+967-774203774 [email protected]
Partner Portal Staff Login
العربية
Part of the Master Guide

Orthopedic Board Prep: Interactive Viva Exam Practice for Trauma & Surgical Cases

Master Orthopedic Board Exams: Interactive MCQ Practice Engine

23 Apr 2026 130 min read 153 Views
In the examination hall

Key Takeaway

An interactive MCQ engine significantly enhances orthopedic board exam preparation by providing realistic clinical scenarios and immediate feedback. It allows candidates to practice critical decision-making under timed conditions, simulate exam environments, and identify knowledge gaps. Detailed explanations for each question deepen understanding, optimizing study efficiency for successful board certification.

Comprehensive Exam


00:00

Start Quiz

Question 1

A 45-year-old male presents following a high-speed motor vehicle collision. He is hemodynamically unstable, with a heart rate of 120 bpm and blood pressure of 80/50 mmHg. Physical examination reveals a widely abducted lower extremity, perineal ecchymosis, and scrotal swelling. A Foley catheter insertion is attempted but meets resistance. A CT scan confirms an open-book pelvic fracture (APC-III) with significant symphyseal diastasis and sacral fractures. Which of the following is the most appropriate immediate next step in management after initial ATLS protocol?





Explanation

The most immediate and life-saving intervention for a hemodynamically unstable patient with an open-book pelvic fracture (APC-III) after initial ATLS assessment is the application of a circumferential pelvic binder. This maneuver reduces pelvic volume, compresses vascular structures, and helps tamponade hemorrhage, thereby improving hemodynamic stability. While other interventions like angiography/embolization, C-clamp, or external fixation may be required, they are typically performed after initial stabilization with a binder. Laparotomy would be considered for identified intra-abdominal hemorrhage, but the initial focus is on the pelvic instability as the primary source of bleeding in this scenario. The urethral injury (resistance to Foley) needs to be addressed with a suprapubic catheter, but it is secondary to hemodynamic instability in this critical phase.

Question 2

A 7-year-old child presents after a fall from a trampoline, complaining of neck pain and bilateral lower extremity weakness. Neurological examination reveals 2/5 strength in both lower extremities, normal upper extremity strength, and intact sensation throughout. Reflexes are hyperreflexic in the lower extremities. X-rays of the cervical spine are normal, and a subsequent MRI shows no fracture, dislocation, or spinal cord compression, but reveals subtle signal changes within the cord. What is the most likely diagnosis?





Explanation

The clinical presentation of a child with neurological deficits after trauma, coupled with normal radiographs and absence of bony pathology on MRI, but with signal changes within the cord, is pathognomonic for Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). This condition is more common in children due to increased spinal elasticity and laxity of ligaments, allowing for transient cord stretch or compression without bony injury. Atlantoaxial instability would typically show radiographic evidence. Transient myelopathy and acute transverse myelitis are diagnoses of exclusion often related to inflammatory or idiopathic causes, less likely acutely post-trauma with cord signal changes. An epidural hematoma would be visible on MRI as a mass compressing the cord.

Question 3

A 68-year-old female presents with groin pain and a leg length discrepancy 6 months following a cemented total hip arthroplasty for osteoarthritis. She reports increasing pain with ambulation and night pain. Radiographs demonstrate lucencies greater than 2mm around the femoral stem and acetabular component in multiple zones, with some subsidence of the femoral stem. Laboratory markers (ESR, CRP, WBC count) are within normal limits. Aspiration of the hip joint yields a clear, viscous fluid. What is the most likely diagnosis?





Explanation

The clinical picture of increasing groin pain, leg length discrepancy, and classic radiographic lucencies (greater than 2mm in multiple zones) around both components, coupled with normal inflammatory markers and a clear joint aspirate, strongly points towards aseptic loosening. Periprosthetic joint infection would typically present with elevated inflammatory markers and potentially purulent aspirate, although chronic low-grade infections can be subtle. Heterotopic ossification can cause pain and stiffness but is usually identifiable on X-ray as mature bone formation and does not typically present with component lucencies. Stress shielding is a radiographic finding (bone resorption around the implant) that contributes to loosening but is not the primary diagnosis. Component impingement would cause activity-related pain and potentially dislocation, but not the specific radiographic findings of widespread lucency and subsidence.

Question 4

A 72-year-old male with a history of hypertension and osteoporosis sustains a fall, resulting in a periprosthetic fracture of the femur around the stem of his 10-year-old cemented total knee arthroplasty. Radiographs reveal a Vancouver Type B2 fracture. What is the most appropriate management?





Explanation

A Vancouver Type B2 periprosthetic fracture involves a fracture around or distal to a stable femoral stem, with a loose femoral component. Given the described lucencies around the stem and the fracture, the femoral component is likely loose. Therefore, revision of the femoral component with a longer, cemented stem is the appropriate treatment, providing stability both proximally (by bypassing the fracture) and distally (by engaging healthy bone). Non-operative management is typically reserved for stable, non-displaced fractures (e.g., Vancouver Type C or some Type A). ORIF alone is insufficient as the component is loose. An uncemented stem might be considered in younger, healthier patients with good bone quality, but a cemented stem is often preferred in older patients with osteoporosis for immediate stability. Knee fusion is a salvage procedure typically reserved for failed revisions or severe infection.

Question 5

A 65-year-old female presents with chronic, debilitating shoulder pain and weakness, severely limiting her activities of daily living. Physical examination reveals pseudoparalysis, a positive shoulder shrug sign, and severe limitations in active range of motion, particularly elevation and external rotation. Radiographs show severe glenohumeral osteoarthritis and superior migration of the humeral head with complete absence of the rotator cuff. She has failed extensive conservative management. Which surgical option is most appropriate?





Explanation

The constellation of severe glenohumeral osteoarthritis, superior migration of the humeral head, pseudoparalysis, and complete absence of the rotator cuff (referred to as 'rotator cuff arthropathy') are classic indications for a reverse total shoulder arthroplasty (rTSA). Anatomic total shoulder arthroplasty relies on an intact rotator cuff for function and stability. Hemiarthroplasty might address pain but would not restore function in the setting of pseudoparalysis. Arthroscopic debridement and rotator cuff repair are not feasible for a complete, irreparable cuff tear with arthropathy. Shoulder fusion is a salvage procedure for younger, higher-demand patients or failed arthroplasty, and would severely limit motion.

Question 6

A 14-year-old obese male presents with a 3-month history of a painful limp and hip pain that radiates to his knee. He has limited internal rotation and abduction of the hip, and external rotation upon hip flexion (Drehmann sign). Radiographs of the hip show widening of the physis and posterior and inferior displacement of the epiphysis relative to the metaphysis. What is the most appropriate initial management?





Explanation

This clinical presentation is classic for Slipped Capital Femoral Epiphysis (SCFE), characterized by the Drehmann sign and radiographic findings. For stable SCFE, percutaneous pinning in situ with a single screw is the standard of care to prevent further slip and promote physeal closure. This approach minimizes complications and allows for early weight-bearing. Open reduction is reserved for unstable or severely displaced slips. Observation or casting is insufficient and risks progression. Traction and closed reduction are contraindicated due to the risk of avascular necrosis (AVN) as the slip is typically chronic and involves remodeling.

Question 7

A 3-month-old female is diagnosed with a dislocated left hip during a routine well-child check. The Ortolani sign is positive, and the Barlow sign is positive. There are no other abnormalities. What is the most appropriate initial treatment?





Explanation

For infants diagnosed with developmental dysplasia of the hip (DDH) under 6 months of age, especially with positive Ortolani and Barlow signs indicating a reducible, dislocatable hip, the Pavlik harness is the gold standard of treatment. It maintains the hips in a position of flexion and abduction, promoting concentric reduction and acetabular development. Surgical open reduction or osteotomies are reserved for failed harness treatment or later presentations. A hip spica cast may be used after a successful closed reduction for older infants, but the Pavlik harness is preferred initially for reducible hips in this age group. Observation is inappropriate for a dislocated hip.

