Orthopedic Board Review: Upper Extremity & Foot MCQs

Question 1

A 35-year-old male presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with advanced collapse (SNAC). Imaging demonstrates arthritic changes in the radioscaphoid and midcarpal joints, specifically involving the capitate head. The lunate fossa of the distal radius remains completely spared. Which of the following is the most appropriate surgical treatment?

Explanation

This patient has a SNAC stage III wrist, defined by radioscaphoid and midcarpal (capitolunate) arthritis with sparing of the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated because the capitate head is degenerated, which would articulate with the lunate fossa postoperatively, leading to continued pain and failure. Scaphoid excision with four-corner (capitate-hamate-lunate-triquetrum) arthrodesis is the gold standard for SNAC III, as it preserves motion at the spared radiolunate joint.

Question 2

In a patient with Charcot-Marie-Tooth (CMT) disease presenting with a progressive cavovarus foot deformity, which of the following specific muscle imbalances is the primary biomechanical driver of the hindfoot varus deformity?

Explanation

The cavovarus foot deformity in CMT is driven by specific muscle imbalances. The tibialis posterior and peroneus longus muscles are typically spared and relatively strong, whereas the tibialis anterior, peroneus brevis, and intrinsic muscles become weak. The hindfoot varus is primarily driven by the strong tibialis posterior overpowering the weak peroneus brevis. The forefoot cavus (plantarflexed first ray) is driven by the strong peroneus longus overpowering the weak tibialis anterior.

Question 3

A 55-year-old active laborer presents with an irreparable posterosuperior rotator cuff tear. Physical examination reveals an inability to actively externally rotate the shoulder with the arm adducted and a positive Hornblower's sign. Radiographs show minimal glenohumeral arthritis. Which of the following tendon transfers is biomechanically superior for restoring active external rotation in this patient?

Explanation

The lower trapezius transfer is biomechanically superior for restoring external rotation compared to the latissimus dorsi. The line of pull of the lower trapezius closely replicates that of the native infraspinatus. It is highly indicated for patients with profound external rotation deficits (positive Hornblower's sign or drop sign) and irreparable posterosuperior cuff tears without advanced arthropathy.

Question 4

A 28-year-old athlete sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. High-quality randomized controlled trials comparing primary arthrodesis of the medial three rays to open reduction and internal fixation (ORIF) for this specific injury pattern show primary arthrodesis is associated with which of the following?

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the medial three rays (first, second, and third TMT joints) has been shown to yield equivalent or better functional outcomes compared to ORIF, while significantly decreasing the rate of secondary surgeries (due to hardware removal or subsequent salvage arthrodesis for post-traumatic arthritis).

Question 5

During the surgical management of a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, coronoid fracture), which of the following represents the generally recommended sequence of structural reconstruction?

Explanation

The standard surgical approach for a terrible triad injury proceeds from deep to superficial and typically from anterior/medial to lateral. The recommended sequence is first addressing the coronoid fracture (to restore the anterior buttress), followed by the radial head (fixation or arthroplasty to restore the lateral column), and finally repairing the lateral collateral ligament (LCL) complex to the lateral epicondyle to restore rotatory stability.

Question 6

Biomechanical studies evaluating the distal tibiofibular syndesmosis have determined the relative contributions of its ligamentous components. Which of the following anatomical structures provides the greatest resistance to lateral displacement of the fibula?

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmotic complex and provides the greatest resistance (approximately 42%) to lateral displacement of the fibula. This is followed by the AITFL (35%) and the interosseous ligament (22%).

Question 7

A 65-year-old woman presents with the inability to extend her thumb interphalangeal joint. Six weeks prior, she sustained a non-displaced distal radius fracture treated with cast immobilization. Examination confirms rupture of the Extensor Pollicis Longus (EPL) tendon. Which of the following is the most appropriate and reliable surgical treatment?

Explanation

Delayed EPL rupture is a known complication of both operatively and non-operatively treated distal radius fractures, often secondary to ischemic changes or mechanical attrition at the Lister tubercle. Because the tendon ends are typically retracted and degenerated, primary end-to-end repair is rarely feasible. An Extensor Indicis Proprius (EIP) to EPL transfer is the gold standard, providing appropriate excursion, tension, and a reliable functional outcome without significant donor site morbidity.

Question 8

Recent meta-analyses evaluating operative versus nonoperative management of acute Achilles tendon ruptures utilizing modern, accelerated functional rehabilitation protocols demonstrate which of the following?

