The ilioinguinal and modified Stoppa approaches are anterior approaches used for anterior column, anterior wall, or transverse fractures. The extended iliofemoral approach is a more extensive approach for complex bicompartmental fractures but carries higher morbidity. A trochanteric flip osteotomy is typically used for surgical hip dislocation for femoral head or central acetabular pathology, not primarily for posterior column/wall fractures.

Question 9667

Topic: 1. General Principles & Basic Science

A 30-year-old male sustains a traumatic complete brachial plexus avulsion injury (C5-T1) on the left side due to a motorcycle accident. Clinically, he has a flail arm with no motor or sensory function. Electromyography (EMG) at 3 weeks post-injury confirms complete avulsion. What is the optimal timing for surgical exploration and potential reconstruction (e.g., nerve transfers)?

. Within 24-48 hours
. At 3-6 weeks post-injury
. At 3-6 months post-injury
. At 9-12 months post-injury
. After 18 months post-injury

Correct Answer & Explanation

. At 3-6 months post-injury

Explanation

For complete traumatic brachial plexus avulsion injuries in adults, early surgical exploration and reconstruction (e.g., nerve transfers, nerve grafting) should ideally be performed within 3 to 6 months of the injury. This timeframe is critical because waiting longer significantly reduces the potential for reinnervation and functional recovery of target muscles due to irreversible atrophy and fibrosis. Exploration within 24-48 hours is typically for vascular compromise or open injuries. Waiting beyond 6 months dramatically decreases the success rate of nerve reconstruction.

Question 9668

Topic: Biology, Genetics & Bone Healing

A 70-year-old male is found to have elevated serum alkaline phosphatase (ALP) and characteristic findings of Paget's disease on X-rays (thickened cortex, trabecular coarsening) involving his tibia and pelvis. He is asymptomatic. Which of the following is generally considered an indication for medical treatment with bisphosphonates in Paget's disease?

. Elevated alkaline phosphatase alone
. Involvement of weight-bearing bones (e.g., tibia)
. Asymptomatic skull involvement
. Anticipated surgery in an affected bone
. Normal hearing

Correct Answer & Explanation

. Involvement of weight-bearing bones (e.g., tibia)

Explanation

Indications for medical treatment (typically with bisphosphonates) in Paget's disease include: symptomatic disease (bone pain, neurological symptoms like hearing loss, nerve compression), active disease in high-risk locations (e.g., skull near vital structures, spine, weight-bearing long bones with risk of fracture), or prior to surgery on an affected bone to reduce hypervascularity and bone turnover, thereby minimizing blood loss and improving bone quality. Elevated ALP alone without symptoms is often observed, but not an absolute indication for treatment. Asymptomatic involvement of the skull is not an indication unless it is progressive or near vital structures. Normal hearing is not an indication for treatment.

Question 9669

Topic: 1. General Principles & Basic Science

A 38-year-old male undergoes open reduction and internal fixation of a posterior column acetabular fracture via a Kocher-Langenbeck approach. Postoperatively, he develops foot drop. Which nerve is most commonly injured during this approach that could lead to this complication?

. Femoral nerve
. Sciatic nerve
. Obturator nerve
. Superior gluteal nerve
. Inferior gluteal nerve

Correct Answer & Explanation

. Sciatic nerve

Explanation

The sciatic nerve is the most commonly injured nerve during posterior approaches to the acetabulum (e.g., Kocher-Langenbeck approach) due to its anatomical proximity to the posterior column and posterior wall. Injury to the peroneal division of the sciatic nerve typically manifests as foot drop (weakness in ankle dorsiflexion and eversion) and sensory loss in the dorsum of the foot. The femoral and obturator nerves are located anteriorly. The superior gluteal nerve innervates the gluteus medius and minimus, and its injury results in abductor weakness (Trendelenburg gait). The inferior gluteal nerve innervates the gluteus maximus, affecting hip extension.

Question 9670

Topic: Infection, Pharmacology & VTE

A 55-year-old diabetic male has chronic osteomyelitis of the distal tibia following an open fracture 8 months prior, which was treated with ORIF. He presents with a persistent draining sinus tract, localized pain, and imaging showing cortical destruction and a large sequestrum adjacent to the hardware. What is the most critical surgical step for definitive treatment?

