A 29-year-old woman is seen in the emergency department with a 24-hour history of severe back and leg pain precipitated by weight-lifting. The patient reports bilateral leg pain and is unable to urinate. She has dense anesthesia in the perineal regio

Improvement in her pain and sensory symptoms following surgery but may have residual bladder dysfunction

Figures 3a and 3b show the current radiographs of a 59-year-old woman who has pain and deformity after undergoing bunion surgery 1 year ago. Nonsurgical management has failed to provide relief. Treatment should now consist of

metatarsophalangeal arthrodesis.

A 24-year-old former high school wrestler had anterior cruciate ligament (ACL) reconstruction with hamstring autograft 6 years ago. He now experiences daily instability of his knee with routine activities including walking. Examination reveals a grad

Revision ACL reconstruction and posterolateral corner reconstruction

A 6-month-old child is seen in the emergency department with a spiral fracture of the tibia. The parents are vague about the etiology of the injury. There is no family history of a bone disease. In addition to casting of the fracture, initial managem

DNA testing for osteogenesis imperfecta.

A 10-year-old child with cerebral palsy undergoes bilateral hamstring lengthening for severe knee flexion contractures, and knee immobilizers are applied postoperatively. Examination at the initial postoperative check 2 hours after surgery reveals th

remove the left knee immobilizer and flex the knee.

Orthopedics Hyperguide Review MCQs | Dr Hutaif Ortho

Question 1

A 72-year-old female presents with a 3-month history of dull, aching pain in her left thigh, exacerbated by weight-bearing. She has been on alendronate for osteoporosis for 8 years. Physical examination is unremarkable. Initial X-rays of the femur are normal. What is the most appropriate next step in her diagnostic workup?

Explanation

This patient's symptoms and history (long-term bisphosphonate use, thigh pain, normal initial X-rays) are highly suggestive of a prodromal or incomplete atypical femoral fracture (AFF). While a bone scan might show increased uptake, MRI is the most sensitive and specific imaging modality to detect cortical thickening, periosteal reaction, or a transverse lucency, which are characteristic findings of an impending or incomplete AFF. Early diagnosis is crucial to prevent a complete fracture. Discontinuing bisphosphonates might be part of the management but not the immediate next diagnostic step without confirming the pathology. NSAIDs and observation are inappropriate given the high suspicion for an AFF.

Question 2

An 8-month-old female is diagnosed with developmental dysplasia of the hip (DDH) after failing Pavlik harness treatment for 6 weeks. Physical examination reveals a reducible but unstable hip. What is the most appropriate next step in management?

Explanation

For DDH, if Pavlik harness treatment fails in an infant between 6-18 months of age (and sometimes earlier), closed reduction under general anesthesia followed by hip spica cast immobilization is the next standard of care. The goal is to achieve and maintain a concentric reduction. Open reduction is typically reserved for cases where closed reduction is unsuccessful or if there are specific anatomical impediments. CT scans are usually performed post-reduction in a spica cast to confirm reduction rather than as a primary diagnostic step to guide the next treatment after failed Pavlik.

Question 3

A 68-year-old male with a history of a cemented total hip arthroplasty (THA) 10 years ago presents after a fall with severe left thigh pain. Radiographs reveal a periprosthetic femoral fracture classified as Vancouver B2. The patient is active and otherwise healthy. What is the most appropriate surgical management?

Explanation

A Vancouver B2 periprosthetic femoral fracture involves a loose femoral component with adequate bone stock. The treatment for a loose femoral component is revision. Given the B2 classification, a long, diaphyseal-engaging stem is required to bypass the fracture and achieve stable fixation in the diaphysis. While both cemented and uncemented options exist, cemented stems are often preferred in the elderly with poor bone quality and can provide immediate stability, fitting within the context of 'general ortho' options. Uncemented stems are also an option and often preferred in younger, more active patients with good bone stock. However, a cemented stem provides good long-term results in the elderly. ORIF with plates is for Vancouver B1 (stable component), and Girdlestone is a salvage procedure. Cerclage wiring alone is insufficient for a loose component.

Question 4

A 35-year-old male involved in a high-speed motor vehicle collision presents with an unstable pelvic ring injury classified as an APC III (anteroposterior compression type III). He is hemodynamically unstable despite initial resuscitation efforts. What is the most critical immediate management step after addressing life-threatening injuries and initial fluid resuscitation?

Explanation

In an APC III pelvic fracture, especially with hemodynamic instability, the pelvic ring is often widely disrupted, leading to significant volume loss within the pelvic cavity due to venous and arterial bleeding. While transfusion is critical, and angiography may be needed, the most critical immediate orthopedic intervention after initial resuscitation is mechanical stabilization of the pelvic ring using a C-clamp or external fixator. This reduces the pelvic volume, tamponades bleeding, and reduces ongoing hemorrhage. Angiography is typically performed after mechanical stabilization if the patient remains hemodynamically unstable, indicating persistent arterial bleeding. ORIF and traction are definitive treatment steps, not immediate life-saving measures.