Explanation

When modern functional rehabilitation protocols (early weight-bearing and early functional range of motion) are strictly employed, the re-rupture rates between operative and nonoperative management of acute Achilles tendon ruptures are not statistically different. Operative management is associated with a higher risk of soft tissue complications, such as infection and sural nerve injury.

Question 9

A 42-year-old male presents with severe, unprovoked left shoulder pain that awoke him from sleep. The pain lasted intensely for two weeks and then gradually subsided, but was subsequently replaced by profound weakness in shoulder abduction and external rotation. MRI of the shoulder and cervical spine are unremarkable. Electromyography reveals active denervation in the supraspinatus, infraspinatus, and deltoid. What is the most likely diagnosis?

Explanation

This classic presentation—acute, severe, unrelenting shoulder/arm pain lasting days to weeks followed by patchy weakness and atrophy in the shoulder girdle as the pain subsides—is highly characteristic of Parsonage-Turner syndrome (idiopathic brachial neuritis or neuralgic amyotrophy). It most commonly affects the upper trunk nerves (suprascapular, axillary, long thoracic).

Question 10

A 30-year-old male sustains a high-energy motor vehicle collision resulting in a Hawkins Type III talar neck fracture. By definition, which of the following joints are dislocated in this injury pattern, and what is the classic historical rate of avascular necrosis (AVN) of the talar body?

Explanation

The Hawkins classification for talar neck fractures: Type I is nondisplaced (0-15% AVN). Type II involves subluxation or dislocation of the subtalar joint (20-50% AVN). Type III involves dislocation of both the subtalar and tibiotalar joints (historically associated with a nearly 100% risk of AVN, though modern series report 70-100%). Type IV adds talonavicular joint dislocation.

Question 11

A 24-year-old manual laborer with Kienbock's disease presents with chronic dorsal wrist pain. Radiographs reveal lunate sclerosis and collapse, fixed volar rotation of the scaphoid (ring sign), and a decreased carpal height ratio. The radioscaphoid and midcarpal joints do not show signs of arthritis. He has 3 mm of ulnar negative variance. What Lichtman stage does this represent, and what is the preferred surgical treatment?

Explanation

The patient has Lichtman Stage IIIB Kienbock's disease, defined by lunate collapse with fixed scaphoid rotation and decreased carpal height, but without generalized carpal arthritis (which would be Stage IV). While joint-leveling procedures (like radial shortening osteotomy) are ideal for Stages II and IIIA (where carpal height is maintained), they are less effective in Stage IIIB. Limited intercarpal arthrodesis (such as STT or scaphocapitate fusion) is preferred to unload the lunate and stabilize the carpus in Stage IIIB.

Question 12

A 55-year-old female is diagnosed with Stage IIB adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Clinical examination reveals a flexible deformity with marked hindfoot valgus and significant forefoot abduction (uncovering of the talar head >40%). In addition to a flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO), which adjunctive procedure is most indicated to specifically correct the transverse plane (abduction) deformity?

Explanation

Stage IIB adult acquired flatfoot deformity is characterized by a flexible deformity with significant forefoot abduction (transverse plane deformity). While an MDCO corrects the coronal plane (valgus) deformity, a lateral column lengthening (such as an Evans calcaneal osteotomy) is specifically indicated to correct the substantial transverse plane abduction by effectively lengthening the lateral column and rotating the midfoot back over the talus.

Question 13

An elite collegiate baseball pitcher is diagnosed with Glenohumeral Internal Rotation Deficit (GIRD) after presenting with a significant loss of internal rotation and a total arc of motion that is 20 degrees less than his non-throwing shoulder. Which of the following pathologic changes is the primary driver of this symptomatic internal rotation loss?

Explanation

Pathologic GIRD is primarily driven by contracture and thickening of the posteroinferior capsule, resulting from repetitive microtrauma during the deceleration phase of throwing. While osseous retroversion of the humeral head alters the arc of motion (shifting it toward external rotation), it preserves the total arc of motion. A loss of the total arc of motion (>5-10 degrees) combined with internal rotation deficit indicates true pathologic capsular contracture.

Question 14

A 22-year-old athlete sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Jones fracture). The high propensity for nonunion in this region is attributed to a vascular watershed area. This watershed zone exists between the vascular supply of the metatarsal base and the diaphysis. Which of the following describes the primary blood supply to the diaphyseal side of this watershed zone?

