Orthopedic Board Prep: 100 OITE & ABOS MCQs Pt 210

Question 1

A 22-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A pre-operative CT scan demonstrates a 25% anterior glenoid bone defect. What is the most appropriate surgical treatment to minimize his risk of recurrence?

Explanation

The open Latarjet procedure is the gold standard for patients with recurrent anterior shoulder instability and significant glenoid bone loss (>20-25%), particularly in high-demand contact athletes. Arthroscopic Bankart repair, even with remplissage, has an unacceptably high failure rate in the setting of critical glenoid bone loss.

Question 2

During an arthroscopic osteochondroplasty for a cam-type femoroacetabular impingement, the surgeon must avoid extending the resection too far posterolaterally on the femoral neck to prevent avascular necrosis. The retinacular vessels at risk in this region are terminal branches of which artery?

Explanation

The primary blood supply to the femoral head is provided by the retinacular branches of the medial femoral circumflex artery (MFCA). These vessels course superiorly and posteriorly along the femoral neck and are at risk if an osteochondroplasty for a cam lesion extends excessively posterolaterally.

Question 3

A lateral extra-articular tenodesis (LET) is frequently added to revision anterior cruciate ligament (ACL) reconstructions to control rotational laxity. The anterolateral ligament (ALL), often the anatomical target of this augmentation, inserts on the tibia at which of the following locations?

Explanation

The anterolateral ligament (ALL) originates near the lateral epicondyle of the femur and inserts on the proximal lateral tibia, midway between Gerdy's tubercle and the anterior margin of the fibular head, approximately 5 mm distal to the joint line.

Question 4

During an anterior intrapelvic (Stoppa) approach for the fixation of an acetabular fracture, massive hemorrhage is encountered from a vessel located over the posterior aspect of the superior pubic ramus. This bleeding is most likely due to an injury to an anastomosis between which two vascular systems?

Explanation

The corona mortis ('crown of death') is a common vascular anastomosis between the external iliac or inferior epigastric vessels and the obturator vessels (a branch of the internal iliac system). It is located on the posterior aspect of the superior pubic ramus and is highly vulnerable during anterior pelvic approaches.

Question 5

A 30-year-old male is evaluated for increasing leg pain following a high-energy closed tibial shaft fracture. Which of the following continuous pressure measurements is the most reliable threshold for diagnosing acute compartment syndrome and indicating the need for fasciotomy?

Explanation

The differential pressure, or delta pressure (Diastolic Blood Pressure - Compartment Pressure), is the most reliable indicator for acute compartment syndrome. A delta pressure of less than 30 mmHg indicates inadequate tissue perfusion and is the standard threshold for proceeding with fasciotomy.

Question 6

A 45-year-old female undergoes an MRI of her knee, which demonstrates a complete tear of the posterior root of the medial meniscus. If left untreated, biomechanical studies demonstrate that this injury alters knee joint contact pressures to a level most equivalent to which of the following?

Explanation

A posterior root tear of the medial meniscus disrupts the circumferential hoop stresses of the meniscus, leading to extrusion of the meniscus during axial loading. Biomechanically, this functional loss is equivalent to a total meniscectomy, severely increasing peak articular contact pressures and accelerating osteoarthritis.

Question 7

An obturator oblique radiograph of the pelvis in a patient with an acetabular fracture demonstrates an intact segment of the ilium protruding posteriorly, independent of the articular surface. This radiographic 'spur sign' is pathognomonic for which type of acetabular fracture?

Explanation

The spur sign represents the posterior portion of the intact iliac wing (the strut connecting the sacroiliac joint to the rest of the axial skeleton) extending superiorly and posteriorly to the displaced articular fracture fragments. It is pathognomonic for a both-column acetabular fracture.

Question 8

A 16-year-old female is undergoing a medial patellofemoral ligament (MPFL) reconstruction. The surgeon uses intraoperative fluoroscopy to identify Schottle's point for the femoral attachment. Which of the following best describes the location of Schottle's point on a perfect lateral radiograph?

Explanation

Schottle's point anatomically approximates the femoral origin of the MPFL. Radiographically, on a true lateral view, it is located 1 mm anterior to the line extending the posterior femoral cortex, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the level of Blumensaat's line.

Question 9

A 28-year-old male sustains a Hawkins Type II talar neck fracture. Eight weeks post-operatively, an anteroposterior radiograph of the ankle reveals a subchondral radiolucent band in the dome of the talus. What is the clinical significance of this finding?

Explanation

The Hawkins sign is a subchondral radiolucent band seen in the talar dome 6 to 8 weeks after a talar neck fracture. It represents disuse osteopenia (subchondral atrophy), which can only occur if there is active bone resorption mediated by an intact vascular supply. Its presence is highly predictive of talar body viability.

Question 10

A 29-year-old elite volleyball player presents with insidious onset right shoulder weakness. Examination reveals isolated profound atrophy of the infraspinatus with preserved supraspinatus strength and bulk. An MRI is most likely to show nerve compression by a paralabral cyst in which anatomic location?

Explanation

The suprascapular nerve innervates the supraspinatus muscle before passing through the spinoglenoid notch to innervate the infraspinatus. Entrapment at the spinoglenoid notch (commonly by a cyst associated with a posterior labral tear) results in isolated infraspinatus weakness. Entrapment at the suprascapular notch would affect both muscles.

Question 11

Recent anatomical studies have fundamentally changed the understanding of the blood supply to the proximal humerus, an important consideration in the surgical management of proximal humerus fractures. Which vessel is now recognized as providing the majority of the blood supply to the humeral head?

Explanation

Historically, the arcuate branch of the anterior humeral circumflex artery was believed to be the primary blood supply to the humeral head. However, modern cadaveric studies (e.g., Hettrich et al.) have demonstrated that the posterior humeral circumflex artery actually provides the majority (up to 64%) of the blood supply.

Question 12

During an ulnar collateral ligament (UCL) reconstruction using the docking technique in a baseball pitcher, the surgeon aims to anatomically restore the anterior bundle of the UCL. What is the anatomic insertion site of this anterior bundle on the ulna?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. It originates on the anterior undersurface of the medial epicondyle and inserts on the sublime tubercle, which is located on the anteromedial facet of the coronoid process of the ulna.

