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

Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

Orthopedic Board Prep: Interactive MCQ Engine for Spinal Pathology & Radiculopathy

23 Apr 2026 88 min read 112 Views
model33

Key Takeaway

This interactive MCQ engine simulates Orthopedic Board Exam questions, focusing on complex spinal pathologies like radiculopathy and nerve root compression. Users can practice diagnosing conditions, identifying neurological deficits, and understanding anatomical structures. It’s an effective tool to test knowledge, improve critical thinking, and prepare thoroughly for board certification in orthopedics.

Comprehensive Exam


00:00

Start Quiz

Question 1

A 45-year-old construction worker presents with chronic low back pain radiating into his left buttock and posterior thigh, worsening with prolonged sitting and lifting. Physical examination reveals a positive straight leg raise test at 45 degrees on the left, diminished left ankle dorsiflexion strength (4/5), and decreased sensation in the first web space. Deep tendon reflexes are symmetrical. Which of the following anatomical structures is most likely compressed?





Explanation

The patient's symptoms (pain radiating to buttock/posterior thigh), motor weakness (ankle dorsiflexion), and sensory deficit (first web space) are classic signs of L5 radiculopathy. An L5 compression typically affects ankle dorsiflexion (tibialis anterior), toe extension (extensor hallucis longus), and sensation in the dorsum of the foot, including the first web space. The positive straight leg raise test further supports nerve root compression. S1 compression would typically involve plantarflexion weakness and sensory loss in the lateral foot, with a diminished Achilles reflex.

Question 2

A 68-year-old male undergoes a cementless total hip arthroplasty. Four years post-operatively, he presents with sudden onset groin pain and inability to bear weight. Radiographs show a peri-prosthetic fracture around the femoral stem, classified as Vancouver B2. What is the most appropriate management?





Explanation

A Vancouver B2 peri-prosthetic femoral fracture indicates a loose femoral component with adequate bone stock for revision. The most appropriate management is revision of the femoral stem. A longer stem, often cemented or press-fit depending on bone quality and surgeon preference, is typically used to bypass the fracture site by at least two cortical diameters, providing stable fixation and addressing the underlying loosening. Allograft strut may be an adjunct but is not the primary definitive management for the loose component itself.

Question 3

A 10-year-old boy presents with a 3-month history of left hip pain and a limping gait. He is overweight. Radiographs show widening of the physis, subchondral lucency, and flattening of the femoral head epiphysis with medial and posterior displacement. What is the most critical immediate management step?





Explanation

The description is classic for Slipped Capital Femoral Epiphysis (SCFE). Given the acute or acute-on-chronic presentation, immediate non-weight-bearing is crucial to prevent further slippage and potential osteonecrosis. Prompt surgical pinning in situ is the definitive treatment to stabilize the physis. Delay can lead to worsening slip, chondrolysis, or avascular necrosis. MRI may be useful for atypical presentations or early avascular necrosis, but it is not the most critical immediate step when SCFE is clinically and radiographically evident.

Question 4

Which of the following interventions has the strongest evidence for reducing the risk of heterotopic ossification after total hip arthroplasty?





Explanation

Both NSAIDs (e.g., indomethacin) and low-dose radiation therapy are highly effective and considered first-line prophylaxis for heterotopic ossification (HO) after total hip arthroplasty. However, NSAIDs are generally preferred due to their ease of administration and lower cost, with comparable efficacy to radiation for most patients. For high-risk patients, a combination or radiation may be used. Bisphosphonates and corticosteroids have not shown consistent efficacy for this indication. Early mobilization is important for general recovery but does not directly prevent HO.

Question 5

A 28-year-old professional basketball player sustains a non-contact knee injury while cutting. He reports feeling a 'pop' and immediate swelling. Lachman test is positive, and pivot shift test is also positive. What is the most appropriate next step in management?





Explanation

The clinical presentation (pop, swelling, positive Lachman and pivot shift) is highly suggestive of an ACL rupture. While surgery is often indicated in high-demand athletes, an MRI is crucial to confirm the diagnosis, assess the extent of the ACL injury, and, critically, identify any associated injuries such as meniscal tears, collateral ligament injuries, or osteochondral lesions, which frequently co-occur and influence surgical planning and timing. RICE and bracing are initial palliative measures, but MRI guides definitive management. Immediate surgery without MRI is generally not recommended due to the potential for missed concomitant injuries.

Question 6

A 55-year-old male presents with worsening right shoulder pain, especially at night and with overhead activities. He has limited active range of motion, particularly abduction and external rotation, but passive range of motion is relatively preserved. Impingement signs are positive. Plain radiographs show superior migration of the humeral head and sclerosis of the greater tuberosity. What is the most likely diagnosis?





Explanation

The presence of superior migration of the humeral head on radiographs, combined with significant pain, limited active range of motion (especially abduction and external rotation), positive impingement signs, and relatively preserved passive range of motion, is highly indicative of a massive rotator cuff tear. Superior migration occurs when the deltoid acts unopposed by the torn supraspinatus, leading to superior subluxation of the humeral head. Glenohumeral osteoarthritis would typically show joint space narrowing and osteophytes, and adhesive capsulitis would significantly limit both active and passive range of motion.