. Removal of the existing hardware only.
. Aggressive debridement of all necrotic bone (sequestrum) and infected soft tissues.
. Long-term oral antibiotic therapy for several months.
. Bone grafting of the defect immediately after hardware removal.
. Placement of an external fixator for stability.

Correct Answer & Explanation

. Aggressive debridement of all necrotic bone (sequestrum) and infected soft tissues.

Explanation

For chronic osteomyelitis, especially with a sequestrum (devitalized bone), the most critical surgical step is aggressive and complete debridement of all non-viable bone and infected soft tissues until bleeding bone is encountered ('paprika sign'). This removes the bacterial nidus. While hardware removal is often necessary if it's infected or hindering debridement, it's the debridement itself that's paramount. Antibiotics are adjunctive to surgical debridement; they cannot penetrate devitalized bone. Bone grafting is typically performed later, after eradication of infection and normalization of inflammatory markers, to fill the defect. An external fixator might be used for stability post-debridement, but it's not the primary definitive treatment step for infection eradication.

Question 9671

Topic: Biology, Genetics & Bone Healing

A 70-year-old female on long-term bisphosphonate therapy (alendronate for 7 years) for osteoporosis presents with dull, aching thigh pain for 6 months. A recent fall resulted in a complete, transverse fracture of the subtrochanteric femur with characteristic cortical thickening laterally. What is the most important component of her management, in addition to surgical fixation?

. Continue bisphosphonate therapy to prevent further fractures.
. Initiate immediate high-dose calcium and Vitamin D supplementation.
. Discontinue bisphosphonate therapy.
. Weight-bearing as tolerated to stimulate bone healing.
. Referral for genetic testing for bone fragility.

Correct Answer & Explanation

. Discontinue bisphosphonate therapy.

Explanation

This patient presents with a classic atypical femoral fracture (AFF), which is strongly associated with long-term bisphosphonate use. While surgical fixation (typically intramedullary nailing) is necessary for a complete fracture, the most important medical management is to discontinue bisphosphonate therapy. Bisphosphonates suppress bone turnover, which is thought to contribute to the accumulation of microdamage and lead to these characteristic fractures. Continuing bisphosphonates would hinder bone healing. Calcium and Vitamin D are generally part of osteoporosis management but are not the primary, immediate medical management for an AFF. Weight-bearing is not indicated until after stable surgical fixation, and genetic testing is not typically indicated for AFFs.

Question 9672

Topic: Surgical Anatomy & Approaches

A 28-year-old male sustains a complete avulsion of the C5 and C6 nerve roots from the spinal cord following a high-energy motorcycle accident. Six months post-injury, he has no voluntary contraction in his deltoid, biceps, or wrist extensors. Electromyography confirms no reinnervation across the C5-C6 territory. For restoration of elbow flexion, which of the following nerve transfer options is generally considered the most effective for a patient with C5-C6 avulsion?

. Intercostal nerve to musculocutaneous nerve transfer.
. Accessory nerve to suprascapular nerve transfer.
. Ulnar fascicle of the median nerve to musculocutaneous nerve (Oberlin transfer).
. Pectoralis major motor branch to musculocutaneous nerve transfer.
. Phrenic nerve to musculocutaneous nerve transfer.

Correct Answer & Explanation

. Ulnar fascicle of the median nerve to musculocutaneous nerve (Oberlin transfer).

Explanation

For complete C5-C6 root avulsion, where no proximal nerve stumps are available for grafting, nerve transfers are the treatment of choice to restore function, particularly elbow flexion. The Oberlin transfer (transfer of a fascicle from the ulnar nerve to the biceps branch of the musculocutaneous nerve) is a highly effective and commonly utilized procedure for restoring elbow flexion, as it provides a strong, reliable donor with minimal donor site morbidity. Intercostal nerves can be used but provide less robust power. Accessory to suprascapular is for shoulder abduction/external rotation. Pectoralis major motor branch is an option but less commonly used than Oberlin for isolated C5-C6. Phrenic nerve transfer is considered a last resort due to potential respiratory compromise.