Question 13

A 24-year-old male polytrauma patient presents with severe bilateral pulmonary contusions, a borderline Glasgow Coma Scale score, and a closed midshaft femur fracture. To minimize his risk of developing Acute Respiratory Distress Syndrome (ARDS), what is the most appropriate initial orthopaedic management of the femur fracture?

Explanation

In severely polytraumatized patients, particularly those with significant chest trauma ('borderline' or 'unstable' patients), the systemic inflammatory response is profound. Damage control orthopedics (DCO) utilizing temporary external fixation prevents the 'second hit' phenomenon associated with intramedullary nailing, thereby minimizing the risk of ARDS and multiorgan failure.

Question 14

The posterior cruciate ligament (PCL) consists of two distinct functional bundles. Which of the following statements correctly describes the biomechanical properties of the anterolateral (AL) bundle?

Explanation

The PCL consists of the larger, stiffer anterolateral (AL) bundle and the smaller posteromedial (PM) bundle. The AL bundle is tight in flexion and loose in extension, whereas the PM bundle is tight in extension and loose in flexion. The PCL originates on the lateral aspect of the medial femoral condyle.

Question 15

Following a severe tibial plateau fracture, a patient develops impending acute compartment syndrome of the leg. In the deep posterior compartment, which muscle is most vulnerable to ischemia and contracture due to its central location and bipennate structure?

Explanation

The tibialis posterior muscle is located centrally within the deep posterior compartment. Its bipennate architecture and tightly confined fascial boundaries make its blood supply exceptionally vulnerable to increased intracompartmental pressure, making it the most susceptible muscle to ischemic necrosis and subsequent contracture if fasciotomy is delayed.

Question 16

A 42-year-old manual laborer presents with persistent anterior shoulder pain and catching after a lifting injury 6 months ago. MRI and subsequent diagnostic arthroscopy confirm an isolated Type II SLAP tear. Given the patient's age and high physical demands, which procedure is statistically associated with the most reliable return to full work duties and lowest reoperation rate?

Explanation

Extensive recent literature indicates that in patients over the age of 35-40 (especially laborers), biceps tenodesis offers more reliable pain relief, significantly lower reoperation rates, and higher return to work satisfaction compared to SLAP repair, which frequently results in postoperative stiffness and persistent pain in this demographic.

Question 17

A 45-year-old male sustains a Schatzker IV tibial plateau fracture with a large, displaced posteromedial fragment. The surgeon elects to buttress this fragment using a standard posteromedial approach with the patient prone. Which anatomic interval is utilized to access the posteromedial tibial plateau?

Explanation

The standard posteromedial approach to the tibial plateau uses the interval between the medial head of the gastrocnemius (which is retracted laterally along with the neurovascular bundle to protect it) and the pes anserinus tendons (which are retracted medially). This safely exposes the posteromedial cortex of the proximal tibia.

Question 18

A 21-year-old professional football player suffers an acute syndesmotic injury (high ankle sprain) with dynamic widening of the distal tibiofibular joint visualized on stress fluoroscopy. He is treated with a flexible suture-button construct. Compared to traditional rigid syndesmotic screw fixation, what is the primary biomechanical advantage of the suture-button construct?

Explanation

Suture-button constructs provide dynamic stabilization of the syndesmosis. The primary biomechanical advantage over rigid screw fixation is that they allow for the maintenance of physiologic micromotion and normal kinematics of the distal tibiofibular joint during the normal gait cycle, while preventing pathologic widening.

Question 19

A 30-year-old female sustains a vertically oriented, Pauwels Type III femoral neck fracture after a fall from a height. Because of the vertical fracture line, the fracture is subject to extremely high shear forces. Which of the following internal fixation constructs provides the highest biomechanical stability against shear forces for this fracture pattern?

Explanation

Pauwels Type III fractures (>50 degree angle to the horizontal) are highly unstable due to significant vertical shear forces. Biomechanical studies have consistently shown that fixed-angle devices, such as a sliding hip screw supplemented with a derotational cancellous screw, provide superior resistance to shear and varus collapse compared to multiple parallel cancellous screws.

Question 20

During a routine ACL reconstruction on a 19-year-old soccer player, the surgeon systematically evaluates the menisci and identifies a 'ramp lesion' utilizing a posteromedial portal. A ramp lesion specifically describes a tear at which of the following anatomic locations?

Explanation

A ramp lesion is a peripheral tear involving the meniscocapsular and meniscotibial attachments of the posterior horn of the medial meniscus. It is highly associated with acute ACL ruptures and is often missed if a systematic evaluation of the posteromedial compartment (via the intercondylar notch or a dedicated posteromedial portal) is not performed.

Question 21

A 22-year-old collision athlete presents with recurrent anterior shoulder instability. A 3D CT scan reveals 26% anterior glenoid bone loss. What is the most appropriate surgical intervention?

Explanation

For glenoid bone loss greater than 20-25% in a collision athlete, an arthroscopic or open Bankart soft-tissue repair has an unacceptably high failure rate. A coracoid transfer (Latarjet procedure) or structural bone graft is indicated to restore the anterior bony arc and provide a sling effect via the conjoined tendon.

Question 22

A 25-year-old male sustains a vertically oriented (Pauwels type III) femoral neck fracture. Which of the following internal fixation constructs provides the greatest biomechanical stability for this fracture pattern?

Explanation

Biomechanical studies have demonstrated that for unstable, vertically oriented (Pauwels III) femoral neck fractures, a sliding hip screw (with or without an anti-rotation screw) provides superior biomechanical stability and higher failure loads compared to multiple parallel cancellous screws, primarily by better resisting the high shear forces.

Question 23

A 45-year-old female undergoes MRI of the knee showing a complete posterior root tear of the medial meniscus. If left untreated, this injury most closely approximates the altered joint contact mechanics of which of the following conditions?

Explanation

A complete posterior root tear of the medial meniscus disrupts the circumferential hoop stresses of the meniscus, resulting in radial extrusion. This functional incompetence alters tibiofemoral joint contact pressures and areas to levels biomechanically equivalent to a total meniscectomy, predisposing the patient to rapid articular cartilage degeneration.