Question 7

A 3-year-old child presents with refusal to bear weight on her left leg for the past 24 hours. She has a low-grade fever (100.5°F) and appears irritable. Physical examination reveals exquisite tenderness to palpation over the left proximal tibia and pain with passive range of motion of the hip and knee, particularly with internal rotation of the hip. Laboratory tests show elevated white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). What is the most appropriate initial diagnostic imaging modality?





Explanation

The constellation of symptoms (fever, irritability, refusal to bear weight, localized tenderness, elevated inflammatory markers) suggests a musculoskeletal infection, such as septic arthritis or osteomyelitis. Given the child's age and presenting symptoms, an ultrasound of the hip is an excellent initial imaging modality to quickly assess for joint effusion, especially considering the pain with hip internal rotation, which can be seen in septic hip arthritis. Plain radiographs are often normal early in osteomyelitis or septic arthritis. MRI is highly sensitive but might not be immediately available or feasible for initial rapid assessment. Bone scan is more for chronic or occult infections. CT is less sensitive for early soft tissue or bone marrow edema.

Question 8

Regarding the pathogenesis of avascular necrosis (AVN) of the femoral head, which of the following mechanisms is considered the most common final common pathway leading to osteocyte death?





Explanation

While several factors contribute to AVN (e.g., steroid use, trauma, alcoholism), the final common pathway leading to osteocyte death is often considered to be venous outflow obstruction and increased intraosseous pressure. This increased pressure compromises arterial inflow and results in ischemia. Corticosteroid-induced adipogenesis is a significant etiological factor, leading to fat cell hypertrophy within the confined medullary space, which then contributes to the venous outflow obstruction and increased pressure. Fat embolism and hypercoagulability are also implicated in some cases, but the pressure-induced ischemia is the more unifying pathway.

Question 9

A 72-year-old woman with a history of osteoporosis falls and sustains an isolated intertrochanteric hip fracture (AO/OTA 31-A2). She is otherwise healthy and active. What is the most appropriate surgical management?





Explanation

For unstable intertrochanteric fractures (like AO/OTA 31-A2, which implies comminution of the posterior-medial cortex), a cephalomedullary nail is generally preferred over a dynamic hip screw (DHS). The intramedullary position of the nail provides superior biomechanical stability, especially against varus collapse, and has been shown to have lower rates of implant failure in unstable patterns. Arthroplasty is typically reserved for highly comminuted fractures with femoral head involvement or pre-existing severe arthritis. External fixation is rarely used for these fractures.

Question 10

Which of the following describes the characteristic histological finding in Paget's disease of bone?





Explanation

Paget's disease of bone (osteitis deformans) is characterized by a high turnover state involving both excessive osteoclastic resorption and disorganized osteoblastic bone formation. Histologically, this leads to a classic 'mosaic pattern' of lamellar and woven bone with prominent, irregular cement lines, often described as a 'jigsaw puzzle' appearance. This disorganization results in weakened, enlarged bones.

Question 11

A 30-year-old male sustains a traumatic knee dislocation with gross instability in all planes. What is the most crucial initial step in his acute management?





Explanation

In traumatic knee dislocations, there is a high incidence of associated neurovascular injury, particularly to the popliteal artery and peroneal nerve. Therefore, the most crucial initial step, after gross reduction if needed, is a detailed assessment of the neurovascular status of the extremity, including ankle-brachial index (ABI), Doppler assessment, and neurological exam. Missed vascular injury can lead to limb loss. While reduction is urgent, it should be followed by diligent neurovascular checks. MRI and surgery come later, once the limb is stable and perfused.

Question 12

A 6-month-old infant is diagnosed with developmental dysplasia of the hip (DDH) after a positive Barlow test and limited abduction on clinical examination, confirmed by ultrasound showing a dislocated hip (Graf type IV). What is the most appropriate initial treatment?





Explanation

For infants aged 0-6 months with a dislocatable or dislocated hip (Graf type IIc or worse), a Pavlik harness is the gold standard initial treatment. It maintains the hip in flexion and abduction, promoting concentric reduction and acetabular development. Double diapering is ineffective. Spica cast or open reduction is reserved for harness failures or older infants/children where the harness is no longer effective.

Question 13

Which of the following pathologies is most commonly associated with a 'sunburst' or 'onion skin' appearance on plain radiographs?





Explanation

Ewing sarcoma is classically associated with an 'onion skin' or lamellated periosteal reaction due to its rapid growth and cyclical bone formation. It can also present with a 'sunburst' pattern, although the 'sunburst' pattern is more often described with osteosarcoma due to aggressive tumor spicules radiating from the cortex. Given the two options, Ewing sarcoma is strongly linked to the 'onion skin' appearance. Osteosarcoma typically presents with a 'sunburst' or Codman's triangle.

Question 14

A 35-year-old sedentary patient presents with insidious onset of unilateral heel pain, particularly worse with the first steps in the morning and after periods of rest. The pain is localized to the plantar aspect of the heel. Physical examination reveals tenderness at the origin of the plantar fascia on the medial calcaneal tuberosity. What is the most effective initial non-operative treatment?