Question 8

A 32-year-old construction worker presents with chronic wrist pain and tenderness in the anatomical snuffbox after falling onto an outstretched hand 6 months ago. Initial radiographs taken at an urgent care clinic were reported as normal, and he was treated conservatively with a wrist brace. Current radiographs show a sclerotic nonunion of the scaphoid at the waist with evidence of early degenerative changes in the radiocarpal joint. What is the most appropriate next step in management?





Explanation

The presence of chronic pain, tenderness in the anatomical snuffbox, and radiographic evidence of a sclerotic scaphoid nonunion with early degenerative changes (SNAC wrist) indicates the need for surgical intervention. Percutaneous screw fixation is not appropriate for established nonunions, especially with sclerosis. Given the presence of a nonunion and early degenerative changes, a vascularized or non-vascularized bone graft with internal fixation (e.g., screw or K-wires) is the standard treatment to achieve union and prevent progression of osteoarthritis. Continued conservative management has failed. Excision of the fragment is not a reconstructive option. Wrist arthrodesis is a salvage procedure for advanced radiocarpal arthritis after failed reconstruction.

Question 9

A 22-year-old amateur boxer punches a wall in frustration, sustaining a deformity and pain in his dominant right hand. Examination reveals swelling and tenderness over the fifth metacarpal head, with mild rotational deformity of the small finger. Radiographs show an angulated, irreducible fracture of the fifth metacarpal neck with dorsal angulation of 60 degrees. Which of the following is the most appropriate management?





Explanation

For an angulated, irreducible fifth metacarpal neck fracture (Boxer's fracture) with 60 degrees of dorsal angulation, closed reduction and ulnar gutter splinting is often the preferred initial treatment. The acceptable angulation for a fifth metacarpal neck fracture is typically up to 70 degrees due to the inherent mobility of the carpometacarpal joint. While 60 degrees is significant, it is often reducible, and stability can be achieved with an ulnar gutter splint. Surgical fixation (K-wires or plate) is reserved for unstable fractures, severe rotational deformity, or excessive angulation that cannot be reduced or maintained, especially in the fourth and fifth metacarpals, which tolerate more angulation than the second and third. Observation or buddy taping is insufficient for this degree of angulation and instability.

Question 10

A 35-year-old male sustains a crush injury to his foot after a heavy object falls on it. He complains of severe midfoot pain and inability to bear weight. Physical examination reveals swelling and ecchymosis over the dorsum of the foot, tenderness at the tarsometatarsal joints, and subtle widening of the interval between the first and second toes. Plain radiographs are equivocal, but a weight-bearing radiograph shows diastasis between the medial cuneiform and the base of the second metatarsal. What is the most appropriate definitive management?





Explanation

The clinical presentation and radiographic findings (diastasis between medial cuneiform and second metatarsal base) are highly suggestive of a Lisfranc injury. Given the instability and potential for long-term functional impairment, surgical intervention is almost always indicated for displaced or unstable Lisfranc injuries. ORIF with screws (across the medial and intermediate cuneiforms to the second metatarsal base, and other unstable joints) is the standard of care for acute, displaced injuries to restore anatomical alignment and stability. Non-weight bearing in a cast is for stable, non-displaced injuries. Primary arthrodesis may be considered for chronic or highly comminuted injuries, or if severe degenerative changes are already present. Excision of the second metatarsal base is not a standard treatment. Early weight-bearing with a walking boot is contraindicated.

Question 11

A 50-year-old male recreational athlete feels a sudden 'pop' in his right ankle while playing basketball. He experiences immediate pain and difficulty pushing off. Examination reveals a palpable gap approximately 5 cm proximal to the calcaneal insertion of the Achilles tendon. The Thompson test is positive. What is the most appropriate management for this acute injury?





Explanation

An acute Achilles tendon rupture, as described by the sudden pop, palpable gap, and positive Thompson test, requires definitive management. For an active, relatively young recreational athlete, surgical repair (either open or percutaneous) is generally recommended to restore strength, minimize re-rupture risk, and facilitate an earlier return to sports. While non-operative treatment can be successful in select low-demand patients, surgical repair is often preferred in active individuals. Percutaneous repair can be an option to minimize wound complications, but open repair is often considered the gold standard for robust repair. Non-weight bearing in a splint alone is not definitive. A long-leg cast is overly restrictive and may lead to stiffness. Corticosteroids are contraindicated as they weaken tendons.

Question 12

When performing an ACL reconstruction in a 25-year-old high-demand athlete, which of the following graft choices is associated with the highest rate of anterior knee pain post-operatively, but also excellent outcomes in terms of graft strength and re-rupture rates?





Explanation

The autologous patellar tendon (BTB) graft is widely considered the 'gold standard' for ACL reconstruction, especially in high-demand athletes, due to its strong bone-to-bone healing, predictable stiffness, and low re-rupture rates. However, it is also associated with the highest incidence of anterior knee pain (e.g., patellofemoral pain, patellar tendonitis, kneeling pain) and potential patellar fracture or patellar tendon rupture. Hamstring grafts have lower rates of anterior knee pain but can be associated with hamstring weakness and some loss of proprioception. Quadriceps tendon grafts offer a good compromise. Allografts carry risks of disease transmission and slower incorporation, and synthetic ligaments have largely fallen out of favor due to high failure rates and synovitis.

Question 13

A 30-year-old male sustains a bucket-handle tear of the medial meniscus. Arthroscopic examination confirms a displaced, reducible tear in the red-red zone (periphery) of the meniscus, measuring 3 cm in length, without significant chondral damage. What is the most appropriate management strategy?





Explanation

A displaced bucket-handle tear in the red-red zone (vascularized periphery) of the meniscus, especially in a young, active patient, is an ideal candidate for meniscal repair. Repair preserves meniscal tissue, which is crucial for joint load distribution and preventing osteoarthritis. Partial meniscectomy is indicated for irreparable tears or tears in the avascular zone. Total meniscectomy leads to accelerated degenerative changes. Microfracture is for chondral defects. Observation is inappropriate for a displaced, symptomatic tear.

Question 14

A 16-year-old male presents with persistent knee pain, swelling, and a palpable mass in the distal femur. Radiographs show a lytic, destructive lesion with a 'sunburst' periosteal reaction and Codman's triangle in the metaphysis of the distal femur. A biopsy confirms osteosarcoma. Which of the following is the most important prognostic factor for this patient?





Explanation

The most important prognostic factor in osteosarcoma is the response to neoadjuvant chemotherapy (percentage of tumor necrosis). A good histological response (typically >90% necrosis) is strongly correlated with improved overall survival and decreased recurrence rates. While the presence of pulmonary metastases at diagnosis (Stage IV disease) is a very poor prognostic indicator, the response to chemotherapy is a dynamic and critical factor in determining the effectiveness of treatment and guiding subsequent surgical and adjuvant therapy. Age, tumor location, and tumor size are less significant than the chemotherapy response.

Question 15

A 48-year-old male presents with worsening lower back pain, bilateral leg numbness, and progressive weakness, particularly in his quadriceps muscles. He describes his symptoms as being worse with standing and walking, and relieved by sitting or leaning forward (shopping cart sign). Physical examination reveals diminished patellar reflexes and weak knee extension bilaterally. MRI shows severe degenerative changes at L3-L4 and L4-L5 with significant narrowing of the spinal canal. What is the most appropriate initial management approach?





Explanation

The patient's symptoms (neurogenic claudication, 'shopping cart sign,' motor weakness, diminished reflexes) are classic for lumbar spinal stenosis. The initial management for symptomatic lumbar spinal stenosis, especially without acute neurological deficits (e.g., cauda equina syndrome), is typically conservative. This involves a trial of NSAIDs, activity modification, and physical therapy focused on flexion exercises to open the spinal canal, improve posture, and strengthen core muscles. Epidural steroid injections can provide temporary symptomatic relief. Surgical decompression and fusion are reserved for those who fail conservative management or develop progressive neurological deficits. Rigid bracing is generally not effective and can lead to muscle atrophy. Progressive resistance exercises are often part of physical therapy but not a standalone initial approach.