Question 24

A 40-year-old male sustains a Schatzker IV tibial plateau fracture. Imaging demonstrates a displaced posteromedial shear fragment. Which surgical approach is most appropriate for direct visualization and stable buttress plating of this specific fragment?

Explanation

The posteromedial fragment in a Schatzker IV fracture pattern typically involves a coronal shear component that cannot be adequately reduced or plated via standard anterior or anterolateral approaches. A posteromedial approach allows for direct visualization of the fracture apex and the application of an anti-glide or buttress plate to counteract the deforming shear forces.

Question 25

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

Explanation

While both BTB and hamstring autografts provide excellent stability and return to play, BTB autograft has been consistently shown in the literature to have a higher rate of donor site morbidity, specifically anterior knee pain and difficulty kneeling, compared to hamstring autograft.

Question 26

According to classic trauma literature (e.g., Godina), free tissue transfer for soft tissue coverage of a Gustilo-Anderson type IIIB open tibia fracture should ideally be performed within what timeframe to minimize deep infection and flap failure?

Explanation

Godina's classic 1986 study demonstrated that early microsurgical reconstruction (within 72 hours of injury) of complex lower extremity trauma with open fractures significantly reduces the rates of flap failure, deep infection, and nonunion compared to delayed coverage.

Question 27

A 28-year-old male sustains a multiligamentous knee injury. Which of the following injury patterns (Schenck classification) carries the highest risk of associated common peroneal nerve injury?

Explanation

Multiligament knee injuries involving the posterolateral corner (PLC) and lateral side (KD-III-L) are most highly associated with common peroneal nerve palsies. This is often due to the traction mechanism (varus and hyperextension) that injures both the lateral structures and the tethered peroneal nerve.

Question 28

Which of the following ligamentous structures remains intact in an anteroposterior compression type II (APC-II) pelvic ring injury but is disrupted in an APC-III injury?

Explanation

In APC-II injuries, the symphysis opens and the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments are disrupted. However, the strong posterior sacroiliac ligaments remain intact, providing vertical stability. In APC-III injuries, the posterior SI ligaments are also disrupted, leading to complete global (rotational and vertical) hemipelvic instability.

Question 29

A 19-year-old collegiate baseball pitcher presents with anterior shoulder pain. Examination reveals scapular malposition, inferior medial border prominence, coracoid pain, and dyskinesis (SICK scapula syndrome). What is the primary physical therapy focus for this condition?

Explanation

SICK scapula syndrome typically involves a tight pectoralis minor and weak scapular stabilizers, namely the serratus anterior and lower trapezius. Rehabilitation focuses on stretching the pectoralis minor (to reduce anterior tilt) and strengthening the serratus anterior and lower trapezius to restore proper scapular kinematics.

Question 30

A 35-year-old female sustains a coronal shear fracture of the distal femur (Hoffa fracture). Which condyle is most commonly involved, and what is the preferred direction of lag screw fixation to optimally capture the fragment while minimizing articular cartilage damage?

Explanation

Hoffa fractures most commonly involve the lateral femoral condyle. The standard internal fixation utilizes anterior-to-posterior directed lag screws (often headless and countersunk). They are placed from the non-articular anterior surface into the posterior fragment, oriented perpendicular to the fracture plane to maximize compression without violating the weight-bearing articular cartilage of the posterior condyle.

Question 31

A 48-year-old manual laborer presents with persistent shoulder pain. MRI arthrogram reveals an isolated Type II SLAP tear. Nonoperative management has failed. Current literature suggests which of the following surgical interventions provides the most reliable return to work and highest patient satisfaction in this demographic?

Explanation

In older patients (typically >35-40 years) and workers' compensation populations, primary biceps tenodesis for isolated Type II SLAP tears has been shown to have lower complication rates, lower reoperation rates, higher satisfaction, and more reliable return to work compared to SLAP repair, which carries a higher risk of postoperative stiffness and persistent pain.

Question 32

A 42-year-old roofer undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Which of the following is the most common early postoperative complication associated with this specific approach?

Explanation

Wound healing complications, specifically wound edge necrosis or dehiscence at the apex of the L-shaped flap, are the most common early complication (occurring in up to 10-25% of cases) associated with the extensile lateral approach to the calcaneus. This is largely due to the tenuous blood supply from the lateral calcaneal artery network.

Question 33

When performing a posterior cruciate ligament (PCL) reconstruction, the tibial inlay technique was developed primarily to avoid which of the following phenomena associated with the transtibial technique?

Explanation

The tibial inlay technique avoids the acute sharp angle (the "killer turn") that the graft must negotiate when passed through a transtibial tunnel and over the posterior proximal tibia. This acute angle is theorized to lead to graft abrasion, attenuation, and eventual failure over time.

Question 34

A 26-year-old male sustains a closed comminuted tibial shaft fracture. Two hours post-injury, he complains of severe pain out of proportion to the injury. Which of the following objective measurements is most highly diagnostic for acute compartment syndrome and an absolute indication for fasciotomy?

Explanation

The diagnosis of acute compartment syndrome is most accurately made using the delta P, calculated as Diastolic Blood Pressure minus Compartment Pressure. A delta P of less than 30 mmHg represents inadequate tissue perfusion pressure and is an absolute indication for emergency fasciotomy.

Question 35

The anterior band of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow. Which of the following statements accurately describes the tension of its functional bundles during elbow range of motion?

Explanation

The anterior band of the UCL consists of distinct anterior and posterior bundles. The anterior bundle is tight in extension (primary restraint to valgus stress from 0-30 degrees), while the posterior bundle of the anterior band is tight in flexion (most active at 60-120 degrees).

Question 36

A 22-year-old athlete sustains a midfoot sprain. Radiographs reveal a "fleck sign" in the first intermetatarsal space. This bony avulsion typically originates from which of the following structures?

Explanation

The Lisfranc ligament is a stout interosseous ligament that originates on the lateral aspect of the medial cuneiform and inserts on the medial aspect of the base of the second metatarsal. The "fleck sign" pathognomonic for a Lisfranc injury represents a bony avulsion of this ligament, most commonly pulling off a fragment from the base of the second metatarsal.