Explanation

The patient's symptoms are highly consistent with plantar fasciitis. The most effective initial non-operative treatment involves a combination of stretching exercises for the plantar fascia and Achilles tendon, activity modification, night splints, and appropriate footwear. While orthotics can be helpful, stretching is considered a cornerstone of treatment. Corticosteroid injections provide temporary relief but carry risks, and ESWT is typically reserved for recalcitrant cases. Surgical release is a last resort.

Question 15

Which rotator cuff tendon is most commonly involved in degenerative tears?





Explanation

The supraspinatus tendon is by far the most commonly torn rotator cuff tendon. This is attributed to its anatomical position (most susceptible to impingement under the acromion), its critical role in abduction, and its relative hypovascularity in the 'critical zone'.

Question 16

A 60-year-old male with a history of chronic alcoholism presents with insidious onset of progressive bilateral hip pain. Radiographs show sclerosis and lucency in the subchondral bone of both femoral heads, without significant joint space narrowing. What is the most likely diagnosis?





Explanation

The combination of chronic alcoholism (a known risk factor), insidious onset of bilateral hip pain, and radiographic findings of subchondral sclerosis and lucency (representing repair and collapse, often with the 'crescent sign' in later stages) in the femoral heads, without significant joint space narrowing initially, is classic for avascular necrosis (AVN) of the femoral head. Osteoarthritis would typically show joint space narrowing and osteophytes. Rheumatoid arthritis would present with inflammatory signs and more diffuse joint involvement.

Question 17

In the management of open fractures, what is the recommended time frame for debridement and irrigation to minimize infection risk?





Explanation

Historically, the '6-hour rule' was emphasized for debridement of open fractures. However, more recent evidence suggests that while earlier debridement is ideal, the critical factor is thorough and aggressive debridement, rather than a rigid time cut-off. Nevertheless, the general consensus still aims for debridement within 6-8 hours of injury to significantly reduce the risk of infection. Some studies indicate a benefit for even earlier debridement (e.g., within 2-4 hours) for significantly contaminated wounds. So, 'within 6 hours' is the most widely accepted and practical guideline to minimize infection risk.

Question 18

A 7-year-old boy presents with pain, swelling, and redness over his distal femur. Radiographs show a lytic lesion with a 'Codman's triangle' and a 'sunburst' periosteal reaction. Which of the following is the most appropriate next diagnostic step?





Explanation

The described radiographic findings (lytic lesion, Codman's triangle, sunburst periosteal reaction) are highly suggestive of an aggressive bone tumor, most commonly osteosarcoma, in this age group. Before biopsy, an MRI of the entire femur is crucial. MRI provides detailed information about the extent of intramedullary and soft tissue involvement, skip lesions, and neurovascular relationships, which is essential for staging and surgical planning. A needle biopsy would follow the MRI to obtain tissue for definitive diagnosis.

Question 19

Which of the following nerves is most commonly injured with a supracondylar humerus fracture in a child?





Explanation

The anterior interosseous nerve (AIN), a motor branch of the median nerve, is the most commonly injured nerve in supracondylar humerus fractures, particularly in extension-type injuries. AIN injury manifests as inability to make an 'OK' sign (flexion of IP joint of thumb and DIP joint of index finger). While the median nerve itself and the radial nerve can be injured, the AIN is specifically highlighted due to its vulnerability in this common pediatric fracture.

Question 20

In the management of adult diaphyseal tibia fractures, what is the primary indication for surgical intervention (e.g., intramedullary nailing) over non-operative treatment (e.g., cast immobilization)?





Explanation

The primary indications for surgical management (most commonly intramedullary nailing) of adult diaphyseal tibia fractures include open fractures (to stabilize after debridement), highly unstable closed fractures (e.g., comminuted, segmental, spiral with significant displacement, or those with significant soft tissue compromise), and failure of conservative management. While other factors like shortening or patient preference play a role, open or unstable fractures necessitate surgical stabilization for optimal healing and function.

Question 21

A 22-year-old female presents with chronic anterior knee pain, worse with prolonged sitting, climbing stairs, and squatting. Physical examination reveals mild atrophy of the vastus medialis obliquus and tenderness along the medial patellar facet. Patellar apprehension test is positive. What is the most appropriate initial management?





Explanation

This presentation is classic for patellofemoral pain syndrome (PFPS) or patellar instability. The cornerstone of initial management for PFPS and mild patellar instability is physical therapy. This therapy should focus on strengthening the quadriceps (particularly the VMO), stretching tight structures (hamstrings, IT band), hip abductor strengthening, and core stability to improve lower extremity mechanics. Surgical interventions are generally reserved for failed conservative treatment or severe instability. Bracing can be adjunctive but not primary.

Question 22

Which of the following statements regarding osteomyelitis in adults is true?





Explanation

CRP is a more reliable and faster-responding inflammatory marker than ESR for monitoring treatment response in osteomyelitis, as its levels change more rapidly with infection resolution. In adults, contiguous focus infection (e.g., from trauma, surgery, or vascular insufficiency) is more common than hematogenous spread. Staphylococcus aureus is the most common causative organism. Plain radiographs often lag behind clinical symptoms, showing changes only after 10-14 days. Chronic osteomyelitis typically requires surgical debridement in addition to prolonged antibiotic therapy.

