OITE & ABOS Orthopedic Board Review MCQs | Part 114

Question 1

A 22-year-old collegiate soccer player undergoes an arthroscopic anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft. Postoperatively, she successfully regains full knee flexion but struggles with a persistent 10-degree loss of terminal knee extension. Which of the following technical errors during graft tunnel placement is the most likely cause of this complication?

Explanation

Placing the tibial tunnel too anteriorly causes the ACL graft to impinge against the roof of the intercondylar notch during knee extension, leading to a mechanical block to terminal extension. Conversely, a femoral tunnel placed too anteriorly leads to increased graft tension in flexion, resulting in a loss of knee flexion.

Question 2

A 45-year-old male is brought to the trauma bay in hemorrhagic shock following a motorcycle collision. Radiographs demonstrate an AP Compression Type III (APC-III) pelvic ring injury. A resident rapidly applies a pelvic binder and positions it firmly over the iliac crests. What is the most appropriate next step in management regarding the placement of this binder?

Explanation

Pelvic binders provide the most effective mechanical advantage for reducing pelvic volume and controlling hemorrhage when centered over the greater trochanters. Placement over the iliac crests is less effective and can paradoxically widen the true pelvis, worsening hemorrhage in certain fracture patterns.

Question 3

A 72-year-old male with pre-existing cervical spondylosis presents after a hyperextension injury sustained in a rear-end motor vehicle collision. He exhibits severe bilateral upper extremity weakness, profound loss of hand dexterity, and localized numbness. His lower extremity strength and gait are relatively preserved. MRI reveals intramedullary signal changes at C4-C5 but no fracture. What is the most likely diagnosis?

Explanation

Central cord syndrome is classically seen in older patients with cervical spondylosis who suffer a hyperextension injury. The mechanical pinch of the spinal cord leads to central gray and medial white matter damage, disproportionately affecting the upper extremities (especially hand dexterity) more than the lower extremities, as the cervical tracts are located more centrally.

Question 4

A 78-year-old low-demand female sustains a closed distal femur fracture after a mechanical fall. Radiographs demonstrate severe, non-reconstructible intra-articular comminution (AO/OTA 33-C3) with severe osteopenia. Which of the following is considered the strongest indication for distal femoral replacement (megaprosthesis) rather than open reduction and internal fixation in this setting?

Explanation

Distal femoral replacement is indicated for highly comminuted, non-reconstructible intra-articular distal femur fractures in elderly, severely osteopenic, or low-demand patients where internal fixation is likely to fail. It allows for immediate weight-bearing and early mobilization, reducing complications associated with prolonged bed rest.

Question 5

A 19-year-old rugby player is evaluated for recurrent anterior shoulder instability. A 3D CT reconstruction of the shoulder demonstrates anterior glenoid bone loss estimated at 28%. Which of the following is the most appropriate surgical treatment to prevent further recurrence?

Explanation

Critical anterior glenoid bone loss (generally >20-25%) results in a high failure rate if treated with isolated soft-tissue procedures (Bankart repair). A bony augmentation procedure, such as the Latarjet procedure (transfer of the coracoid process with the attached conjoint tendon to the anterior glenoid), is required to restore glenohumeral stability.

Question 6

A 30-year-old construction worker falls from scaffolding and sustains an L1 burst fracture. Axial CT imaging shows a vertical split (greenstick) fracture of the lamina. The presence of this specific posterior element fracture pattern most strongly increases the likelihood of which of the following?

Explanation

In the setting of a thoracolumbar burst fracture, a vertical split or greenstick fracture of the lamina is highly associated with a dural tear and subsequent entrapment of the neural elements (nerve roots of the cauda equina) within the fracture site. Surgeons must be cautious of dural tears when performing posterior decompression or stabilization in these patients.

Question 7

A 42-year-old male sustains a severe Schatzker VI tibial plateau fracture. On examination, the leg is tense with extensive hemorrhagic fracture blisters over the proximal tibia. A spanning external fixator is immediately placed. What clinical sign indicates the optimal timing to proceed with definitive open reduction and internal fixation?

Explanation

Definitive internal fixation of severe, high-energy tibial plateau fractures must be delayed until the soft tissue envelope has adequately recovered to minimize the risk of devastating wound complications and infection. The classic 'wrinkle sign' indicates that swelling has subsided enough to safely allow surgical incisions and primary wound closure.

Question 8

A 52-year-old female presents with acute medial knee pain after a squatting maneuver. MRI demonstrates a complete radial tear at the posterior root of the medial meniscus, with 4 mm of meniscal extrusion. If left untreated, what is the primary biomechanical consequence of this specific meniscal injury?

Explanation

The meniscal roots anchor the meniscus to the tibial plateau, allowing it to convert axial loads into circumferential hoop stresses. A root tear disrupts these fibers, resulting in meniscal extrusion and a complete loss of hoop stresses. Biomechanically, the peak contact pressures and contact area in the compartment become nearly identical to a knee that has undergone a total meniscectomy, rapidly predisposing the joint to osteoarthritis.

Question 9

Based on the Spine Patient Outcomes Research Trial (SPORT) data for patients with degenerative spondylolisthesis and spinal stenosis, what is the consensus regarding long-term outcomes of surgical decompression and fusion compared to nonoperative management?

Explanation

The SPORT study for degenerative spondylolisthesis showed that patients who underwent surgical treatment (decompression with or without fusion) had significantly greater improvements in pain and function compared to those who received nonoperative treatment, and these benefits were maintained at long-term (4-year and 8-year) follow-up.

Question 10

A 25-year-old male sustains a displaced scaphoid waist fracture. The proximal pole of the scaphoid is at exceptionally high risk for avascular necrosis due to its tenuous blood supply. Which of the following arteries provides the primary blood supply to the proximal pole via a retrograde intraosseous course?

Explanation

The scaphoid receives 70-80% of its blood supply via the dorsal carpal branch of the radial artery, which enters the bone at the dorsal ridge (distal pole and waist) and flows in a retrograde fashion to the proximal pole. Fractures at the waist or proximal pole disrupt this delicate supply, predisposing the proximal fragment to avascular necrosis.

Question 11

During an arthroscopic SLAP (Superior Labrum Anterior to Posterior) repair on a right shoulder, the surgeon prepares to place a suture anchor at the 1 o'clock position on the glenoid rim. Deep drill penetration past the far cortex at this specific location places which of the following neurovascular structures at greatest risk of injury?

Explanation

The suprascapular nerve courses through the suprascapular notch and winds around the spinoglenoid notch. It passes dangerously close (often within 1 cm) to the base of the coracoid process and the anterosuperior glenoid neck. Anteriorly placed anchors for SLAP repairs (1 to 2 o'clock position) that penetrate too deeply place the suprascapular nerve at high risk.

Question 12

A 34-year-old male is involved in a high-speed motor vehicle collision and sustains a Hawkins Type III talar neck fracture. According to the Hawkins classification, a Type III injury is characterized by a fracture of the talar neck with dislocation of which of the following joints?

Explanation

The Hawkins classification describes talar neck fractures: Type I is non-displaced; Type II involves subtalar subluxation/dislocation; Type III involves both subtalar and tibiotalar (ankle) dislocation; Type IV involves subtalar, tibiotalar, and talonavicular dislocation. Type III carries a nearly 100% risk of avascular necrosis if not rapidly reduced.