Question 37

A 30-year-old cyclist undergoes surgical reconstruction for a severe Type V acromioclavicular (AC) joint separation. To accurately restore the native anatomy of the coracoclavicular ligaments, the surgeon must account for their respective insertions. Which of the following is true regarding the conoid and trapezoid ligaments?

Explanation

The conoid ligament inserts more posteromedially on the conoid tubercle of the clavicle and serves as the primary restraint to superior translation. The trapezoid ligament inserts more anterolaterally on the trapezoid line and is the primary restraint to axial compression (anterior-posterior translation).

Question 38

A 72-year-old male sustains an acetabular fracture after a low-energy fall. Radiographs demonstrate an anterior column and posterior hemitransverse fracture pattern, and a "gull sign" is present on the AP pelvis radiograph. What does the "gull sign" signify in this context?

Explanation

The "gull sign" on an AP radiograph of an older patient with an acetabular fracture (typically anterior column posterior hemitransverse) signifies superomedial osteochondral impaction of the acetabular dome (roof). It is a poor prognostic indicator for joint-preserving internal fixation and often prompts consideration for acute total hip arthroplasty.

Question 39

In medial patellofemoral ligament (MPFL) reconstruction, incorrect femoral tunnel placement is the most common cause of graft failure. If the femoral tunnel is placed erroneously proximal to the anatomic footprint (Schöttle point), how will the graft tension behave during knee range of motion?

Explanation

The MPFL normally acts as a checkrein primarily in early flexion (0-30 degrees). If the femoral tunnel is placed too far proximal, the distance between the patellar and femoral attachments increases as the knee goes into deeper flexion. This causes the graft to become excessively tight in flexion, leading to medial patellar overload, stiffness, or graft failure.

Question 40

A 55-year-old female presents with a complex intra-articular distal radius fracture. CT imaging reveals a small, displaced volar ulnar corner (volar lunate facet) fragment. Failure to adequately reduce and stabilize this specific fragment is most likely to result in which of the following complications?

Explanation

The volar ulnar corner (volar lunate facet) of the distal radius provides critical tethering support to the lunate via the short radiolunate ligament. If this fragment (often called the critical corner or tear-drop fragment) escapes fixation, the lunate and the entire carpus are at high risk for catastrophic volar subluxation or dislocation.

Question 41

A 22-year-old competitive rugby player presents with recurrent anterior shoulder instability. He has had four prior dislocations. Imaging reveals a 22% anterior glenoid bone loss and an engaging Hill-Sachs lesion. His Instability Severity Index Score (ISIS) is 7. Which of the following is the most appropriate surgical management?

Explanation

In a young, high-demand contact athlete with recurrent anterior instability, significant glenoid bone loss (>20%), and a high ISIS score (>6), soft-tissue stabilization alone carries an unacceptably high failure rate. The Latarjet procedure (coracoid transfer to the anterior glenoid) is the standard of care for restoring stability through the 'triple blocking effect' (increasing articular arc, sling effect of the conjoint tendon, and capsular repair). Remplissage with Bankart is typically reserved for subcritical glenoid bone loss (<15-20%) with off-track engaging Hill-Sachs lesions.

Question 42

In the Young-Burgess classification of pelvic ring injuries, which of the following structures fails in an Anteroposterior Compression Type III (APC-III) injury but remains completely intact in an APC-II injury?

Explanation

An APC-II injury is characterized by symphyseal diastasis and disruption of the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments, resulting in a 'vertically stable but rotationally unstable' pelvis (opening like a book). The defining feature that differentiates an APC-III injury from an APC-II is the complete disruption of the posterior sacroiliac complex (posterior sacroiliac ligaments), rendering the hemipelvis both rotationally and vertically unstable.

Question 43

A complete radial tear adjacent to the posterior horn medial meniscus root attachment alters the biomechanics of the knee joint. Biomechanical studies have shown that peak contact pressures in this scenario most closely resemble which of the following conditions?

Explanation

A complete radial tear at or near the meniscal root completely disrupts the circumferential hoop fibers of the meniscus. Biomechanically, this leads to extrusion of the meniscus under axial load, effectively eliminating its load-sharing capability. Consequently, the peak contact pressures and contact areas in the medial compartment become essentially equivalent to those seen in a knee following a total meniscectomy.

Question 44

A 35-year-old patient sustains a coronal plane fracture of the distal femur (Hoffa fracture) following a high-energy motor vehicle accident. Which portion of the distal femur is most commonly involved in this specific fracture pattern?

Explanation

A Hoffa fracture (AO/OTA 33-B3) is a coronal shear fracture of the distal femur. It most commonly involves the lateral femoral condyle. The mechanism of injury is typically an axial load applied to a knee in 90 degrees or more of flexion with an associated valgus force. Because of normal physiologic valgus, the lateral condyle receives greater axial stress, making it more prone to this specific shear fracture pattern.

Question 45

A 58-year-old manual laborer presents with profound weakness in external rotation of the shoulder and a positive hornblower's sign. MRI demonstrates a massive, retracted, and irreducible tear of the posterosuperior rotator cuff with advanced fatty infiltration of the infraspinatus and teres minor. The glenohumeral joint shows no signs of osteoarthritis. Which of the following tendon transfers is most appropriate to restore external rotation?

Explanation

In the setting of a massive, irreparable posterosuperior rotator cuff tear with an absent teres minor (evidenced by external rotation lag/Hornblower's sign) and intact glenohumeral cartilage, tendon transfer is indicated. The lower trapezius transfer, often augmented with Achilles allograft, has gained favor over latissimus dorsi transfer because its line of pull more closely replicates that of the infraspinatus, making it mechanically superior for restoring active external rotation and treating pseudoparalysis of external rotation.

Question 46

During open reduction and internal fixation of a distal tibia pilon fracture, a large anterolateral articular fragment (the Chaput fragment) is identified. Which of the following ligamentous structures remains attached to this specific fragment?

Explanation

The anterolateral distal tibial articular fragment in a pilon or complex ankle fracture is known as the Chaput fragment (or Tillaux-Chaput). It serves as the tibial attachment site for the Anterior Inferior Tibiofibular Ligament (AITFL). The fibular attachment of the AITFL is the Wagstaffe-Le Fort fragment. The posterior tibial fragment (Volkmann's triangle) is the attachment for the Posterior Inferior Tibiofibular Ligament (PITFL).