Question 23

A 50-year-old female presents with numbness and tingling in her thumb, index, middle finger, and radial half of the ring finger, particularly at night. Phalen's test and Tinel's sign at the wrist are positive. What is the most appropriate initial non-operative treatment?





Explanation

This presentation is classic for carpal tunnel syndrome. The most appropriate initial non-operative treatment is night splinting in a neutral wrist position to reduce pressure on the median nerve. While corticosteroid injections can offer temporary relief and are often used as a next step, night splinting is generally the first-line non-invasive approach. Physical therapy and activity modification are also important adjuncts. Surgical release is reserved for failed conservative management or severe cases.

Question 24

Which of the following is considered a relative contraindication to total knee arthroplasty (TKA)?





Explanation

Unrealistic patient expectations are a relative contraindication to TKA, as they can lead to patient dissatisfaction despite a technically successful surgery. While age over 80, obesity, and nicotine use increase surgical risks, they are generally not absolute contraindications if the patient is otherwise healthy and motivated. Active infection in a remote site is an absolute contraindication, as it significantly increases the risk of periprosthetic joint infection.

Question 25

A 4-year-old child presents with a limp, and radiographs show an osteochondroma arising from the medial distal femur, pointing away from the joint. What is the most common complication of osteochondromas that typically warrants surgical excision?





Explanation

While malignant transformation (to chondrosarcoma) is a serious concern, it is rare (especially in solitary lesions) and less common than symptomatic complications. The most common reasons for surgical excision of an osteochondroma are pain due to mechanical irritation (e.g., rubbing against muscles or tendons), nerve compression, vascular compression (rare), or fracture through the stalk. Bursitis is also a common cause of pain. Growth disturbance is less common in solitary lesions compared to hereditary multiple exostoses.

Question 26

Which factor is most predictive of successful union in an operatively managed scaphoid fracture?





Explanation

The location of the scaphoid fracture is a critical predictor of healing. Proximal pole fractures have a higher risk of nonunion and avascular necrosis due to their precarious blood supply (which enters distally and runs proximally). Waist fractures have a better, but still guarded, prognosis, while distal fractures have the highest union rates. While time to surgery and adequate fixation are important, the inherent vascularity related to fracture location is a dominant factor. DISI deformity is a carpal instability pattern, not a direct predictor of scaphoid union itself.

Question 27

A 25-year-old female presents with bilateral foot pain, flatfoot deformity, and posterior tibial tendon dysfunction. She has a history of rheumatoid arthritis. Which of the following is the most appropriate initial non-operative treatment?





Explanation

In patients with flexible flatfoot and posterior tibial tendon dysfunction (PTTD), especially those with inflammatory arthritis, custom-molded orthotics with medial arch support are the cornerstone of initial non-operative management. They help support the arch, reduce stress on the posterior tibial tendon, and prevent further progression of the deformity. A rigid AFO may be needed for more advanced, rigid deformities. Surgical reconstruction is reserved for failed conservative treatment. Corticosteroid injections are generally avoided due to the risk of tendon rupture.

Question 28

Regarding the surgical treatment of acute Achilles tendon rupture, what is the primary advantage of percutaneous repair compared to open repair?





Explanation

The primary advantage of percutaneous Achilles tendon repair compared to open repair is a reduced risk of wound complications, including infection, dehiscence, and scar-related issues, due to smaller incisions. While re-rupture rates are generally comparable between modern open and percutaneous techniques, and functional outcomes are similar, the soft tissue envelope benefits are distinct for percutaneous methods.

Question 29

A 6-year-old boy falls off a jungle gym and sustains an isolated mid-diaphyseal femur fracture. He is hemodynamically stable. What is the most appropriate definitive management?





Explanation

For mid-diaphyseal femur fractures in children aged 5-11 years, flexible intramedullary nailing (e.g., Ender nails or titanium elastic nails) is the preferred definitive treatment. It provides stable fixation, allows early mobilization, and avoids the complications associated with rigid intramedullary nails (e.g., AVN of the femoral head, trochanteric apophysis injury) in younger children, or prolonged cast immobilization in older children. Skeletal traction followed by casting is an option for younger children (<5 years) or very short oblique fractures, but flexible nailing is often favored for robust fixation and early mobility in this age group.

Question 30

Which of the following is the most common cause of painful total hip arthroplasty revisions after 10 years?





Explanation

After 10 years, osteolysis secondary to polyethylene wear is the most common cause of aseptic loosening and thus the most frequent indication for revision total hip arthroplasty. The wear debris triggers a foreign body reaction, leading to bone resorption and subsequent implant loosening. While dislocation and infection are important complications, aseptic loosening driven by polyethylene wear-induced osteolysis dominates in the long term.

Question 31

A 60-year-old female presents with progressively worsening pain in her first metatarsophalangeal (MTP) joint, stiffness, and a painful 'bump' dorsally. Radiographs show joint space narrowing, dorsal osteophytes, and subchondral sclerosis. What is the most appropriate initial management?





Explanation

The patient's symptoms and radiographic findings are consistent with hallux rigidus (osteoarthritis of the first MTP joint). Initial non-operative management includes stiff-soled shoes with a rocker bottom modification, which limits motion at the MTP joint and reduces stress. Activity modification, NSAIDs, and stretching can also be beneficial. Cheilectomy is a surgical procedure for earlier stages, while arthrodesis or excisional arthroplasty are for advanced stages or failed cheilectomy.

