Question 1

You are referred a 68-year-old man who smokes 40 cigarettes per day and has had chronic cough for the past 6 months, increasingly associated with haemoptysis. He also has a dull ache on the left side of his chest, and his chest X-ray reveals a left hilar mass that is suspicious of bronchial carcinoma. You are considering radical radiotherapy in this man. Which of the following is the most significant contraindication to radical radiotherapy?

Explanation

Correct Answer: C- Malignant pleural effusion Explanation Malignant pleural effusion Studies have shown that the presence of a malignant pleural effusion is predictive of poor outcome with radical radiotherapy. Adenocarcinoma Adenocarcinoma is incorrect. Adenocarcinoma is not a contraindication to radical radiotherapy. Forced expiratory volume in 1 s (FEV1) < 60% Forced expiratory volume in 1 s (FEV1) < 60% is incorrect. It was previously thought that patients with a forced expiratory volume in 1 s (FEV1) of less than 50% were at particular risk of post-radiotherapy pneumonitis, but it has been shown that some patients enrolled in radical radiotherapy trials with severe disease actually showed a small improvement in lung function. Superior vena caval obstruction Superior vena caval (SVC) obstruction is incorrect. SVC obstruction and position of the tumour adjacent to the hilum can increase surgical difficultly, but targeted radiotherapy might not be a problem in the majority of patients. Tumour adjacent to the hilum Tumour adjacent to the hilum is incorrect. Tumour adjacent to the hilum is not a contraindication to radical radiotherapy.

Question 2

A patient presents with symptoms suggesting bronchiectasis and with abdominal distension, bloating and foul-smelling faeces. What is the most likely diagnosis?

Explanation

Correct Answer: B- Cystic fibrosis Explanation Cystic fibrosis The United States Cystic Fibrosis Foundation Registry data show that as many as 10% of people with cystic fibrosis are not diagnosed until adult life. The main presentation is with respiratory problems, usually recurrent lower respiratory infections with chronic sputum production. Some patients have been diagnosed in the past with bronchiectasis, atypical asthma, nasal polyposis or allergic bronchopulmonary aspergillosis. A new diagnosis of cystic fibrosis has even been described in adults in their seventh decade. Depletion of sodium, chloride and potassium due to excessive sweating, and secondary renal chloride retention, can result in presentation with dehydration and heat exhaustion in an otherwise apparently completely fit adult. Pancreatic insufficiency can lead to steatorrhoea. The vast majority of patients with cystic fibrosis can be diagnosed by a sweat test. Carcinoma of the lung Carcinoma of the lung is incorrect. Lung carcinoma would typically present with breathlessness, cough, weight loss, chest pain or haemoptysis. The history here suggests bronchiectasis and intestinal malabsorption, which are not typical presenting features of lung malignancy. Goodpasture syndrome Goodpasture syndrome is incorrect. Bronchiectasis and intestinal malabsorption are not associated with Goodpasture syndrome, making this an unlikely diagnosis based on the history provided. Granulomatosis with polyangiitis Granulomatosis with polyangiitis is incorrect. Bronchiectasis and intestinal malabsorption are not associated with granulomatosis with polyangiitis. This diagnoses is unlikely based on this history. Pneumococcus pneumonia Pneumococcus pneumonia is incorrect. There is clearly more going on in this case than an acute pneumonia. The history given is of bronchiectasis, not an uncomplicated pneumonia. Pneumococcal pneumonia is not associated with intestinal malabsorption.

Question 3

A 50-year-old sales representative with a body mass index (BMI) of 34 kg/m2 is referred to the Sleep Clinic because he keeps falling asleep at the wheel. His wife complains that he keeps her awake all night with his snoring. A sleep study confirms moderate sleep apnoea. He has been warned not to return to driving until he has been treated and his symptoms are under control. Which one of the treatments below would be the most appropriate management in this case?

Explanation

Correct Answer: A- Continuous positive airway pressure Explanation Continuous positive airway pressure Obstructive sleep apnoea is caused by loss of upper airway pharyngeal muscle tone during rapid eye movement (REM) sleep, which leads to airway obstruction and consequent apnoeic episodes. It affects 1–2% of middle-aged men. CPAP is an effective treatment for sleep apnoea and should be offered (alongside weight loss and alcohol reduction) to this patient. Long-term oxygen therapy Long-term oxygen therapy is incorrect. Long-term oxygen therapy is really only an adjunct in patients who have co-existent lung conditions. Mandibular advancement splinting Mandibular advancement splinting is incorrect. Many trials have looked at the effectiveness of mandibular advancement splints (a tailor-made mouthpiece which helps to keep the jaw forward and aids upper airway muscle tone when asleep). Mandibular advancement splints are recommended as second-line therapy where patients tolerate them or can be used as a first-line treatment in mild sleep apnoea.

Pharyngeal wall surgery

Pharyngeal wall surgery is incorrect. Surgery is really a last-ditch attempt to solve the problem. Tracheostomy Tracheostomy is incorrect. Tracheostomy is not used to treat sleep apnoea.

Question 4

A 56-year-old man with confirmed squamous-cell carcinoma of the right upper lobe of the lung has a normal FEV1 and normal serum biochemistry. Which one of the following investigations is most appropriate to assess operability?

Explanation

Correct Answer: B- Chest computed tomography Explanation Chest computed tomography Chest computed tomography is the best method for staging squamous-cell carcinoma of the lung. This would indicate the extent of involvement and would inform the surgical approach. Five-year survival rates are > 75% in stage I disease (no nodes, tumour confined within the visceral pleura) and 55% in stage II disease, which includes resection in patients with ipsilateral peribronchial or hilar node involvement. Bone scan Bone scan is incorrect. A bone scan is not required as there is no clinical, haematological or biochemical evidence of tumour spread to bony sites. Differential perfusion lung scan Differential perfusion lung scan is incorrect. Differential perfusion lung scans are not helpful in staging. Measurement of total lung capacity Measurement of total lung capacity is incorrect. Measurement of total lung capacity is not helpful in staging. Sputum cytology Sputum cytology is incorrect. Sputum cytology is irrelevant, as the diagnosis has already been established.

Question 5

The anatomical dead space can be used to calculate alveolar ventilation by subtracting it from the tidal volume and multiplying the result by the respiratory rate. What would you expect the normal anatomical dead space to be in a healthy adult male?

Explanation

Correct Answer: B-150 ml Explanation 150 ml This is a know it or you don’t question. The normal anatomical dead space is approximately 150 ml. If we take the tidal volume to be about 500 ml and the respiratory rate to be about 15/min, this gives a normal alveolar ventilation of (500 – 150) × 15 = 5250 ml/min. The dead space can be increased in diseases that cause an additional physiological dead space, where parts of lung do not take part in gas exchange (eg pneumonia). 50 ml 50ml is incorrect. The normal anatomical dead space is approximately 150ml in a healthy adult. 250 ml 250ml is incorrect. The normal anatomical dead space is approximately 150ml, but dead space may be abnormally increased in diseases where parts of the lung do not take part in gas exchange. 350 ml 350ml is incorrect. Total dead space is the sum of anatomical dead space and alveolar dead space. This can be increased with conditions such as pulmonary embolism and low cardiac output. 450 ml 450ml is incorrect. The normal value for dead space volume (in mL) is approximately the lean mass of the person in pounds and is approximately a third of the resting tidal volume (between 400-500ml in an adult).

