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

Orthopedic Board Prep MCQs: Foot & Ankle, Trauma, & Shoulder | Part 42

23 Apr 2026 152 min read 45 Views
OITE & ABOS Orthopedic Board Prep: Practice Exam Part 42

Key Takeaway

This page offers Part 42 of a comprehensive OITE and AAOS Orthopedic Surgery Board Review. Authored by Dr. Mohammed Hutaif, it contains 50 high-yield multiple-choice questions (MCQs) designed for orthopedic surgeons and residents preparing for board certification exams, covering topics like Ankle, Foot, Fracture, and Shoulder.

Orthopedic Board Prep MCQs: Foot & Ankle, Trauma, & Shoulder | Part 42

Comprehensive 100-Question Exam


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Question 1

A 34-year-old male sustains a highly displaced Hawkins type III talar neck fracture. During the surgical approach for open reduction and internal fixation, the surgeon utilizes a dual-incision technique. What is the primary anatomical rationale for preserving the deep deltoid ligament during the medial approach to the talus?





Explanation

In displaced talar neck fractures (especially Hawkins II and III), the blood supply from the artery of the tarsal canal and tarsal sinus is often disrupted. The deltoid branch of the posterior tibial artery, which supplies the medial body of the talus, may be the only remaining intact blood supply. The deep deltoid ligament must be meticulously preserved during medial exposure to protect this critical vascular contribution and minimize the risk of avascular necrosis.

Question 2

A 68-year-old female presents with vague thigh pain for 3 months. She has a history of osteoporosis and has been on alendronate for 8 years. Radiographs demonstrate an incomplete transverse fracture of the lateral cortex of the femoral shaft. According to the 2013 American Society for Bone and Mineral Research (ASBMR) criteria, which of the following is considered a 'Major' criterion required for the diagnosis of an atypical femur fracture (AFF)?





Explanation

The ASBMR 2013 revised criteria for an atypical femur fracture require that all 5 major criteria be present. These include: 1) Location along the femur from just distal to the lesser trochanter to just proximal to the supracondylar flare; 2) Minimal or no trauma; 3) Transverse or short oblique configuration; 4) Complete fractures extending through both cortices or incomplete fractures involving only the lateral cortex; and 5) Noncomminuted or minimally comminuted. Prodromal pain, delayed healing, and bilateral fractures are 'Minor' criteria.

Question 3

A 26-year-old male weightlifter feels a painful 'pop' in his right axilla while performing a heavy bench press. Magnetic resonance imaging confirms a complete pectoralis major tendon rupture at its humeral insertion. Which of the following accurately describes the normal anatomical arrangement of the pectoralis major tendon at its insertion?





Explanation

The pectoralis major has a unique twisted insertion on the lateral lip of the bicipital groove. The clavicular head descends relatively straight to insert anteriorly and distally. The sternocostal head twists 180 degrees, passing deep to the clavicular head, to insert proximal and posterior to the clavicular head. This biomechanical arrangement places the sternocostal fibers under maximal tension when the arm is extended and externally rotated, making it the most frequently injured portion during exercises like the bench press.

Question 4

A 22-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs show no overt diastasis, but an MRI confirms an isolated tear of the primary Lisfranc ligament. Which of the following correctly describes the anatomic attachments of the primary Lisfranc ligament?





Explanation

The primary Lisfranc ligament is an interosseous ligament that runs from the plantar-lateral aspect of the medial cuneiform to the plantar-medial aspect of the base of the second metatarsal. It is the strongest of the ligaments stabilizing the second tarsometatarsal joint. There is no direct ligamentous connection between the first and second metatarsal bases.

Question 5

A 45-year-old male sustains a closed pelvic ring injury in a high-speed motor vehicle collision. Physical examination reveals a large, fluctuant, soft tissue swelling over the greater trochanter with overlying skin ecchymosis. Aspiration yields serosanguinous fluid. Which of the following accurately characterizes the pathophysiology of this specific lesion?