Question 5

A 65-year-old male presents with severe neurogenic claudication and L4-L5 degenerative spondylolisthesis (Grade II) with associated spinal stenosis, unresponsive to extensive conservative management. He reports significant functional limitation due to leg pain and numbness. Which surgical approach is most appropriate to address both the instability and the neural compression?

Explanation

For symptomatic degenerative spondylolisthesis (Grade II) with spinal stenosis that has failed conservative management, decompression with fusion is generally recommended to address both the neural compression and the instability. While TLIF and ALIF are also valid fusion options, posterolateral fusion (PLF) following decompression has long been a workhorse procedure for this condition, demonstrating good clinical outcomes and stability. It effectively treats the instability and decompresses the neural elements. Decompression alone carries a higher risk of postoperative instability and progression of spondylolisthesis. The choice between PLF, TLIF, or ALIF can depend on surgeon preference and specific patient factors, but PLF is a well-established and commonly used approach for this scenario in 'General Ortho'.

Question 6

A 45-year-old female presents 3 months after a distal radius fracture with persistent, burning pain, allodynia, swelling, and trophic changes in her hand, disproportionate to the initial injury. The limb appears cool and mottled. Nerve conduction studies are normal. This clinical picture is most consistent with Complex Regional Pain Syndrome Type 1 (CRPS-1). What is the most appropriate initial management strategy for this condition?

Explanation

The mainstay of CRPS-1 management is a multidisciplinary approach focusing on early, active rehabilitation. A comprehensive physical and occupational therapy program emphasizing desensitization, active range of motion, and gradual weight-bearing is crucial to break the pain-spasm cycle and restore function. Immobilization is contraindicated as it exacerbates the condition. Opioids are typically not the primary long-term solution due to risks of dependence and limited efficacy for neuropathic pain. While nerve blocks and medications (e.g., gabapentin, tricyclic antidepressants, bisphosphonates) may be used adjunctively, early, focused therapy is paramount. Surgical exploration is not indicated unless there's a specific, treatable nerve lesion, which is not suggested by normal nerve conduction studies. Corticosteroids may be used in acute phases but not typically as the primary long-term strategy.

Question 7

A 58-year-old diabetic male presents with a warm, swollen, and erythematous midfoot. He denies any recent trauma or fever. Radiographs show disorganization of the midfoot joints, fragmentation, and a 'rocker-bottom' deformity. There are no signs of osteomyelitis or open wounds. What is the most appropriate initial management for this presentation?

Explanation

This patient presents with acute Charcot neuroarthropathy, characterized by inflammation, bone and joint destruction, and deformity in the setting of neuropathy. The most critical initial management step in the acute phase (Eichenholtz Stage I) is strict immobilization and off-loading to prevent further collapse and deformity. A total contact cast (TCC) is the gold standard for this, as it evenly distributes pressure, reduces edema, and protects the foot. Surgical reconstruction is typically reserved for stable deformities in the chronic phase (Eichenholtz Stage III) or for severe unstable deformities causing ulceration. Antibiotics are not indicated without evidence of infection. Custom orthotics are for stable, chronic deformities, and bed rest alone is not as effective as TCC.

Question 8

A 16-year-old male presents with a suspicious lesion in the distal femur, highly concerning for osteosarcoma. A biopsy is planned. Which principle is most critical to ensure optimal management and potential limb salvage?

Explanation

For suspected bone tumors like osteosarcoma, the biopsy technique is paramount and can significantly impact the patient's prognosis and potential for limb salvage. The most critical principle is that the biopsy tract must be meticulously planned and performed so that it can be completely excised en bloc with the tumor during the definitive oncologic resection. A contaminated biopsy tract can necessitate a wider margin of resection or even amputation if not properly managed. Transverse incisions are generally avoided in extremities, and planning through muscle bellies should also consider the definitive surgical approach. While avoiding neurovascular structures is important, it shouldn't completely compromise access or proper planning. The choice between core needle and open biopsy depends on the tumor and institutional expertise, and neither is 'always superior'.

Question 9

A 28-year-old professional athlete presents with chronic posterior knee instability and functional limitations due to an isolated Grade II posterior cruciate ligament (PCL) tear, sustained 18 months ago. Non-operative management, including extensive physical therapy, has failed to restore stability or allow return to sport. Which surgical technique is generally considered the most biomechanically advantageous for PCL reconstruction in this patient?

Explanation

For a chronic, symptomatic PCL deficiency in an active individual, surgical reconstruction is indicated. Among the options, the femoral inlay technique (both single and double bundle) has been shown to be biomechanically superior to the transtibial technique. The transtibial technique often creates a 'killer turn' or acute angle for the graft as it exits the tibia, which can lead to graft abrasion, lengthening, and failure. The femoral inlay technique avoids this acute turn, providing a more anatomical and biomechanically sound reconstruction. While double-bundle techniques may offer theoretical advantages in some cases, the single-bundle femoral inlay technique is a robust option that avoids the 'killer turn' and is highly effective for isolated Grade II/III tears, making it a strong choice. Double-bundle inlay would be even more complex, but single-bundle inlay is a significant step up from transtibial. Dynamic stabilization is a historical technique not commonly used for isolated PCL reconstruction in athletes.