Question 47

When considering graft choices for Anterior Cruciate Ligament (ACL) reconstruction, high-dose irradiation of bone-patellar tendon-bone allografts is sometimes utilized to ensure sterility. At what minimum irradiation dose are the structural and biomechanical properties of the graft significantly compromised?

Explanation

Terminal sterilization of allografts using gamma irradiation decreases the risk of disease transmission (e.g., HIV) but dose-dependently alters the biomechanical properties of the tissue. Studies show that doses > 2.5 Mrad cause significant alterations in the collagen cross-linking, leading to reduced structural integrity, stiffness, and ultimate load to failure, increasing the risk of graft rupture.

Question 48

A surgeon is performing an open reduction and internal fixation of a Schatzker IV (medial) tibial plateau fracture utilizing a posteromedial approach. Which of the following defines the primary internervous/intermuscular interval for this surgical approach?

Explanation

The posteromedial approach to the tibial plateau is the standard workhorse for medial plateau shear fractures. The surgical interval is developed between the pes anserinus tendons (sartorius, gracilis, semitendinosus) anteriorly, and the medial head of the gastrocnemius posteriorly. Retracting the medial gastroc posteriorly protects the neurovascular bundle.

Question 49

A 12-year-old patient presents with vague knee pain and is diagnosed with Osteochondritis Dissecans (OCD) of the medial femoral condyle. Which of the following is the most reliable predictor of spontaneous healing with non-operative management?

Explanation

The healing potential of OCD lesions in the knee is highly correlated with skeletal maturity. Juvenile OCD (patients with open physes) has a very high rate of spontaneous healing with non-operative management (e.g., rest, activity modification). In contrast, adult OCD (closed physes), larger lesions, cystic changes, or sclerotic margins suggest a poor prognosis for non-operative healing.

Question 50

When utilizing the modified Judet (posterior) approach to the scapula for the fixation of a highly displaced extra-articular scapular body fracture, the primary intermuscular interval is developed between which of the following two muscles?

Explanation

The classic Judet approach is an extensile posterior approach reflecting the infraspinatus from medial to lateral. The modified Judet approach minimizes muscle detachment by exploiting the interval between the infraspinatus (suprascapular nerve) and the teres minor (axillary nerve). This exposes the lateral border and body of the scapula for plating.

Question 51

On an anteroposterior (AP) radiograph of the pelvis, the 'crossover sign' is indicative of acetabular retroversion. Which of the following correctly describes this radiographic finding?

Explanation

The crossover sign is a classic plain radiographic marker of cranial acetabular retroversion, commonly seen in pincer-type femoroacetabular impingement (FAI). It occurs when the projection of the anterior acetabular wall crosses medial to the projection of the posterior acetabular wall on a true AP pelvis radiograph.

Question 52

Compared to the traditional extensile lateral approach for the operative treatment of displaced intra-articular calcaneus fractures, the sinus tarsi approach has been shown in recent literature to result in which of the following?

Explanation

The primary advantage of the minimally invasive sinus tarsi approach over the traditional extensile lateral approach for calcaneus fractures is a dramatic reduction in soft tissue complications, such as wound dehiscence, flap necrosis, and deep infection. Clinical outcomes and quality of joint reduction have been shown to be comparable between the two approaches in appropriately selected patterns.

Question 53

A 24-year-old professional baseball pitcher presents with posterior elbow pain during the deceleration phase of throwing and loss of terminal extension. He is diagnosed with valgus extension overload syndrome. Where is the characteristic osteophyte located in this condition?

Explanation

Valgus extension overload (VEO) syndrome in overhead athletes results from repetitive valgus stress and extreme extension forces. It leads to impingement of the olecranon in the olecranon fossa, characteristically producing an osteophyte at the posteromedial tip of the olecranon.

Question 54

According to Hertel's radiographic criteria, which of the following is considered the most reliable predictor of humeral head ischemia (avascular necrosis) following a complex proximal humerus fracture?

Explanation

Hertel described specific criteria predicting ischemia of the humeral head in proximal humerus fractures. The most significant risk factors for AVN include a short metaphyseal head extension (calcar segment attached to the head < 8 mm), disruption of the medial hinge (> 2 mm displacement), and an anatomical neck fracture pattern.

Question 55

During a physical examination of a knee following acute trauma, the dial test (tibial external rotation) demonstrates 15 degrees of increased external rotation at 30 degrees of flexion compared to the contralateral side. At 90 degrees of flexion, the external rotation is identical to the normal side. What is the most likely diagnosis?

Explanation

The dial test assesses injury to the posterolateral corner (PLC) and the posterior cruciate ligament (PCL). Increased external rotation (>10 degrees compared to the normal side) at 30 degrees of knee flexion but NOT at 90 degrees indicates an isolated PLC injury. If increased external rotation is present at both 30 and 90 degrees, it indicates a combined PLC and PCL injury.

Question 56

A 30-year-old male is 8 weeks status post open reduction and internal fixation of a Hawkins type II talar neck fracture. An AP radiograph of the ankle demonstrates a subchondral radiolucent band extending across the talar dome. What does this radiographic finding indicate?

Explanation

The finding described is the 'Hawkins sign', which is a subchondral radiolucent band seen on the AP or mortise radiograph 6-8 weeks following a talar neck fracture. It represents subchondral osteopenia secondary to disuse and active hyperemia, which confirms that the talar body has an intact vascular supply. Its presence is a highly reliable indicator that AVN will NOT occur.

Question 57

The coracoclavicular (CC) ligaments are the primary restraints to superior translation of the clavicle relative to the acromion. In normal anatomy, the footprint of the conoid ligament on the undersurface of the clavicle is located in what position relative to the footprint of the trapezoid ligament?

Explanation

The CC ligament complex consists of the conoid and trapezoid ligaments. The conoid is located posteromedial to the trapezoid. It attaches to the conoid tubercle of the clavicle and is the primary restraint to superior/inferior translation. The trapezoid is situated anterolateral to the conoid and primarily resists axial compression to the acromioclavicular joint.

Question 58

A 28-year-old male sustains a closed tibia fracture and subsequently develops acute compartment syndrome isolated to the deep posterior compartment of the leg. If left untreated, the patient will most likely develop ischemic contracture resulting in weakness of which movement and sensory loss in which anatomic distribution?