Question 13

An 84-year-old female with severe osteoporosis and multiple medical comorbidities presents with an isolated, minimally displaced Anderson-D'Alonzo Type II odontoid fracture after a fall from a standing height. Given her frailty and high surgical risk, which of the following treatments is associated with the lowest treatment-related morbidity and mortality, despite a recognized high rate of nonunion?

Explanation

In frail elderly patients, halo vest immobilization is poorly tolerated and associated with high complication rates, including respiratory failure and significant mortality. While surgical fusion (posterior C1-C2) provides definitive stability, the surgical risk is often prohibitive. Rigid cervical collar immobilization provides an acceptable risk-to-benefit profile; although the nonunion rate is high, a stable fibrous nonunion is a common, well-tolerated outcome in this population.

Question 14

A 13-year-old gymnast presents with vague, activity-related knee pain and a sensation of catching. Radiographs reveal an osteochondritis dissecans (OCD) lesion. Where is the classic and most frequent anatomical location for an OCD lesion in the knee?

Explanation

The classic location for osteochondritis dissecans (OCD) in the knee is the posterolateral aspect of the medial femoral condyle (often remembered by the acronym LAME: Lateral Aspect of the Medial Epicondyle/Condyle). This accounts for approximately 70-80% of knee OCD lesions.

Question 15

A 28-year-old male develops severe leg pain out of proportion to his injury following a closed tibia shaft fracture. A four-compartment lower extremity fasciotomy via a two-incision technique is planned. If the medial incision is made incorrectly and the fascial release is superficial, which compartment is most frequently missed or inadequately decompressed?

Explanation

The deep posterior compartment is the most commonly missed or inadequately decompressed compartment during leg fasciotomies. Access requires releasing the soleus bridge from the posteromedial aspect of the tibia to expose and incise the deep posterior fascia.

Question 16

A 12-year-old premenarchal female (Risser stage 0) is diagnosed with adolescent idiopathic scoliosis (AIS). Standing posteroanterior radiographs reveal a right thoracic curve measuring 34 degrees. What is the most appropriate initial, evidence-based management strategy to prevent curve progression to surgical magnitude?

Explanation

According to the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), TLSO bracing is indicated and highly effective for skeletally immature patients (Risser 0-2, premenarchal) with curves between 25 and 45 degrees. Bracing significantly decreases the progression of high-risk curves to the surgical threshold (generally >50 degrees).

Question 17

A 35-year-old male sustains a closed, isolated midshaft humerus fracture (Holstein-Lewis type). Upon presentation in the emergency department, he exhibits a complete inability to extend his wrist and fingers, alongside dorsal first web space numbness. Which of the following is the most appropriate initial management?

Explanation

A primary radial nerve palsy in the setting of a closed humerus shaft fracture is overwhelmingly a neurapraxia that resolves spontaneously in 70-90% of cases. The standard of care is conservative management with observation and functional bracing. Immediate surgical exploration is generally reserved for open fractures, associated vascular injuries, or secondary nerve palsies that develop after closed reduction.

Question 18

A 22-year-old collegiate baseball pitcher is scheduled for an ulnar collateral ligament (UCL) reconstruction using an autograft. Which specific bundle of the UCL is the primary restraint to valgus stress during the late cocking and early acceleration phases of throwing, and is thus the primary structure reconstructed in this procedure?

Explanation

The anterior bundle of the medial ulnar collateral ligament is the primary restraint to valgus stress at the elbow from approximately 30 to 120 degrees of flexion. It is the structure most susceptible to microtrauma and rupture during overhead throwing and is the focus of UCL ('Tommy John') reconstruction.

Question 19

A 58-year-old male presents with progressively worsening hand dexterity, frequent dropping of objects, and a broad-based, unsteady gait. Physical examination demonstrates an inverted brachioradialis reflex (striking the brachioradialis tendon produces finger flexion without wrist extension). This specific physical exam finding most reliably localizes spinal cord pathology to which cervical level?

Explanation

The inverted brachioradialis reflex is highly specific for cervical myelopathy at the C5-C6 level. It represents a simultaneous lower motor neuron lesion at the C5-C6 level (absent normal brachioradialis reflex) and an upper motor neuron lesion below that level (hyperactive finger flexion mediated by the C8 nerve root).

Question 20

A 40-year-old roofer falls 15 feet onto his feet, sustaining a severely comminuted, joint-depression type intra-articular calcaneus fracture with profound loss of height and varus deformity. On a lateral radiograph of the foot, which of the following angles is typically decreased (flattened) as a result of the posterior facet impaction?

Explanation

Böhler's angle is normally between 20 and 40 degrees. It is formed by a line from the highest point of the anterior process to the highest point of the posterior facet, and a second line from the posterior facet to the superior edge of the calcaneal tuberosity. In intra-articular calcaneus fractures with depression of the posterior facet, Böhler's angle decreases or becomes negative.

Question 21

Proper placement of a pelvic binder for a hemodynamically unstable patient with an anteroposterior compression (APC) type pelvic ring injury is centered at the level of the:

Explanation

For effective reduction and stabilization of the pelvic ring, a pelvic binder or sheet should be centered directly over the greater trochanters. Placement over the iliac crests or ASIS can paradoxically open the pelvic ring further in certain fracture patterns and provides less effective mechanical advantage.

Question 22

A 30-year-old male is brought to the emergency department intubated and sedated after a high-speed motor vehicle collision. CT imaging reveals a unilateral C5-C6 facet dislocation. What is the most appropriate next step prior to attempted surgical reduction and stabilization?

Explanation

In an obtunded or unexaminable patient with a cervical facet dislocation, an MRI is mandatory prior to open or closed reduction to rule out a herniated disc. In an awake, cooperative patient, closed cranial traction can be attempted prior to MRI, but this requires an intact mental status to report neurological changes during the reduction process.

Question 23

When comparing bone-patellar tendon-bone (BTB) autograft to hamstring autograft for primary anterior cruciate ligament (ACL) reconstruction, BTB autograft is associated with a statistically higher rate of which of the following postoperative complications?

Explanation

Bone-patellar tendon-bone (BTB) autografts historically exhibit a higher incidence of anterior knee pain and kneeling pain postoperatively compared to hamstring autografts. Rates of graft rupture and DVT are comparable or slightly favor BTB depending on the study, but anterior knee pain is a well-established drawback of the BTB harvest.

Question 24

A 65-year-old female presents with the sudden inability to actively extend her thumb interphalangeal joint 6 weeks after nonoperative treatment of a nondisplaced distal radius fracture. Radiographs show a healing fracture. What is the most appropriate definitive management?

Explanation

The patient has experienced a spontaneous rupture of the extensor pollicis longus (EPL) tendon, a known complication of nondisplaced distal radius fractures due to ischemia or mechanical attrition at Lister's tubercle. Because the tendon ends typically retract and undergo degeneration, primary repair is rarely possible. An EIP to EPL tendon transfer is the standard of care.

Question 25

An 82-year-old male with a history of hypertension and diabetes sustains a Type II odontoid fracture after a ground-level fall. He is neurologically intact. Which of the following treatments is associated with the lowest morbidity and mortality in this specific patient demographic?

Explanation

In elderly patients (typically over 80 years) with Type II odontoid fractures, rigid cervical collar immobilization is often preferred despite a high rate of nonunion. Halo vest immobilization in this age group is associated with high morbidity and a mortality rate approaching 40%. Nonunion in a collar is often a stable, asymptomatic fibrous nonunion, making it a safe alternative to high-risk surgical procedures or halo placement.