Question 10

A 70-year-old male with a history of left total knee arthroplasty (TKA) 2 years ago presents with persistent knee pain, swelling, and warmth for 4 months. Laboratory tests show ESR 55 mm/hr and CRP 80 mg/L. A knee aspirate reveals 3,500 WBCs/µL with 75% polymorphonuclear leukocytes (PMNs). According to the Musculoskeletal Infection Society (MSIS) criteria for prosthetic joint infection (PJI), what additional finding is most crucial for definitively confirming a PJI diagnosis?

Explanation

According to the revised MSIS criteria (2018), a definitive PJI diagnosis can be made if one of the following is met:
1. A sinus tract communicating with the prosthesis.
2. Two positive cultures of the same organism from separate periprosthetic tissue or fluid samples.
3. Four out of six minor criteria (ESR/CRP, D-dimer, synovial fluid WBC, synovial fluid PMN%, alpha-defensin, leukocyte esterase).

The provided information (ESR, CRP, synovial WBC, PMN%) strongly suggests PJI, but to definitively confirm with one major criterion, a draining sinus tract is one of the most direct and undeniable signs. While intraoperative purulence is highly indicative, it's not a formal MSIS definitive criterion on its own without cultures or other findings. Positive cultures (at least two of the same organism) are crucial, but the question asks for the most crucial additional finding, and a sinus tract meets a standalone major criterion. A single positive culture (Option D) is insufficient as per MSIS criteria, as two positive cultures of the same organism are needed, or one positive culture of a virulent organism. Alpha-defensin and leukocyte esterase are minor criteria or adjuncts but not standalone definitive criteria unless combined with other minor criteria.

Question 11

A 15-year-old boy presents with progressive knee pain and a palpable mass over the distal femur. Radiographs reveal a mixed lytic and sclerotic lesion with a 'sunburst' periosteal reaction. Biopsy confirms high-grade intramedullary osteosarcoma. What is the most widely accepted standard of care?

Explanation

Osteosarcoma is treated optimally with a combination of neoadjuvant chemotherapy, wide surgical resection (limb salvage when possible), and adjuvant chemotherapy. This multimodal approach significantly improves long-term survival rates compared to surgery alone.

Question 12

A 13-year-old obese male presents with left groin pain and a limp. On examination, his left hip obligatorily externally rotates when flexed to 90 degrees. Radiographs confirm a slipped capital femoral epiphysis (SCFE). Through which histologic zone of the physis does this slippage primarily occur?

Explanation

Slipped capital femoral epiphysis (SCFE) typically occurs through the hypertrophic zone of the physis. This zone is biomechanically the weakest due to its large cell volume and lack of extensive collagen matrix.

Question 13

A 70-year-old man presents with progressive pain in his right hip 12 years after a total hip arthroplasty. Radiographs show eccentric wear of the polyethylene liner and focal radiolucencies in the proximal femur. Which of the following is the primary biologic mechanism responsible for this complication?

Explanation

Aseptic loosening secondary to osteolysis is primarily driven by macrophage phagocytosis of ultra-high molecular weight polyethylene (UHMWPE) wear particles. These macrophages subsequently release osteoclast-activating cytokines like TNF-alpha and IL-1, leading to bone resorption.

Question 14

A 42-year-old weekend warrior feels a 'pop' in his posterior ankle while playing tennis. Clinical examination demonstrates a positive Thompson test. If nonoperative management is chosen, the healing relies heavily on the vascular watershed area of the Achilles tendon. Where is this hypovascular zone located?

Explanation

The Achilles tendon has a distinct hypovascular zone located approximately 2 to 6 cm proximal to its insertion on the calcaneus. This anatomic watershed area correlates closely with the most common site of tendon rupture.

Question 15

A patient suffers a closed humerus fracture and subsequent radial nerve palsy. Electromyography at 4 weeks suggests an axonotmesis injury (Sunderland second-degree). Which of the following best describes the pathophysiology of this nerve injury?

Explanation

In an axonotmesis (Sunderland second-degree) injury, the axon is disrupted, leading to distal Wallerian degeneration, but the endoneurial tubes remain intact. These intact tubes guide the regenerating axons, allowing for a good prognosis for spontaneous recovery.

Question 16

A 6-year-old girl sustains a severely displaced (Gartland Type III) supracondylar humerus fracture. On presentation, her radial pulse is absent, but the hand is warm, pink, and has capillary refill less than 2 seconds. What is the most appropriate initial management?