Explanation

The clinical presentation describes a Morel-Lavallée lesion, which is a closed degloving injury. It is characterized by the traumatic separation of the subcutaneous fat and skin from the underlying deep fascia. This creates a potential space that fills with blood, lymph, and necrotic fat (hemolymphatic fluid). If unrecognized or improperly treated, it carries a high risk of soft tissue necrosis and deep infection.

Question 6

A 30-year-old female presents with progressive right shoulder weakness and a dull ache following a cervical lymph node biopsy performed three months ago. On examination, when she attempts to push against a wall with her arms elevated, the medial border of her right scapula translates laterally and superiorly. Injury to which of the following nerves and corresponding muscle deficit is most likely responsible for her condition?





Explanation

The patient is exhibiting 'lateral winging' of the scapula (the scapula translates laterally and superiorly), which is the hallmark of trapezius muscle paralysis due to spinal accessory nerve (Cranial Nerve XI) injury. This nerve is superficially located in the posterior triangle of the neck and is highly susceptible to iatrogenic injury during lymph node biopsies. In contrast, 'medial winging' (prominence of the medial border translating medially) is associated with serratus anterior weakness secondary to long thoracic nerve injury.

Question 7

A 24-year-old downhill skier presents with severe lateral ankle pain and a palpable snapping sensation behind the lateral malleolus after an acute forceful dorsiflexion-inversion injury. Static and dynamic ultrasound confirms anterior dislocation of the peroneal tendons out of the retromalleolar groove. What is the primary anatomical restraint that is disrupted in this condition?





Explanation

The superior peroneal retinaculum (SPR) is the primary restraint preventing anterior subluxation and dislocation of the peroneus longus and brevis tendons from the retromalleolar groove. Forceful dorsiflexion of an inverted foot leads to violent contraction of the peroneal muscles, which can tear or strip the SPR off its fibular attachment, resulting in tendon dislocation.

Question 8

A 35-year-old male is admitted with a highly comminuted, closed tibial shaft fracture following a crush injury. Six hours post-injury, he complains of severe leg pain out of proportion to the injury. His blood pressure is 105/75 mmHg. Intracompartmental pressure (ICP) monitoring is performed. Which of the following pressure relationships strongly supports the diagnosis of acute compartment syndrome and the need for immediate fasciotomy?





Explanation

The most reliable indicator for acute compartment syndrome is the delta pressure (ΔP), calculated as the diastolic blood pressure minus the intracompartmental pressure (ICP). A delta pressure of less than 30 mmHg accurately indicates inadequate tissue perfusion and is a strong indication for immediate four-compartment fasciotomy. Absolute pressure readings can be misleading due to variations in systemic blood pressure.

Question 9

In the evaluation of a displaced proximal humerus fracture, maintaining the viability of the humeral head relies predominantly on the integrity of the intra-osseous circulation and capsular attachments. According to the Hertel radiographic criteria, which of the following fracture characteristics is the most reliable predictor of subsequent avascular necrosis (AVN) of the humeral head?





Explanation

Hertel et al. described highly predictive radiographic criteria for ischemia and AVN in proximal humerus fractures. The best predictors are: 1) a medial calcar hinge disruption > 2 mm, 2) a short calcar length (medial metaphyseal head extension attached to the articular segment) of < 8 mm, and 3) an anatomic neck fracture. Therefore, a disrupted medial hinge > 2 mm strongly portends AVN.

Question 10

A 55-year-old diabetic male with severe peripheral neuropathy presents with a globally swollen, erythematous, and warm right foot. He denies fevers, chills, or an open wound. Radiographs reveal prominent subchondral osteopenia, bony fragmentation, joint debris, and subluxation of the midfoot. According to the Eichenholtz classification, what is the appropriate stage of this Charcot arthropathy and the most appropriate initial management?