Question 6

A 62-year-old housewife presents with a 2-month history of lethargy associated with shortness of breath. She has never smoked and takes no medication. Her chest X-ray shows multiple round lesions, increasing in size and numbers at the base, and bulky hilar lymph nodes. Urine testing reveals 2+ haematuria, but no protein. What is the most likely diagnosis?

Explanation

Correct Answer: B- Pulmonary metastases Explanation Pulmonary metastases This lady is likely to have a primary renal cell carcinoma with pulmonary metastases. Multiple metastases range enormously in size and number, from ‘cannon balls’ to miliary shadowing, and can be accompanied by hilar lymphadenopathy or pleural effusion. The most common underlying tumours are breast, colon, renal and lung primaries, but other tumours (that are amenable to chemotherapy) can metastasise to the lung, such as testicular cancer and choriocarcinoma. Diagnosis can be achieved by cytology or histology on various samples from the pleura or lung, and can occasionally be made from cytology of expectorated or induced sputum. Lung abscesses Lung abscesses is incorrect. Lung abscesses are rounded lesions, but air/fluid levels would be visible. There are also no infective symptoms described here, making lung abscesses unlikely. Rib fractures Rib fractures is incorrect. No part in the description of this case is suggestive of rib fractures. Silicosis Silicosis is incorrect. Silicosis is characterised by pulmonary nodules, but these are usually small and predominantly affect the upper lobes. Silicosis is not associated with haematuria. Hilar nodes classically show ‘eggshell’ calcification. Tuberculosis Tuberculosis is incorrect. Tuberculosis can present with lung lesions, lymphadenopathy and lethargy; however, the description of the lesions as round with increasing size and numbers at the base is more in keeping with lung metastases. There is no mention of fever, night sweats or productive cough. If renal TB was suspected it is likely there would be proteinuria as well as haematuria.

Question 7

A 30-year-old woman with a history of asthma presents for review. She has been taking 400 µg bd of beclometasone and salbutamol as required, which she is using with increasing frequency. What is the best-fit next change to her therapy?

Explanation

Correct Answer: D- Trial of monteleukast Explanation Trial of monteleukast In the event that control of symptoms isn’t achieved with lower doses of inhaled corticosteroids, addition of a leukotriene receptor antagonist such as monteleukast is preferred. In the event a trial of therapy is not successful, then a long-acting beta-2 agonist should be introduced. Add in a long-acting inhaled ß2-agonist Add in a long-acting inhaled ß2-agonist is incorrect.

Although this was formerly the recommended next step in NICE guidelines, a trial of leukotriene receptor antagonist is now preferred. In the event the trial is unsuccessful then a long-acting inhaled beta-2-agonist should be introduced. Change her inhaled steroid to fluticasone Change her inhaled steroid to fluticasone is incorrect. Changing her steroid is not appropriate management here, she requires additional therapy. Do nothing Do nothing is incorrect. This lady has uncontrolled asthma on her current regimen. She therefore requires a change in her management. Increase her regular repeat prescriptions for salbutamol Increase her regular repeat prescriptions for salbutamol is incorrect. Salbutamol should be used as rescue therapy and in well-controlled asthma should not need to be used more than a few times a week. If salbutamol is required for relief of symptoms more than this then maintenance treatment should be ‘stepped up’ as per BTS/SIGN guidelines. This lady would benefit from Montelukast, (as per the NICE 2017 guidelines).

Question 8

A 62-year-old man who underwent treatment for tuberculosis 8 years ago presents via his GP complaining of haemoptysis. He also says that over the past 3 months he has had night sweats on a few occasions each week and a chronic cough. He smokes ten cigarettes per day. On examination he is mildly pyrexial (37.4°C) and his blood pressure is 142/89 mmHg. Auscultation of the chest reveals evidence of consolidation affecting the right upper lobe. Investigations show: haemoglobin 11.9 g/dl, white cell count 11.1 × 109/l, platelets 190 × 109/l,

sodium 138 mmol/l, potassium 4.8 mmol/l, creatinine 105 μmol/l. The chest X-ray shows a right upper-lobe cavitating lesion. Aspergillus precipitins are positive. Which of the following is the most likely diagnosis?

Explanation

Correct Answer: B- Aspergilloma Explanation Aspergilloma Aspergilloma is known to occur in patients who have had previous cavitating lung disease, such as tuberculosis. It is associated with positive Aspergillus precipitins. Surgical resection is successful as long as the patient’s preoperative lung function is good enough to tolerate the procedure. Other treatment options include chronic long- term therapy with antifungals such as itraconazole or locally delivered amphotericin B. If bleeding becomes severe, selective bronchial artery embolisation may be considered. Allergic bronchopulmonary aspergillosis Allergic bronchopulmonary aspergillosis is incorrect. Allergic bronchopulmonary aspergillosis would be associated with more widespread, patchy shadowing. It presents with symptoms akin to asthma and also expectoration of mucous plugs. Investigations would show a raised eosinophil count, raised total IgE and raised IgE to Aspergillus. Invasive aspergillosis Invasive aspergillosis is incorrect. Invasive aspergillosis tends to occur in patients who are immunocompromised due to immunosuppressive therapy, haematological malignancy or HIV infection. It is rapidly fatal if untreated and even with intravenous antifungal therapy mortality is high. Lung cancer Lung cancer is incorrect. The history here is more suggestive of infection than malignancy. Reactivated tuberculosis Reactivated tuberculosis is incorrect. Reactivated tuberculosis is a reasonable differential diagnosis, but given the positive Aspergillus precipitins and the presence of a cavity, aspergilloma is more likely.

Question 9

A 35-year-old woman with recently diagnosed primary pulmonary hypertension asks you some questions regarding treatment options. She is awaiting transfer to a specialist centre for right heart catheterisation. Which of the following is true?

Explanation

Correct Answer: C- She will benefit from taking long- term anticoagulation with warfarin Explanation She will benefit from taking long-term anticoagulation with warfarin All patients with primary pulmonary hypertension (PPH, a syndrome of pulmonary hypertension of unknown aetiology) are at risk of thromboembolic disease. Several uncontrolled studies have suggested a survival benefit from anticoagulation, although no randomised controlled trials exist. She will be able to have children, as long as she is carefully monitored She will be able to have children, as long as she is carefully monitored is incorrect. Pregnancy is poorly tolerated in patients with PPH. She will benefit from taking lisinopril She will benefit from taking lisinopril is incorrect. Angiotensin-converting enzyme (ACE) inhibitors have no useful effect in PPH. She will benefit from taking the oral contraceptive pill She will benefit from taking the oral contraceptive pill is incorrect. Oral contraceptives increase the risk of venous thromboembolism, so are not advised; however, contraception is very important in management of PPH due to pregnancy being poorly tolerated. She will benefit from taking verapamil She will benefit from taking verapamil is incorrect. Vasodilator studies are performed in patients with PPH to assess vasodilator response. However, verapamil is not used because it has negatively inotropic effects.