Explanation

The fifth metatarsal has a predictable vascular watershed zone at the metaphyseal-diaphyseal junction (Zone 2). The base and tuberosity are supplied by metaphyseal arteries, while the diaphysis is supplied by a single intramedullary nutrient artery that typically enters the medial cortex at the junction of the proximal and middle thirds and courses proximally. The region between these two blood supplies is relatively avascular, contributing to the high nonunion rate of Jones fractures.

Question 15

During an ulnar collateral ligament (UCL) reconstruction in an overhead throwing athlete, accurate tunnel placement is crucial to recreate the anterior bundle of the UCL. What are the correct anatomical landmarks for the origin and insertion of the anterior bundle?

Explanation

The anterior bundle is the primary restraint to valgus stress at the elbow. It originates on the anteroinferior surface of the medial epicondyle and inserts on the sublime tubercle, which is located on the medial aspect of the base of the coronoid process. Recreating these specific footprints is critical for isometric graft function during UCL reconstruction.

Question 16

Osteochondral lesions of the talus frequently occur in distinct anatomical patterns associated with specific mechanisms of injury. Which of the following accurately describes the classical morphological characteristics and mechanism of a medial talar dome lesion?

Explanation

The classical mnemonic for osteochondral lesions of the talus is 'DIAL a PIMP'. DIAL: Dorsiflexion Inversion = Anterior Lateral lesions (which are typically shallow and wafer-shaped). PIMP: Plantarflexion Inversion = Medial Posterior lesions (which are typically deep and cup-shaped). Therefore, medial lesions are characteristically posterior, deep/cup-shaped, and result from plantarflexion and inversion.

Question 17

A 12-year-old boy presents with severe finger flexion contractures three months after an untreated forearm compartment syndrome secondary to a supracondylar humerus fracture. In established Volkmann ischemic contracture, which of the following muscles is typically the most profoundly ischemic and subsequently fibrotic?

Explanation

Volkmann's ischemic contracture results from untreated compartment syndrome in the forearm. The deep flexor compartment is the most severely affected due to its central location and reliance on the anterior interosseous artery, which is highly vulnerable to occlusion from elevated compartment pressures. The flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) are typically the most profoundly infarcted and fibrotic muscles.

Question 18

A 52-year-old male runner presents with dorsal foot pain and limited great toe dorsiflexion. Radiographs reveal moderate dorsal osteophytes and mild joint space narrowing at the first metatarsophalangeal (MTP) joint, consistent with Grade 2 hallux rigidus (Coughlin and Shurnas classification). He has 25 degrees of active dorsiflexion. Which of the following is the most appropriate initial surgical intervention if nonoperative management fails?

Explanation

Grade 2 hallux rigidus features mild to moderate joint space narrowing, dorsal osteophytes, and preserved plantar cartilage with some maintained range of motion (>15-20 degrees dorsiflexion). If conservative measures fail, a dorsal cheilectomy (removal of the dorsal osteophytes and dorsal 20-30% of the metatarsal head) is the procedure of choice. Arthrodesis is reserved for Grade 3 (severe narrowing) or Grade 4 (pain throughout the entire range of motion).

Question 19

During the surgical repair of a Zone II flexor tendon laceration in the hand, preservation or reconstruction of specific components of the flexor sheath is critical to prevent bowstringing and maintain digital kinematics. Which two annular pulleys are biomechanically the most important to preserve?

Explanation

The flexor tendon sheath consists of five annular (A1-A5) and three cruciform (C1-C3) pulleys. The A2 pulley (located over the proximal phalanx) and the A4 pulley (located over the middle phalanx) are the most critical biomechanically. Disruption of these pulleys leads to significant bowstringing of the flexor tendons, loss of mechanical advantage, and a substantial decrease in active interphalangeal joint flexion.

Question 20

A professional football player sustains a high-energy hyperdorsiflexion injury to his first metatarsophalangeal (MTP) joint. Clinical examination and MRI confirm a Grade III 'turf toe' injury, defined by complete disruption of the plantar plate complex with proximal migration of the sesamoids. To maximize the probability of return to elite-level sports, which of the following is the most appropriate management?

Explanation

Turf toe is a sprain of the first MTP joint capsuloligamentous complex. Grade I and II injuries are managed nonoperatively. A Grade III injury involves a complete tear of the plantar plate with proximal sesamoid migration. In elite athletes (such as professional football players), nonoperative management of Grade III injuries frequently results in chronic pain, instability, and weak push-off. Surgical repair of the plantar plate and capsuloligamentous complex is the definitive treatment of choice to restore anatomy and allow return to high-level play.