Explanation

A pulseless but well-perfused (pink, warm) hand following a displaced supracondylar humerus fracture should undergo urgent closed reduction and percutaneous pinning in the operating room. Anatomical reduction often relieves arterial kinking or spasm, restoring the pulse without needing vascular exploration.

Question 17

A 12-year-old boy presents with progressive mid-thigh pain and fevers. Radiographs show a permeative diaphyseal lesion with an 'onion skin' periosteal reaction. A biopsy reveals a small, round, blue cell tumor. Which of the following chromosomal translocations is most characteristic of this diagnosis?

Explanation

Ewing sarcoma is classically characterized by the t(11;22) chromosomal translocation, which results in the EWS-FLI1 fusion protein. This genetic marker is diagnostic and essential in differentiating it from other small round blue cell tumors.

Question 18

A 35-year-old man undergoes rigid plate fixation for a transverse radius shaft fracture. During the healing process, no fracture callus is visualized on radiographs. Which biological process dictates primary bone healing in this scenario?

Explanation

Primary bone healing occurs under absolute stability and relies on osteoclastic cutting cones crossing the fracture site, followed by osteoblasts depositing new lamellar bone. This process entirely bypasses the formation of a fibrocartilaginous callus.

Question 19

An infant is diagnosed with idiopathic congenital talipes equinovarus (clubfoot). The treating orthopedic surgeon plans to utilize the Ponseti method of serial casting. In what sequence should the components of the deformity be corrected?

Explanation

The Ponseti method systematically corrects clubfoot deformities using the 'CAVE' sequence: Cavus (elevating the first ray), Adductus, Varus, and finally Equinus. The equinus correction is typically achieved last, often requiring a percutaneous Achilles tenotomy.

Question 20

A 60-year-old man presents with progressive clumsiness in his hands, difficulty buttoning his shirts, and gait unsteadiness. Physical examination reveals hyperreflexia and a positive Hoffmann's sign. Which of the following is the most likely diagnosis?

Explanation

Clumsy hands, gait instability, and upper motor neuron signs (such as a positive Hoffmann's sign and hyperreflexia) are hallmark clinical features of cervical spondylotic myelopathy. It results from compression of the spinal cord in the cervical region.

Question 21

A 24-year-old male sustains a comminuted tibia fracture and subsequently develops severe leg pain out of proportion to the injury, worsening with passive toe extension. The clinical suspicion for acute compartment syndrome is high. Which of the following intracompartmental pressure measurements confirms the diagnosis?

Explanation

Acute compartment syndrome is diagnosed when the Delta P (diastolic blood pressure minus the intracompartmental pressure) drops below 30 mmHg. This dynamic measurement is more reliable than absolute pressure as it accounts for the patient's systemic tissue perfusion pressure.

Question 22

During a posterior approach to the hip (Kocher-Langenbeck), the surgeon takes care to protect the primary blood supply to the adult femoral head. Which of the following describes the anatomical course of the main branch of the medial femoral circumflex artery (MFCA)?

Explanation

The deep branch of the medial femoral circumflex artery (MFCA) is the predominant blood supply to the femoral head. It runs anterior to the quadratus femoris muscle and posterior to the obturator externus before ascending along the femoral neck.

Question 23

A 65-year-old female presents with a painful total knee arthroplasty 5 years after the index procedure. Joint aspiration yields a synovial fluid WBC count of 45,000 cells/uL with 92% neutrophils. Cultures are pending. What is the most widely accepted definitive surgical management for this chronic infection?

Explanation

For a chronic periprosthetic joint infection (typically presenting months or years postoperatively with mature biofilm), a two-stage revision arthroplasty is the gold standard in North America. DAIR is strictly reserved for acute postoperative infections or acute hematogenous seeding.

Question 24

A 32-year-old motorcyclist sustains a Gustilo-Anderson Type IIIB open fracture of the distal third of the tibia. Following aggressive debridement, bone stabilization, and appropriate antibiotic therapy, a large soft tissue defect with exposed bone remains. What is the most appropriate option for soft tissue coverage?

Explanation

Soft tissue defects in the distal third of the tibia lack adequate local muscle bulk for rotational coverage. They necessitate free tissue transfer (such as an anterolateral thigh or latissimus dorsi flap) to provide durable coverage over exposed bone or hardware.

Question 25

A 75-year-old man complains of bilateral leg and buttock pain that worsens with prolonged standing and walking. He notes significant relief when leaning over a shopping cart at the grocery store. Which of the following features best differentiates this condition from vascular claudication?

Explanation

The patient's 'shopping cart sign' is classic for neurogenic claudication caused by lumbar spinal stenosis. Lumbar flexion (e.g., leaning forward, walking uphill) increases the volume of the spinal canal, thereby relieving neurovascular compression and differentiating it from vascular claudication.

Question 26

Female athletes demonstrate a higher incidence of non-contact anterior cruciate ligament (ACL) injuries compared to males. Which of the following is considered an anatomic or biomechanical risk factor for this disparity?