Question 10

A 25-year-old man suffers a spontaneous pneumothorax which is aspirated in the Emergency Department. He has no history of previous chest disease, but is noted to be tall and thin when reviewed in the department, at over 6 feet in height with a BMI of 20. He wants to go travelling, including undertaking a scuba diving course in Thailand. What advice do you give him?

Explanation

Correct Answer: D- He should never scuba dive again Explanation He should never scuba dive again British Thoracic Society guidelines state that patients who have had spontaneous pneumothorax should avoid scuba diving in the future unless they are treated by bilateral surgical pleurectomy and associated with normal lung function and thoracic CT scan performed after surgery. This is because of the risk of significant expansion of pneumothorax during diving ascent. He can scuba dive after 3 months He can scuba dive after 3 months is incorrect. British Thoracic Society guidelines state that patients who have had spontaneous pneumothorax should avoid scuba diving in the future unless they are treated by bilateral surgical pleurectomy and associated with normal lung function and thoracic CT scan performed after surgery. This is because of the risk of significant expansion of pneumothorax during diving ascent. He can scuba dive after 6 months He can scuba dive after 6 months is incorrect. British Thoracic Society guidelines state that patients who have had spontaneous pneumothorax should avoid scuba diving in the future unless they are treated by bilateral surgical pleurectomy and associated with normal lung function and thoracic CT scan performed after surgery. This is because of the risk of significant expansion of pneumothorax during diving ascent. He may fly again after one year He may fly again after 1 year is incorrect. Medical guidelines suggest that patients may fly as little as 5 days after a treated pneumothorax, as long as a check X-ray proves that air has been successfully reabsorbed and lung expansion has been restored. He should not fly again but may scuba dive within 4 weeks He should not fly again but may scuba dive within 4 weeks is incorrect. Medical guidelines suggest that patients may fly as little as 5 days after a treated pneumothorax, as long as a check X-ray proves that air has been successfully reabsorbed and lung expansion has been restored.

Question 11

A 25-year-old smoker of five cigarettes per day comes to the clinic complaining of recurrent haemoptysis that he has had for the past 2 years. He has been treated for intermittent cough and respiratory infections over the past few years. On examination he looks a little thin but is otherwise well. Respiratory examination raises the suggestion of left upper-lobe collapse. There are no other abnormal findings.

Investigation:

Hb 11.9 g/dl

WCC 5.9 x 109/l

PLT 187 x 109/l

Sodium 141 mmol/l

Potassium 4.2 mmol/l

Creatinine 110 µmol/l The chest X-ray shows left upper-lobe collapse. Which of the following is the most likely diagnosis?

Explanation

Correct Answer: A- Bronchial carcinoid Explanation Bronchial carcinoid Recurrent haemoptysis with segmental collapse is a typical presentation of bronchial carcinoid. The prolonged clinical course, without features of carcinoid syndrome, is typical of a bronchial carcinoid tumour. Bronchial carcinoma Bronchial carcinoma is incorrect. Because this patient is relatively well and has limited chest disease, bronchial carcinoid is much more likely than a carcinoma. Bronchiectasis Bronchiectasis is incorrect. No features suggest that there is active infection, which makes both left upper-lobe pneumonia and bronchiectasis unlikely. Inhaled foreign body Inhaled foreign body is incorrect. An inhaled foreign body would be more likely to lie in the right main bronchus and so does not fit with the clinical scenario here. Left upper-lobe pneumonia Left upper-lobe pneumonia is incorrect. No features suggest that there is active infection, which makes both left upper-lobe pneumonia and bronchiectasis unlikely.

Question 12

A 67-year-old patient with non-small-cell lung cancer complains of difficulty breathing, coughing and swelling of his face, neck, upper body and arms. Superior vena cava syndrome is diagnosed. Which of the following treatments is most likely to be successful in giving early relief of symptoms?

Explanation

Correct Answer: D- Radiotherapy Explanation Radiotherapy Superior vena cava syndrome (SVCS) is a collection of symptoms caused by the partial blockage of the vein that carries blood from the head, neck, chest and arms to the heart. Symptoms can include difficulty breathing, coughing and swelling of the face, neck, upper body and arms. In rare instances patients complain of hoarseness, chest pain, difficulty swallowing and coughing up blood.

Physical signs of SVCS include swelling of the neck or chest veins, collection of fluid in the face or arms, and rapid breathing. In patients with SVCS secondary to non-small-cell carcinoma of the lung, radiotherapy is the primary treatment of choice. The likelihood of patients benefiting from such therapy is high, but the overall prognosis of these patients is poor. The fractionation schedule for radiotherapy usually includes two to four large initial fractions of 3–4 Gy, followed by daily delivery of conventional fractions of 1.5–2 Gy, up to a total dose of 30–50 Gy. The radiation dose depends on tumour size and radioresponsiveness. The radiation field should include a 2 cm margin around the tumour. Anti- hypertensive drugs Anti-hypertensive drugs is incorrect. Anti-hypertensive therapy will have no influence on the underlying cause of SVCS and is not a key part of immediate management. Chemotherapy Chemotherapy is incorrect. SVC stenting may provide relief of severe symptoms for patients while the histologic diagnosis of the malignancy causing the obstruction is being actively pursued. It may also be indicated in patients in whom chemotherapy or radiation has failed. Corticosteroids Corticosteroids is incorrect. Corticosteroids and diuretics are often used to relieve laryngeal or cerebral oedema related to SVCS, although documentation of their efficacy is questionable. Radiotherapy is the most likely of the options given to be successful in giving early relief of symptoms. Surgery Surgery is incorrect. Surgery for SVCS (surgical bypass) is rarely performed and is generally reserved for patients with advanced intrathoracic disease who have not responded to non-surgical treatments such as radiotherapy, chemotherapy and stenting.

Question 13

A man came in to the Emergency Department with breathlessness and anterior chest pain. Chest X- ray showed a large pneumothorax on the right side, with midline shift away from the side of the pneumothorax. His pulse was 95 bpm and blood pressure was 95/70 mmHg. What should be done next?

Explanation

Correct Answer: E- Wide-bore cannula inserted through second intercostal space mid-clavicular line Explanation Wide-bore cannula inserted through second intercostal space mid-clavicular line This man has a large pneumothorax with mediastinal shift and significant symptoms. In the presence of midline shift, the most appropriate initial management would be needle decompression, with placement of an intravenous cannula in the second intercostal space. This should be followed later by placement of a formal chest drain. This is the course of management recommended by British Thoracic Society guidelines. Chest drain insertion Chest drain insertion is incorrect. The midline shift and hypotension indicate tension pneumothorax, which requires immediate needle decompression prior to intercostal drain insertion. Chest drain insertion under radiographic control Chest drain insertion under radiographic control is incorrect. A large pneumothorax should not require radiographic guidance. Nevertheless, this man has signs of tension pneumothorax and requires immediate needle decompression. Needle aspiration in the mid-axillary line Needle aspiration in the mid-axillary line is incorrect. The appropriate site for needle aspiration in tension pneumothorax is the second intercostal space in the mid- clavicular line. Repeat chest X-ray after a few hours Repeat chest X-ray after a few hours is incorrect. This man has evidence of a tension pneumothorax, which is a life-threatening condition and requires urgent intervention with needle decompression.