Question 16

A 60-year-old female presents with a 6-month history of progressive clumsiness, difficulty with fine motor tasks (e.g., buttoning shirts), and gait instability. She denies acute trauma. On examination, she has hyperreflexia in the lower extremities, a positive Babinski sign, and a wide-based, spastic gait. Sensory examination reveals decreased vibratory sensation in her feet. MRI of the cervical spine shows severe multilevel degenerative changes with cord compression at C5-C6 and C6-C7. What is the most appropriate management?





Explanation

The patient's symptoms and signs (clumsiness, fine motor difficulty, gait instability, hyperreflexia, Babinski sign, sensory deficits) are indicative of cervical myelopathy due to cord compression. This is a progressive neurological condition. Surgical decompression and stabilization (e.g., ACDF or laminoplasty) is the definitive treatment to halt progression of neurological deficits and, in some cases, achieve improvement. Conservative management, such as collars, physical therapy, or injections, does not address the underlying cord compression and is generally ineffective for established myelopathy; they may be considered for radiculopathy without myelopathy. Observation carries the risk of continued and potentially irreversible neurological decline.

Question 17

A 70-year-old male presents with worsening bowing of his right tibia and increasing warmth and pain in the affected leg. Radiographs show cortical thickening, bone expansion, and a 'blade of grass' or 'V-shaped' osteolytic front in the tibia. Serum alkaline phosphatase is significantly elevated, and urinary hydroxyproline levels are also high. What is the most appropriate initial pharmacological treatment?





Explanation

The clinical and radiographic findings, along with elevated alkaline phosphatase and urinary hydroxyproline, are characteristic of Paget's disease of bone. Bisphosphonates are the first-line treatment for symptomatic Paget's disease, as they inhibit osteoclast activity, reducing bone turnover, pain, and biochemical markers. Calcium and Vitamin D are general supplements but not specific treatments for Paget's. Teriparatide is an anabolic agent for severe osteoporosis. Calcitonin is less potent than bisphosphonates. Denosumab is also an anti-resorptive agent but typically reserved for cases where bisphosphonates are contraindicated or ineffective.

Question 18

A 5-year-old child presents with a high fever, refusal to bear weight on his left leg, and exquisite tenderness over the distal metaphysis of the left femur. Laboratory tests show elevated ESR, CRP, and WBC count. Radiographs initially appear normal. What is the most likely diagnosis, and what is the next most appropriate diagnostic step?





Explanation

The constellation of fever, refusal to bear weight, localized bony tenderness, and elevated inflammatory markers in a child is highly suggestive of acute osteomyelitis. While radiographs may initially be normal, MRI with contrast is the most sensitive and specific imaging modality to confirm the diagnosis, localize the infection, and assess for abscess formation. Septic arthritis presents with joint pain and refusal to bear weight but typically involves joint effusions and pain with range of motion. Transient synovitis is a diagnosis of exclusion, usually with lower inflammatory markers and no specific bony tenderness. Juvenile idiopathic arthritis is a chronic condition. A stress fracture would not present with acute fever and high inflammatory markers.

Question 19

A 16-year-old female is diagnosed with idiopathic scoliosis with a 42-degree thoracic curve (King Moe Type II) and a negative Risser sign (Grade 0). She is still growing. What is the most appropriate management plan?





Explanation

For adolescent idiopathic scoliosis, the management depends on curve magnitude and skeletal maturity. For a growing patient with a curve between 25-45 degrees, bracing (e.g., TLSO) is indicated to prevent curve progression. A 42-degree curve in a skeletally immature patient (Risser 0) falls within this range. Observation is for curves less than 25 degrees or skeletally mature patients with curves less than 45 degrees. Surgical correction is typically indicated for curves >45-50 degrees in growing patients or >50-60 degrees in skeletally mature patients. Physical therapy and chiropractic manipulation are not proven to halt curve progression.

Question 20

A 55-year-old female presents with persistent pain and decreased range of motion in her right shoulder. She describes weakness with overhead activities and difficulty sleeping on the affected side. Physical examination reveals tenderness over the greater tuberosity, a positive Neer's and Hawkins' impingement sign, and weakness with active abduction and external rotation against resistance. She has a positive 'drop arm' test. Radiographs show superior migration of the humeral head relative to the glenoid. What is the most likely diagnosis?





Explanation

The combination of chronic pain, weakness with overhead activities, positive impingement signs, a positive 'drop arm' test (indicating inability to hold the arm in abduction), and superior migration of the humeral head on radiographs are highly suggestive of a massive, irreparable rotator cuff tear. Adhesive capsulitis primarily presents with global stiffness. Calcific tendinitis typically has acute, severe pain. Rotator cuff tendinopathy would not typically have superior humeral head migration or a positive drop arm sign. Glenohumeral osteoarthritis would show joint space narrowing and osteophytes, which are not the primary findings described here, although it can be secondary to chronic massive cuff tears (rotator cuff arthropathy).

Question 21

A 78-year-old female falls onto her outstretched left hand. She presents with severe pain, swelling, and a 'dinner fork' deformity of her left wrist. Radiographs show a dorsally displaced and angulated fracture of the distal radius with involvement of the articular surface. The fracture is comminuted with significant dorsal tilt and shortening. What is the most important factor in determining the need for surgical intervention for this fracture?





Explanation

For distal radius fractures, the key radiographic parameters that dictate the need for surgical intervention are generally the amount of dorsal tilt (angulation), radial shortening, and articular step-off/gap. Significant dorsal angulation (e.g., >20 degrees), radial shortening (e.g., >3-5 mm), or articular step-off/gap (e.g., >2 mm) are indications for surgical stabilization, especially in active patients. While age and activity level are important in shared decision-making, these radiographic parameters are critical objective measures of fracture stability and potential for functional outcome. Comminution contributes to instability but the primary focus is on the resultant alignment. An associated ulnar styloid fracture is common but usually does not determine the need for distal radius surgery.

Question 22

A 40-year-old male sustains a high-energy fall directly onto his flexed knee, resulting in a tibial plateau fracture. CT scan reveals a Schatzker Type VI fracture with significant comminution, articular depression, and involvement of both medial and lateral condyles. There is concern for associated soft tissue injury and neurovascular compromise. What is the most appropriate management strategy?





Explanation

A Schatzker Type VI tibial plateau fracture is a high-energy, bicondylar fracture with significant soft tissue compromise and high complication rates. Given the significant soft tissue swelling and potential for neurovascular injury, immediate definitive ORIF is often contraindicated due to the risk of wound complications and compartment syndrome. The most appropriate initial management is typically external fixation as a temporizing measure to restore length, alignment, and reduce soft tissue swelling (ligamentotaxis). Definitive open reduction and internal fixation (ORIF) with dual plating is then performed in a staged manner, once the soft tissue envelope has improved, usually 7-14 days later. Closed reduction alone is insufficient for such a complex, unstable fracture. Arthrodesis or acute knee replacement are salvage options.

Question 23

A 28-year-old male polytrauma patient sustains a comminuted femoral shaft fracture, an ipsilateral open tibial shaft fracture, a pelvic ring injury, and a head injury. He is hemodynamically stable after initial resuscitation. What is the most appropriate management strategy for the femoral shaft fracture?





Explanation

In a polytrauma patient, damage control orthopedics principles are paramount. For a femoral shaft fracture in a patient with an ipsilateral open tibial fracture and a head injury, intramedullary nailing is generally the preferred definitive treatment. However, reamed nailing carries a risk of systemic inflammatory response (fat emboli, lung injury) which can exacerbate a head injury. Therefore, unreamed intramedullary nailing is often preferred in polytrauma patients, especially with head injuries or pulmonary compromise, as it minimizes intramedullary pressure and systemic insult, while still providing stable fixation. Immediate reamed nailing can be performed in stable patients without significant pulmonary or head injuries. External fixation can be used for temporary stabilization but requires a second surgery. Traction and cast immobilization are generally not preferred for adult femoral shaft fractures due to malunion and prolonged immobilization issues. Plate fixation is typically reserved for cases where nailing is not feasible or contraindicated.

Question 24

Which phase of bone healing is characterized by the formation of a soft callus by chondroblasts and fibroblasts, bridging the fracture gap?