Explanation

Female athletes are predisposed to ACL tears due to several intrinsic risk factors, including increased generalized ligamentous laxity, increased Q angle, and a narrower intercondylar notch. Increased posterior tibial slope and hormonal fluctuations also contribute to this elevated risk.

Question 27

A 45-year-old man sustains an anteroposterior compression (APC) Type II pelvic ring injury in a high-speed motor vehicle collision. Which of the following accurately describes the ligamentous disruption associated with this specific injury pattern?

Explanation

An APC II pelvic injury is characterized by pubic symphysis diastasis and tearing of the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments. The strong posterior sacroiliac ligaments remain intact, rendering the pelvis rotationally unstable but vertically stable.

Question 28

A 22-year-old soccer player undergoes knee arthroscopy for a longitudinal tear in the peripheral third of the medial meniscus. The surgeon decides to repair rather than resect the meniscus. From which vascular source does this specific zone of the meniscus derive its blood supply to facilitate healing?

Explanation

The peripheral third of the meniscus (the red-red zone) is well-vascularized by the superior and inferior medial and lateral genicular arteries. This rich blood supply affords tears in this region a high potential for healing following surgical repair.

Question 29

A 14-year-old active male complains of poorly localized, intermittent knee pain and catching over the past six months. Radiographs reveal osteochondritis dissecans (OCD) of the knee. What is the most common anatomical location for this lesion?

Explanation

The classic and most common location for osteochondritis dissecans (OCD) in the knee is the lateral aspect of the medial femoral condyle. It accounts for approximately 70-80% of all knee OCD lesions.

Question 30

A 72-year-old woman, who has been treated with alendronate for 10 years, presents with a transverse fracture of the subtrochanteric femur after simply rising from a chair. Radiographs reveal focal lateral cortical thickening and a 'beaking' appearance. What is the underlying pathophysiologic mechanism caused by her prolonged medication use?

Explanation

Prolonged bisphosphonate therapy inhibits osteoclast activity and induces their apoptosis, heavily suppressing normal bone remodeling. This failure to clear normal microdamage over time reduces bone toughness, leading to atypical subtrochanteric or diaphyseal femur fractures.

Question 31

A 35-year-old male is brought to the emergency department intubated after a motorcycle collision. He has a closed, comminuted midshaft tibia fracture. His blood pressure is 90/60 mmHg. Intracompartmental pressure of the anterior compartment is measured at 45 mmHg. What is the most appropriate next step in management?

Explanation

The patient has a delta pressure (diastolic BP minus compartment pressure) of 15 mmHg. A delta pressure of less than 30 mmHg is an absolute indication for immediate fasciotomy to prevent irreversible muscle and nerve ischemia.

Question 32

During a total knee arthroplasty, the surgeon evaluates the trial components. The knee is symmetric and stable in extension, but the flexion gap is unacceptably tight. Which of the following adjustments is the most appropriate next step?

Explanation

A tight flexion gap with a balanced extension gap requires decreasing the anteroposterior dimension of the femur. Downsizing the femoral component or increasing the posterior slope of the tibial cut effectively increases the flexion gap without altering the extension gap.

Question 33

A 13-year-old obese male presents with a 4-week history of left groin and knee pain. On examination, as the left hip is passively flexed, it obligatorily externally rotates. Radiographs show a widening of the left proximal femoral physis. What is the most appropriate definitive management?

Explanation

The patient has a slipped capital femoral epiphysis (SCFE). The gold standard treatment is immediate in situ fixation with a single cannulated screw to prevent further slippage and reduce the risk of osteonecrosis.

Question 34

A 22-year-old rugby player presents with recurrent anterior shoulder dislocations. A pre-operative CT scan reveals an inverted pear-shaped glenoid with 30% anterior glenoid bone loss. What is the most appropriate surgical intervention?

Explanation

In the setting of recurrent anterior shoulder instability with critical glenoid bone loss (greater than 25%), soft tissue repairs alone have a high failure rate. A bony augmentation procedure, such as the Latarjet (coracoid transfer), is required to restore glenoid width and stability.

Question 35

A 15-year-old male presents with deep, aching distal femur pain. Plain radiographs reveal a mixed lytic and sclerotic lesion in the distal femoral metaphysis with a sunburst periosteal reaction. What is the most appropriate next step in management before performing a biopsy?

Explanation

The clinical and radiographic presentation is highly suspicious for osteosarcoma. Prior to any biopsy, complete local and systemic staging must be performed, including an MRI of the entire involved bone (to check for skip lesions) and a chest CT (to evaluate for pulmonary metastases).

Question 36

A 65-year-old male complains of progressive clumsiness in his hands, difficulty buttoning his shirt, and a wide-based gait. Physical examination reveals a positive Hoffmann sign bilaterally and an inverted supinator reflex. What is the most likely diagnosis?