Question 21

A 68-year-old male with massive rotator cuff tear arthropathy presents with an inability to actively elevate his arm and severe external rotation weakness. On physical examination, he has a positive Hornblower's sign and an external rotation lag sign. He is planned for a reverse total shoulder arthroplasty (RTSA). Which of the following is the most appropriate concurrent procedure to optimize his postoperative function?

Explanation

A positive Hornblower's sign indicates severe teres minor deficiency. In the setting of a reverse total shoulder arthroplasty for pseudoparalysis, an associated latissimus dorsi/teres major transfer (L'Episcopo) is indicated to restore active external rotation.

Question 22

The primary biomechanical stability of the Lisfranc complex relies heavily on the Lisfranc ligament. Which of the following accurately describes the anatomic origin and insertion of this critical structure?

Explanation

The Lisfranc ligament is the strongest ligament in the midfoot, originating on the plantar-lateral aspect of the medial cuneiform and inserting on the plantar-medial aspect of the second metatarsal base. There is no direct ligamentous connection between the bases of the first and second metatarsals.

Question 23

A 40-year-old male sustains a 'terrible triad' injury of the elbow following a fall on an outstretched hand. During operative intervention, what is the most widely accepted standard surgical sequence for reconstruction to restore elbow stability?

Explanation

The standard surgical algorithm for a terrible triad injury proceeds from deep to superficial and medial to lateral: coronoid fixation first, followed by radial head repair or arthroplasty, and finally LCL complex repair. This sequence provides a logical progression to restore concentric stability of the elbow.

Question 24

A 52-year-old female is diagnosed with Stage IIB posterior tibial tendon dysfunction (PTTD), demonstrating a flexible flatfoot with severe forefoot abduction and greater than 30% talonavicular uncoverage on radiographs. In addition to a flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO), what additional procedure is biomechanically required to correct her specific deformity?

Explanation

Stage IIB PTTD involves a flexible flatfoot with significant forefoot abduction (talonavicular uncoverage >30%). An Evans lateral column lengthening is required in addition to MDCO and FDL transfer to effectively correct the severe forefoot abduction.

Question 25

A patient presents with acute wrist pain and swelling following a high-energy motorcycle collision. Lateral radiographs demonstrate a 'spilled teacup' sign, with the lunate displaced volarly and the capitate aligned with the distal radius. This injury mechanism most commonly occurs due to terminal disruption of ligaments in which of the following anatomic zones?

Explanation

The patient has a Stage IV perilunate dislocation (lunate dislocation). The terminal event in Mayfield's progressive perilunate instability involves failure of the dorsal radiocarpal ligaments and volar extrusion of the lunate through the Space of Poirier, an area of inherent weakness between the capitate and lunate.

Question 26

At 6 weeks post-injury, a 28-year-old patient who underwent open reduction and internal fixation for a Hawkins Type II talar neck fracture undergoes routine follow-up radiographs. A distinct subchondral radiolucent band is noted in the dome of the talus. What is the clinical significance of this radiographic finding?

Explanation

The subchondral radiolucent band is known as Hawkins' sign. It represents subchondral osteopenia due to bone resorption, which is a physiologic process that can only occur if the vascular supply to the talar dome remains intact, making it a reliable negative predictor for AVN.

Question 27

In a patient with a known Martin-Gruber anastomosis, a high complete transection of the ulnar nerve just proximal to the elbow would most likely result in which of the following unexpected clinical findings?

Explanation

A Martin-Gruber anastomosis is a crossing of motor nerve fibers from the median to the ulnar nerve in the forearm. In a high ulnar nerve injury, these median nerve fibers bypass the lesion and unexpectedly preserve motor function in ulnar-innervated intrinsic hand muscles, such as the first dorsal interosseous.

Question 28

Recent high-quality, randomized controlled trials comparing operative versus non-operative management of acute Achilles tendon ruptures demonstrate which of the following regarding complication rates when patients undergo early functional rehabilitation?

Explanation

Modern literature, notably the WILL trial and similar studies, shows that when early functional rehabilitation protocols are utilized, the re-rupture rates between operative and non-operative management of Achilles tendon ruptures are statistically equivalent.