Explanation

Bone healing traditionally involves several overlapping phases. The 'soft callus formation phase' (also known as the reparative or proliferation phase) immediately follows the inflammatory phase. During this phase, fibroblasts and chondroblasts proliferate, forming a fibrous and cartilaginous callus that bridges the fracture gap, providing initial stability. The inflammatory phase is characterized by hematoma formation and cell recruitment. The hard callus phase involves endochondral ossification and woven bone formation. The remodeling phase is the longest, replacing woven bone with lamellar bone. Revascularization occurs throughout these phases.

Question 25

A 38-year-old male with a history of psoriasis presents with inflammatory back pain, bilateral sacroiliac joint pain, and enthesitis at the Achilles tendon insertions. Radiographs of the pelvis show sacroiliitis. Genetic testing reveals positivity for HLA-B27. What is the most likely associated orthopedic manifestation requiring close monitoring?





Explanation

The patient's presentation (psoriasis, inflammatory back pain, sacroiliitis, enthesitis, HLA-B27 positivity) is highly characteristic of psoriatic arthritis (PsA) and other seronegative spondyloarthropathies, such as ankylosing spondylitis. Atlantoaxial subluxation is a serious orthopedic manifestation that can occur in these conditions, particularly in advanced cases, leading to cervical myelopathy if left untreated. Gout is characterized by monosodium urate crystal deposition. Rheumatoid arthritis typically involves small joints of the hands and feet, is often seropositive for RF/anti-CCP, and has a different systemic profile. Osteonecrosis can be associated with corticosteroid use, but not directly with PsA. Charcot arthropathy is neuropathic and related to loss of sensation.

Question 26

A 60-year-old male with a history of alcohol abuse presents with acute, severe pain, swelling, and redness in his right first metatarsophalangeal (MTP) joint. Synovial fluid aspiration reveals needle-shaped, negatively birefringent crystals. What is the most appropriate initial pharmacological treatment for the acute attack?





Explanation

The clinical presentation and presence of needle-shaped, negatively birefringent crystals in the synovial fluid are diagnostic of acute gouty arthritis. For an acute attack, the primary goal is rapid pain and inflammation control. Colchicine, NSAIDs, and corticosteroids (such as oral prednisone or intra-articular injection) are the mainstays of acute treatment. Allopurinol, febuxostat, and probenecid are urate-lowering therapies used for long-term management to prevent recurrent attacks, but they are generally contraindicated during an acute flare as they can paradoxically worsen the attack by mobilizing urate crystals.

Question 27

A 45-year-old female office worker presents with 6 months of worsening numbness and tingling in her right thumb, index, middle, and radial half of the ring finger, particularly at night. She reports dropping objects and difficulty with fine motor tasks. Physical examination reveals a positive Phalen's test and Tinel's sign at the wrist, and thenar atrophy. What is the most appropriate next step in management after failed conservative treatment (splinting, NSAIDs)?





Explanation

The patient's symptoms and signs are highly classic for Carpal Tunnel Syndrome (CTS). Given that conservative management (splinting, NSAIDs) has failed, a corticosteroid injection into the carpal tunnel is the next appropriate step. This provides diagnostic confirmation if symptoms improve and often provides significant, albeit temporary, relief, potentially delaying or obviating surgery. EMG/NCS are useful for confirming diagnosis and severity but are not typically the next step after failed non-invasive conservative treatment. Cervical or wrist MRI are generally not indicated unless there are atypical symptoms or concerns for other pathology. Surgical carpal tunnel release is indicated if non-operative measures, including injections, fail or if there is severe, unrelenting nerve compression with motor deficits.

Question 28

A 68-year-old male presents with chronic pain and paresthesias along the medial aspect of his elbow and forearm, extending into his ring and small fingers. He reports weakness in grip strength and difficulty with fine motor movements. Examination reveals a positive Tinel's sign at the cubital tunnel, atrophy of the intrinsic muscles of the hand (e.g., first dorsal interosseous), and impaired two-point discrimination in the small finger. What is the most likely diagnosis?





Explanation

The symptoms (paresthesias in ring/small fingers, grip weakness, intrinsic muscle atrophy, positive Tinel's at the elbow) and signs are classic for ulnar nerve entrapment at the elbow, also known as cubital tunnel syndrome. Carpal tunnel syndrome affects the median nerve distribution (thumb, index, middle, radial half of ring finger). Cervical radiculopathy can mimic these symptoms but would typically have neck pain and different reflex findings. Ulnar nerve entrapment at the wrist (Guyon's canal) typically spares the dorsal ulnar sensory branch, which supplies the dorsal aspect of the small finger and ulnar half of the ring finger. Radial tunnel syndrome affects the radial nerve and presents with lateral elbow pain and forearm weakness.

Question 29

A 58-year-old obese female presents with a progressive, painful flatfoot deformity of her right foot. She reports swelling and tenderness along the medial ankle, particularly posterior to the medial malleolus. Examination reveals a 'too many toes' sign, hindfoot valgus, and inability to perform a single-leg heel raise. The patient can actively invert her foot against resistance when non-weight-bearing, but loses the arch upon weight-bearing. What is the most likely diagnosis?





Explanation

The patient's presentation of a progressive, painful flatfoot with 'too many toes' sign, hindfoot valgus, inability to perform a single-leg heel raise, and tenderness along the posterior tibial tendon are all hallmarks of adult acquired flatfoot deformity due to Posterior Tibial Tendon Dysfunction (PTTD). The ability to actively invert non-weight-bearing but collapse on weight-bearing suggests a flexible deformity. Spring ligament rupture can contribute to or result from PTTD. Tarsal coalition is usually diagnosed in childhood/adolescence as a rigid flatfoot. Charcot arthropathy is neuropathic. Plantar fasciitis causes heel pain, not typically a progressive flatfoot deformity with tendon dysfunction.

Question 30

A 6-year-old child falls from a tree, sustaining a supracondylar humerus fracture. The arm is markedly swollen, and the radial pulse is absent. The hand is cool and pale, but the child can still move his fingers. What is the most appropriate immediate management?





Explanation

An absent radial pulse with a pale and cool hand, despite some finger movement (which indicates viable median nerve function at that moment), in the context of a supracondylar humerus fracture is a medical emergency. This suggests compromise of the brachial artery. While some surgeons might attempt a gentle closed reduction first, the safest and most definitive immediate management for a pulseless but still viable hand is emergent surgical exploration of the brachial artery to restore perfusion. Delaying this can lead to Volkmann's ischemic contracture. Closed reduction and pinning would ideally precede this but not with an absent pulse and ischemia. Applying a cast in full extension is incorrect. Traction is not the most immediate or definitive solution for arterial compromise.

Question 31

A 10-year-old male sustains a fall, resulting in a fracture through the growth plate and a small metaphyseal fragment attached to the epiphysis of the distal tibia. Radiographs demonstrate an oblique fracture line extending from the physis into the metaphysis. Which Salter-Harris classification type best describes this fracture?





Explanation

The Salter-Harris classification describes physeal fractures. A Type II fracture is the most common and involves a fracture line through the physis and extending into the metaphysis, leaving a triangular metaphyseal fragment attached to the epiphysis (Thurston-Holland sign). Type I is a fracture 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. The description clearly matches Type II.

Question 32

A 25-year-old male presents with a painful, enlarging mass over his distal femur. Radiographs show a lytic lesion with a 'soap-bubble' appearance, located eccentrically in the epiphysis, extending into the metaphysis. Histological biopsy reveals multinucleated giant cells and mononuclear stromal cells. What is the most appropriate definitive surgical management to minimize local recurrence rates?





Explanation

The clinical, radiographic (eccentric epiphyseal-metaphyseal lytic lesion with 'soap-bubble' appearance), and histological findings (multinucleated giant cells) are classic for a Giant Cell Tumor (GCT) of bone. GCTs are locally aggressive with a high recurrence rate after simple curettage. The most appropriate definitive surgical management to minimize local recurrence, especially for active lesions (Campanacci Stage II or III), is intralesional curettage combined with adjuvant therapy (e.g., cryosurgery, phenol, argon beam coagulation, or high-speed burr) and bone grafting or cementation. This adjuvant therapy kills residual tumor cells. En bloc resection with wide margins is typically reserved for recurrent tumors, very aggressive lesions, or those that have breached the cortex. Radiation therapy is used for unresectable lesions. Amputation is a last resort.