Question 14

A 33-year-old man presents with increasing symptoms of severe breathlessness on exercise. Up until the last few months he had been holding down a job as a successful salesman. There is a history of smoking 8–10 cigarettes per day. His father died at a young age (under 50) of severe chest disease. Routine blood tests reveal that this patient is mildly jaundiced with a bilirubin of 90 µmol/l; his aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are also outside the normal range. Chest X-ray reveals basal emphysema. Which diagnosis best fits this clinical picture?

Explanation

Correct Answer: A- α1-Antitrypsin deficiency Explanation α1-Antitrypsin deficiency This man, who is under 40 years of age, presents with breathlessness and with radiographic evidence of emphysema. Cigarette smoking acts synergistically to promote the development of emphysema. Hereditary α1- antitrypsin deficiency accounts for around 2% of cases of emphysema. Around 75% of patients with α1-antitrypsin deficiency develop chest pathology and around 15% of patients have associated cirrhosis, the likely diagnosis in this case. Patients with hepatic decompensation might be offered liver transplantation; those with chest pathology are strongly advised to stop smoking. Around one in ten northern Europeans carry a gene mutation for this deficiency. Heterozygotes may be at increased risk of lung disease if they smoke; homozygotes are pre-disposed to presentation with early emphysema. Chronic obstructive pulmonary disease secondary to excessive smoking Chronic obstructive pulmonary disease secondary to excessive smoking is incorrect. The smoking history is not excessive here. Basal emphysema is classically associated with α1-antitrypsin deficiency, which is one clue that this case is not just smoking-related COPD. Also, COPD due to excessive smoking would not explain the hepatic dysfunction that ths man has (which is another feature suggestive of α1-antitrypsin deficiency). Cirrhosis Cirrhosis is incorrect. Cirrhosis could explain abnormal liver function, but would not explain the basal emphysema that this gentleman has, despite his fairly modest smoking history and young age. Gilbert syndrome Gilbert syndrome is incorrect. Gilbert syndrome is associated with elevated bilirubin. It is not associated with elevated liver enzymes, nor is it associated with emphysema. Stress Stress is incorrect. Stress cannot explain his emphysema or his abnormal liver function tests.

Question 15

You see a 70-year-old woman in the clinic with chronic obstructive pulmonary disease. She currently smokes 10 cigarettes per day and is breathless when walking around her house and garden. She has an FEV1 of 1.2 litres (40% predicted) and an FVC of 2.0 litres (50% predicted). She had minimal bronchodilator reversibility following nebulised salbutamol. Her oxygen saturations are 93% on air and she takes salbutamol only as needed. What would be the next treatment option for her?

Explanation

Correct Answer: B- Long-acting anticholinergic inhaler Explanation Long-acting anticholinergic inhaler This woman has severe chronic obstructive pulmonary disease (COPD) on the evidence of her spirometry and is now symptomatic. Clearly she needs to stop smoking, but the next treatment would be a long-acting anticholinergic inhaler or high-dose inhaled corticosteroids combined with a long-acting β-2 agonist Inhaled steroids as monotherapy Inhaled steroids as monotherapy is incorrect. Inhaled steroids are used in COPD but not as montherapy, only in combination with a long-acting bronchodilator. Long-term domiciliary oxygen Long-term domiciliary oxygen is incorrect. She does not fulfil the requirements for long-term oxygen therapy because she smokes and her oxygen saturations indicate her pO2 is likely > 7.3 kPa. Oral leukotriene-receptor antagonist Oral leukotriene-receptor antagonist is incorrect. Oral leukotriene-receptor antagonists are not used in the management of COPD. Oral theophylline Oral theophylline is incorrect. Oral theophylline is used, but only after adequate inhaled therapy is established. Oral theophyllines are favoured less in recent COPD management guidelines.

Question 16

A 58-year-old man comes to the Emergency Department. He has been treated at home with nebulisers and oral steroids for a chronic obstructive pulmonary disease (COPD) exacerbation but continues to deteriorate. When you see him he has been in the department for 30 min and is on his third salbutamol nebuliser. On examination he looks tired and cyanosed. He has poor air entry and wheeze on auscultation of his chest. Arterial blood gasses on 24% O2 (turned down from 28% 15 min earlier) pO2 8.0 kPa

PCO2 9.2 kPa

pH 7.2 15 min earlier

pO2 8.2 kPa

pCO2 8.5 kPa

pH 7.31 Which of the following is the next appropriate management step?

Explanation

Correct Answer: D- Non-invasive positive pressure ventilation Explanation Non-invasive positive pressure ventilation This patient has CO2 retention, hypoxia and respiratory acidosis, which has worsened over the past 15 min, despite reducing his inspired O2. As such the next logical option is NIPPV as he is not responding to medical therapy. Doxapram Doxapram is incorrect. Although doxapram is a respiratory stimulant it is inferior to NIPPV in terms of outcomes. Further nebulisers Further nebulisers is incorrect. The patient has already deteriorated despite 3 nebulisers. He requires help with his ventilator requirements via NIPPV as the next most appropriate step. Intubation and ventilation Intubation and ventilation is incorrect. Intubation and ventilation may be considered if the patient fails to respond to NIPPV.

Sodium bicarbonate

Sodium bicarbonate is incorrect. Sodium bicarbonate will not affect his CO2 retention and may exacerbate fluid retention.

Question 17

A 65-year-old man complains of lethargy, fever, dry cough, headache, chest pain and increasing shortness of breath. He returned from a cruise 2 days ago. His chest X-ray shows bilateral consolidation and his Po2 is 8.35 kPa. What is the most likely diagnosis?

Explanation

Correct Answer: A- Legionella pneumonia Explanation Legionella pneumonia Legionella infection is the cause of around 2–5% of cases of community-acquired pneumonia admitted to hospital, although there is wide geographical and seasonal variation. Infection tends to lead to moderate or severe infection rather than mild illness, and most patients require hospital admission within 5–7 days of the start of symptoms. The incubation period is usually 2–10 days, with a mean of 7 days; males are two to three times more frequently affected than females. Infection at the extremes of age is rare and the highest incidence is in the 40- to 70-year-old age group, with a mean age of 53 years. People especially at risk include:

• Cigarette smokers • Alcoholics • Diabetics • People with a chronic illness • People receiving corticosteroids or immunosuppressive therapy Consequently, the type of patient who requires admission to hospital is particularly at risk from a nosocomial source. Typically, the illness starts fairly abruptly with high fever, shivers, severe headache and muscle pains. Upper respiratory tract symptoms, herpes labialis and skin rashes are uncommon. The cough is usually dry initially, but dyspnoea is common and the illness often progresses quickly. Sometimes there is a history of a recent hotel holiday abroad or a stay in hospital, which can alert the clinician to the possible diagnosis. The patient commonly looks toxic and ill, with a high fever over 39 °C. Confusion and delirium or diarrhoea can dominate the clinical picture, masking the true diagnosis of pneumonia. Focal neurological signs, particularly of a cerebellar type, have been described. Amnesia on recovery is common. Pulmonary embolism Pulmonary embolism is incorrect. This situation clearly describes a case of pneumonia with fever and bilateral consolidation on chest radiography. Therefore, pulmonary embolism is unlikely. Sarcoidosis Sarcoidosis is incorrect. This situation clearly describes a case of pneumonia with fever and bilateral consolidation on chest radiography. Therefore, sarcoidosis is unlikely. Small-cell carcinoma of the lung Small-cell carcinoma of the lung is incorrect. This situation clearly describes a case of pneumonia with fever and bilateral consolidation on chest radiography. Therefore, small-cell carcinoma of the lung is unlikely. Tuberculosis Tuberculosis is incorrect. The history indicates respiratory infection and hence, although tuberculosis is a possibility, Legionella pneumonia is more likely given the dry cough, headache and travel history, where he may have been exposed to a large-scale air conditioning system and complex potable water systems.