Explanation

The deep posterior compartment contains the flexor hallucis longus (FHL), flexor digitorum longus (FDL), and tibialis posterior, as well as the tibial nerve. Untreated compartment syndrome here leads to weakness in toe flexion and ankle inversion, along with sensory loss on the plantar aspect of the foot (supplied by the tibial nerve). Ankle dorsiflexion and 1st web space sensation are anterior compartment structures (deep peroneal nerve).

Question 59

Recent high-quality randomized controlled trials comparing operative versus non-operative management of acute Achilles tendon ruptures have concluded which of the following when early functional rehabilitation protocols (including early weight-bearing and mobilization) are employed in both groups?

Explanation

Historically, non-operative management of Achilles ruptures with prolonged cast immobilization resulted in higher re-rupture rates compared to surgery. However, modern RCTs (e.g., Willits et al.) have demonstrated that when early functional rehabilitation (early range of motion and weight-bearing in a functional brace) is utilized, the re-rupture rates between operative and non-operative groups are essentially equal, while surgery carries a higher risk of wound complications.

Question 60

A 25-year-old patient sustains a high-energy Pauwels Type III (vertical) femoral neck fracture. Due to the vertical fracture angle, significant shear forces act across the fracture site. Biomechanically, which of the following internal fixation constructs provides the greatest resistance to these vertical shear forces?

Explanation

Pauwels Type III femoral neck fractures have a fracture angle > 50 degrees from the horizontal, subjecting the fracture to severe vertical shear forces. Multiple biomechanical studies have proven that a fixed-angle construct, such as a sliding hip screw (often augmented with a derotation screw), is biomechanically superior to multiple parallel cancellous screws at resisting these high shear forces, thereby reducing the rate of nonunion and varus collapse.

Question 61

A 45-year-old weightlifter feels a pop in his anterior shoulder. MRI shows an isolated full-thickness subscapularis tendon tear. What structure is most likely to be unstable or subluxated as a result?

Explanation

The subscapularis is crucial for stabilizing the long head of the biceps (LHB) tendon in the bicipital groove. A full-thickness tear often leads to medial subluxation or dislocation of the LHB tendon.

Question 62

A 28-year-old man sustains a displaced, vertical (Pauwels III) femoral neck fracture. To maximize biomechanical stability during internal fixation, which construct is most appropriate?

Explanation

Displaced, vertically oriented (Pauwels III) femoral neck fractures in young adults experience high shear forces. A sliding hip screw with a derotational screw provides superior biomechanical stability against vertical shear compared to multiple cancellous screws.

Question 63

A 30-year-old football player sustains a posterolateral corner (PLC) knee injury. Which physical exam finding best differentiates an isolated PLC injury from a combined PCL and PLC injury?

Explanation

An isolated PLC injury typically presents with increased external rotation (positive dial test) at 30 degrees of knee flexion but not at 90 degrees. Increased external rotation at both 30 and 90 degrees indicates a combined PCL and PLC injury.

Question 64

A 40-year-old woman sustains a Schatzker VI tibial plateau fracture. Postoperatively, she develops severe pain with passive stretch of her hallux. Intracompartmental pressure testing is ordered. Which of the following pressure readings definitively indicates the need for emergent fasciotomy?

Explanation

Compartment syndrome is best diagnosed using the delta pressure, calculated as diastolic blood pressure minus compartment pressure. A delta pressure of less than 30 mmHg is an accepted indication for emergent fasciotomy.

Question 65

During a medial patellofemoral ligament (MPFL) reconstruction, the femoral tunnel is being localized. According to Schottle's radiographic criteria on a true lateral radiograph, where should the anatomic femoral footprint be positioned?

Explanation

Schottle's point defines the anatomic femoral footprint of the MPFL. On a strict lateral radiograph, it is located 1 mm anterior to the posterior cortical line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the posterior aspect of Blumensaat's line.

Question 66

During an anterior intrapelvic (modified Stoppa) approach for an acetabular fracture, significant hemorrhage occurs while dissecting over the superior pubic ramus. This is most likely due to an injury to the 'corona mortis,' which represents an anastomosis between which two vessels?

Explanation

The corona mortis is a vascular anastomosis between the external iliac (or inferior epigastric) vessels and the obturator vessels. It is located on the posterior aspect of the superior pubic ramus and is at high risk during the Stoppa approach.

Question 67

A 14-year-old male presents with knee pain. Radiographs reveal a large osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. MRI shows fluid behind the lesion, indicating instability. What is the most appropriate surgical management?

Explanation

In a young patient with open physes and an unstable OCD lesion (fluid behind the lesion on MRI), fixation with drilling to stimulate healing is the standard of care. Cartilage restoration techniques are reserved for unsalvageable or failed cases.

Question 68

A 35-year-old man sustains a closed distal third spiral fracture of the humerus (Holstein-Lewis fracture) with an immediate, complete radial nerve palsy. What is the most appropriate initial management?

Explanation

Immediate radial nerve palsy associated with a closed humeral shaft fracture is initially treated observationally, usually with a coaptation splint or functional brace. Nerve exploration is indicated if the palsy develops after a closed reduction attempt or fails to recover by 3-4 months.

Question 69

Following an arthroscopic rotator cuff repair, tendon-to-bone healing occurs through the formation of a fibrocartilaginous transition zone. What collagen type is predominantly found in the uncalcified fibrocartilage layer of a normal rotator cuff insertion?

Explanation

The normal rotator cuff insertion consists of four zones: tendon (Type I), uncalcified fibrocartilage (Type II and aggrecan), calcified fibrocartilage (Type II and Type X), and bone (Type I).

Question 70

A 27-year-old man sustains a displaced talar neck fracture (Hawkins Type III). Radiographs obtained 8 weeks post-operatively demonstrate a subchondral radiolucent line in the talar dome. What does this finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucent band seen 6-8 weeks post-injury on an AP or mortise view of the ankle. It represents subchondral osteopenia due to hyperemia, indicating an intact blood supply and effectively ruling out avascular necrosis.

Question 71

A 25-year-old baseball pitcher undergoes an arthroscopic repair of a Type II SLAP tear. Postoperatively, he develops severe stiffness and loss of external rotation. Entrapment or over-tensioning of which structure is most likely responsible for this complication?