Question 33

A 60-year-old diabetic male undergoes an open reduction and internal fixation of a distal tibia fracture. Six months post-operatively, he presents with persistent drainage from the surgical site, pain, and erythema. Plain radiographs show sequestrum formation and involucrum. Laboratory markers indicate mildly elevated CRP, but ESR is normal. A deep tissue culture grows Staphylococcus aureus. What is the most appropriate definitive management for this chronic osteomyelitis?





Explanation

The presence of persistent drainage, radiographic evidence of sequestrum and involucrum, and a positive deep tissue culture confirm chronic osteomyelitis. For chronic osteomyelitis, surgical debridement (including sequestrectomy, removal of infected hardware, and debridement of necrotic bone), followed by reconstruction (e.g., bone grafting, muscle flaps if needed) and prolonged targeted antibiotic therapy (intravenous initially, then oral) is the cornerstone of definitive treatment. Long-term oral antibiotics alone are insufficient due to the presence of devitalized bone and biofilm. Amputation is a salvage procedure. Hyperbaric oxygen therapy is an adjunct, not a standalone definitive treatment.

Question 34

A 30-year-old female sustains a high-energy motor vehicle collision, resulting in a fracture of the L1 vertebra. She was wearing a lap belt only. Radiographs show a horizontal fracture through the vertebral body, pedicles, and spinous process, with distraction of the posterior elements. Neurological examination is intact. This fracture pattern is best described as what type of injury?





Explanation

The description of a horizontal fracture through the vertebral body, pedicles, and spinous process with distraction of the posterior elements, typically associated with a lap belt injury, is the classic description of a Chance fracture (also known as a flexion-distraction injury). These are highly unstable fractures involving all three columns of the spine. A burst fracture involves axial compression causing vertebral body comminution. A wedge compression fracture involves anterior compression. Fracture-dislocation implies more severe displacement and instability. Transverse process fractures are generally stable and not typically associated with lap belt injuries.

Question 35

A 75-year-old female falls at home and sustains a displaced femoral neck fracture. She undergoes an uncemented hemiarthroplasty. Six weeks post-operatively, while attempting to sit in a low chair, she experiences sudden, severe hip pain and shortening of the limb, with the leg held in internal rotation. What is the most likely diagnosis?





Explanation

The clinical presentation of sudden, severe hip pain, limb shortening, and the classic post-dislocation position (internal rotation, adduction, flexion for posterior dislocation; external rotation, abduction, flexion for anterior dislocation) after a total hip or hemiarthroplasty strongly suggests prosthetic dislocation. Posterior dislocation is the most common type after THA, often occurring with combined hip flexion, adduction, and internal rotation. Periprosthetic infection or aseptic loosening usually presents with more insidious onset pain. A periprosthetic fracture would likely show distinct radiographic changes. Heterotopic ossification causes stiffness and pain, not acute mechanical instability.

Question 36

A 65-year-old male with a history of osteoarthritis underwent a total knee arthroplasty 5 years ago. He now complains of increasing knee pain, especially with activity. Radiographs show subsidence of the tibial component, lucency greater than 2mm around the cement-bone interface of both components, and signs of polyethylene wear. Inflammatory markers are normal. What is the most likely diagnosis?





Explanation

The combination of increasing pain with activity, radiographic evidence of component subsidence, and lucency greater than 2mm around the cement-bone interface in multiple zones of both components, along with polyethylene wear, are classic signs of aseptic loosening of a total knee arthroplasty. Normal inflammatory markers further support an aseptic etiology. Periprosthetic joint infection would typically present with elevated inflammatory markers, though chronic low-grade infections can be subtle. Patellofemoral pain syndrome is specific to the patellofemoral joint. Extensor mechanism rupture is an acute, dramatic event. Adhesive capsulitis is more common in the shoulder and would present with global stiffness.

Question 37

A 28-year-old baseball pitcher presents with chronic shoulder pain, especially during the late cocking phase of throwing. He describes a 'dead arm' sensation and clicking. Examination reveals tenderness at the posterior-superior glenoid, a positive O'Brien's test (active compression test), and a positive Speed's test. MRI shows a superior labral anterior-posterior (SLAP) tear extending into the biceps anchor. What is the most appropriate management for this high-level overhead athlete?





Explanation

For a high-level overhead athlete with a symptomatic SLAP tear (especially Type II or IV involving the biceps anchor) confirmed by MRI and clinical examination, arthroscopic SLAP repair is generally the most appropriate treatment to restore stability and function for throwing activities. Conservative management may be attempted initially but is often unsuccessful in athletes with mechanical symptoms. Arthroscopic debridement is reserved for degenerative or stable tears without significant biceps involvement. Biceps tenodesis is typically considered for older, less active patients or when the biceps anchor is significantly diseased/degenerate, as it removes the biceps from the glenoid and alters shoulder kinematics. Subacromial decompression addresses impingement, not a labral tear.

Question 38

A 45-year-old male presents with chronic lateral elbow pain, worsened by gripping and lifting. He is a carpenter and reports increased pain with using a hammer or screwdriver. Examination reveals tenderness over the lateral epicondyle and pain elicited by resisted wrist extension and resisted forearm supination. Radiographs are normal. What is the most effective initial non-surgical treatment?





Explanation

The patient's symptoms and signs are classic for lateral epicondylitis (tennis elbow). The most effective initial non-surgical treatment typically involves activity modification, NSAIDs for pain relief, and a structured physical therapy program emphasizing eccentric strengthening of the wrist extensor muscles (e.g., extensor carpi radialis brevis). While corticosteroid injections can provide short-term pain relief, they have been shown to have worse long-term outcomes and potential for tendon degeneration. PRP and shockwave therapy are second-line treatments with variable evidence. Surgical debridement is reserved for refractory cases that fail prolonged conservative management.

Question 39

A 60-year-old male presents with progressive flexion contractures of his ring and small fingers, making it difficult to put his hand in his pocket or wear gloves. He has a history of Scandinavian descent and no prior trauma. Examination reveals palpable cords and pits in the palm, with fixed flexion contractures of 40 degrees at the MCP joint of the ring finger and 30 degrees at the PIP joint of the small finger. What is the most appropriate indication for surgical intervention in this case?





Explanation

This patient has Dupuytren's contracture. The traditional indication for surgical intervention (e.g., fasciectomy, needle aponeurotomy) is a positive 'Tabletop test,' meaning the patient cannot place their palm flat on a table. This correlates with significant functional impairment and generally indicates a MCP joint contracture of 30 degrees or more, or any significant PIP joint contracture (often 20 degrees or more due to the more debilitating effect on function). A palpable cord alone without significant contracture is not an indication. Difficulty with fine motor tasks is a symptom, but the Tabletop test is the objective measure.

Question 40

A 3-month-old male is diagnosed with congenital clubfoot (talipes equinovarus) of his right foot. Physical examination reveals a rigid deformity with hindfoot varus and equinus, midfoot adduction, and forefoot supination that cannot be passively corrected. What is the gold standard initial treatment method?





Explanation

For congenital clubfoot, the Ponseti method of serial manipulation and casting is the universally accepted gold standard initial treatment. This non-surgical approach involves gentle stretching and casting over several weeks to gradually correct the deformity, often followed by a percutaneous Achilles tenotomy and then bracing (foot abduction orthosis). Surgical correction is typically reserved for severe, rigid, or recurrent deformities after failure of the Ponseti method. Observation, simple stretching, or fixed AFOs alone are inadequate for the correction of true clubfoot.

Question 41

A 30-year-old male suffers a severe crush injury to his right calf. He complains of increasing pain disproportionate to the injury, especially with passive stretching of the toes. On examination, the calf is tense and swollen, and there is pain with passive dorsiflexion of the ankle. Pulses are palpable, and sensation is intact. What is the most appropriate next step in management?