Question 18

A 72-year-old former coal-miner visits you for review. He reports having frequently worked at the coal face in cramped conditions, with exposure to a large volume of coal dust. He says he has had increasing symptoms of cough and shortness of breath over the past few years, but continues to smoke 10–15 cigarettes per day. His chest X-ray reveals a large number of small, round opacities within the lung fields, with almost complete obscuration of normal lung markings. Which diagnosis fits best with this clinical picture?

Explanation

Correct Answer: D- Category 3 pneumoconiosis Explanation Category 3 pneumoconiosis The severity of X-ray changes described here suggests category 3 (the most severe) form of pneumoconiosis. The 0–3 classification is defined by the international labour organisation and reflects an increasing density of small opacities on the chest radiograph. Asthma Asthma is incorrect. The abnormal chest X-ray appearances and occupational history given make pneumoconiosis more likely than asthma. Category 1 pneumoconiosis Category 1 pneumoconiosis is incorrect. Category 1 pneumoconiosis is the least severe, with fewer opacities and normal lung markings clearly visible. Category 2 pneumoconiosis Category 2 pneumoconiosis is incorrect. Category 2 pneumoconiosis is less severe, with a number of opacities but normal lung markings still visible. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is incorrect. Although he could have some smoking- related COPD, his chest X-ray is diagnostic in the presence of his occupational history of category 3 pneumoconiosis.

Question 19

A 42-year-old salesman was admitted with a diagnosis of pneumonia. His chest X-ray showed a hazy opacity in the right lower lobe and mid-zone. He is allergic to erythromycin. Blood investigations showed hyponatraemia and a slight rise in the level of liver aminotransferases. On the 5th day after starting medication he became acutely jaundiced and his liver aminotransferase levels became very high. He also complained of discoloration of his urine, though dipstick testing did not show haematuria. Which one of the following drugs probably caused the jaundice?

Explanation

Correct Answer: E- Rifampicin Explanation Rifampicin This patient has Legionella pneumonia and so rifampicin was prescribed. However, rifampicin is a hepatic-enzyme inducer and its use can lead to acute jaundice, with a rise in liver aminotransferases. It also causes red or orange discoloration of the urine and other body fluids and patients should be warned about this side- effect.Monotherapy with rifampicin is associated with the development of resistance and is not generally used to treat Legionella pneumonia. As this patient is allergic to the macrolides, ciprofloxacin would be the other drug of choice. Amoxicillin Amoxicillin is incorrect. Amoxicillin is not an effective treatment for Legionella pneumonia and should not be prescribed in a case such as this. Regardless, hepatotoxicity from amoxicillin is ucommon. Ciprofloxacin Ciprofloxacin is incorrect. Ciprofloxacin may be used to treat Legionella pneumonia in macrolide allergic patients but it is not usually associated with hepatotoxicity. Furthermore, the discolouration of urine is suggestive of rifampicin which is more likely to be associated with hepatotoxicity and is therefore the correct answer. Clarithromycin Clarithromycin is incorrect. He is allergic to macrolides so would not have been prescribed clarithromycin. Flucloxacillin Flucloxacillin is incorrect. Flucloxacillin can be associated with hepatotoxicity but this is rare. The risk of hepatotoxicity is increased with use over 2 weeks and with increased patient age. Furthermore, flucloxacillin is not an effective treatment for Legionella pneumonia and should not be prescribed in a case such as this.

Question 20

You are reviewing a 67-year-old man with a history of chronic obstructive pulmonary disease (COPD) who comes to the clinic. He feels increasingly short of breath despite maximal therapy with home nebulisers, high- dose Seretide and tiotropium. Which of the following features would drive you towards a prescription for long-term oxygen therapy (LTOT) with respect to two blood gases sampled > 3 weeks apart?

Explanation

Correct Answer: B- PaO2 7.2 kPa Explanation

PaO2 7.2 kPa NICE guidance on LTOT suggests it should be used in patients with PaO2 < 7.3 kPa measured when disease is stable, three or more weeks apart. Where O2 is 7.3 kPa or greater but less than 8 kPa when stable, and there is secondary polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulmonary hypertension, LTOT may also be prescribed. CO2 is not a criterion for prescription of LTOT.

PaCO2 5.6 kPa

PaCO2 5.6 kPa is incorrect. This is a normal PaCO2. Regardless, the degree of hypoxia determines the need for oxygen prescription.

PaO2 8.4 kPa with secondary polycythaemia

PaO2 8.4 kPa with secondary polycythaemia is incorrect. NICE guidance on LTOT suggests it should be used in patients with PaO2 < 7.3 kPa measured when disease is stable, three or more weeks apart. Where O2 is 7.3 kPa or greater but less than 8 kPa when stable, and there is secondary polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulmonary hypertension, LTOT may also be prescribed. CO2 is not a criterion for prescription of LTOT.

PaO2 8.6 kPa with right heart failure

PaO2 8.6 kPa with right heart failure is incorrect. NICE guidance on LTOT suggests it should be used in patients with PaO2 < 7.3 kPa measured when disease is stable, three or more weeks apart. Where O2 is 7.3 kPa or greater but less than 8 kPa when stable, and there is secondary polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulmonary hypertension, LTOT may also be prescribed. CO2 is not a criterion for prescription of LTOT.

PaO2 8.8 kPa

PaO2 8.8 kPa is incorrect. NICE guidance on LTOT suggests it should be used in patients with PaO2 < 7.3 kPa measured when disease is stable, three or more weeks apart. Where O2 is 7.3 kPa or greater but less than 8 kPa when stable, and there is secondary polycythaemia, peripheral oedema, nocturnal hypoxaemia or pulmonary hypertension, LTOT may also be prescribed. CO2 is not a criterion for prescription of LTOT.

Question 21

A 32-year-old male sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III). What biomechanical advantage does a sliding hip screw (SHS) with a derotation screw provide over multiple cancellous screws for this specific fracture pattern?

Explanation

Pauwels type III fractures experience high vertical shear forces. An SHS with a derotation screw offers superior biomechanical resistance to these shear forces compared to multiple cancellous screws, significantly reducing the risk of varus collapse.

Question 22

A 14-year-old boy presents with progressive distal thigh pain. Radiographs show a destructive metaphyseal lesion with a "sunburst" periosteal reaction. A biopsy confirms high-grade intramedullary osteosarcoma. Following neoadjuvant chemotherapy, what is the most significant prognostic factor for long-term survival?

Explanation

The degree of tumor necrosis following neoadjuvant chemotherapy is the most critical prognostic indicator in high-grade osteosarcoma. Greater than 90% necrosis indicates a strong response and significantly improves long-term survival rates.