Question 26

A 55-year-old female experiences a sudden 'pop' in the posterior aspect of her knee while squatting. MRI reveals a medial meniscus posterior root tear. Biomechanical studies demonstrate that this injury alters tibiofemoral contact pressures most similarly to which of the following conditions?

Explanation

A posterior root tear of the medial meniscus disrupts the hoop stresses of the meniscus, causing it to extrude. Biomechanically, this results in peak contact pressures and contact areas that are equivalent to those seen following a total medial meniscectomy, predisposing the joint to rapid articular cartilage degeneration.

Question 27

A 28-year-old male sustains a displaced, intracapsular femoral neck fracture. He is scheduled for urgent closed reduction and internal fixation. According to the literature, which of the following factors is most strongly associated with the subsequent development of avascular necrosis (AVN) of the femoral head in this patient?

Explanation

The most significant predictive factor for the development of avascular necrosis (AVN) following a femoral neck fracture in a young adult is the initial degree of fracture displacement, which dictates the extent of injury to the medial femoral circumflex artery. While time to surgery and capsulotomy are heavily debated, the initial displacement remains the strongest independent risk factor.

Question 28

A 22-year-old female is involved in a high-speed motor vehicle collision while wearing a lap belt. She sustains a flexion-distraction (Chance) injury of L2. What associated concomitant injury must be most carefully evaluated and ruled out?

Explanation

Chance fractures (flexion-distraction injuries) are frequently caused by lap seatbelts during rapid deceleration. They have a high association with intra-abdominal visceral injuries, specifically hollow viscus injuries (e.g., bowel perforation), which occur in up to 40-50% of cases and require careful general surgical evaluation.

Question 29

A 19-year-old female gymnast presents with bilateral shoulder pain and a sensation of 'slipping.' Examination reveals a positive sulcus sign that does not decrease with external rotation, and a positive apprehension test without distinct trauma. What is the most appropriate initial management?

Explanation

The patient's presentation (bilateral symptoms, positive sulcus sign, atraumatic) is classic for multidirectional instability (MDI). The gold standard initial management for MDI is a minimum of 6 months of physical therapy emphasizing periscapular stabilizer and rotator cuff strengthening. Surgery (e.g., capsular shift) is reserved for patients who fail an extensive course of targeted therapy.

Question 30

The Sanders classification for intra-articular calcaneal fractures is based on the number and location of primary fracture lines seen on which of the following radiographic imaging views?

Explanation

The Sanders classification system is based on coronal CT images. Specifically, it assesses the number of fracture lines through the posterior facet of the calcaneus at its widest point. Type I is non-displaced, Type II has one fracture line (two fragments), Type III has two lines (three fragments), and Type IV is highly comminuted (four or more fragments).

Question 31

A 68-year-old male presents with bilateral lower extremity pain, heaviness, and cramping that worsens with walking. He notes the pain is relieved by leaning over a shopping cart. Which of the following historical or physical examination findings best differentiates his symptoms from vascular claudication?

Explanation

The patient's symptoms suggest neurogenic claudication secondary to lumbar spinal stenosis. Walking uphill requires lumbar flexion, which increases the canal volume and relieves the symptoms of neurogenic claudication. Conversely, walking downhill requires lumbar extension, which worsens symptoms. Patients with vascular claudication typically experience increased pain walking uphill due to the increased metabolic demand on the muscles.

Question 32

The primary restraint to posterior tibial translation at 90 degrees of knee flexion is the posterior cruciate ligament (PCL). Which of the following bundles of the PCL is tightest in this position?

Explanation

The PCL consists of two main bundles: the anterolateral (AL) and posteromedial (PM) bundles. The anterolateral bundle is the larger of the two and is tightest in knee flexion (particularly around 90 degrees). The posteromedial bundle is tightest in knee extension.

Question 33

A 32-year-old male presents with a severely comminuted midshaft tibia fracture. Clinical concern for acute compartment syndrome arises due to pain out of proportion to the injury. Which of the following intracompartmental pressure measurements represents the most widely accepted threshold indicating the need for immediate fasciotomy?

Explanation

The most reliable indicator for diagnosing acute compartment syndrome in an objective manner is the delta pressure (ΔP), defined as the diastolic blood pressure minus the absolute compartment pressure. A delta pressure of less than 30 mm Hg is the widely accepted threshold for surgical decompression (fasciotomy) because it accounts for individual variations in perfusion pressure.

Question 34

A 45-year-old male falls from a roof and sustains an L1 burst fracture. According to the Denis three-column classification of the thoracolumbar spine, a burst fracture is characterized by failure of which columns under axial compression?

Explanation

In the Denis classification, the spine is divided into three columns. A compression fracture involves failure of the anterior column only. A burst fracture is characterized by failure of both the anterior and middle columns under axial compression, leading to retropulsion of bone into the spinal canal.

Question 35

A 60-year-old male with a massive, retracted posterosuperior rotator cuff tear complains of pronounced weakness in external rotation. MRI reveals that fatty infiltration is most severe in the infraspinatus. Entrapment of the suprascapular nerve as a result of profound tendon retraction would most likely occur at which of the following anatomic locations?

Explanation

Massive retraction of the supraspinatus and infraspinatus tendons can place extreme traction on the suprascapular nerve. The nerve is most vulnerable to tethering and entrapment at the spinoglenoid notch due to the direct medial pull of the retracted infraspinatus muscle belly. Entrapment here causes isolated infraspinatus denervation.

Question 36

A 24-year-old male sustains a closed, distal-third spiral fracture of the humeral shaft (Holstein-Lewis fracture) following an arm-wrestling match. On physical examination, he is unable to extend his wrist or fingers. What is the most appropriate initial management of this patient?

Explanation

A primary radial nerve palsy in the setting of a closed humeral shaft fracture (including Holstein-Lewis patterns) is typically a neuropraxia. The standard of care is non-operative management initially, using a coaptation splint or functional brace, with clinical observation. Spontaneous recovery occurs in over 70-90% of cases. Immediate exploration is generally reserved for open fractures, penetrating trauma, or palsies that develop after closed reduction.

Question 37

A 72-year-old male with long-standing diffuse idiopathic skeletal hyperostosis (DISH) presents with neck pain after a minor fall. Radiographs and CT reveal an isolated, non-displaced fracture through the C6 vertebral body. Which of the following is the most appropriate definitive management?

Explanation

Fractures through the ankylosed spine (such as in DISH or Ankylosing Spondylitis) act biomechanically like long bone fractures. Even if seemingly non-displaced, they are highly unstable and carry a significant risk of secondary neurologic deterioration or epidural hematoma. Surgical stabilization (often long-segment posterior fusion) is the standard of care to prevent catastrophic displacement.

Question 38

A 25-year-old male hockey player presents with anterior groin pain exacerbated by hip flexion and internal rotation. Radiographs reveal a cam-type femoroacetabular impingement (FAI). This specific morphology is best described by which of the following anatomic abnormalities?

Explanation

Cam-type FAI is caused by an aspherical contour of the femoral head-neck junction, often described as a 'pistol grip' deformity or an osseous bump on the anterosuperior neck. This is quantified by an increased alpha angle. Pincer-type FAI is characterized by acetabular overcoverage, such as acetabular retroversion, coxa profunda, or protrusio acetabuli.

Question 39

According to the Hawkins classification of talar neck fractures, a Type III fracture involves displacement of the talar neck with subluxation or dislocation of the talar body from which of the following articulations?