Explanation

The clinical presentation (severe crush injury, pain disproportionate to injury, pain with passive stretching, tense compartment, intact pulses and sensation) is highly suspicious for acute compartment syndrome. Although sensation and pulses may initially be intact, these are late signs. The most appropriate next diagnostic step is to measure compartment pressures. If pressures are elevated above a critical threshold (e.g., within 30 mmHg of diastolic blood pressure, or absolute pressure >30 mmHg), an emergent fasciotomy is indicated. Delay in diagnosis and treatment can lead to irreversible muscle and nerve damage. Other options like elevation, ice, analgesics, or dressings are inappropriate and will delay definitive treatment. MRI is not an emergency diagnostic tool for acute compartment syndrome.

Question 42

A 68-year-old female with known breast cancer presents with new onset severe, dull pain in her left hip and thigh, worse at night and with weight-bearing. Radiographs show a lytic lesion involving the subtrochanteric region of the left femur, with cortical thinning and impending fracture. What is the most appropriate initial management for this metastatic bone lesion?





Explanation

For a painful, impending pathological fracture of the femur secondary to metastatic disease, particularly in the weight-bearing subtrochanteric region, prophylactic surgical stabilization (e.g., intramedullary nailing) is often indicated to prevent fracture and improve pain control. The Mirels' score can help guide this decision, but a painful lytic lesion in a weight-bearing bone with cortical thinning typically warrants stabilization. Radiation therapy is often effective for pain control and local tumor control but may not be sufficient to prevent fracture in an impending lesion. Systemic chemotherapy addresses the underlying cancer but not the immediate structural integrity of the bone. Bisphosphonates are used to reduce skeletal-related events but do not acutely prevent impending fracture. Non-weight-bearing and observation risk fracture progression.

Question 43

A 48-year-old male presents with worsening right shoulder pain and weakness for the past 6 months. He denies trauma. Physical examination reveals a positive impingement sign, painful arc of motion, and weakness with external rotation against resistance. MRI shows a full-thickness rotator cuff tear of the supraspinatus tendon, measuring 1.5 cm. There is no significant fatty infiltration or muscle atrophy. What is the most appropriate management for this active, non-throwing patient?





Explanation

For an active patient with a symptomatic, full-thickness rotator cuff tear, especially a relatively small (1.5 cm) tear with good tissue quality (no significant fatty infiltration or atrophy), surgical repair is generally recommended to restore function, relieve pain, and prevent tear enlargement. Arthroscopic repair is the gold standard approach, offering less morbidity than open repair while achieving comparable outcomes. Conservative management (PT, injections) may be attempted but often fails to provide lasting relief in full-thickness tears. Hemiarthroplasty is for advanced cuff tear arthropathy.

Question 44

Which of the following describes the optimal indication for using an uncemented femoral stem in a total hip arthroplasty?





Explanation

Uncemented femoral stems rely on biological fixation (bone ingrowth) for long-term stability. Therefore, they are optimally indicated in younger, active patients with good bone quality who have the biological capacity for bone ingrowth into the porous-coated surface of the implant. Elderly patients with severe osteoporosis and poor bone quality often benefit from cemented stems for immediate mechanical interlock and stability. Revision surgery for aseptic loosening often considers uncemented options, but 'optimal indication' refers to primary surgery. Early full weight-bearing might be achieved with a good press-fit, but cemented stems generally allow for more immediate full weight-bearing in certain scenarios due to immediate mechanical stability.

Question 45

A 6-year-old child presents with a limp, mild hip pain, and limited hip abduction and internal rotation. Radiographs are normal. The child has no fever, and inflammatory markers (ESR, CRP) are normal. What is the most likely diagnosis?





Explanation

The presentation of a limp, mild hip pain, limited motion, normal radiographs, absence of fever, and normal inflammatory markers in a 6-year-old child is highly characteristic of transient synovitis of the hip. This is a self-limiting inflammatory condition. Septic arthritis would typically present with high fever, marked pain, severe limitation of motion, and elevated inflammatory markers. Legg-Calvé-Perthes disease would show characteristic changes on radiographs (e.g., flattening of the femoral head) or MRI. SCFE typically affects older, often obese adolescents. Proximal femoral focal deficiency is a congenital malformation.

Question 46

A 30-year-old male sustains a spiral fracture of the mid-shaft tibia and fibula in a skiing accident. There is minimal displacement, and the skin is intact. What is the most appropriate definitive management for this isolated tibia fracture?





Explanation

For an isolated, closed, stable, spiral mid-shaft tibial fracture with minimal displacement, reamed intramedullary nailing is generally considered the gold standard of treatment in adults. It provides excellent stability, allows for early weight-bearing, and has predictable union rates. Closed reduction and cast immobilization can be used for very stable, non-displaced fractures, but nailing offers faster rehabilitation and superior biomechanical properties for a mid-shaft injury. Unreamed nailing is preferred for open fractures or patients with compartment syndrome/polytrauma. Plate fixation is typically reserved for non-union, malunion, or fractures unsuitable for nailing (e.g., proximal/distal metaphysis). External fixation is often a temporizing measure for open or highly comminuted fractures.

Question 47

A 5-year-old child presents with a 2-month history of a painless limp. Examination reveals limited hip abduction and internal rotation, and a positive Trendelenburg sign. Radiographs show increased density (sclerosis) and flattening of the femoral epiphysis. What is the most appropriate initial management?





Explanation

The clinical picture (painless limp, limited abduction/internal rotation, Trendelenburg sign) and radiographic findings (sclerosis and flattening of the femoral epiphysis) are classic for Legg-Calvé-Perthes disease (LCPD), which is osteonecrosis of the femoral head in children. The primary goal of management is to maintain the femoral head containment within the acetabulum while it revascularizes and remodels. Initial management usually involves observation with activity modification (avoiding high-impact activities), protected weight-bearing, and possibly bracing or casts to maintain abduction and internal rotation, especially for younger children or those with less severe involvement. Urgent MRI confirms the diagnosis and extent but is not the initial management. Epiphysiodesis or other surgeries are reserved for specific stages or to contain the femoral head when conservative measures fail. NSAIDs alone only address symptoms.

Question 48

A 70-year-old female presents with acute, severe pain in her right knee, accompanied by warmth, swelling, and redness. She is afebrile. Synovial fluid aspiration reveals rhomboid-shaped, positively birefringent crystals. What is the most likely diagnosis?





Explanation

The presence of rhomboid-shaped, positively birefringent crystals in the synovial fluid is diagnostic of calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, commonly known as pseudogout. Gout is characterized by needle-shaped, negatively birefringent crystals. Septic arthritis requires ruling out with cell count and culture, but crystal findings point away from it. Rheumatoid arthritis is a chronic inflammatory polyarthritis, and an acute flare would not typically show these crystals. Osteoarthritis is degenerative and does not typically involve crystal deposition unless it's a co-existing condition.

Question 49

A 62-year-old male presents with a chronic, non-healing ulcer on his left heel. He has a history of type 2 diabetes with peripheral neuropathy. Examination reveals a deep, infected ulcer over the plantar aspect of the calcaneus with surrounding cellulitis. Radiographs show diffuse bony destruction and disorganization of the midfoot and hindfoot joints. What is the most appropriate management of the underlying bony pathology?





Explanation

The patient's history (diabetes, neuropathy), clinical presentation (non-healing ulcer, cellulitis), and radiographic findings (bony destruction and disorganization of midfoot/hindfoot joints) are classic for a Charcot arthropathy (neuropathic osteoarthropathy) complicated by infection. While strict offloading with a total contact cast and antibiotics are crucial for managing the acute infection and preventing progression, definitive management of the underlying bony pathology in a stable, non-infected Charcot foot often involves surgical reconstruction and internal fixation to stabilize the joints, correct deformity, and facilitate wound healing, especially when conservative measures fail or deformity is severe. Amputation is a salvage procedure. Surgical debridement of the ulcer alone does not address the underlying bony instability. Aggressive glycemic control is important but not a direct treatment for the structural foot deformity.

Question 50

A 12-year-old female presents with right shoulder pain and swelling. Radiographs show a lytic lesion in the proximal humerus with a narrow zone of transition and a well-defined sclerotic rim. There is no periosteal reaction. A biopsy reveals fibrous tissue with giant cells and hemosiderin deposition. What is the most likely diagnosis?