Question 23

During a revision total hip arthroplasty for recurrent posterior instability, the surgeon notes that the existing acetabular component is well-fixed but positioned in 0 degrees of anteversion. The femoral component is well-fixed with 15 degrees of anteversion. What is the most appropriate management?

Explanation

The acetabular component is malpositioned in retroversion (0 degrees), predisposing the patient to posterior instability. The most appropriate and anatomic management is revising the acetabular component to achieve optimal anteversion (15-20 degrees).

Question 24

A 65-year-old man presents with deteriorating handwriting, frequent dropping of objects, and a broad-based, unsteady gait. Examination reveals a positive Hoffmann sign and hyperreflexia in both lower extremities. MRI demonstrates severe cervical stenosis at C4-C5 with a hyperintense signal within the spinal cord on T2-weighted images. What is the most appropriate definitive management?

Explanation

The patient exhibits classic signs of cervical spondylotic myelopathy with MRI confirmation of cord compression and myelomalacia. Surgical decompression, such as ACDF, is indicated to halt the progression of neurologic deficits.

Question 25

An obese 12-year-old boy presents with a 3-week history of right groin and knee pain, walking with an externally rotated limp. Radiographs demonstrate widening of the capital femoral physis with the epiphysis displaced posteriorly and inferiorly. Which of the following is the most feared complication directly associated with attempted forceful closed reduction of this condition?

Explanation

Forceful closed reduction of a slipped capital femoral epiphysis (SCFE) significantly increases the risk of avascular necrosis due to stretching or tearing of the tenuous retinacular vessels. In situ pinning is the standard of care to avoid this catastrophic complication.

Question 26

A 28-year-old rugby player is unable to flex the distal interphalangeal (DIP) joint of his right ring finger after aggressively grabbing an opponent's jersey. Radiographs reveal a bony avulsion fragment retracted to the level of the A2 pulley. According to the Leddy and Packer classification, what type of injury is this?

Explanation

A Leddy and Packer Type II jersey finger involves retraction of the flexor digitorum profundus (FDP) tendon to the level of the PIP joint or A2 pulley. A small avulsion fracture often catches at the chiasm of the FDS, preserving some regional blood supply.

Question 27

A 24-year-old female soccer player sustains a non-contact pivoting injury to her left knee. MRI confirms an isolated anterior cruciate ligament (ACL) tear. When performing an anatomic single-bundle ACL reconstruction, where should the femoral tunnel be positioned in relation to the lateral femoral condyle?

Explanation

The native ACL femoral footprint is located low and posterior on the medial aspect of the lateral femoral condyle within the notch. Anatomic tunnel placement in this location best restores anterior and rotational kinematics.

Question 28

A 45-year-old construction worker falls from a ladder, sustaining a severely comminuted, depressed lateral tibial plateau fracture with associated widening of the metaphysis (Schatzker Type II). Which of the following surgical strategies is essential to restore joint congruity and prevent late varus/valgus collapse?

Explanation

Schatzker II fractures require anatomical reduction of the articular surface to prevent post-traumatic arthritis. This mandates elevating the depressed articular fragments, filling the resulting metaphyseal void with bone graft, and supporting the construct with a lateral plate.

Question 29

A 21-year-old gymnast presents with midfoot pain and swelling after landing awkwardly. Radiographs demonstrate a subtle widening of the space between the base of the first and second metatarsals, with a small bony fragment visible in this space (the "fleck sign"). Which ligament is critically injured?

Explanation

The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. The "fleck sign" represents a bony avulsion of this ligament, indicating high-grade midfoot instability that typically requires surgical stabilization.

Question 30

A 24-year-old male sustains a closed comminuted diaphyseal femur fracture. 36 hours post-admission, he develops tachycardia, a petechial rash over his axilla, and confusion. What is the most likely diagnosis?

Explanation

Fat embolism syndrome typically presents 24-72 hours after long bone fractures with the classic triad of hypoxemia, neurological abnormalities, and a petechial rash. The rash is considered pathognomonic but only occurs in a subset of patients.

Question 31

A 35-year-old construction worker presents with a swollen, painful index finger after a minor puncture wound. Which of the following is NOT one of Kanavel's cardinal signs of flexor tendon sheath infection?

Explanation

Kanavel's four signs of suppurative flexor tenosynovitis are fusiform swelling, flexed posture, tenderness along the tendon sheath, and severe pain on passive extension. Erythema extending proximal to the wrist is not a specific Kanavel sign.

Question 32

When managing an infant with congenital idiopathic clubfoot using the Ponseti method, what is the correct sequence of deformity correction?

Explanation

The Ponseti method sequentially corrects the deformities using the CAVE acronym: Cavus, Adductus, Varus, and finally Equinus. The cavus is corrected first by supinating the forefoot to align it with the hindfoot.

Question 33

A 45-year-old male is involved in a motor vehicle collision and sustains a traumatic spondylolisthesis of the axis (Hangman's fracture). What is the primary mechanism of this injury?

Explanation

A Hangman's fracture (bilateral pars interarticularis fractures of C2) is classically caused by hyperextension and axial loading. This mechanism leads to bilateral failure of the pars interarticularis.

Question 34

A 14-year-old boy presents with progressive knee pain. Radiographs reveal a metaphyseal lesion in the distal femur with a sunburst periosteal reaction and a Codman's triangle. A biopsy shows pleomorphic spindle cells producing malignant osteoid. What is the diagnosis?

Explanation

Osteosarcoma typically presents in adolescents with a sunburst periosteal reaction and Codman's triangle. The histological hallmark is the production of malignant osteoid by pleomorphic mesenchymal cells.

Question 35

An obese 12-year-old boy presents with an inability to bear weight on his left leg and severe left hip pain. Radiographs show a posterior and inferior slip of the proximal femoral epiphysis. He is diagnosed with an unstable slipped capital femoral epiphysis (SCFE). Which complication is most highly associated with this specific presentation?

Explanation

Unstable SCFE (defined as the inability to bear weight even with crutches) has a high risk of avascular necrosis, with rates up to 50%. Prompt diagnosis and careful surgical management are required to minimize this risk.

Question 36

The Lisfranc ligament is critical for midfoot stability. Which of the following accurately describes the anatomic attachments of the Lisfranc ligament?

Explanation

The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is a critical stabilizer of the tarsometatarsal joint complex.

Question 37

A 28-year-old male undergoes four-compartment fasciotomies of the leg for acute compartment syndrome following a severe tibial plateau fracture. Which compartment is most frequently inadequately decompressed, leading to residual necrosis?

Explanation

The deep posterior compartment is the most commonly missed or inadequately released compartment in the lower leg. Inadequate release can lead to muscle necrosis, contractures, and severe claw toe deformities.

Question 38

In a patient undergoing revision total hip arthroplasty (THA) for aseptic loosening, the presence of particulate polyethylene debris is noted. What is the primary biological mechanism mediating the resulting osteolysis?

Explanation

Aseptic loosening due to particulate wear debris is driven by macrophages that phagocytose the particles and release cytokines such as TNF-alpha and IL-1. These cytokines stimulate osteoclastogenesis and inhibit osteoblasts, leading to osteolysis.

Question 39

A 22-year-old professional soccer player is choosing a graft for primary anterior cruciate ligament (ACL) reconstruction. If he selects a bone-patellar tendon-bone (BPTB) autograft, he should be counseled about an increased risk of which of the following post-operative complications compared to hamstring autograft?