Question 32

Which of the following describes the 'UnPappy' clinical sign in the context of developmental dysplasia of the hip (DDH)?





Explanation

Asymmetry of the gluteal (or thigh) folds is often referred to as a 'Pappy' sign, or simply gluteal fold asymmetry. It is an indirect sign of DDH and indicates tightness of adductor muscles or shortening of the thigh, but it is not a direct diagnostic maneuver for hip instability. Limited hip abduction is a more specific and consistent clinical finding. Ortolani and Barlow tests are direct tests for hip stability. Galeazzi sign is apparent leg length discrepancy due to hip dislocation.

Question 33

A 40-year-old male with a history of intravenous drug use presents with acute onset of fever, chills, and severe pain in his left shoulder. Physical examination reveals exquisite tenderness over the anterior shoulder and pain with any attempt at passive or active shoulder motion. Labs show elevated WBC, ESR, and CRP. What is the most likely diagnosis?





Explanation

The clinical picture of acute fever, chills, severe pain, and 'pseudoparalysis' (inability to move due to pain) of the shoulder in a patient with risk factors (IV drug use) points strongly to septic arthritis of the glenohumeral joint. Elevated inflammatory markers further support an infectious process. Definitive diagnosis requires joint aspiration. The other conditions are less likely to present with such an acute, systemic febrile illness.

Question 34

In the surgical management of adolescent idiopathic scoliosis (AIS), what is the primary goal of instrumentation and fusion?





Explanation

The primary goal of surgical instrumentation and fusion in AIS is to prevent further progression of the curve and to achieve a balanced spine. While some correction of the curve and the rib hump is achieved, the aim is not to eliminate all curvature or restore normal flexibility (as fusion limits motion). Decompression is not typically the primary goal in AIS unless there's neurological compromise, which is rare.

Question 35

Which ligament is primarily responsible for preventing anterior translation of the tibia on the femur?





Explanation

The anterior cruciate ligament (ACL) is the primary static stabilizer that prevents anterior translation of the tibia on the femur. It also resists internal rotation of the tibia. The PCL prevents posterior translation. The MCL and LCL provide varus/valgus stability.

Question 36

A 3-month-old infant presents with a 'click' heard during hip examination. Ortolani and Barlow tests are negative. Limited abduction is noted. Ultrasound shows an alpha angle of 55 degrees and a beta angle of 65 degrees. What is the Graf classification of this hip?





Explanation

According to Graf's classification for hip ultrasound, an alpha angle of 55 degrees (normal > 60 degrees) and a beta angle of 65 degrees (normal < 55 degrees) would classify this hip as Type IIb. This indicates an immature hip with a dysplastic acetabular roof, usually requiring intervention (e.g., Pavlik harness) in an infant over 3 months of age. A normal hip (Type I) would have an alpha angle > 60 and beta < 55. Type IIa is for infants <3 months with similar angles, considered physiologically immature, often just observed. Type III and IV are dislocated hips.

Question 37

What is the most common benign bone tumor?





Explanation

Osteochondroma is the most common benign bone tumor. It is a cartilage-capped bony projection on the external surface of bone, arising from the growth plate. It accounts for approximately 35-50% of all benign bone tumors. Non-ossifying fibromas are also very common but often asymptomatic and resolve spontaneously.

Question 38

A 28-year-old male sustains a spiral fracture of the middle third of the tibia and fibula in a motor vehicle accident. He presents with severe pain, swelling, and a tense compartment in the leg. Dorsiflexion of the ankle and toes is painful and weak, and sensation in the first web space is diminished. Pedal pulses are palpable. What is the most appropriate immediate management?





Explanation

The patient presents with classic signs and symptoms of acute compartment syndrome: severe pain disproportionate to the injury, swelling, tense compartment, pain with passive stretch (dorsiflexion), and neurological deficits (weakness, diminished sensation). While pulses may still be palpable, the presence of neurologic compromise and a tense compartment in the setting of a high-energy injury warrants immediate operative exploration and fasciotomy to prevent irreversible muscle and nerve damage. Delay can lead to Volkmann's ischemic contracture. Compartment pressure measurements can confirm the diagnosis but should not delay surgery if clinical signs are clear.

Question 39

Which of the following conditions is most likely to result in a 'Charcot joint' (neuroarthropathy)?





Explanation

Diabetes mellitus is the most common cause of neuroarthropathy (Charcot joint) in industrialized countries. Prolonged high blood glucose can lead to peripheral neuropathy, resulting in loss of protective sensation, proprioception, and autonomic dysfunction, which ultimately leads to repetitive microtrauma, bone resorption, and severe joint destruction. Syphilis (tabes dorsalis) and syringomyelia are other historical causes.

Question 40

A 55-year-old female presents with chronic lateral elbow pain, worse with gripping and wrist extension. Physical examination reveals tenderness over the lateral epicondyle and pain with resisted wrist extension and resisted middle finger extension. What is the most appropriate initial treatment?