Explanation

The radiographic appearance (lytic lesion, narrow zone of transition, well-defined sclerotic rim, no periosteal reaction) and histological features (fibrous tissue, giant cells, hemosiderin) are characteristic of an Aneurysmal Bone Cyst (ABC). ABCs are benign, expansile, lytic bone lesions, often seen in children and adolescents. Osteosarcoma and Ewing sarcoma are malignant and would typically present with a wide zone of transition, aggressive periosteal reaction ('sunburst' or 'onion skin'), and different histological findings. Non-ossifying fibroma is typically a cortical lesion in the metaphysis. Fibrous dysplasia has a 'ground glass' appearance.

Question 51

Which of the following interventions has been shown to be most effective in reducing the risk of subsequent contralateral Slipped Capital Femoral Epiphysis (SCFE) in a patient diagnosed with a unilateral stable SCFE?





Explanation

For patients diagnosed with unilateral stable Slipped Capital Femoral Epiphysis (SCFE), the risk of developing SCFE in the contralateral hip is significant (reported between 20-60%), especially in younger patients and those with endocrine disorders. Prophylactic pinning of the contralateral asymptomatic hip is often recommended, particularly in skeletally immature patients, to prevent the contralateral slip. While weight loss and activity modification are important for overall health, they are not proven to prevent contralateral slips as effectively as prophylactic pinning. Bisphosphonates are not indicated. Regular MRI surveillance would detect a slip, but not prevent it.

Question 52

A 4-year-old child presents with a progressive antalgic gait and external rotation deformity of the right leg. Physical examination reveals limited hip abduction and internal rotation, and a positive Galeazzi sign (unequal knee height when hips and knees are flexed to 90 degrees with feet flat on table). Radiographs confirm Developmental Dysplasia of the Hip (DDH) with a dislocated right hip. What is the most appropriate initial treatment in this older child?





Explanation

For a 4-year-old child with a confirmed dislocated hip due to DDH, a Pavlik harness is ineffective due to the child's age and rigidity of the tissues. An abduction brace would also be insufficient. At this age, the hip dislocation is often irreducible by closed means, and there are likely significant adaptive changes in the acetabulum and proximal femur. Therefore, open reduction with possible concomitant pelvic osteotomy (to improve acetabular coverage) or femoral osteotomy (to correct femoral anteversion or valgus) is typically required to achieve and maintain concentric reduction. Observation or physical therapy alone would lead to progressive deformity and functional limitations.

Question 53

A 55-year-old male undergoes arthroscopic ACL reconstruction using an autologous hamstring graft. Two months post-operatively, he complains of anterior knee pain and crepitus with knee flexion. Examination reveals localized tenderness over the patellar tendon insertion and pain with resisted knee extension. Radiographs are normal. What is the most likely diagnosis?





Explanation

The symptoms of anterior knee pain, crepitus, and catching with flexion after ACL reconstruction, especially at 2 months post-op, are classic for a Cyclops lesion. This is a nodule of fibrous tissue that forms anterior to the ACL graft in the intercondylar notch, causing impingement and blocking full extension. Patellar tendinopathy is less common with hamstring grafts, and graft failure would usually present with instability. Arthrofibrosis would present with more global stiffness and loss of range of motion. An MCL sprain would cause medial knee pain and instability.

Question 54

Which type of fracture pattern of the talar neck is associated with the highest risk of avascular necrosis (AVN) of the talar body?





Explanation

Hawkins classification for talar neck fractures is based on the degree of dislocation of the subtalar and ankle joints, and it correlates with the risk of avascular necrosis (AVN) of the talar body. Type III fractures (talar neck fracture with dislocation of the subtalar and ankle joints) have the highest risk of AVN, approaching 90-100%, because both major blood supplies to the talar body (from the tarsal sinus/canal and deltoid branch) are disrupted. Type I has no displacement (0-15% AVN), Type II has subtalar dislocation (20-50% AVN), and Type IV involves dislocation of the talonavicular joint in addition to Type III (also very high AVN risk, often grouped with Type III for highest risk).

Question 55

A 68-year-old male with a history of chronic kidney disease and hypertension presents with shoulder pain and weakness. Imaging reveals extensive calcific deposits within the rotator cuff tendons, particularly the supraspinatus. What is the most likely underlying metabolic etiology?





Explanation

The presence of extensive calcific deposits within the rotator cuff tendons, especially in a patient with chronic kidney disease, is highly suggestive of secondary hyperparathyroidism. Chronic kidney disease leads to impaired phosphate excretion and decreased vitamin D activation, resulting in hypocalcemia, which stimulates parathyroid hormone (PTH) release. High PTH levels can cause ectopic calcification in soft tissues, including tendons. Gout involves urate crystals. CPPD deposition (pseudogout) can cause calcific tendinitis, but hyperparathyroidism is a more direct cause in CKD. Oxalosis is rare. Milwaukee shoulder syndrome involves basic calcium phosphate crystals leading to rapid destructive arthropathy, often in older females.

Question 56

A 28-year-old male sustains an open comminuted fracture of the distal tibia and fibula (Pilon fracture). After initial irrigation and debridement, external fixation is applied. What is the most critical factor to assess before proceeding with definitive open reduction and internal fixation?





Explanation

For Pilon fractures, especially open or high-energy injuries, the soft tissue envelope is crucial. Definitive ORIF is typically delayed until the soft tissue swelling has subsided, indicated by the presence of a 'wrinkle sign' in the skin. This minimizes the risk of devastating wound complications such as necrosis, dehiscence, and deep infection. Complete resolution of pain/swelling is desirable but the wrinkle sign is the most objective indicator. Normalization of inflammatory markers is important for infection but less critical for soft tissue readiness. Early fracture healing is not expected. Superficial pin site infections should be managed, but do not necessarily delay definitive fixation if the soft tissues are ready.

Question 57

A 72-year-old female presents with severe pain and deformity of her right wrist following a fall. Radiographs show a volar displaced, comminuted fracture of the distal radius. This fracture pattern is best described as what?





Explanation

A Smith's fracture is a fracture of the distal radius with volar (anterior) displacement of the distal fragment. It is often referred to as a 'reverse Colles' fracture. A Colles' fracture involves dorsal displacement. A Barton's fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint (dorsal or volar). A Chauffeur's fracture (Hutchinson fracture) is an oblique fracture of the radial styloid. A Galeazzi fracture involves a fracture of the radial shaft with dislocation of the distal radioulnar joint (DRUJ).

Question 58

Which of the following describes a key biomechanical advantage of reverse total shoulder arthroplasty (rTSA) in patients with rotator cuff arthropathy?





Explanation

The primary biomechanical advantage of the reverse total shoulder arthroplasty (rTSA) in rotator cuff arthropathy is that it medializes and distalizes the center of rotation of the shoulder joint. This significantly increases the deltoid muscle's moment arm, allowing the deltoid to compensate for the absent or dysfunctional rotator cuff and effectively elevate the arm. Anatomic TSA restores the normal center of rotation. rTSA does not reconstruct the torn rotator cuff. It increases, rather than reduces, the deltoid's role. It does not improve external rotation by tensioning the infraspinatus, which is absent/non-functional; rather, external rotation can be limited.

Question 59

A 4-year-old child presents with a limp, knee pain, and difficulty bearing weight. Radiographs show a small, irregular appearance of the medial femoral condyle. The child has no history of trauma, fever, or inflammatory markers. What is the most likely diagnosis?





Explanation

Osteochondritis dissecans (OCD) commonly presents in children and adolescents with knee pain, limp, and mechanical symptoms. Radiographic findings of an irregular appearance or fragmentation of the medial femoral condyle are characteristic. While the exact etiology is unknown, it involves avascular changes in the subchondral bone. Juvenile idiopathic arthritis would present with more diffuse joint swelling and inflammatory markers. Septic arthritis would involve acute pain, fever, and markedly elevated inflammatory markers. Blount's disease affects the proximal tibia, causing bowing. Osgood-Schlatter disease causes pain at the tibial tubercle, typically in older adolescents.

Question 60

Which of the following is the most appropriate indication for surgical stabilization of a chronically painful symptomatic os trigonum?