Explanation

The Hawkins classification for talar neck fractures is: Type I (nondisplaced), Type II (displaced with subtalar subluxation/dislocation), Type III (displaced with both subtalar and tibiotalar dislocation), and Type IV (displaced with subtalar, tibiotalar, and talonavicular dislocation). The risk of avascular necrosis increases progressively with the grade.

Question 40

A 14-year-old female gymnast complains of persistent lower back pain that worsens with lumbar extension. Oblique radiographs of the lumbar spine demonstrate a 'Scottie dog with a collar' sign. The primary pathology is a stress fracture or defect of which of the following bony structures?

Explanation

The 'Scottie dog with a collar' sign on an oblique lumbar radiograph represents a radiolucent defect in the pars interarticularis, indicating spondylolysis. This injury is a stress fracture resulting from repetitive hyperextension, commonly seen in young athletes like gymnasts and football linemen.

Question 41

A 45-year-old male sustains a lateral compression type II (LC-II) pelvic ring injury in a motor vehicle collision. According to the Young-Burgess classification, which of the following is the hallmark posterior ring injury associated with this specific pattern?

Explanation

The Young-Burgess classification divides lateral compression (LC) injuries into three types. LC-I involves a sacral compression fracture on the side of impact. LC-II is characterized by the continuation of the lateral compressive force resulting in a crescent fracture (fracture-dislocation of the sacroiliac joint involving the posterior ilium). LC-III involves a 'windswept' pelvis, with an LC-I or LC-II injury on the ipsilateral side and an external rotation (APC-type) injury on the contralateral side.

Question 42

A 72-year-old male with long-standing ankylosing spondylitis presents to the emergency department after a ground-level fall. He complains of severe neck pain. What is the most common mechanism of injury for cervical fractures in this patient population, and what is a highly associated critical complication?

Explanation

Patients with ankylosing spondylitis have rigid, osteopenic spines that behave like long bones, making them highly susceptible to fractures even from low-energy trauma. The most common mechanism in the cervical spine is hyperextension, resulting in an extension-distraction (through-and-through) fracture. These fractures are highly unstable and are strongly associated with spinal epidural hematomas, which can cause rapidly progressive neurologic deficits.

Question 43

A 24-year-old rugby player presents with recurrent anterior shoulder instability. An MRI arthrogram reveals an abnormal contour of the inferior glenohumeral ligament (IGHL) with a 'J-sign' and contrast extravasation into the axillary pouch, but the anterior labrum remains attached to the glenoid. What is the most likely diagnosis?

Explanation

A HAGL (Humeral Avulsion of the Glenohumeral Ligament) lesion occurs when the IGHL is avulsed from its humeral attachment. On coronal MRI arthrogram, the normal U-shape of the axillary recess is lost and appears as a 'J-sign' due to the dropping down of the torn ligament, allowing contrast to extravasate into the axillary tissues. It is an important cause of recurrent instability without a Bankart lesion.

Question 44

A 30-year-old female is evaluated for a high-energy distal femur fracture. Computed tomography reveals an isolated coronal plane fracture of the lateral femoral condyle. What is the AO classification for this fracture, and what is the preferred surgical approach for optimal articular reduction?

Explanation

A coronal plane fracture of the femoral condyle is a Hoffa fracture, classified as AO 33-B3. It most commonly involves the lateral condyle. An anterolateral approach (or lateral arthrotomy) is preferred for lateral Hoffa fractures as it allows direct visualization of the articular surface for anatomic reduction prior to placement of anterior-to-posterior (or posterior-to-anterior) headless compression screws.

Question 45

A 22-year-old female is involved in a high-speed motor vehicle collision while wearing a lap-belt only. She sustains a severe flexion-distraction injury (Chance fracture) of the L2 vertebra. Which of the following concomitant injuries must be aggressively ruled out, as it is most highly associated with this specific spinal fracture pattern?

Explanation

Chance fractures (flexion-distraction injuries) are historically associated with lap-belt use without shoulder harnesses. The fulcrum of flexion moves anteriorly to the abdominal wall, resulting in distraction forces through the middle and posterior columns of the spine. This mechanism strongly correlates with intra-abdominal injuries, most notably hollow viscus (bowel) injuries, which occur in up to 40-50% of patients with a lap-belt sign and a Chance fracture.

Question 46

A 28-year-old male sustains a knee dislocation (KD-III) while stepping off a curb. Upon arrival in the emergency department, his knee is spontaneously reduced, and pedal pulses are palpable and symmetric to the contralateral leg. His Ankle-Brachial Index (ABI) is calculated at 0.85. What is the most appropriate next step in management regarding his vascular status?

Explanation

In the setting of a multiligament knee injury or knee dislocation, an ABI of less than 0.90 is highly sensitive for an occult arterial injury (popliteal artery). Even in the presence of palpable pulses, an ABI < 0.90 mandates advanced imaging, typically CT angiography (or traditional arteriography), to definitively rule out a flow-limiting intimal flap or other vascular injury.

Question 47

According to Mayfield's stages of progressive perilunate instability, what structural disruption defines Stage III of the cascade?

Explanation

The Mayfield classification describes the progressive perilunate instability cascade resulting from wrist hyperextension, ulnar deviation, and intercarpal supination. Stage I: Scapholunate interosseous ligament disruption. Stage II: Disruption of the capitolunate articulation. Stage III: Disruption of the lunotriquetral interosseous ligament (resulting in a perilunate dislocation). Stage IV: Failure of the dorsal radiocarpal ligament allowing the lunate to dislocate completely (usually volarly).

Question 48

An 82-year-old male presents with a Type II odontoid fracture displaced 6 mm posteriorly following a low-energy fall. He is neurologically intact. In this specific elderly population, which of the following immobilization methods is associated with the highest rate of morbidity and mortality?

Explanation

In the elderly population (generally considered >75-80 years old), halo vest immobilization is poorly tolerated and is associated with exceptionally high rates of morbidity and mortality (respiratory compromise, pin site infections, cardiac events, and death). Standard of care for Type II odontoid fractures in elderly poor surgical candidates is typically a rigid cervical collar (accepting a stable fibrous nonunion), or posterior C1-C2 fusion if they are medically fit to undergo surgery.

Question 49

A 22-year-old collegiate hockey player is diagnosed with symptomatic femoroacetabular impingement (FAI), Cam type. He has an alpha angle of 75 degrees. During hip arthroscopy, which of the following intra-articular pathologies is most classically encountered as a direct biomechanical result of this specific femoral deformity?

Explanation

Cam-type FAI is characterized by an aspherical femoral head-neck junction (high alpha angle) that acts like a cam, forcefully jamming into the anterosuperior acetabulum during hip flexion and internal rotation. This causes excessive shear forces across the articular cartilage, classically resulting in anterosuperior chondral delamination and separation of the labrum from the adjacent articular cartilage.

Question 50

A 34-year-old male sustains a talar neck fracture. Radiographs taken 8 weeks postoperatively demonstrate a subchondral radiolucent band in the dome of the talus on the AP ankle view. What is the physiological and prognostic significance of this radiographic finding (Hawkins sign)?

Explanation

The Hawkins sign is characterized by a subchondral radiolucent band in the talar dome on an AP mortise view typically seen 6 to 8 weeks after a talar neck fracture. It represents subchondral osteopenia secondary to active hyperemia and bone resorption. The presence of this sign is a highly reliable indicator that the talar body has sufficient blood supply and is undergoing revascularization, effectively ruling out total avascular necrosis.