Explanation

The patient's symptoms are classic for lateral epicondylitis (tennis elbow), which is typically a degenerative process of the common extensor origin (extensor carpi radialis brevis). Initial treatment is overwhelmingly non-operative and involves rest, NSAIDs, counterforce bracing, and a structured physical therapy program emphasizing eccentric strengthening exercises of the wrist extensors. Corticosteroid injections offer short-term relief but can have long-term adverse effects on tendon integrity and recurrence rates. Surgery or PRP are reserved for failed conservative management.

Question 41

In the context of bone healing, what is the primary role of the callus formation stage?





Explanation

Callus formation (soft callus followed by hard callus) is a crucial stage in secondary bone healing. Its primary role is to provide temporary mechanical stability to the fracture site, bridging the gap between fracture fragments. This stability allows for subsequent remodeling into lamellar bone. Direct restoration of cortical bone is a feature of primary healing or later remodeling. Angiogenesis occurs earlier, and osteocyte differentiation is part of the bone formation process within the callus.

Question 42

A 30-year-old male sustains a proximal humerus fracture (AO/OTA 11-B2) with a displaced greater tuberosity fragment and impaction of the articular surface. He is a smoker. What is the most significant risk factor for avascular necrosis (AVN) of the humeral head in this specific fracture pattern?





Explanation

In proximal humerus fractures, the most significant anatomical factor contributing to avascular necrosis (AVN) of the humeral head is the disruption of the medial calcar blood supply, specifically the ascending branch of the anterior humeral circumflex artery and its arcade. This artery provides the dominant blood supply to the humeral head. Fracture patterns that severely compromise this supply (e.g., 3- and 4-part fractures with significant displacement or angulation) are at highest risk. While smoking and age are general risk factors, the specific vascular disruption is paramount for this fracture. Greater tuberosity displacement itself does not directly correlate as strongly with AVN as the calcar blood supply.

Question 43

Which of the following ligaments is considered the primary static stabilizer against posterior translation of the tibia on the femur?





Explanation

The posterior cruciate ligament (PCL) is the primary static stabilizer against posterior translation of the tibia on the femur. It is a strong ligament that also limits tibial external rotation. The ACL primarily resists anterior translation.

Question 44

A 65-year-old female presents with severe, intractable pain in her right foot, described as burning and hypersensitivity to touch, following a remote ankle fracture 6 months ago. The foot is swollen, cool, mottled, and shows patchy osteopenia on radiographs. What is the most likely diagnosis?





Explanation

The constellation of symptoms (severe burning pain, allodynia/hyperalgesia, swelling, temperature changes, skin discoloration, and patchy osteopenia) developing after a traumatic event is classic for Complex Regional Pain Syndrome (CRPS) Type I (formerly Reflex Sympathetic Dystrophy). It involves dysregulation of the autonomic nervous system. Peripheral neuropathy typically involves sensory loss, not hypersensitivity to the extent of CRPS. DVT would not present with such chronic skin changes and sensory abnormalities. Tarsal tunnel syndrome is a specific nerve compression, not a global pain syndrome.

Question 45

Which of the following is an absolute contraindication to initiating bone mineral density (BMD) testing with DEXA scan?





Explanation

Pregnancy is an absolute contraindication to DEXA scanning due to the ionizing radiation exposure to the fetus, even though the dose is low. Other options listed are indications for BMD testing or risk factors for osteoporosis, not contraindications.

Question 46

A 14-year-old competitive gymnast complains of progressive low back pain, worse with extension and gymnastics activities. Radiographs show a defect in the pars interarticularis of L5. What is the most likely diagnosis?





Explanation

The clinical presentation (low back pain in an adolescent athlete, especially one performing repetitive hyperextension activities like gymnastics) combined with a radiographic defect in the pars interarticularis is classic for spondylolysis. Spondylolisthesis implies anterior slippage of one vertebra over another, which can result from bilateral spondylolysis, but the initial defect is spondylolysis. Lumbar disc herniation is rare in this age group unless from acute trauma, and Scheuermann's kyphosis affects the thoracic spine primarily.

Question 47

Which of the following is typically a feature of osteoarthritis but not inflammatory arthritis (e.g., rheumatoid arthritis)?





Explanation

Pain worsening with activity and relieved by rest is a classic characteristic of osteoarthritis (OA), as it is a mechanical/degenerative process. Inflammatory arthritis, such as rheumatoid arthritis (RA), typically features pain that is worse with rest and improves with activity, prolonged morning stiffness (often > 30 minutes to an hour), systemic symptoms, and often symmetrical polyarticular involvement, accompanied by elevated inflammatory markers (ESR, CRP).

Question 48

A 4-year-old child presents with a painless limp and thigh atrophy. Radiographs show increased density and fragmentation of the femoral head epiphysis. What is the most appropriate initial management?





Explanation

The clinical presentation and radiographic findings are consistent with Legg-Calvé-Perthes disease. The primary goal of management is containment of the femoral head within the acetabulum to maintain its spherical shape during revascularization and remodeling, thereby preventing collapse and promoting a better long-term outcome. This is achieved through various containment methods, including bracing (e.g., Scottish Rite brace) or surgical osteotomies (femoral or pelvic) for specific age groups and stages of the disease, depending on the severity of involvement. Non-weight-bearing alone is generally insufficient as a definitive treatment in most cases, and physical therapy is an adjunct, not primary treatment for containment.

Question 49

Which type of collagen is primarily found in articular cartilage?