Explanation

When repairing a SLAP lesion, placing an anchor anterior to the biceps root carries the risk of inadvertently capturing or over-tensioning the middle glenohumeral ligament (MGHL). This directly leads to a significant postoperative loss of external rotation.

Question 72

A 65-year-old osteoporotic woman undergoes locked plating for a supracondylar distal femur fracture. Which of the following biomechanical principles will increase the working length and decrease the stiffness of the construct, promoting secondary bone healing?

Explanation

Omitting screws close to the fracture increases the working length of the plate. This reduces construct stiffness and allows for controlled micromotion, which promotes secondary bone healing via robust callus formation.

Question 73

During an ulnar collateral ligament (UCL) reconstruction using the docking technique, the sublime tubercle is utilized for the ulnar tunnel. The sublime tubercle serves as the anatomic insertion for which bundle of the UCL?

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. It originates on the anterior inferior surface of the medial epicondyle and inserts distally on the sublime tubercle of the ulna.

Question 74

A 32-year-old man sustains a pronation-external rotation (PER) ankle fracture. Which of the following structures is injured first in the sequence of a PER injury according to Lauge-Hansen?

Explanation

In a Pronation-External Rotation (PER) injury, the sequence begins medially. Stage 1 is a medial malleolus fracture or deltoid ligament rupture, followed by AITFL rupture (Stage 2), high fibular fracture (Stage 3), and PITFL rupture (Stage 4).

Question 75

A 26-year-old female undergoes hip arthroscopy for labral repair. Postoperatively, she reports numbness over the perineum and medial thigh, as well as transient sexual dysfunction. Which nerve was most likely compressed by the perineal post during traction?

Explanation

Pudendal nerve neuropraxia is a well-known complication of hip arthroscopy caused by compression against a poorly padded or malpositioned perineal post. It typically presents with groin, perineal, and genital numbness or dysfunction.

Question 76

An extensile lateral approach is planned for open reduction and internal fixation of a displaced intra-articular calcaneus fracture. The full-thickness soft tissue flap must be carefully elevated deep to the periosteum to protect the flap's primary blood supply. Which artery provides this primary blood supply?

Explanation

The lateral calcaneal artery, a terminal branch of the peroneal artery, provides the primary blood supply to the lateral soft tissues of the heel. The extensile lateral approach relies on creating a full-thickness subperiosteal flap to protect this critical vascular network.

Question 77

A 19-year-old soccer player sustains an ACL tear. Radiographs show a small avulsion fracture from the lateral tibial plateau (Segond fracture). This avulsion represents the bony attachment of which capsuloligamentous structure?

Explanation

A Segond fracture is a pathognomonic avulsion fracture of the lateral tibial plateau heavily associated with ACL tears. It is recognized as the tibial insertion of the anterolateral ligament (ALL) and the meniscotibial band of the lateral capsule.

Question 78

A 25-year-old man sustains a low-velocity gunshot wound to the thigh resulting in a comminuted femoral shaft fracture. There is no evidence of an expanding hematoma, and distal pulses are intact and symmetric. What is the most appropriate initial management of the wound and fracture?

Explanation

Low-velocity gunshot wounds with associated femur fractures and no hard signs of vascular injury can be safely managed with local wound care, a short course of IV antibiotics, and standard intramedullary nailing without formal surgical debridement of the bullet track.

Question 79

A 45-year-old woman undergoes repair of a posterior medial meniscal root tear. Biomechanically, complete avulsion of the posterior horn of the medial meniscus root alters the peak contact pressures of the medial compartment to be most comparable to which of the following conditions?

Explanation

A complete posterior medial meniscal root tear eliminates the hoop stresses of the meniscus, causing it to extrude. Biomechanically, this failure causes peak contact pressures in the medial compartment to approximate those seen in a totally meniscectomized knee.

Question 80

In a double-bundle posterior cruciate ligament (PCL) reconstruction, the two distinct bundles are tensioned at different angles of knee flexion to restore native biomechanics. In the native knee, the anterolateral bundle is tightest in which of the following positions?

Explanation

The PCL consists of the anterolateral (AL) and posteromedial (PM) bundles. The larger AL bundle is tightest in knee flexion (around 90 degrees), while the smaller PM bundle is tightest in extension.

Question 81

A 35-year-old male sustains an anteroposterior compression (APC-II) pelvic ring injury following a motorcycle collision. Based on the Young-Burgess classification, which of the following posterior pelvic ligaments remains intact by definition in this injury pattern?

Explanation

An APC-II injury is characterized by symphyseal diastasis and disruption of the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments. The posterior sacroiliac ligaments remain intact, providing rotational instability but maintaining vertical stability.

Question 82

A 24-year-old elite baseball pitcher presents with shoulder pain during the late cocking phase of throwing. MRI reveals a type II SLAP tear. What physical exam finding is most characteristically associated with this pathology due to posteroinferior capsular contracture?

Explanation

Overhead throwing athletes frequently develop posteroinferior capsular contracture, clinically presenting as GIRD. This contracture shifts the glenohumeral contact point posterosuperiorly in maximum external rotation, leading to internal impingement and subsequent SLAP tears.

Question 83

When performing a posteromedial approach to the knee for open reduction and internal fixation of a Schatzker IV tibial plateau fracture, the dissection is typically carried out between the medial head of the gastrocnemius and which of the following structures?

Explanation

The classic posteromedial approach to the tibial plateau utilizes the interval between the medial head of the gastrocnemius (retracted laterally with the neurovascular bundle) and the pes anserinus tendons (retracted medially).

Question 84

During hip arthroscopy for femoroacetabular impingement, prolonged traction against the perineal post is required to distract the joint. This maneuver most commonly places which of the following nerves at risk for neurapraxia?

Explanation

Prolonged compression against the perineal post during hip distraction can cause pudendal nerve neurapraxia. This manifests as perineal numbness or sexual dysfunction, which is usually transient if traction time is minimized.

Question 85

During retrograde intramedullary nailing of a distal femur fracture, the ideal starting point in the intercondylar notch is located in line with the anatomic axis of the femoral shaft and specifically:

Explanation

The optimal starting point for a retrograde femoral nail is perfectly centered in the intercondylar notch in the coronal plane, and just anterior to the origin of the posterior cruciate ligament (PCL) in the sagittal plane.