Question 51

A 45-year-old male presents with severe lower back pain, bilateral sciatica, perineal numbness, and new-onset urinary retention with overflow incontinence. MRI reveals a massive L4-L5 central disc herniation. Based on the meta-analysis by Ahn et al., surgical decompression should ideally be performed within what timeframe from the onset of symptoms to maximize the chance of full neurologic recovery?

Explanation

Cauda Equina Syndrome (CES) is a surgical emergency. The classic meta-analysis by Ahn et al. (2000) demonstrated a significant advantage in neurological outcomes, including motor, sensory, and urologic recovery, when surgical decompression is performed within 48 hours of symptom onset compared to after 48 hours. This remains the highly tested 'golden rule' on board exams, though many surgeons advocate for the earliest possible decompression.

Question 52

A 65-year-old male presents with chronic right shoulder pain and an inability to actively elevate his arm above 45 degrees (pseudoparalysis). Passive forward elevation is 160 degrees. MRI demonstrates a massive, retracted tear of the supraspinatus and infraspinatus with Goutallier stage 4 fatty infiltration. The subscapularis and teres minor are intact. What is the most appropriate, definitive surgical intervention to restore active forward elevation?

Explanation

This patient has pseudoparalysis of the shoulder secondary to a massive, irreparable rotator cuff tear (Goutallier stage 4 fatty infiltration indicates irreversibility). Reverse total shoulder arthroplasty (RTSA) is the gold standard for restoring active forward elevation in older patients with pseudoparalysis, as it medializes and distalizes the center of rotation, recruiting the deltoid to initiate and maintain forward elevation.

Question 53

A 40-year-old male is admitted with a high-energy Schatzker VI tibial plateau fracture. Twelve hours later, he complains of severe, escalating leg pain unrelieved by opioids. Passive stretch of his great toe elicits excruciating pain. Which of the following pressure measurements provides the most reliable indication for performing an emergency four-compartment fasciotomy?

Explanation

The diagnosis of acute compartment syndrome relies heavily on clinical suspicion and continuous pressure monitoring in equivocal cases. The most reliable threshold for intervention is a Delta P (Diastolic Blood Pressure minus Compartment Pressure) of less than 30 mmHg. Relying solely on absolute compartment pressures (e.g., > 30 mmHg) can lead to unnecessary fasciotomies, particularly in hypertensive patients.

Question 54

A 60-year-old male with pre-existing cervical spondylosis presents after a hyperextension injury. He has marked weakness in his hands and upper extremities with minimal weakness in his lower extremities. Which of the following best describes the typical pattern of sensory and bladder dysfunction expected in this specific incomplete spinal cord injury syndrome?

Explanation

This patient has Central Cord Syndrome, the most common incomplete spinal cord injury, classically seen in older patients with cervical spondylosis who sustain a hyperextension injury. It affects the centrally located cervical tracts supplying the upper extremities more than the peripherally located sacral/lumbar tracts supplying the lower extremities. Sensory loss is variable (often patchy), and bowel/bladder dysfunction (such as urinary retention) may be present but is less severe than in complete lesions.

Question 55

A 20-year-old collegiate baseball pitcher experiences chronic posteromedial elbow pain during the deceleration phase of throwing. He has a 15-degree flexion contracture. Radiographs show prominent osteophytes on the posteromedial olecranon. The surgeon plans an arthroscopic posteromedial olecranon resection for valgus extension overload. What complication is directly associated with resecting more than 3 mm of the posteromedial olecranon?

Explanation

In valgus extension overload, repetitive impingement of the olecranon into the olecranon fossa causes posteromedial osteophytes. The posteromedial olecranon is an important secondary bony stabilizer to valgus stress. Resecting excessive bone (typically defined as > 2 to 3 mm) from the posteromedial olecranon unmasks underlying Ulnar Collateral Ligament (UCL) insufficiency and transfers excessive valgus stress to the anterior band of the UCL, leading to medial instability.

Question 56

A 28-year-old male sustains a midshaft clavicle fracture during a cycling accident. He is a high-level manual laborer. Which of the following radiographic parameters is widely accepted as a strong relative indication for primary open reduction and internal fixation rather than conservative management?

Explanation

Absolute indications for operative fixation of clavicle fractures include open fractures, neurovascular compromise, and severe skin tenting threatening to progress to an open fracture. Relative indications, especially in active patients, include 100% displacement (no cortical contact) combined with significant shortening (typically defined as > 1.5 to 2.0 cm), as these are associated with higher rates of nonunion, malunion, and decreased shoulder strength if treated non-operatively.

Question 57

A 13-year-old premenarchal female presents for routine evaluation of adolescent idiopathic scoliosis. Standing posteroanterior radiographs demonstrate a right thoracic curve measuring 35 degrees using the Cobb method. Her Risser stage is 1. What is the most appropriate management to halt curve progression?

Explanation

The indications for bracing in Adolescent Idiopathic Scoliosis (AIS) include a growing child (Risser stage 0-2, premenarchal or < 1 year postmenarchal) with a progressive curve between 25 and 45 degrees. The goal of bracing is to halt curve progression and prevent the need for surgery. Bracing for 16-23 hours per day (dose-dependent) with a rigid TLSO has been shown in the BRAIST trial to significantly decrease the rate of progression to the surgical threshold.

Question 58

During primary anterior cruciate ligament (ACL) reconstruction, a surgeon elects to use a bone-patellar tendon-bone (BPTB) autograft rather than a multi-strand hamstring autograft. Which of the following represents the primary biological and biomechanical advantage of the BPTB graft?

Explanation

The primary advantage of a bone-patellar tendon-bone (BPTB) autograft is that the bone plugs allow for rigid interference fixation and rapid bone-to-bone healing within the osseous tunnels (typically fully incorporating in about 6 weeks). In contrast, soft tissue grafts (like hamstrings) rely on Sharpey's fiber formation for tendon-to-bone healing, which is a slower biological process taking roughly 8 to 12 weeks. BPTB is known for a higher incidence of anterior knee pain.

Question 59

A 65-year-old male sustains a subtrochanteric fracture of the femur. On plain radiographs, the proximal fragment is noted to be severely displaced in a predictable pattern of flexion, abduction, and external rotation. Which specific muscle group is the primary deforming force responsible for the abduction of the proximal fragment?

Explanation

In a subtrochanteric femur fracture, the proximal fragment is subjected to distinct muscular deforming forces. The iliopsoas (attaching to the lesser trochanter) causes flexion. The short external rotators (piriformis, gemelli, obturator internus) cause external rotation. The abductors, primarily the gluteus medius and minimus (attaching to the greater trochanter), pull the proximal fragment into profound abduction. The adductors cause the distal fragment to translate medially.

Question 60

A 24-year-old male is evaluated in the trauma bay following a severe motorcycle accident resulting in a complete fracture-dislocation at T6. He is hypotensive (BP 80/40), bradycardic (HR 50), and has warm, well-perfused extremities. He has absent motor and sensory function below the umbilicus and an absent bulbocavernosus reflex. Which of the following pathophysiological mechanisms is primarily responsible for his acute hemodynamic instability?

Explanation

The patient is exhibiting signs of neurogenic shock, which is characterized by hypotension, bradycardia, and warm, flushed extremities. It is caused by the sudden loss of sympathetic vasomotor tone and unopposed vagal parasympathetic tone after a cervical or high thoracic (above T6) spinal cord injury. This differs from spinal shock, which refers to the transient loss of somatic reflex activity (e.g., absent bulbocavernosus reflex) below the level of the injury, regardless of hemodynamic status.