Explanation

Type II collagen is the predominant collagen type found in articular cartilage, providing its tensile strength and structural integrity. Type I collagen is found in bone, tendons, ligaments, and skin. Type III is in blood vessels and skin (reticular fibers). Type IV is a major component of basement membranes.

Question 50

A 35-year-old male sustains a Lisfranc injury to his midfoot. Which of the following is the most critical anatomical structure to assess for stability and guide treatment?





Explanation

The Lisfranc ligament complex primarily connects the medial cuneiform to the base of the second metatarsal. The keystone of the Lisfranc joint is the second metatarsal, which is recessed into the middle cuneiform. Injury to this area, particularly the articulation between the second metatarsal and the middle cuneiform, and the Lisfranc ligament itself, is paramount for stability and dictates the diagnosis and treatment of Lisfranc injuries. Disruption of this articulation signifies an unstable injury requiring surgical stabilization. While other joints may be involved, the second metatarsal-middle cuneiform articulation is the critical nexus.

Question 51

In the context of adult spinal deformity, which of the following radiographic parameters is most strongly correlated with health-related quality of life (HRQOL) and patient-reported outcomes?





Explanation

Sagittal vertical axis (SVA), which measures the plumb line from C7 relative to the sacral promontory, is widely considered the most important radiographic parameter correlating with health-related quality of life (HRQOL) and patient-reported outcomes in adult spinal deformity. Patients with positive sagittal imbalance (forward lean) tend to have significantly worse pain and functional scores. While Cobb angle, PI, and PT are also important, SVA directly reflects global sagittal balance and its impact on energy expenditure and posture.

Question 52

A 70-year-old male with symptomatic severe lumbar spinal stenosis, refractory to conservative management, is considering surgical decompression. Which of the following co-morbidities carries the highest risk for adverse outcomes following lumbar spine surgery?





Explanation

Current smoking is consistently identified as one of the most significant modifiable risk factors for adverse outcomes following lumbar spine surgery. It is associated with higher rates of surgical site infection, impaired wound healing, pseudarthrosis (nonunion), increased pain, and overall worse patient-reported outcomes. While other comorbidities like obesity, diabetes, and cardiovascular disease increase risk, smoking is particularly detrimental to fusion and healing processes.

Question 53

A 1-year-old child presents with a limp, and a 'waddling' gait. Physical examination reveals limited hip abduction and internal rotation bilaterally, and an exaggerated lumbar lordosis. Radiographs show bilateral hip dislocations. What is the most likely diagnosis?





Explanation

The clinical presentation (limp, waddling gait, limited abduction/internal rotation, exaggerated lumbar lordosis to compensate for dislocated hips) and radiographic findings (bilateral hip dislocations) in a 1-year-old are highly suggestive of developmental dysplasia of the hip (DDH). At this age, the dislocations are often fixed, and the typical newborn clinical tests may no longer be positive. SCFE and Perthes are conditions of older children. Cerebral palsy could cause gait abnormalities, but primary bilateral hip dislocation is more indicative of DDH. Transient synovitis is acute and self-limiting.

Question 54

Which of the following conditions is characterized by excessive and disorganized bone remodeling leading to enlarged, weakened bones, and often elevated serum alkaline phosphatase levels?





Explanation

Paget's disease of bone (osteitis deformans) is characterized by a focal disorder of bone remodeling, involving periods of intense osteoclastic resorption followed by compensatory, but disorganized, osteoblastic bone formation. This leads to enlarged, often weakened, and deformed bones. Serum alkaline phosphatase, a marker of bone formation, is typically markedly elevated. Osteogenesis imperfecta is a genetic collagen defect, osteoporosis is decreased bone mass, osteomalacia is defective mineralization, and fibrous dysplasia is fibrous tissue replacing bone.

Question 55

A 25-year-old male sustains a closed, isolated mid-shaft clavicle fracture. He is active and desires the quickest return to sports. Radiographs show 100% displacement and 2 cm of shortening. What is the most appropriate management strategy?





Explanation

While many mid-shaft clavicle fractures can be treated non-operatively, significant displacement (>100%), shortening (>1.5-2 cm), or comminution in an active patient, especially those desiring the quickest return to function, are increasingly considered indications for surgical intervention. Open reduction internal fixation with a plate and screws offers more reliable anatomical reduction, faster time to union, and earlier return to activity compared to non-operative management for these specific fracture patterns. Sling immobilization is for minimally displaced fractures. Intramedullary nailing is an option but plate fixation is more common for mid-shaft. Non-weight-bearing is not the primary determinant of outcome here.

Question 56

What is the most common presenting symptom of primary bone tumors in children?





Explanation

Persistent localized pain, often insidious in onset and worsening over time, is the most common presenting symptom of primary bone tumors in children. This pain may initially be mild and mistaken for growing pains or minor trauma, but it progresses and may be worse at night. While pathological fractures can occur (especially in benign lesions like unicameral bone cysts), they are not the most common presenting symptom of primary bone tumors overall. Systemic symptoms like fever and weight loss are more common in Ewing sarcoma but less so for osteosarcoma.