Question 29

A 45-year-old female undergoes volar locked plating for a comminuted distal radius fracture. Postoperatively, she develops a spontaneous rupture of the flexor pollicis longus (FPL) tendon. Which of the following technical errors during surgery is the most significant risk factor for this complication?

Explanation

FPL tendon rupture is a known complication of volar plating of the distal radius. Placement of the plate distal to the watershed line (Soong Grade 2) causes the plate to sit proud, creating mechanical attrition on the FPL tendon.

Question 30

A 30-year-old female presents with severe bunion pain. Weight-bearing radiographs reveal a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and clinical hypermobility of the first ray. Which of the following surgical procedures is most appropriate to provide durable correction?

Explanation

The Lapidus procedure (arthrodesis of the first tarsometatarsal joint) is specifically indicated for severe hallux valgus (IMA >15 degrees) accompanied by first ray hypermobility. It stabilizes the medial column and prevents recurrence.

Question 31

In a patient undergoing a Latarjet procedure for recurrent anterior shoulder instability with 30% glenoid bone loss, what is the primary mechanism by which this procedure confers anterior stability?

Explanation

The Latarjet procedure provides stability via a 'triple blocking' effect. The most important biomechanical contributor is the dynamic 'sling effect' of the conjoint tendon compressing the lower subscapularis when the arm is abducted and externally rotated.

Question 32

A 21-year-old collegiate basketball player sustains an acute Zone 2 proximal fifth metatarsal fracture (Jones fracture) during a game. He wishes to return to play as safely and rapidly as possible. What is the recommended standard of care?

Explanation

Zone 2 fractures (Jones fractures) have a high risk of nonunion due to a tenuous blood supply. For elite or competitive athletes desiring early return to play, intramedullary screw fixation is the treatment of choice.

Question 33

When performing a primary flexor tendon repair in Zone II of the hand, which of the following factors has been shown to be the primary determinant of the repair's resistance to gap formation and overall tensile strength?

Explanation

Biomechanical studies demonstrate that the initial strength of a flexor tendon repair and its resistance to gap formation are directly proportional to the number of core suture strands crossing the repair site (e.g., 4-strand vs 2-strand).

Question 34

A 62-year-old male with end-stage ankle arthritis presents to discuss surgical options. He has a history of type II diabetes and peripheral neuropathy. Which of the following is considered an absolute contraindication to primary total ankle arthroplasty (TAA) in this patient?

Explanation

Active or historical Charcot neuroarthropathy with loss of protective sensation is an absolute contraindication to total ankle arthroplasty due to unacceptably high rates of catastrophic failure, loosening, and infection.

Question 35

A 25-year-old competitive athlete sustains a purely ligamentous Lisfranc injury. He undergoes operative stabilization. Compared to open reduction and internal fixation (ORIF) with screws, what is the primary advantage of performing a primary arthrodesis for this specific injury pattern?

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries demonstrates similar functional outcomes to ORIF but significantly reduces the need for hardware removal and revision surgeries.

Question 36

During a Zone II flexor tendon repair, which of the following biomechanical variables is most directly proportional to the ultimate tensile strength of the repair?

Explanation

The ultimate tensile strength of a flexor tendon repair is most directly proportional to the number of core suture strands crossing the repair site. Increased strands provide greater strength but may increase bulk and gliding resistance.

Question 37

A 32-year-old male undergoes ORIF for a Hawkins Type II talar neck fracture. At his 8-week follow-up, an AP radiograph of the ankle demonstrates a distinct subchondral lucency in the talar dome. What does this radiographic finding signify?

Explanation

The Hawkins sign presents as a subchondral lucency in the talar dome on an AP ankle radiograph at 6-8 weeks post-injury. It indicates intact vascularity and active bone resorption, signaling a low risk of avascular necrosis.

Question 38

A 45-year-old female presents with a 'terrible triad' injury of the elbow. Intraoperatively, the surgeon sequentially repairs the coronoid process, the radial head, and the lateral ulnar collateral ligament (LUCL). Upon testing, the elbow remains persistently unstable in full extension. What is the most appropriate next step in management?

Explanation

In the terrible triad of the elbow, the standard surgical sequence is repair of the coronoid, radial head, and LUCL. If the elbow remains unstable in extension after these steps, the MCL should be repaired or a hinged external fixator applied.

Question 39

A 40-year-old weekend warrior opts for a minimally invasive repair of an acute Achilles tendon rupture. To avoid injury to the sural nerve during percutaneous suture passage, the surgeon must be especially cautious to avoid which quadrant of the proximal tendon stump?