Question 9673

Topic: 1. General Principles & Basic Science

A 50-year-old diabetic patient presents with a 6-month history of a persistent sinus tract in the proximal tibia, unresponsive to multiple courses of oral antibiotics. Plain radiographs show sequestrum and involucrum formation. A bone biopsy confirms chronic osteomyelitis with culture growing Pseudomonas aeruginosa. After thorough debridement, a significant bone defect remains. Which of the following is the most appropriate next step in the surgical management of this chronic osteomyelitis?

. Primary wound closure and 6 weeks of intravenous antibiotics.
. Application of a negative pressure wound therapy (NPWT) device.
. Placement of antibiotic-impregnated cement beads or calcium sulfate pellets into the defect.
. Immediate free vascularized fibula graft for bone reconstruction.
. Long-term oral suppressive antibiotics alone.

Correct Answer & Explanation

. Placement of antibiotic-impregnated cement beads or calcium sulfate pellets into the defect.

Explanation

For chronic osteomyelitis, the surgical management principles include aggressive debridement of all non-viable and infected bone and soft tissue, management of dead space, and targeted antibiotic therapy. After debridement creates a bone defect (dead space), filling this space is crucial to prevent hematoma formation and provide a high local concentration of antibiotics. Antibiotic-impregnated cement beads (PMMA) or calcium sulfate pellets are commonly used to fill dead space and deliver high local antibiotic concentrations, which is superior to systemic antibiotics alone for localized eradication. Free vascularized fibula grafts are considered for larger, critical bone defects, usually as a reconstructive step after infection control. Primary wound closure after significant dead space can lead to fluid accumulation and recurrence. NPWT is useful for soft tissue management but not typically sufficient for internal dead space filling in osteomyelitis.

Question 9674

Topic: Biology, Genetics & Bone Healing

An 82-year-old female presents with a distal radius fragility fracture. Her DEXA scan reveals a T-score of -3.2 at the lumbar spine and -3.0 at the femoral neck. She has been on oral alendronate for 5 years and has previously fractured her vertebral body and humerus. Her renal function is normal. Which of the following is the most appropriate next step in her osteoporosis management?

. Increase the dose of alendronate.
. Switch to another oral bisphosphonate like risedronate.
. Initiate an anabolic agent such as teriparatide or romosozumab.
. Prescribe calcium and Vitamin D supplementation only.
. Discontinue all osteoporosis medications due to bisphosphonate failure.

Correct Answer & Explanation

. Initiate an anabolic agent such as teriparatide or romosozumab.

Explanation

This patient has severe osteoporosis with multiple fragility fractures despite 5 years of oral bisphosphonate therapy, indicating a 'failure' of bisphosphonate treatment. In such cases, switching to an anabolic agent is the most appropriate next step. Teriparatide (a parathyroid hormone analog) and romosozumab (a sclerostin inhibitor) are potent bone-forming agents that are highly effective in patients who fail bisphosphonates or have very severe osteoporosis. Increasing the dose of alendronate or switching to another oral bisphosphonate is unlikely to be effective. Calcium and Vitamin D are supportive but not sufficient for severe osteoporosis. Discontinuing medication would leave her at very high risk for further fractures.

Question 9675

Topic: Surgical Anatomy & Approaches

During an anterior intrapelvic (modified Stoppa) approach for an acetabular fracture, significant hemorrhage is encountered from a vascular anastomosis over the superior pubic ramus. This structure represents an anastomosis between which two vascular systems?

. External iliac artery and internal iliac artery
. External iliac artery and superior gluteal artery
. Internal pudendal artery and obturator artery
. Inferior epigastric artery and obturator artery
. Superior gluteal artery and obturator artery

Correct Answer & Explanation

. Inferior epigastric artery and obturator artery

Explanation

The corona mortis ('crown of death') is a highly variable vascular anastomosis between the obturator and external iliac systems. Most commonly, it connects the inferior epigastric artery or vein (branches of the external iliac system) to the obturator artery or vein (branches of the internal iliac system). It is typically located 5-6 cm from the pubic symphysis along the superior pubic ramus.

Question 9676

Topic: Biology, Genetics & Bone Healing

A 72-year-old female with severe osteoporosis is started on romosozumab. This medication increases bone mineral density by binding to and inhibiting sclerostin. Sclerostin normally functions to inhibit which of the following cellular pathways?