Question 61

A 35-year-old male sustains an Anterior-Posterior Compression (APC) type III pelvic ring injury following a motorcycle collision. A retrograde cystogram demonstrates an isolated extraperitoneal bladder rupture. The orthopedic team plans to perform an open reduction and internal fixation (ORIF) of the pubic symphysis with a plate. What is the recommended management for the concomitant extraperitoneal bladder rupture?

Explanation

Standard management for an isolated extraperitoneal bladder rupture is nonoperative treatment with Foley catheter drainage. However, an absolute indication for operative repair of an extraperitoneal bladder rupture is when the patient is concurrently undergoing open reduction and internal fixation of the anterior pelvic ring. Repairing the bladder reduces the risk of hardware contamination and deep pelvic infection by sealing off the source of urine leakage from the orthopedic surgical bed.

Question 62

A 68-year-old female presents with severe 'flatback' syndrome and forward truncal inclination following prior long-segment lumbar fusion. She has exhausted nonoperative management. In evaluating her spinopelvic parameters to plan a corrective osteotomy, you note that she has a high Pelvic Incidence (PI). Which of the following best describes the expected compensatory changes in her Pelvic Tilt (PT) and Sacral Slope (SS) as her body attempts to maintain global sagittal balance?

Explanation

Pelvic Incidence (PI) is a fixed morphological parameter representing the relationship between the sacrum and the femoral heads, defined by the equation PI = PT + SS. In conditions like flatback syndrome where there is a loss of lumbar lordosis, the patient shifts their center of gravity anteriorly. To compensate and bring the center of gravity back over the pelvis, the patient retroverts the pelvis. Pelvic retroversion corresponds to an increase in Pelvic Tilt (PT). Because PI is a constant, an increase in PT mathematically and anatomically mandates a decrease in Sacral Slope (SS).

Question 63

A 22-year-old collegiate baseball pitcher presents with vague dominant shoulder pain. Physical examination reveals a glenohumeral internal rotation deficit (GIRD). Which of the following examination findings defines a 'pathologic' GIRD that warrants intervention rather than an expected anatomic adaptation to overhead throwing?

Explanation

Overhead throwing athletes frequently develop an adaptive loss of internal rotation with a compensatory gain in external rotation, resulting in an unaltered total arc of motion compared to the non-dominant arm. This is a physiologic adaptation (anatomic GIRD) primarily due to osseous humeral retroversion. 'Pathologic GIRD' is defined clinically as a loss of >20 degrees of internal rotation associated with a loss of >5 degrees in the total arc of motion compared to the contralateral side. Pathologic GIRD is associated with posterior capsule contracture and an increased risk of SLAP tears and internal impingement.

Question 64

A 65-year-old female presents with atraumatic thigh pain and a subsequent radiograph showing a noncomminuted subtrochanteric femur fracture. To correctly diagnose an Atypical Femur Fracture (AFF) according to the 2013 American Society for Bone and Mineral Research (ASBMR) task force criteria, certain major criteria must be met. Which of the following is considered a major criterion for an AFF?

Explanation

The 2013 ASBMR criteria for Atypical Femur Fractures dictate that at least four of five major criteria must be present. These are: 1) associated with minimal or no trauma; 2) fracture line originates at the lateral cortex and is transverse in orientation (may become short oblique as it progresses medially); 3) complete fractures extend through both cortices and may be associated with a medial spike; incomplete fractures involve only the lateral cortex; 4) noncomminuted or minimally comminuted; 5) localized periosteal or endosteal thickening of the lateral cortex (beaking or flaring) at the fracture site. Bilateral findings, prodromal pain, delayed healing, and bisphosphonate use are all MINOR criteria.

Question 65

A 55-year-old male with progressive hand clumsiness and gait imbalance is diagnosed with cervical spondylotic myelopathy (CSM). He is scheduled for an anterior cervical discectomy and fusion (ACDF). Which of the following MRI findings is most predictive of a poor prognosis for postoperative neurologic recovery?

Explanation

In the setting of cervical spondylotic myelopathy (CSM), MRI changes within the spinal cord provide important prognostic information. The presence of T2 hyperintensity alone can indicate cord edema, which is potentially reversible and implies a moderate prognosis. However, the presence of T1 hypointensity combined with T2 hyperintensity represents myelomalacia, gliosis, or cystic necrosis of the spinal cord. This finding is a strong predictor of irreversible cord damage and poor functional recovery postoperatively.

Question 66

An orthopedic sports surgeon is discussing autograft options for an anterior cruciate ligament (ACL) reconstruction with a 19-year-old competitive soccer player. When comparing the initial biomechanical properties of standard autografts, which of the following possesses the highest ultimate load to failure?

Explanation

The initial ultimate load to failure of various ACL grafts compared to the native ACL is a frequent board testable concept. The native ACL has an ultimate tensile load of approximately 2160 N. A 10-mm BPTB graft has a load of roughly 2900 N. The central third quadriceps tendon is approximately 2300 N. A quadruple-strand hamstring graft (semitendinosus and gracilis) provides the highest initial ultimate load to failure at over 4000 N. However, despite these biomechanical numbers, clinical failure rates depend more on graft incorporation, fixation methods, and biologic healing rather than pure initial tensile strength.

Question 67

During retrograde intramedullary nailing of a supracondylar distal femur fracture (AO/OTA 33A), the fracture tends to fall into a characteristic deformity. To prevent the most common angular malalignment, a blocking (Poller) screw should be strategically placed. Which of the following is the characteristic deformity, and what is the primary deforming muscle force responsible?

Explanation

Distal femur fractures typically fall into an apex posterior (extension) and varus deformity. The apex posterior angulation is caused by the pull of the gastrocnemius heads on the distal articular fragment. The varus angulation is primarily driven by the adductor magnus pulling the distal femur medially, while the unsupported lateral cortex collapses. To combat varus using blocking (Poller) screws, the screw should be placed on the concavity of the deformity (medial side of the distal fragment) to force the nail laterally and correctly align the mechanical axis.

Question 68

A 52-year-old male intravenous drug user presents with back pain and a fever. MRI reveals a spinal epidural abscess. In which of the following scenarios is nonoperative management with broad-spectrum intravenous antibiotics ALONE most appropriate?

Explanation

Surgical decompression (laminectomy/evacuation) and concurrent antibiotics is the gold standard for most spinal epidural abscesses. Absolute indications for surgery include progressive neurologic deficit, presence of spinal instability/deformity, and failure of medical management. Medical management alone (IV antibiotics) is generally reserved for patients who are medically unfit for surgery, patients completely paralyzed for >48-72 hours, or neurologically intact patients with extensive pan-spinal (multilevel) epidural abscesses where wide laminectomies would induce massive spinal instability and morbidity.

Question 69

A 26-year-old male ice hockey player is diagnosed with symptomatic cam-type femoroacetabular impingement (FAI). He elects to undergo hip arthroscopy for osteochondroplasty of the femoral head-neck junction. During diagnostic arthroscopy, the surgeon evaluates the acetabular labrum and articular cartilage. Which region of the acetabulum is most likely to exhibit articular cartilage delamination secondary to this specific impingement morphology?

Explanation

Cam impingement occurs due to a loss of sphericity of the femoral head (decreased head-neck offset), creating an 'aspherical' cam lesion typically on the anterosuperior aspect of the head-neck junction. During hip flexion and internal rotation, this cam lesion engages the anterosuperior acetabular rim. The outside-in shear forces generated by the cam lesion cause separation of the articular cartilage from the subchondral bone, presenting clinically and arthroscopically as chondral delamination or the 'wave sign' predominantly in the anterosuperior acetabulum.