Explanation

Bone-patellar tendon-bone (BPTB) autografts are associated with a higher incidence of anterior knee pain and donor-site morbidity compared to hamstring autografts. However, BPTB grafts generally provide excellent structural stability.

Question 40

A 26-year-old man presents with chronic wrist pain and is diagnosed with a scaphoid nonunion. MRI demonstrates avascular necrosis (AVN) of the proximal pole. Which surgical intervention is most appropriate to optimize healing?

Explanation

In the setting of a scaphoid nonunion complicated by avascular necrosis of the proximal pole, a vascularized bone graft is recommended to revascularize the bone and promote union. Non-vascularized grafts have a significantly higher failure rate in the presence of AVN.

Question 41

A 30-year-old male is brought to the trauma bay after a motorcycle accident. He has an anteroposterior compression (APC) type III pelvic ring injury. His blood pressure is 70/40 mmHg, and he is tachycardic. After initial fluid resuscitation and application of a pelvic binder, he remains hemodynamically unstable. FAST exam is negative. What is the most appropriate next step in management?

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and negative FAST, the source of bleeding is likely retroperitoneal from the pelvic fracture. Preperitoneal pelvic packing or angioembolization are the treatments of choice to control the hemorrhage.

Question 42

A 6-year-old boy sustains a severe extension-type supracondylar humerus fracture. Upon arrival, his hand is warm and pink, but the radial pulse is absent. After successful closed reduction and percutaneous pinning, the hand remains warm and pink with capillary refill less than 2 seconds, but the radial pulse remains unpalpable. What is the best next step?

Explanation

A pink, pulseless hand after reduction of a pediatric supracondylar humerus fracture is generally managed with observation, as collateral circulation is adequate to perfuse the hand. Vascular exploration is typically indicated only if the hand becomes cold and white.

Question 43

A 32-year-old male sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III). What is the biomechanical rationale for using a sliding hip screw with a derotation screw rather than three parallel cancellous screws?

Explanation

Pauwels type III fractures experience high shear forces and are mechanically unstable. A fixed-angle device like a sliding hip screw offers superior biomechanical stability against varus collapse compared to parallel cancellous screws.

Question 44

A 6-year-old child presents with a pulseless, pale, and poorly perfused hand following a displaced extension-type supracondylar humerus fracture. After anatomical closed reduction and percutaneous pinning, the hand remains pulseless and poorly perfused. What is the next most appropriate step in management?

Explanation

A dysvascular hand that remains poorly perfused after anatomical reduction of a supracondylar humerus fracture requires immediate surgical exploration. The anterior approach allows direct visualization and release of the entrapped brachial artery.

Question 45

In the acute management of an unstable anteroposterior compression (APC III) pelvic ring injury, where should a pelvic binder be anatomically centered to optimally reduce the pelvic volume?

Explanation

A pelvic binder must be centered over the greater trochanters to effectively compress the pelvic ring and reduce pelvic volume. Placement over the iliac crests can cause paradoxical opening of the pelvic floor and exacerbate bleeding.

Question 46

A 28-year-old male sustains a closed tibial shaft fracture. Within 8 hours, he complains of severe pain out of proportion to the injury. Which of the following clinical findings is the earliest and most sensitive indicator of acute compartment syndrome?

Explanation

Pain with passive stretch is generally the earliest and most sensitive clinical sign of acute compartment syndrome. Pulselessness, pallor, and paralysis are late signs indicating irreversible ischemia.

Question 47

A 24-year-old male falls on an outstretched hand and sustains a fracture of the proximal pole of the scaphoid. Why is this specific fracture pattern at highest risk for avascular necrosis?

Explanation

The scaphoid receives its primary blood supply from branches of the radial artery that enter distally and flow retrograde. Fractures at the proximal pole disrupt this supply, leading to a high rate of avascular necrosis and nonunion.

Question 48

A 45-year-old male falls from a roof and sustains an L1 burst fracture. He has weakness in ankle dorsiflexion and decreased perianal sensation. Which of the following radiographic findings dictates the need for anterior column support during surgical stabilization?

Explanation

Significant anterior column comminution, such as greater than 50% loss of vertebral height or severe kyphosis, indicates gross instability. This necessitates anterior column reconstruction to prevent delayed kyphosis and hardware failure.

Question 49

When performing an anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone (BTB) autograft, which of the following is the most frequently reported donor-site complication?

Explanation

Anterior knee pain, especially with kneeling, is the most common donor-site complication following BTB autograft harvest. While patellar fracture and tendon rupture can occur, they are significantly less frequent.

Question 50

An 18-month-old child is diagnosed with untreated developmental dysplasia of the hip (DDH) on the right side. Which of the following is the most appropriate initial surgical management?

Explanation

After 18 months of age, closed reduction is rarely successful due to severe soft tissue contractures and acetabular dysplasia. Open reduction, often combined with a pelvic or femoral osteotomy, is the standard of care to achieve stable concentric reduction.

Question 51

A 72-year-old female presents with severe shoulder pain and pseudoparalysis. Radiographs reveal a high-riding humeral head and severe glenohumeral osteoarthritis. She has a massive, irreparable rotator cuff tear. What is the most appropriate surgical treatment?

Explanation

Reverse total shoulder arthroplasty is indicated for rotator cuff tear arthropathy with pseudoparalysis. It relies on the deltoid muscle for elevation, bypassing the deficient rotator cuff and restoring overhead function.

Question 52

A 40-year-old recreational athlete sustains an acute Achilles tendon rupture. During non-operative management with functional bracing, what is the optimal foot position during the initial weeks of immobilization?

Explanation

Initial immobilization in plantar flexion brings the ruptured ends of the Achilles tendon closer together, facilitating proper healing. The foot is gradually brought to neutral over several weeks in a functional rehabilitation protocol.

Question 53

In total hip arthroplasty, which bearing surface combination offers the lowest linear wear rate but carries a risk of squeaking and catastrophic fracture?

Explanation

Ceramic-on-ceramic bearings have the lowest wear rates among THA options. However, they are associated with unique complications including catastrophic bearing fracture and squeaking.

Question 54

A 45-year-old male presents with acute lower back pain, bilateral sciatica, and new-onset urinary retention. An MRI reveals a massive L4-L5 central disc herniation. To maximize the chance of neurologic recovery, surgical decompression should ideally be performed within what timeframe?

Explanation

Cauda equina syndrome with urinary retention is an absolute surgical emergency. Decompression should ideally be performed within 24 to 48 hours to maximize the recovery of bladder and bowel function.

Question 55

A 65-year-old female undergoes volar locked plating for a comminuted distal radius fracture. Postoperatively, she develops an inability to actively flex the interphalangeal joint of her thumb. Which tendon is most likely injured?

Explanation

The flexor pollicis longus (FPL) tendon is at risk of attrition and rupture from prominent hardware on the volar aspect of the distal radius. Loss of active interphalangeal joint flexion confirms FPL injury.

Question 56

A 13-year-old obese male presents with right thigh pain and a limp. Examination reveals obligate external rotation of the right hip during passive flexion. Radiographs confirm a severe, stable slipped capital femoral epiphysis (SCFE). What is the most appropriate definitive management?