Explanation

The sural nerve crosses from midline to the lateral border of the Achilles tendon roughly 10 cm proximal to its insertion. Minimally invasive repairs risk capturing the nerve, particularly when passing sutures in the posterolateral quadrant.

Question 40

A 75-year-old female with a complex 4-part proximal humerus fracture undergoes a reverse total shoulder arthroplasty (RTSA). Which specific technical factor during glenoid component placement most significantly decreases the risk of postoperative scapular notching?

Explanation

Scapular notching in reverse total shoulder arthroplasty can be minimized by inferior positioning of the baseplate and lateralization of the glenosphere. This improves the impingement-free range of motion during shoulder adduction.

Question 41

A 50-year-old female presents with Stage IIb adult acquired flatfoot deformity, characterized by a flexible hindfoot and greater than 40% talonavicular uncoverage on radiographs. Which combination of procedures is the most appropriate surgical management?

Explanation

Stage IIb adult acquired flatfoot deformity involves a flexible hindfoot with significant forefoot abduction. Management typically requires an FDL transfer, a medializing calcaneal osteotomy, and a lateral column lengthening to correct the forefoot abduction.

Question 42

Following volar locking plate fixation of a distal radius fracture, a patient develops attrition and rupture of the flexor pollicis longus (FPL) tendon. Which radiographic parameter on the postoperative lateral view is most highly predictive of this complication?

Explanation

Plate prominence volar to the watershed line, classified as Soong Grade 2, significantly increases the risk of flexor tendon irritation. This mechanical conflict most commonly leads to rupture of the flexor pollicis longus (FPL).

Question 43

When utilizing suture button fixation for an ankle syndesmotic injury, what is a primary biomechanical advantage compared to traditional rigid trans-syndesmotic screw fixation?

Explanation

Suture button fixation for syndesmotic injuries allows for physiological micromotion and fibular rotation within the incisura during ankle dorsiflexion. It also mitigates the need for routine hardware removal.

Question 44

During a routine carpal tunnel release, the surgeon notes an anomalous neural connection between the median and ulnar nerves in the forearm, known as the Martin-Gruber anastomosis. What is the typical directional flow of these crossing fibers?

Explanation

The Martin-Gruber anastomosis is a common anatomical variant in the forearm where motor nerve fibers cross from the median nerve (or anterior interosseous nerve) to the ulnar nerve. It typically innervates intrinsic hand muscles.

Question 45

A 60-year-old male with Coughlin Grade 3 hallux rigidus undergoes a first metatarsophalangeal (MTP) joint arthrodesis. What is the optimal position for the arthrodesis to maximize postoperative function and footwear compatibility?

Explanation

The optimal position for a first MTP joint arthrodesis is 10-15 degrees of valgus and 10-15 degrees of dorsiflexion relative to the floor. This position restores normal push-off mechanics and accommodates standard footwear.

Question 46

A 50-year-old laborer presents with scapholunate advanced collapse (SLAC) Stage III, demonstrating arthritic changes in the radioscaphoid and capitolunate joints. The radiolunate joint is spared. Which of the following is the most appropriate surgical treatment?

Explanation

SLAC Stage III involves arthritic changes extending to the capitolunate joint. Proximal row carpectomy is contraindicated due to capitate arthritis, making scaphoid excision with four-corner fusion the preferred and durable treatment.

Question 47

A 22-year-old collegiate basketball player sustains a Zone 2 proximal fifth metatarsal (Jones) fracture and is treated with intramedullary screw fixation. Which technical error during screw insertion most significantly increases the risk of nonunion?

Explanation

When fixing a Jones fracture, if the screw threads cross the fracture site, the screw acts as a position screw rather than a lag screw. This prevents adequate interfragmentary compression and increases the risk of clinical failure or nonunion.

Question 48

Which of the following surgical techniques is most effective in minimizing the risk of scapular notching during a reverse total shoulder arthroplasty?

Explanation

Scapular notching is a common complication in reverse shoulder arthroplasty caused by mechanical impingement of the humeral component against the scapular neck. Inferior translation and inferior tilt of the glenosphere are the most reliable techniques to prevent this impingement.