Explanation

The patient's symptoms of loss of fine motor skills, gait instability, and upper motor neuron signs (Hoffmann sign, inverted supinator reflex) are classic for cervical spondylotic myelopathy. It is the most common cause of spinal cord dysfunction in older adults.

Question 37

A patient is prescribed rivaroxaban for deep vein thrombosis prophylaxis following a total hip arthroplasty. What is the specific mechanism of action of this medication?

Explanation

Rivaroxaban is an oral anticoagulant that works by directly inhibiting Factor Xa, interrupting both the intrinsic and extrinsic pathways of the blood coagulation cascade. It does not require routine coagulation monitoring.

Question 38

A 28-year-old male presents with chronic wrist pain. He sustained a fall onto an outstretched hand 2 years ago. Radiographs demonstrate a scaphoid nonunion with radioscaphoid osteoarthritis, while the midcarpal joint is spared (SNAC Stage II). What is the most appropriate surgical treatment?

Explanation

In Scaphoid Nonunion Advanced Collapse (SNAC) Stage II, arthritis involves the radioscaphoid joint but spares the midcarpal and radiolunate joints. Appropriate salvage procedures include proximal row carpectomy or scaphoid excision with four-corner arthrodesis.

Question 39

A 30-year-old equestrian falls from his horse, sustaining an axial load to a plantarflexed foot. Examination reveals plantar ecchymosis. Weight-bearing radiographs show 3 mm of widening between the medial cuneiform and the base of the second metatarsal without visible fractures. What is the most appropriate management?

Explanation

The patient has a purely ligamentous Lisfranc injury. Evidence suggests that primary arthrodesis of the medial column tarsometatarsal joints yields superior functional outcomes and lower revision rates compared to ORIF for purely ligamentous Lisfranc injuries.

Question 40

A 9-year-old male presents with right hip pain and a limp. BMI is in the 90th percentile. Radiographs reveal a mild right slipped capital femoral epiphysis (SCFE). What is the most appropriate routine screening indicated for this patient?

Explanation

Patients presenting with SCFE at an atypical age (less than 10 or greater than 16 years old) or with a weight less than the 50th percentile should be evaluated for endocrine disorders. Hypothyroidism is the most common associated endocrine abnormality in this population.

Question 41

During a primary total knee arthroplasty, the surgeon uses spacer blocks and notes the knee is well-balanced in extension but tight in flexion. Which of the following intraoperative adjustments is the most appropriate next step?

Explanation

A knee that is tight in flexion and balanced in extension requires an increase in the flexion gap without altering the extension gap. Downsizing the femoral component selectively increases the flexion gap.

Question 42

A 32-year-old male sustains a Hawkins Type II fracture of the talar neck. At his 8-week follow-up, radiographs reveal subchondral radiolucency in the talar dome. What does this radiographic finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucent band seen in the talar dome 6 to 8 weeks post-injury, indicating subchondral bone resorption. This process requires an intact blood supply, thereby prognosticating a low risk of avascular necrosis.

Question 43

A 35-year-old female presents with a destructive, lytic lesion in the distal femur extending to the subchondral bone. Biopsy confirms a Giant Cell Tumor of bone. If medical therapy is considered, what is the primary mechanism of action of the most commonly utilized pharmacological agent?

Explanation

Denosumab is a monoclonal antibody frequently used in the treatment of Giant Cell Tumor of bone. It works by binding to and inhibiting RANKL, which prevents the maturation and activation of the osteoclast-like multinucleated giant cells.

Question 44

A 21-year-old collegiate rugby player with recurrent anterior shoulder instability undergoes advanced imaging. A 3D CT scan reveals 25 percent anterior glenoid bone loss. What is the most appropriate surgical management?

Explanation

In patients with anterior shoulder instability and significant glenoid bone loss (typically greater than 20 to 25 percent), soft tissue stabilization alone has an unacceptably high failure rate. A bony augmentation procedure, such as the Latarjet coracoid transfer, is indicated.

Question 45

An 11-year-old boy presents with pain and swelling in his left mid-thigh. Radiographs show a permeative diaphyseal lesion with an 'onion-skin' periosteal reaction. Which of the following cytogenetic abnormalities is most characteristically associated with this tumor?

Explanation

Ewing sarcoma classically presents with a permeative diaphyseal lesion and 'onion-skin' periostitis. It is genetically characterized by the t(11;22)(q24;q12) translocation, resulting in the EWS-FLI1 fusion gene.

Question 46

A 15-year-old boy presents with progressive knee pain and swelling. Radiographs show a destructive metaphyseal lesion in the distal femur with a sunburst periosteal reaction and Codman's triangle. Biopsy confirms high-grade osteosarcoma. What is the most appropriate treatment algorithm?

Explanation

High-grade osteosarcoma is treated with a combination of neoadjuvant chemotherapy, wide surgical resection, and adjuvant chemotherapy. Radiation therapy is generally ineffective for osteosarcoma and is reserved for highly specific, unresectable cases.