Explanation

In situ percutaneous pinning with a single central cannulated screw is the gold standard for a stable SCFE. This prevents further slippage while minimizing the risk of avascular necrosis and chondrolysis.

Question 57

A 16-year-old male complains of dull, aching pain in his distal femur that worsens at night. Radiographs show a destructive metaphyseal lesion with a "sunburst" periosteal reaction and a Codman triangle. Biopsy confirms high-grade osteosarcoma. What is the standard treatment protocol?

Explanation

The standard of care for high-grade conventional osteosarcoma includes neoadjuvant chemotherapy, followed by wide surgical resection (limb salvage or amputation), and then adjuvant chemotherapy. This approach targets micrometastases and improves overall survival.

Question 58

A 22-year-old male presents with recurrent anterior shoulder instability. An MRI arthrogram reveals an anterior labral tear and an engaging Hill-Sachs lesion. Which of the following procedures specifically addresses the engaging Hill-Sachs defect?

Explanation

The Remplissage procedure involves tenodesis of the infraspinatus tendon and posterior capsule into the Hill-Sachs defect. This essentially converts an intra-articular defect to an extra-articular one, preventing it from engaging the anterior glenoid rim.

Question 59

During open reduction and internal fixation of a Weber C ankle fracture, the surgeon performs a hook test which demonstrates widening of the tibiofibular clear space. A syndesmotic screw is planned. What is the recommended position of the ankle during syndesmotic screw fixation?

Explanation

The syndesmotic screw should be placed with the ankle in neutral dorsiflexion. This ensures that the widest portion of the talar dome sits within the mortise, preventing over-tightening of the syndesmosis and subsequent loss of dorsiflexion.

Question 60

A 35-year-old male is evaluated for a hypertrophic nonunion of a tibial shaft fracture 9 months after intramedullary nailing. Radiographs show abundant callus formation that fails to bridge the fracture site. What is the most appropriate surgical treatment?

Explanation

Hypertrophic nonunions have adequate biology but lack sufficient mechanical stability. Exchange nailing with a larger diameter reamed nail provides increased stability and directly addresses the mechanical failure.

Question 61

A 5-year-old child presents with a fever of 39°C, inability to bear weight on the left leg, and exquisite tenderness over the proximal tibial metaphysis. MRI confirms acute hematogenous osteomyelitis without an abscess. What is the most appropriate initial management?

Explanation

In pediatric acute hematogenous osteomyelitis without a discrete drainable abscess, empiric intravenous antibiotics are the first-line treatment. Surgery is reserved for cases that fail to respond clinically within 48-72 hours or present with a subperiosteal collection.

Question 62

A 60-year-old diabetic male with a history of intravenous drug use presents with worsening back pain, fevers, and new-onset bilateral lower extremity weakness. MRI reveals a large ventral epidural abscess at T8-T10 causing severe cord compression. What is the best definitive management?

Explanation

A ventral epidural abscess with neurologic deficit requires urgent anterior decompression to directly remove the pathology and decompress the spinal cord. Posterior laminectomy alone for a ventral thoracic lesion often fails to adequately decompress the cord and can cause instability.

Question 63

A 45-year-old male presents with hemorrhagic shock following an anteroposterior compression type III (APC-III) pelvic ring injury. Despite application of a pelvic binder, he remains hypotensive. What is the most common anatomic source of major pelvic hemorrhage in this setting?

Explanation

The presacral venous plexus and bleeding from fractured cancellous bone surfaces account for 80-90% of bleeding in pelvic ring injuries. Arterial bleeding accounts for only 10-20% of cases, despite being the target of angioembolization.

Question 64

A 9-year-old boy presents with a 3-week history of right groin pain and an antalgic limp. His BMI is in the 25th percentile for his age. Radiographs confirm a mild stable slipped capital femoral epiphysis (SCFE). Given the patient's age and weight, which of the following is the most appropriate initial laboratory workup?

Explanation

SCFE in children under 10 years of age, or in those whose weight is less than the 50th percentile, is highly associated with underlying endocrine disorders. Hypothyroidism is the most common endocrine etiology, making TSH and free T4 essential in the initial screening.

Question 65

A 15-year-old boy presents with right knee pain and swelling. Radiographs show a destructive, permeative metaphyseal lesion in the distal femur with a sunburst periosteal reaction and Codman's triangle. A core needle biopsy reveals malignant spindle cells producing unmineralized osteoid. What is the most appropriate definitive management strategy?

Explanation

The patient has a high-grade intramedullary osteosarcoma. Standard of care consists of neoadjuvant chemotherapy, followed by limb-salvage wide surgical resection (or amputation if limb salvage is not feasible), and adjuvant chemotherapy.

Question 66

A 78-year-old woman with a history of a primary total hip arthroplasty (THA) 10 years ago presents with her third posterior dislocation in the past 6 months. Radiographs and CT show well-fixed components with appropriate anteversion and inclination. Intraoperative assessment reveals severely deficient abductor musculature. Which of the following surgical options is most appropriate?

Explanation

For recurrent instability in the setting of well-positioned and well-fixed components, particularly with abductor deficiency, a constrained acetabular liner or a dual mobility construct is the most appropriate surgical treatment to maximize stability.

Question 67

A 62-year-old male presents with progressive hand clumsiness and difficulty walking. Examination reveals a positive Hoffmann's sign bilaterally, hyperreflexia in the lower extremities, and an inverted brachioradialis reflex. MRI demonstrates multilevel cervical spondylosis with severe cord compression from C3 to C6 and neutral cervical sagittal alignment. Which of the following surgical approaches is most appropriate?

Explanation

In multilevel cervical myelopathy (>3 levels) with neutral or lordotic sagittal alignment, posterior decompression via laminoplasty avoids the morbidity and pseudarthrosis risks of multilevel anterior approaches. Laminectomy without fusion in an adult risks progressive post-laminectomy kyphosis.

Question 68

A 25-year-old rugby player presents 2 days after aggressively grabbing an opponent's jersey. He felt a "pop" in his right ring finger and cannot actively flex the distal interphalangeal (DIP) joint. Physical examination reveals tenderness in the palm and absence of the profundus cascade. Radiographs show no fracture. What is the most likely location of the retracted tendon end?

Explanation

This is a Type I flexor digitorum profundus (FDP) avulsion (Jersey finger), where the tendon tears entirely from the bone and retracts into the palm at the lumbrical origin. It requires prompt surgical repair within 7-10 days before tendon contracture occurs.

Question 69

A 12-year-old female soccer player sustains a non-contact pivoting injury to her knee, resulting in an anterior cruciate ligament (ACL) tear. She is Tanner stage 2 and has significant remaining growth. Which of the following surgical techniques poses the lowest risk of physeal arrest?

Explanation

In a skeletally immature patient with significant remaining growth (Tanner stage 1 or 2), an all-epiphyseal or physeal-sparing ACL reconstruction technique avoids drilling across the open growth plates. This minimizes the risk of iatrogenic growth arrest or angular deformity.

Orthopedic Prometric MCQs - Chapter 4 Part 1

Orthopedic Prometric MCQs - Chapter 4 Part 8

Orthopedic Prometric MCQs - Chapter 4 Part 8

Chapter Index