Explanation

An os trigonum is an accessory ossicle posterior to the talus, usually fused by age 7-10. Symptomatic os trigonum, often causing posterior ankle impingement, typically presents with chronic posterior ankle pain exacerbated by forced plantarflexion (e.g., ballet dancers). Surgical excision is indicated only after failure of conservative management (rest, NSAIDs, injections). Acute ankle sprains might reveal an os trigonum, but it's not the primary pathology. Asymptomatic ossicles do not warrant surgery. Anterior ankle impingement involves anterior osteophytes. Recurrent Achilles tendinitis is a separate pathology, though it can co-exist.

Question 61

A 22-year-old football player sustains an injury to his knee during a tackle, resulting in a large hemarthrosis. Examination reveals a positive Lachman test and pivot shift test. MRI confirms a complete tear of the anterior cruciate ligament (ACL) and a medial meniscal tear. What is the optimal timing for ACL reconstruction in this patient?





Explanation

For an acute ACL tear, especially with an associated meniscal tear, the optimal timing for reconstruction is typically delayed until the acute inflammation has subsided, and the patient has regained a near-full range of motion, usually 3-6 weeks post-injury. Early surgery (within 1-2 weeks) is associated with a significantly higher risk of arthrofibrosis (stiff knee syndrome). Waiting for full range of motion allows the knee to 'cool down,' improving surgical outcomes and rehabilitation potential. Delaying for 3 months or waiting for recurrent instability might be options for less active patients, but not typically for a football player aiming for return to sport.

Question 62

Which of the following is the most accurate radiographic sign for diagnosing an unstable slipped capital femoral epiphysis (SCFE)?





Explanation

While all options except 'absence of palpable pulse' are relevant to SCFE, the definition of an unstable SCFE is the inability to bear weight on the affected extremity, even with crutches. This clinical finding distinguishes unstable from stable SCFE and carries a significantly higher risk of complications, particularly avascular necrosis. Radiographic signs like physeal widening, positive Klein's line (metaphysis not intersecting the epiphysis), and posterior/inferior displacement are characteristic of SCFE but do not differentiate between stable and unstable slips. A palpable pulse is generally present, as vascular compromise is a complication, not a defining characteristic of instability.

Question 63

A 35-year-old male with a history of intravenous drug use presents with acute onset back pain and fever. He has tenderness to palpation over the L4-L5 vertebral bodies. Laboratory tests show elevated ESR, CRP, and WBC count. MRI of the lumbar spine reveals fluid collection and enhancement consistent with discitis and vertebral osteomyelitis at L4-L5. What is the most appropriate initial management?





Explanation

The patient's presentation (fever, back pain, tenderness, IV drug use, elevated inflammatory markers, MRI findings) is highly suspicious for bacterial discitis and vertebral osteomyelitis. The most appropriate initial management, after confirming the diagnosis with imaging, is to obtain a percutaneous biopsy for culture and histology. This identifies the causative organism, allowing for targeted intravenous antibiotic therapy. While surgical debridement and stabilization may eventually be necessary for neurological deficits, spinal instability, or failed medical management, it is not the immediate first step. Long-term oral antibiotics alone are insufficient. Radiation therapy is for malignancy.

Question 64

A 50-year-old female presents with a chronic, painful swelling over the anterior aspect of her knee. She is a housekeeper and frequently kneels. Examination reveals a fluctuant, non-tender mass anterior to the patella. There is no warmth or redness. Aspiration yields clear, viscous fluid. What is the most likely diagnosis?





Explanation

The patient's history (occupational kneeling), location of swelling (anterior to the patella), and physical examination (fluctuant, non-tender mass, no warmth/redness, clear aspirate) are classic for aseptic prepatellar bursitis, often called 'housemaid's knee.' Septic bursitis would present with warmth, redness, significant tenderness, and purulent aspirate. Infrapatellar tendinitis (Jumper's knee) causes pain at the inferior pole of the patella, not a fluctuant mass. Osteochondroma is a bony tumor. A ganglion cyst is less common in this location and typically firm.

Question 65

Which of the following is the primary indication for surgical intervention in patients with hallux valgus deformity?





Explanation

The primary indication for surgical correction of hallux valgus (bunion deformity) is symptomatic pain that significantly interferes with daily activities or shoe wear, and has failed conservative management. While radiographic angles (HVA, IMA) and shoe-fitting difficulties are important considerations, pain is the overarching factor that drives the decision for surgery. Cosmetic improvement alone is generally not considered a primary indication for elective orthopedic surgery due to potential complications. Hammertoe is an associated deformity but not the primary indication for bunion surgery.

Question 66

A 6-month-old infant is found to have an irreducible, complete dislocation of the radial head. The forearm is in pronation and flexion, and there is limited supination. Radiographs confirm radial head dislocation and an abnormal radial head configuration. The child has no other obvious deformities. What is the most likely underlying condition?





Explanation

The description of an irreducible, complete radial head dislocation with an abnormal radial head configuration in a 6-month-old infant, without history of trauma (implying congenital), is characteristic of congenital radial head dislocation. Nursemaid's elbow is a subluxation of the radial head that is usually reducible and occurs after a pull injury. A Monteggia fracture-dislocation involves a fracture of the ulna with radial head dislocation, typically traumatic. Madelung's deformity involves dorsal subluxation of the distal ulna with premature physeal closure of the distal radius. Olecranon fracture is a traumatic elbow injury.

Question 67

Which of the following biomaterials used in total hip arthroplasty (THA) has historically been most associated with osteolysis due to particulate wear debris?





Explanation

Ultra-high molecular weight polyethylene (UHMWPE) has historically been the leading cause of osteolysis in total hip arthroplasty. Wear debris generated from the polyethylene acetabular liner (articulating with a metal or ceramic femoral head) stimulates a macrophage-mediated inflammatory response that leads to bone resorption (osteolysis) and subsequent aseptic loosening. While metal-on-metal implants have also been associated with adverse tissue reactions and osteolysis from metal ion release, polyethylene was the predominant material associated with osteolysis in earlier generations of THA. Ceramic and metal alloys are used for the femoral head and stem, but polyethylene is the primary bearing surface responsible for wear-induced osteolysis.

Question 68

A 65-year-old male with severe shoulder pain and crepitus undergoes a total shoulder arthroplasty. Intraoperatively, the surgeon notes significant glenoid bone loss and a deficient rotator cuff. Which type of glenoid component is contraindicated in this scenario?





Explanation

In anatomic total shoulder arthroplasty, a metallic-backed glenoid component (with a polyethylene liner) requires robust glenoid bone stock for long-term fixation and stability. Its use is contraindicated in cases of significant glenoid bone loss, as seen with severe glenoid erosion from osteoarthritis or in patients with deficient rotator cuffs, where superior migration of the humeral head can lead to eccentric loading and early failure. All-polyethylene pegged or keeled components are more commonly used in patients with good bone stock. For significant glenoid bone loss and deficient rotator cuff, a reverse total shoulder arthroplasty is typically indicated, which uses a metallic glenosphere. Resurfacing components are for limited indications.

Question 69

A 16-year-old male presents with chronic anterior knee pain, worse with activity and stair climbing. Examination reveals generalized knee laxity, a positive apprehension test, and J-sign. Radiographs are normal. What is the most likely diagnosis?





Explanation

The patient's age, chronic anterior knee pain, pain with activity, generalized knee laxity, a positive apprehension test (indicating fear of patellar dislocation), and J-sign (lateral patellar tracking during knee extension) are all characteristic of recurrent patellar instability (subluxation or dislocation). Patellar tendinopathy causes pain at the inferior pole of the patella. Osgood-Schlatter disease causes pain at the tibial tubercle. Chondromalacia patellae is a descriptive term for cartilage softening and is often a symptom, not a diagnosis. Plica syndrome presents with medial knee pain and snapping.

Previous ChapterOrthopedic Board Prep: MCQ Practice & Systematic Exam Answe… Next Chapter Examiner: How Would You Ace Your Hip Viva? Expert Answers
Dr. Mohammed Hutaif
Medically Verified Content by
Prof. Dr. Mohammed Hutaif
Consultant Orthopedic & Spine Surgeon
Chapter Index
    Back to Master Guide