Question 47

A 28-year-old male sustains a closed midshaft tibia fracture. Four hours post-injury, he complains of severe leg pain out of proportion to the injury, not relieved by opioids. Passive stretch of the toes elicits excruciating pain. Compartment pressure monitoring reveals an anterior compartment pressure of 45 mmHg and a diastolic blood pressure of 65 mmHg. What is the most appropriate management?

Explanation

The patient demonstrates classic clinical signs of acute compartment syndrome, confirmed by a delta P (diastolic BP minus compartment pressure) of 20 mmHg, which is well below the 30 mmHg threshold. Emergent four-compartment fasciotomy is indicated to prevent irreversible muscle and nerve necrosis.

Question 48

A 2-week-old male infant is brought to the clinic with bilateral idiopathic clubfoot. The parents elect to proceed with the Ponseti method of serial casting. What is the correct order of deformity correction in this technique?

Explanation

The Ponseti method corrects the clubfoot deformity in a specific sequence remembered by the acronym CAVE: Cavus, Adductus, Varus, and finally Equinus. The cavus is corrected first by elevating the first metatarsal to align the forefoot with the hindfoot.

Question 49

A 6-year-old boy falls from monkey bars and sustains a Gartland type III extension supracondylar humerus fracture. On examination, the hand is pink but the radial pulse is absent. The child has strong capillary refill and normal motor function. What is the most appropriate next step in management?

Explanation

For a "pulseless pink hand" following a severe supracondylar humerus fracture, the initial step is prompt closed reduction and percutaneous pinning to restore alignment. If the hand remains well-perfused despite an absent pulse post-reduction, observation is generally acceptable, avoiding immediate vascular exploration.

Question 50

A 32-year-old female presents with knee pain. Radiographs reveal an eccentric, lytic, expansile lesion in the epiphysis of the proximal tibia without a sclerotic margin. MRI shows no soft tissue extension. Biopsy confirms mononuclear cells with scattered multinucleated giant cells. What is the standard surgical treatment?

Explanation

Giant cell tumors (GCT) of bone are locally aggressive epiphyseal lesions typically seen in young adults. Standard treatment involves extended intralesional curettage with chemical or thermal adjuvants (e.g., high-speed burr, phenol) and packing with polymethylmethacrylate (PMMA) to reduce recurrence risk.

Question 51

A 13-year-old obese boy presents with a 2-month history of left knee pain and an antalgic gait. Examination shows obligatory external rotation of the left hip when it is passively flexed. Radiographs reveal a widening of the left capital femoral physis. What is the most appropriate definitive management?

Explanation

The patient has a slipped capital femoral epiphysis (SCFE), characterized by obligatory external rotation during hip flexion. The gold standard treatment is in situ fixation using a single, centrally placed cannulated screw to prevent further slippage without risking osteonecrosis from forceful reduction.

Question 52

A 45-year-old male sustains a severe open tibia fracture with a 12 cm laceration, extensive muscle stripping, and massive contamination after a motorcycle accident. Following initial debridement, bone is exposed requiring flap coverage. According to the Gustilo-Anderson classification, what type of fracture is this and what is the optimal timing for initial antibiotic administration?

Explanation

This is a Gustilo-Anderson Type IIIB fracture due to the extensive soft tissue injury requiring a flap for coverage. Early administration of broad-spectrum systemic antibiotics, ideally within 1 hour of injury, is the most critical factor in reducing infection rates in open fractures.

Question 53

A 28-year-old carpenter presents with a swollen, erythematous, and exquisitely tender left index finger 2 days after a wood splinter puncture. The finger is held in slight flexion, and there is severe pain with passive extension. What is the most appropriate management?

Explanation

The patient has Kanavel's four cardinal signs of acute suppurative flexor tenosynovitis (fusiform swelling, flexed posture, tenderness along the sheath, and pain on passive extension). This is a surgical emergency requiring prompt incision and drainage combined with systemic antibiotics to prevent tendon necrosis.

Question 54

A 75-year-old male complains of severe right shoulder pain and inability to actively raise his arm above 45 degrees. Radiographs demonstrate severe glenohumeral osteoarthritis with high-riding humeral head and an acromiohumeral interval of 3 mm. MRI confirms a massive, retracted, irreparable rotator cuff tear. What is the best surgical option?

Explanation

This patient has rotator cuff tear arthropathy with pseudoparalysis (inability to actively elevate the arm). A reverse total shoulder arthroplasty is indicated as it bypasses the deficient rotator cuff by medializing and lowering the center of rotation, allowing the deltoid to initiate and maintain arm elevation.

Question 55

A 32-year-old female presents with progressive knee pain. Radiographs reveal an eccentric, lytic epiphyseal lesion in the distal femur without sclerotic margins. Biopsy shows multinucleated giant cells in a background of mononuclear stromal cells. Which of the following is the most appropriate initial surgical management?