Question 70

You are assessing a 32-year-old male with a comminuted midshaft tibia fracture for suspected acute compartment syndrome. Clinical signs are equivocal, and you decide to obtain intra-compartmental pressure measurements. To obtain the highest and most accurate peak pressure representative of the zone of injury, where should the transducer needle be placed?

Explanation

Intracompartmental pressures in the setting of acute compartment syndrome following a tibia fracture are not uniform throughout the compartment. Research has shown that the highest pressure is usually located in the anterior compartment, specifically within 5 cm of the fracture site. Measurements taken further away (e.g., >5 cm) will yield progressively lower and potentially falsely reassuring pressures. Inserting the needle directly into the fracture hematoma itself may yield inaccurate pressure readings.

Question 71

A 72-year-old male presents with bilateral lower extremity pain, heaviness, and cramping that occurs after walking for 10 minutes. He is evaluated for both lumbar spinal stenosis (neurogenic claudication) and peripheral arterial disease (vascular claudication). Which of the following historical features is the most reliable discriminator pointing toward a diagnosis of neurogenic claudication?

Explanation

Neurogenic claudication secondary to lumbar spinal stenosis is classically exacerbated by lumbar extension (which narrows the spinal canal and neuroforamina) and relieved by lumbar flexion (which increases canal volume). Therefore, leaning forward over a shopping cart, sitting, or walking up an incline typical relieves neurogenic claudication. Vascular claudication is dependent on muscle oxygen demand; it is relieved by simply stopping and resting (standing still) and does not require a change in posture (flexion) for relief. Vascular claudication also tends to ascend (distal to proximal), whereas neurogenic claudication descends (proximal to distal).

Question 72

During a medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability, the surgeon uses intraoperative fluoroscopy to identify Schöttle's point for the femoral tunnel. Due to a technical error, the femoral tunnel is placed 8 mm strictly proximal to the true anatomic footprint. What is the expected kinematic effect of this non-anatomic tunnel placement on the patellofemoral joint?

Explanation

The MPFL acts as the primary soft-tissue restraint to lateral patellar translation from 0 to 30 degrees of knee flexion. Correct femoral tunnel positioning is critical for near-isometric graft behavior. If the femoral tunnel is placed too proximal, the distance between the femoral attachment and patellar attachment increases as the knee goes into flexion. Consequently, the graft will be loose in extension (when it should be restraining the patella) and become excessively tight in flexion, causing increased medial patellofemoral cartilage contact pressures and potentially restricting flexion.

Question 73

A 28-year-old male involved in a high-speed motor vehicle collision sustains a severe closed traction injury to his right upper extremity. Radiographs reveal marked lateral displacement of the scapula with an intact acromioclavicular joint, characteristic of scapulothoracic dissociation. What concomitant injury represents the most significant determinant of long-term functional outcome for his right arm?

Explanation

Scapulothoracic dissociation is a high-energy trauma characterized by complete disruption of the scapulothoracic articulation, essentially an internal amputation of the upper extremity. It involves massive soft tissue damage, subclavian/axillary vessel rupture, and brachial plexus injury. While vascular injuries are life-threatening and require emergent repair, the ultimate long-term functional outcome and limb viability are almost entirely dictated by the neurologic status. A complete brachial plexus avulsion is frequent and portends a devastating functional outcome, often resulting in an insensate, flail limb that may ultimately require early amputation.

Question 74

A 40-year-old male construction worker falls 15 feet and complains of severe back pain. Neurologic examination of the lower extremities is completely intact (ASIA E). A CT scan demonstrates a T12 burst fracture with 40% loss of anterior height and retropulsion into the canal. MRI reveals high T2 signal in the interspinous ligaments but an intact ligamentum flavum, representing an 'indeterminate' posterior ligamentous complex (PLC) injury. Utilizing the Thoracolumbar Injury Classification and Severity (TLICS) score, what is the patient's calculated score and the corresponding treatment recommendation?

Explanation

The Thoracolumbar Injury Classification and Severity (TLICS) score determines treatment based on three categories: 1) Morphology: Burst fracture = 2 points. 2) Neurologic status: Intact = 0 points. 3) PLC integrity: Indeterminate (suspected) = 2 points. Total score = 2 + 0 + 2 = 4 points. According to TLICS, a score of ≤ 3 suggests nonoperative management, a score of ≥ 5 suggests operative management, and a score of exactly 4 is an equivocal indication where either operative or nonoperative management may be chosen based on surgeon preference and patient factors.

Question 75

A 32-year-old competitive bodybuilder presents with acute anterior shoulder pain and a visible deformity in his axillary fold after attempting a max-weight bench press. MRI confirms a complete rupture of the pectoralis major tendon at its humeral insertion. During open repair, understanding the normal anatomy is crucial. Relative to the clavicular head, where does the sternal head of the pectoralis major tendon anatomically insert on the humerus?

Explanation

The pectoralis major tendon undergoes a 180-degree twist as it courses from the chest wall to its insertion on the lateral lip of the bicipital groove of the humerus. Due to this twist, the sternal head (inferior fibers) rotates to insert deep (posterior) and proximal to the clavicular head (superior fibers). The sternal head is under the most tension when the arm is extended and externally rotated (the bottom of a bench press), making it the most frequently injured component.

Question 76

A 24-year-old male sustains an isolated distal-third radial shaft fracture (Galeazzi variant) and undergoes open reduction and internal fixation with a rigid compression plate. Intraoperatively, after anatomic fixation of the radius, the distal radioulnar joint (DRUJ) is tested. It remains grossly unstable in neutral and full pronation, but reliably reduces and remains perfectly stable in full supination. What is the most appropriate next step in management?

Explanation

A Galeazzi fracture involves a distal radius shaft fracture with disruption of the distal radioulnar joint (DRUJ). The primary treatment is rigid anatomic internal fixation of the radius. If the DRUJ is unstable post-fixation, its stability should be assessed in supination. Supination functionally closes the DRUJ by tightening the palmar radioulnar ligaments and reducing the ulna dorsally into the sigmoid notch. If the DRUJ is stable in full supination, the standard of care is nonoperative management of the DRUJ using a long-arm cast or splint in supination for 4-6 weeks. Operative intervention (pinning or TFCC repair) is reserved for DRUJ instability that persists even in full supination.

Question 77

A 45-year-old male is brought to the emergency department after a high-speed motor vehicle collision. He complains of severe neck pain. A cervical spine CT scan demonstrates a traumatic spondylolisthesis of the axis (Hangman's fracture) with severe angulation, minimal translation, and widening of the posterior disc space (Levine-Edwards Type IIA). Which of the following standard cervical interventions is strictly contraindicated in the acute management of this specific fracture pattern?

Explanation

The Levine-Edwards classification of Hangman's fractures dictates specific treatments. A Type IIA fracture is characterized by significant angulation and minimal translation, with widening of the posterior C2-C3 disc space. The mechanism of injury is flexion-distraction. Because the injury represents a distraction vector with severe posterior ligamentous compromise, the application of cervical traction is strictly contraindicated, as it will exacerbate the distraction, worsen the deformity, and potentially cause neurologic compromise. Treatment typically involves reduction in extension under fluoroscopy followed by halo immobilization.