Question 86

A 28-year-old male sustains a traumatic knee dislocation with a high-grade posterolateral corner (PLC) injury. He has a profound foot drop on presentation. Which component of the PLC is most closely associated anatomically with the injured nerve?

Explanation

The common peroneal nerve is highly susceptible to stretch injuries during PLC disruptions. Anatomically, it courses directly posterior and inferior to the biceps femoris tendon as it wraps around the fibular neck.

Question 87

The anterolateral approach to the distal tibia is frequently utilized for pilon fractures. This approach utilizes an internervous plane between muscles innervated by which two nerves?

Explanation

The anterolateral approach utilizes the internervous plane between the lateral compartment (fibularis tertius, innervated by the superficial peroneal nerve) and the anterior compartment (extensor digitorum longus, innervated by the deep peroneal nerve).

Question 88

When performing an anatomic coracoclavicular (CC) ligament reconstruction for an acromioclavicular joint separation, proper clavicular tunnel placement is critical. The footprint of the conoid ligament is typically located at what distance medial to the distal clavicular articular margin?

Explanation

The normal anatomic insertion of the conoid ligament on the clavicle is approximately 45 mm medial to the distal clavicular articular margin. The trapezoid ligament inserts more laterally, approximately 25 mm medial to the joint.

Question 89

The predominant blood supply to the talar body, which is at highest risk of disruption in a displaced talar neck fracture, is the artery of the tarsal canal. This artery is a branch of which parent vessel?

Explanation

The artery of the tarsal canal is a branch of the posterior tibial artery and provides the dominant blood supply to the talar body. It anastomoses with the artery of the tarsal sinus to form a vascular sling inferior to the talar neck.

Question 90

During an ulnar collateral ligament (UCL) reconstruction using the docking technique, an ulnar tunnel is created based on the footprint of the native anterior bundle. Where does the anterior bundle of the UCL primarily insert?

Explanation

The anterior bundle is the primary restraint to valgus stress at the elbow. It originates on the anterior undersurface of the medial epicondyle and inserts on the sublime tubercle of the proximal medial ulna.

Question 91

When utilizing the extensile lateral approach for open reduction internal fixation of a calcaneus fracture, a full-thickness subperiosteal flap must be elevated off the lateral wall. Which nerve is most at risk if the flap is elevated too thinly or sharply dissected?

Explanation

The sural nerve courses superficially over the lateral aspect of the hindfoot. A full-thickness subperiosteal flap must be elevated off the calcaneus to protect this nerve and the lateral calcaneal artery to prevent wound sloughing.

Question 92

A 45-year-old weightlifter feels a pop in his anterior shoulder during a heavy bench press. MRI confirms an isolated, full-thickness upper subscapularis tear. Which of the following physical exam tests is considered the most sensitive for a tear of the upper border of the subscapularis?

Explanation

The bear hug test is considered the most sensitive examination maneuver for detecting upper subscapularis tears. The lift-off test is better suited for assessing the lower portion of the subscapularis muscle belly.

Question 93

A 55-year-old female undergoes volar locked plating for a distal radius fracture. Six months postoperatively, she is unable to actively flex the interphalangeal joint of her thumb. Which aspect of surgical technique is most highly associated with this complication?

Explanation

Iatrogenic rupture of the flexor pollicis longus (FPL) tendon is a known complication of volar plating. It is directly associated with plate prominence volar and distal to the anatomic watershed line of the distal radius.

Question 94

When performing a medial patellofemoral ligament (MPFL) reconstruction, accurate femoral tunnel placement is critical to avoid abnormal graft tension. Radiographically, Schottle's point is located:

Explanation

Schottle's point defines the radiographic femoral origin of the MPFL. It is located 1 mm anterior to the posterior femoral cortical line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to Blumensaat's line.

Question 95

A 6-year-old boy sustains a Bado Type I Monteggia fracture-dislocation. What is the characteristic displacement pattern of the radial head in this specific injury?

Explanation

In the Bado classification of Monteggia fractures, Type I (most common) involves an anterior dislocation of the radial head with an apex anterior fracture of the ulnar diaphysis. Type II is posterior, and Type III is lateral.

Question 96

Intraoperative exploration of an acute pectoralis major tear reveals a rupture at the humerus insertion. The sternal head of the pectoralis major tendon typically inserts on the humerus in what orientation relative to the clavicular head?

Explanation

The pectoralis major tendon twists 180 degrees before inserting on the humerus. This twisting causes the sternal head to insert both proximal and deep to the clavicular head insertion.

Question 97

During a Kocher-Langenbeck approach for a posterior wall acetabular fracture, the surgeon must carefully manage the short external rotators. Which muscle is typically left intact to protect the profound branch of the medial femoral circumflex artery (MFCA)?

Explanation

The quadratus femoris (along with the obturator externus) is left intact during the Kocher-Langenbeck approach to protect the main terminal branch of the medial femoral circumflex artery and preserve the blood supply to the femoral head.

Question 98

Recent high-quality randomized controlled trials comparing early functional rehabilitation (non-operative) versus surgical repair for acute Achilles tendon ruptures demonstrate which of the following outcomes?

Explanation

Level I evidence indicates that when utilizing early functional weight-bearing rehabilitation protocols, the re-rupture rates between operative and non-operative management are statistically similar. However, operative repair carries a higher risk of soft-tissue and nerve complications.

Question 99

When utilizing an extended deltopectoral approach for open reduction internal fixation of a complex proximal humerus fracture, the axillary nerve is at risk inferiorly. What is the average distance from the lateral edge of the acromion to the axillary nerve as it crosses the humerus?

Explanation

The axillary nerve wraps around the surgical neck of the humerus approximately 5 to 7 cm distal to the lateral edge of the acromion. Care must be taken not to place retractors or plate screws blindly in this danger zone.

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

OITE & ABOS Orthopedic Board Prep MCQs: Trauma & Sports Medicine | Part 210

Key Takeaway

OITE & ABOS Orthopedic Board Prep MCQs: Trauma & Sports Medicine | Part 210

Chapter Index