Explanation

Giant cell tumors are locally aggressive, benign bone tumors usually affecting the epiphyses of long bones. The standard of care for resectable lesions is extended intralesional curettage using chemical or thermal adjuvants, followed by filling the defect with polymethylmethacrylate (PMMA).

Question 56

A 28-year-old male sustains a severe open tibia fracture (Gustilo-Anderson IIIB) after a motorcycle collision. After initial thorough surgical debridement and external fixation, a soft tissue defect with exposed bone remains. According to Godina's principles, to minimize the risk of flap failure and deep infection, a definitive free tissue transfer should ideally be performed within what timeframe from injury?

Explanation

Classic literature by Godina demonstrates significantly reduced infection and failure rates when free flap coverage is achieved within 72 hours of injury. Early coverage prevents bacterial colonization of exposed bone and desiccation of surrounding tissues.

Question 57

A 65-year-old male presents with a deteriorating gait, dropping objects, and bilateral hand numbness. Examination reveals intrinsic hand muscle wasting, bilateral hyperreflexia in the lower extremities, and a positive Hoffmann sign. MRI shows severe cervical stenosis at C4-C5 and C5-C6 with T2 hyperintense cord signal changes. What is the most appropriate definitive management?

Explanation

The patient has distinct signs of cervical spondylotic myelopathy accompanied by upper motor neuron signs and cord signal changes on MRI. Surgical decompression (anterior, posterior, or combined) is indicated to halt the progression of the neurologic deficit.

Question 58

A 13-year-old obese boy presents to the emergency department unable to bear weight on his right leg after a minor fall. Radiographs confirm a severe slipped capital femoral epiphysis (SCFE). Which of the following is the most devastating complication associated specifically with this presentation?

Explanation

The inability to bear weight defines an unstable SCFE. Unstable slips carry a notoriously high risk of avascular necrosis (AVN) of the femoral head, approaching 47%, which is the most devastating complication in this scenario.

Question 59

A 24-year-old male falls onto an outstretched hand. Immediate radiographs are negative, but an MRI obtained 1 week later reveals a non-displaced fracture of the proximal pole of the scaphoid. What is the most appropriate management for this specific fracture pattern?

Explanation

Proximal pole scaphoid fractures have a tenuous retrograde blood supply and a high risk of nonunion and avascular necrosis. Operative fixation with a headless compression screw is generally recommended even for non-displaced fractures to promote healing and allow early mobilization.

Question 60

A 55-year-old highly active female underwent a total hip arthroplasty using a ceramic-on-ceramic bearing. Three years postoperatively, she complains of a newly developed, audible squeaking sound from the hip during walking. Her hip is completely painless, and radiographs show well-fixed components with no signs of osteolysis. What is the most appropriate management?

Explanation

Squeaking in a ceramic-on-ceramic THA can affect up to 10% of patients. In a painless, well-fixed hip with normal radiographs and no mechanical symptoms, the condition is benign, making reassurance and observation the standard of care.

Question 61

A 19-year-old soccer player sustains a twisting injury to his knee. He presents with a locked knee and a large effusion. MRI reveals a complete anterior cruciate ligament (ACL) tear and a displaced bucket-handle tear of the medial meniscus. What is the recommended surgical management?

Explanation

A locked knee secondary to a displaced bucket-handle meniscal tear requires urgent surgical intervention. Concurrent ACL reconstruction and meniscal repair should be performed, as the bleeding and bone marrow elements from the ACL reconstruction create a favorable biologic environment that improves meniscal healing rates.

Question 62

A 58-year-old male with long-standing, poorly controlled diabetes presents with a swollen, red, and warm right foot for 3 weeks. He denies systemic symptoms, and there are no open ulcers. Radiographs show periarticular debris, fragmentation, and subluxation of the midfoot joints. What is the most appropriate initial management?

Explanation

The clinical and radiographic presentation is classic for Eichenholtz Stage I (Fragmentation) Charcot arthropathy. The gold standard for initial management in the absence of an open wound or active infection is immobilization and offloading, typically using a total contact cast.

Question 63

A 70-year-old male complains of increasing hat size and dull, deep bone pain in his pelvis and thighs. Laboratory tests show normal serum calcium, normal serum phosphorus, and significantly elevated alkaline phosphatase. Radiographs of the skull show a characteristic "cotton wool" appearance. Which cell type is primarily responsible for the initial phase of this disease process?

Explanation

The patient's presentation and labs are diagnostic of Paget's disease of bone. The disease process is characterized by an initial phase of excessive osteoclastic bone resorption, followed by chaotic osteoblastic bone formation resulting in structurally weak woven bone.

Question 64

During the remodeling phase of secondary fracture healing, woven bone is gradually replaced by highly organized lamellar bone. According to Wolff's Law, this physiological process is primarily driven and directed by which of the following mechanisms?

Explanation

Wolff's law dictates that bone models and remodels in response to the mechanical stresses placed upon it. Mechanical loading generates piezoelectric forces that stimulate osteoclasts and osteoblasts to align trabeculae along lines of stress.

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Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

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