Question 57

A 58-year-old male presents with acute onset of severe pain, redness, and swelling in his great toe. He reports a history of similar episodes, often after consuming alcohol or red meat. Aspiration of the MTP joint reveals negatively birefringent needle-shaped crystals. What is the most appropriate long-term management to prevent recurrent attacks?





Explanation

The clinical picture and synovial fluid analysis (negatively birefringent needle-shaped crystals) are diagnostic for gout. For long-term management to prevent recurrent attacks (urate-lowering therapy), Allopurinol is the most appropriate choice. It reduces uric acid production and is used for chronic management. Colchicine and NSAIDs (like indomethacin) are primarily used for acute attack management. A low-purine diet is helpful but usually insufficient alone for recurrent attacks, and a corticosteroid injection is for acute symptom relief.

Question 58

Which of the following ligaments is most critical for maintaining stability of the distal tibiofibular syndesmosis?





Explanation

The anterior inferior tibiofibular ligament (AITFL) is a key component of the distal tibiofibular syndesmosis, along with the posterior inferior tibiofibular ligament (PITFL) and the interosseous ligament. The syndesmosis maintains the integrity of the 'mortise' and prevents diastasis between the tibia and fibula. Injuries to the syndesmosis often involve the AITFL. The ATFL, CFL, and PTFL are lateral collateral ligaments of the ankle, primarily stabilizing the talus.

Question 59

What is the most common site for osteoid osteoma?





Explanation

The proximal femur is the most common site for osteoid osteoma, especially in the femoral neck. While it can occur in many bones, including the tibia and spine, the femur (proximal) is the most frequently affected long bone.

Question 60

A 75-year-old female sustains a Colles fracture of her distal radius. She has known osteoporosis. Which of the following is the most appropriate initial management for this closed, non-articular, dorsally displaced fracture with good bone quality for reduction?





Explanation

A Colles fracture, characterized by dorsal displacement and often dorsal angulation, is typically treated with closed reduction and casting or splinting. For a non-articular, dorsally displaced fracture with good bone quality, a closed reduction followed by immobilization in a sugar tong splint or volar forearm cast is the standard initial management. The immobilization typically positions the wrist in slight flexion, ulnar deviation, and pronation to maintain reduction. Surgical options are reserved for unstable fractures or those that cannot be adequately reduced or maintained non-operatively. Observation alone is inappropriate for a displaced fracture.

Question 61

Which of the following is considered the most reliable indicator of successful revascularization following fasciotomy for compartment syndrome?





Explanation

While return of pulses, resolution of pain, and decreased compartment tenseness are positive clinical signs, normalized intracompartmental pressures are the most objective and reliable indicator that decompression has been successful and tissue perfusion has been restored adequately within the compartments. Motor function and sensory changes recover more slowly and are not immediate indicators of revascularization.

Question 62

What is the primary function of the medial meniscus in the knee joint?





Explanation

Both the medial and lateral menisci primarily function in shock absorption, load distribution across the tibiofemoral joint, and joint stability. They also play a role in proprioception. While the menisci contribute to overall joint stability, the primary restraints against anterior tibial translation are the ACL, and against valgus stress are the MCL. Menisci do not enhance rotation or protect the patellar tendon.

Question 63

A 16-year-old male presents with insidious onset of anterior knee pain, localized just below the patella, worse with activity. Physical examination reveals tenderness and a prominent bump over the tibial tubercle. Radiographs show fragmentation of the tibial tubercle apophysis. What is the most likely diagnosis?





Explanation

The clinical presentation (adolescent male, anterior knee pain, tenderness/prominence of tibial tubercle, pain with activity) and radiographic findings (fragmentation of the tibial tubercle apophysis) are classic for Osgood-Schlatter disease. This is a traction apophysitis of the tibial tubercle, often associated with growth spurts and repetitive quadriceps contraction. Sinding-Larsen-Johansson disease is similar but affects the inferior pole of the patella. Patellofemoral pain syndrome is typically diffuse anterior knee pain, and jumper's knee affects the patellar tendon itself.

Question 64

Which of the following physical examination findings is most indicative of a complete tear of the anterior cruciate ligament (ACL)?





Explanation

The Lachman test is considered the most sensitive and specific clinical test for an acute anterior cruciate ligament (ACL) rupture. It is performed with the knee in 20-30 degrees of flexion, which isolates the ACL better than the anterior drawer test in 90 degrees of flexion, where secondary restraints (menisci, hamstrings) can mask instability. A positive McMurray test indicates meniscal injury. A positive pivot shift maneuver is highly specific but can be difficult to elicit acutely due to pain.

Question 65

What is the most common cause of radial nerve palsy in the upper extremity?





Explanation

Radial nerve palsy is most commonly associated with humerus shaft fractures, particularly in the middle or distal third, where the nerve courses in the spiral groove. The nerve can be entrapped or directly transected. While other injuries can cause radial nerve involvement, humerus shaft fractures are the classic association. Supracondylar fractures more commonly affect the AIN/median nerve. Carpal tunnel syndrome affects the median nerve.

Next Chapter Orthopedic Surgery Board Review MCQs: Spine & Wrist | Part 1
Dr. Mohammed Hutaif
Medically Verified Content by
Prof. Dr. Mohammed Hutaif
Consultant Orthopedic & Spine Surgeon
Chapter Index
    Back to Master Guide