. RANK/RANKL signaling pathway
. Wnt/beta-catenin signaling pathway
. Osteoprotegerin (OPG) pathway
. Bone morphogenetic protein (BMP) pathway
. Insulin-like growth factor 1 (IGF-1) pathway

Correct Answer & Explanation

. Wnt/beta-catenin signaling pathway

Explanation

Sclerostin is a glycoprotein secreted primarily by osteocytes that inhibits bone formation by binding to LRP5/6 receptors on osteoblasts, thereby antagonizing the canonical Wnt/beta-catenin signaling pathway. Romosozumab is a monoclonal antibody that neutralizes sclerostin, unblocking the Wnt pathway and strongly stimulating bone formation.

Question 9677

Topic: 1. General Principles & Basic Science

Articular cartilage is composed of an extracellular matrix and chondrocytes arranged in highly organized distinct zones. Which of the following best describes the structural and biochemical properties of the superficial (tangential) zone of normal articular cartilage?

. Lowest water content, highest proteoglycan content, collagen fibers oriented perpendicular to the joint surface
. Highest water content, lowest proteoglycan content, collagen fibers oriented parallel to the joint surface
. Highest water content, highest proteoglycan content, random collagen orientation
. Lowest water content, lowest proteoglycan content, chondrocytes arranged in vertical columns
. Highly calcified matrix, delineating the tidemark from subchondral bone

Correct Answer & Explanation

. Highest water content, lowest proteoglycan content, collagen fibers oriented parallel to the joint surface

Explanation

The superficial (tangential) zone of articular cartilage constitutes the top 10-20% of the cartilage thickness. It has the highest water content, highest collagen content, and lowest proteoglycan content. The densely packed Type II collagen fibers are arranged parallel to the articular surface to strongly resist shear forces.

Question 9678

Topic: 1. General Principles & Basic Science
Which biomechanical activity places the greatest intradiscal pressure on the L5-S1 disc?
. Standing in anatomical position
. Supine lying
. Sitting in a chair, leaning forward
. Lifting a 20 kg weight with knees bent
. Walking

Correct Answer & Explanation

. Sitting in a chair, leaning forward

Explanation

Sitting in a chair while leaning forward significantly increases intradiscal pressure, often exceeding pressures seen during standing or even certain lifting tasks. This is due to the combination of lumbar flexion and the compressive forces. Supine lying places the least pressure. Lifting with knees bent (proper lifting technique) is designed to minimize lumbar stress compared to lifting with straight legs, but specific positions like leaning forward while seated can be more detrimental.

Question 9679

Topic: 1. General Principles & Basic Science

What percentage of disc material removal during a lumbar microdiscectomy is generally considered the threshold beyond which there is an increased risk of postoperative segmental instability?

. <10%
. 10-20%
. 20-30%
. 40-50%
. >50%

Correct Answer & Explanation

. >50%

Explanation

While precise thresholds vary, removal of more than 50% of the disc material, especially with concomitant facet joint violation or extensive annular defect, significantly increases the risk of postoperative segmental instability. Surgeons aim to remove only the herniated fragment and preserve as much healthy disc as possible.

Question 9680

Topic: Infection, Pharmacology & VTE

A pregnant patient in her third trimester presents with acute severe L5 radiculopathy due to a large disc extrusion. She has significant motor weakness (4/5) in ankle dorsiflexion. What is the MOST appropriate initial management?

. Immediate surgical microdiscectomy
. Epidural steroid injection
. Strict bed rest for 2 weeks
. Aggressive oral pain medication (opioids)
. Conservative management with physical therapy and acetaminophen, with close neurological monitoring

Correct Answer & Explanation

. Conservative management with physical therapy and acetaminophen, with close neurological monitoring

Explanation

While severe motor weakness is a relative indication for surgery, pregnancy complicates immediate surgical intervention. Conservative management (physical therapy, mild analgesics like acetaminophen, activity modification) with very close neurological monitoring is typically the first step. If symptoms progress or severe neurological deficit develops (e.g., foot drop 3/5 or less, or CES), then surgical intervention may be considered, often with a multidisciplinary approach involving obstetrics. Epidural injections carry risks during pregnancy. Strict bed rest is generally not recommended due to deconditioning and DVT risk. Opioids should be used cautiously.

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