Question 78

A 22-year-old elite basketball player undergoes open surgical debridement of the inferior pole of the patella for chronic, refractory 'jumper’s knee' (patellar tendinopathy). Which of the following describes the most likely classic histologic findings in the excised pathologic tendon tissue?

Explanation

Chronic patellar tendinopathy (jumper's knee), like lateral epicondylitis and Achilles tendinopathy, is histologically a 'tendinosis' rather than a true 'tendinitis'. Pathologic evaluation of the diseased tendon demonstrates a lack of active acute inflammatory cells. Instead, the tissue exhibits angiofibroblastic hyperplasia, mucoid (myxoid) degeneration, disorganized collagen architecture (increased Type III collagen relative to Type I), and increased cellularity of poorly differentiated fibroblasts. This process represents a failed healing response rather than an active inflammatory cascade.

Question 79

During a classic posterolateral approach to the ankle to treat a trimalleolar ankle fracture with a large posterior malleolus fragment, the surgeon develops the primary internervous/intermuscular interval. Dissection is carried down to the posterior tibia between which two specific muscle bellies?

Explanation

The standard posterolateral approach to the ankle is highly effective for exposing the posterior malleolus and lateral malleolus simultaneously. The correct intermuscular interval is between the flexor hallucis longus (FHL, innervated by the tibial nerve) medially and the peroneus brevis (innervated by the superficial peroneal nerve) laterally. During this approach, care must be taken to identify and protect the sural nerve and short saphenous vein, which lie in the superficial subcutaneous tissue crossing from medial to lateral.

Question 80

A 64-year-old male with cervical myelopathy undergoes a posterior C3-C6 laminectomy and instrumented fusion. On postoperative day 4, he suddenly develops profound weakness in bilateral shoulder abduction and elbow flexion, while hand intrinsic function and lower extremity strength remain full. MRI shows adequate decompression with no hematoma or new cord signal. What is the most appropriate initial management and expected natural history for this complication?

Explanation

The patient has developed a C5 palsy, a well-recognized complication occurring in up to 10% of patients following posterior cervical decompression (laminectomy/fusion or laminoplasty). The exact etiology is multifactorial and heavily debated, potentially involving spinal cord shifting/tethering, reperfusion injury, or foraminal stenosis. It classically presents 2 to 5 days postoperatively with deltoid and biceps weakness. If imaging confirms adequate decompression and no correctable cause (like a hematoma), the standard of care is conservative management (observation and PT to prevent stiffness). The prognosis is generally favorable, with the majority of patients experiencing spontaneous recovery within 6 months.

Question 81

A 28-year-old male sustains a vertically oriented, Pauwels type III femoral neck fracture. To minimize the risk of shear-induced displacement and varus collapse, which of the following internal fixation constructs is biomechanically superior?

Explanation

A sliding hip screw (SHS) with a derotational screw provides a fixed-angle construct that is biomechanically superior to parallel cannulated screws in resisting the high vertical shear forces seen in Pauwels type III femoral neck fractures.

Question 82

A 65-year-old female with degenerative spondylolisthesis at L4-L5 and severe neurogenic claudication elects to undergo surgical intervention after failing conservative management. Based on the Spine Patient Outcomes Research Trial (SPORT), what is the expected long-term outcome compared to non-operative treatment?

Explanation

The SPORT trial demonstrated that patients treated surgically for degenerative spondylolisthesis with spinal stenosis maintained significantly greater improvements in pain and function at 4 years compared to those treated non-operatively.

Question 83

A 19-year-old football player presents with recurrent anterior shoulder instability. CT imaging reveals a 28% anterior glenoid bone defect. Which of the following procedures is most appropriate to restore stability and prevent recurrence?

Explanation

In the setting of anterior shoulder instability with critical glenoid bone loss (typically >20-25%), soft tissue stabilization alone is inadequate. A bony augmentation procedure, such as the Latarjet coracoid transfer, is required.

Question 84

A 42-year-old male sustains a high-energy Schatzker type IV tibial plateau fracture with significant posteromedial articular depression. A posteromedial approach is planned. What is the primary internervous/intermuscular interval utilized in this approach?

Explanation

The posteromedial approach to the tibial plateau utilizes the interval between the medial head of the gastrocnemius (tibial nerve) and the pes anserinus tendons (femoral/sciatic nerve branches), allowing direct access to the posteromedial articular fragment.

Question 85

A 55-year-old male presents with severe cervical myelopathy. Imaging demonstrates continuous ossification of the posterior longitudinal ligament (OPLL) from C3 to C6, with a K-line negative alignment on the sagittal radiograph. What is the most appropriate surgical strategy?

Explanation

A negative K-line indicates that the OPLL mass exceeds the line connecting the midpoints of the spinal canal at C2 and C7, typically due to kyphosis. Laminoplasty alone is contraindicated; posterior laminectomy with instrumented fusion or an anterior approach is required to decompress the cord effectively.

Question 86

A 35-year-old active female undergoes arthroscopy for a knee injury. A complete radial tear at the posterior root attachment of the medial meniscus is identified. Biomechanically, how does this specific injury alter knee joint contact pressures?

Explanation

A complete posterior root tear of the medial meniscus disrupts the meniscal hoop stresses entirely. Biomechanical studies have shown this results in decreased contact area and increased peak contact pressures equivalent to a total medial meniscectomy.

Question 87

A 30-year-old male falls from a height of 20 feet. He is hemodynamically stable but has a severely comminuted, U-shaped sacral fracture with spinopelvic dissociation and bilateral lower extremity weakness. What is the classic plain radiographic finding associated with this injury?

Explanation

In spinopelvic dissociation (U-type sacral fractures), the upper sacral segment often flexes forward due to the pull of gravity and the lack of pelvic continuity. This creates a "paradoxical inlet" appearance of the sacrum on a standard AP radiograph.

Question 88

A 24-year-old female sustains a Levine-Edwards Type IIa traumatic spondylolisthesis of the axis (Hangman's fracture) after a high-speed motor vehicle collision. The fracture demonstrates significant angulation with minimal translation. What is the primary contraindication in the initial non-operative management of this specific fracture pattern?

Explanation

Levine-Edwards Type IIa Hangman's fractures involve significant angulation with minimal translation and are caused by a flexion-distraction mechanism. Cervical traction is strictly contraindicated as it can cause over-distraction and catastrophic neurological injury.

Question 89

An orthopedic surgeon is performing a posterior cruciate ligament (PCL) reconstruction and decides to use a tibial inlay technique rather than a transtibial tunnel technique. What is the primary biomechanical advantage of the tibial inlay technique?

Explanation

The tibial inlay technique avoids routing the graft through a tibial tunnel and over the posterior aspect of the tibia. This eliminates the acute "killer turn," reducing repetitive graft abrasion and potential attenuation.

Question 90

During a volar approach (Henry approach) for open reduction and internal fixation of a distal radius fracture, the surgeon develops the internervous plane. Which two structures define this primary interval?

Explanation

The classic volar (Henry) approach to the distal radius utilizes the interval between the flexor carpi radialis (FCR) tendon (median nerve) and the radial artery. The FCR is retracted medially and the radial artery laterally to expose the deeper structures.

Orthopedic Surgery Board Review MCQs: Arthroplasty, Ligament & Spine | Part 149

OITE & ABOS Orthopedic Board Review MCQs: Trauma, Spine & Sports Medicine | Part 114

Key Takeaway

OITE & ABOS Orthopedic Board Review MCQs: Trauma, Spine & Sports Medicine | Part 114

Chapter Index