Question 49

A 28-year-old sustains a Hawkins Type III talar neck fracture. At 8 weeks post-ORIF, a subchondral radiolucent line is seen in the talar dome on the AP mortise radiograph. What does this radiographic finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucent band typically seen 6 to 8 weeks after a talus fracture. It represents subchondral bone resorption secondary to disuse osteopenia, which requires an intact blood supply, thereby indicating viability of the talar body.

Question 50

A 60-year-old female presents with a sudden inability to flex her thumb interphalangeal joint 6 months following volar locked plating of a distal radius fracture. Which of the following plate positions is the most likely biomechanical cause of this complication?

Explanation

Flexor pollicis longus (FPL) rupture is a known complication of volar distal radius plating. It is most frequently caused by placement of the plate distal to the watershed line, leading to mechanical attrition of the tendon against the prominent plate edge.

Question 51

In the surgical treatment of Stage IIb adult-acquired flatfoot deformity, an Evans lateral column lengthening osteotomy is performed. What is the primary biomechanical consequence of this procedure on the adjacent midfoot joints?

Explanation

The Evans lateral column lengthening osteotomy effectively corrects forefoot abduction but significantly increases contact pressures across the calcaneocuboid joint. This can predispose the patient to early calcaneocuboid arthritis.

Question 52

During a Zone II flexor tendon repair, preservation or reconstruction of which specific annular pulleys is most critical to prevent mechanical bowstringing and maintain digital flexion excursion?

Explanation

The A2 and A4 pulleys arise directly from the periosteum of the proximal and middle phalanges, respectively. They are the primary mechanical constraints preventing bowstringing of the flexor tendons during digital flexion.

Question 53

A 24-year-old athlete sustains a pure ligamentous Lisfranc injury with instability of the first, second, and third tarsometatarsal joints. Based on prospective randomized data, which of the following provides the most reliable long-term functional outcome?

Explanation

For primarily ligamentous Lisfranc injuries, prospective randomized studies (e.g., Ly and Coetzee) have demonstrated that primary arthrodesis of the medial columns (TMT 1-3) yields superior functional outcomes and lower reoperation rates compared to ORIF.

Question 54

A 45-year-old male sustains a terrible triad injury of the elbow. During surgical reconstruction, after fixation of the coronoid and radial head arthroplasty, the elbow remains persistently unstable in extension. What is the next most appropriate step in management?

Explanation

The standard surgical algorithm for a terrible triad injury includes fixing the coronoid, restoring the radial head, and repairing the LUCL. If instability persists after addressing the anterior osseous structures, the LUCL must be repaired to the lateral epicondyle to restore lateral stability.

Question 55

When utilizing the extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, the vascular supply to the full-thickness lateral flap is primarily provided by which of the following?

Explanation

The full-thickness lateral flap used in the extensile lateral approach to the calcaneus is primarily supplied by the lateral calcaneal artery, a branch of the peroneal artery. Careful handling of this flap is critical to prevent marginal skin necrosis.

Question 56

A 62-year-old female presents with severe basilar thumb pain. Radiographs demonstrate advanced pantrapezial arthritis involving the trapeziometacarpal and scaphotrapezialtrapezoid (STT) joints (Eaton-Littler Stage IV). Which of the following procedures is most appropriate?

Explanation

In the presence of STT arthritis (Stage IV), joint-sparing or isolated trapeziometacarpal procedures (like arthrodesis or hemiarthroplasty) are contraindicated because they do not address the STT pathology. Complete trapeziectomy with or without LRTI is the treatment of choice.

Question 57

When performing an arthrodesis of the first metatarsophalangeal (MTP) joint for end-stage hallux rigidus, what is the optimal position of fusion to ensure maximal postoperative walking function?

Explanation

The optimal position for first MTP arthrodesis is 10-15 degrees of valgus and 15 degrees of dorsiflexion relative to the floor (which equates to roughly 20-25 degrees relative to the first metatarsal). This allows for normal push-off and accommodates standard footwear.

Question 58

In the open reduction and internal fixation of a 3-part proximal humerus fracture using a locking plate, the placement of calcar screws in the inferomedial quadrant of the humeral head is critical to prevent which of the following complications?

Explanation

Inferomedial calcar screws restore the medial hinge in proximal humerus fractures. Their precise placement is the most important mechanical factor in preventing postoperative varus collapse of the humeral head construct.

Question 59

Recent randomized controlled trials comparing operative and non-operative management of acute Achilles tendon ruptures demonstrate that utilizing an early functional rehabilitation protocol in non-operatively managed patients results in:

Explanation

Level I evidence indicates that when an early functional rehabilitation protocol (weight-bearing and early motion) is used, the re-rupture rates for non-operative management of Achilles tendon ruptures are equivalent to those of operative management, while avoiding surgical complications.

Question 60

Which bundle of the ulnar collateral ligament (UCL) of the elbow is the primary restraint to valgus stress during the late cocking phase of throwing, and where is its isometric origin?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress between 30 and 120 degrees of flexion. Its isometric origin is located on the anteroinferior surface of the medial epicondyle.

Question 61

According to the Ponseti method for the treatment of idiopathic congenital talipes equinovarus, what is the correct sequential order of deformity correction?

Explanation

The mnemonic CAVE dictates the sequential correction of clubfoot deformity in the Ponseti method: Cavus (corrected by elevating the first ray), Adductus, Varus, and finally Equinus (which often requires a percutaneous Achilles tenotomy).

Question 62

A patient with severe cubital tunnel syndrome demonstrates a positive Froment sign when attempting to pinch a piece of paper. This sign is caused by compensatory hyperflexion of the thumb interphalangeal joint driven by a muscle innervated by which nerve?

Explanation

Froment sign occurs due to weakness of the ulnar-innervated adductor pollicis. The patient compensates by utilizing the flexor pollicis longus (FPL) to pinch, resulting in thumb IP joint hyperflexion. The FPL is innervated by the anterior interosseous nerve.

Question 63

A 45-year-old runner presents with chronic medial heel pain. Examination reveals maximal tenderness over the medial calcaneal tuberosity and radiating pain along the course of the first branch of the lateral plantar nerve. This nerve primarily provides motor innervation to which muscle?

Explanation

The first branch of the lateral plantar nerve, also known as Baxter's nerve, courses between the abductor hallucis and quadratus plantae. It provides motor innervation primarily to the abductor digiti minimi, and its entrapment is a classic cause of chronic heel pain.

Question 64

According to Mayfield's progressive stages of perilunate instability, a Stage III injury is characterized by the disruption of which of the following structures, leading to a complete perilunate dislocation?

Explanation

Mayfield staging describes the progressive ligamentous disruption around the lunate. Stage I is scapholunate, Stage II involves the space of Poirier (capitolunate), Stage III is lunotriquetral disruption (resulting in perilunate dislocation), and Stage IV is lunate dislocation.

Question 65

A 25-year-old sustains an external rotation ankle injury. On a standard AP mortise radiograph taken non-weight-bearing, which measurement threshold is most specifically indicative of syndesmotic instability?

Explanation

A tibiofibular clear space of greater than 5 mm on an AP or mortise radiograph is widely considered abnormal and suggests a syndesmotic injury. The tibiofibular overlap can vary based on rotation, making the clear space a more reliable indicator.

Question 66

Among Kanavel's four cardinal signs of flexor tenosynovitis, which is generally considered the most reliable, earliest, and most sensitive indicator of the condition?

Explanation

Pain with passive extension is considered the earliest and most sensitive of Kanavel's signs for pyogenic flexor tenosynovitis. The other signs include fusiform swelling, flexed resting posture, and tenderness along the sheath.

Question 67

A 55-year-old patient with poorly controlled diabetes presents with a red, hot, swollen foot without an open ulcer. Radiographs show periarticular debris, fragmentation, and subluxation of the midfoot. According to the Eichenholtz classification, what is the appropriate stage and initial management?

Explanation

Eichenholtz Stage 1 (development/fragmentation) is characterized by a red, hot, swollen foot with radiographic evidence of bone fragmentation and subluxation. The gold standard initial management is offloading via a total contact cast to prevent further deformity.

Question 68

A 45-year-old construction worker presents with severe wrist pain. Radiographs reveal scapholunate advanced collapse (SLAC) Stage III, with degenerative changes in the radioscaphoid and capitolunate joints. The radiolunate joint is preserved. Which surgical option is most appropriate?

Explanation

SLAC Stage III involves the radioscaphoid and capitolunate joints. A proximal row carpectomy is contraindicated due to capitate head arthritis; therefore, scaphoid excision with four-corner fusion is the most appropriate motion-preserving procedure.

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

Orthopedic Surgery Board Review MCQs: Upper Extremity & Foot/Ankle Part 65

Key Takeaway

Orthopedic Surgery Board Review MCQs: Upper Extremity & Foot/Ankle Part 65

Chapter Index