Explanation

The clinical and radiographic presentation defines Stage 1 (Developmental/Fragmentation) of the Eichenholtz classification for Charcot arthropathy. It is characterized by erythema, swelling, warmth, osteopenia, fragmentation, joint subluxation, and debris. The gold standard for initial management of Stage 1 Charcot is immobilization and offloading, most effectively achieved with a total contact cast (TCC). Surgery is generally contraindicated during this acute, hyperemic phase.

Question 11

A 25-year-old male sustains a displaced, highly vertical (Pauwels type III) femoral neck fracture in a motor vehicle collision. Open reduction and internal fixation is planned. Biomechanically, what is the primary rationale for utilizing a fixed-angle device (e.g., sliding hip screw with an anti-rotation screw) rather than multiple parallel cancellous screws for this specific fracture pattern?





Explanation

Pauwels type III femoral neck fractures have a highly vertical fracture line (angle > 50 degrees to the horizontal), which subjects the fracture site to massive vertical shear forces and varus stress rather than compressive forces. Multiple parallel cancellous screws often fail to resist these shear forces in vertical patterns in young adults. A fixed-angle device, such as a sliding hip screw, provides significantly greater biomechanical resistance to vertical shear and varus collapse.

Question 12

A 60-year-old male with an irreparable, massive posterosuperior rotator cuff tear and intractable pain is undergoing an arthroscopic superior capsular reconstruction (SCR) using a dermal allograft. The graft utilized in an SCR is biomechanically designed to restore normal glenohumeral kinematics primarily by preventing which of the following abnormal translations of the humeral head?





Explanation

The superior capsule is a critical static stabilizer of the glenohumeral joint. In massive posterosuperior rotator cuff tears, the superior restraint provided by the supraspinatus and the superior capsule is lost, leading to dynamic superior migration of the humeral head. Superior Capsular Reconstruction (SCR) tethers the superior glenoid to the greater tuberosity, mechanically preventing superior translation of the humeral head and restoring the functional fulcrum for the deltoid.

Question 13

Based on recent high-quality randomized controlled trials (such as Willits et al.) comparing the management of acute Achilles tendon ruptures, which of the following statements best characterizes the comparison between operative repair and functional rehabilitation (non-operative management)?





Explanation

Modern Level I evidence demonstrates that when a dynamic, early functional rehabilitation and weight-bearing protocol is employed, there is no statistically significant difference in the rerupture rates between non-operative and operative management of acute Achilles tendon ruptures. Furthermore, operative management carries a higher risk of soft-tissue complications, including wound infections and sural nerve injury.

Question 14

A 30-year-old male sustains a low-velocity civilian gunshot wound to the right thigh, resulting in a comminuted midshaft femur fracture. The entry and exit wounds are approximately 1 cm each, with no expanding hematoma, and distal pulses are palpable and symmetric. According to current orthopaedic trauma guidelines, what is the most appropriate initial management of the soft tissues and fracture?





Explanation

Low-velocity handgun injuries resulting in femur fractures without neurovascular compromise or massive contamination do not typically require formal surgical debridement of the bullet tract. The standard of care involves superficial local wound care, administration of tetanus prophylaxis and intravenous antibiotics, and stabilization of the fracture, most commonly with antegrade intramedullary nailing.

Question 15

A 22-year-old competitive rugby player with recurrent anterior shoulder instability undergoes a preoperative 3D CT scan. The 'bare spot' or 'best-fit circle' method is utilized to assess anterior glenoid bone loss. Which of the following thresholds of anterior glenoid bone loss is classically accepted as an absolute indication for a bony augmentation procedure (e.g., Latarjet) rather than an isolated arthroscopic Bankart repair?





Explanation

The classic threshold for critical anterior glenoid bone loss, which serves as an absolute indication for a bony augmentation procedure (such as the Latarjet procedure), is generally accepted as > 20-25%. While recent literature discusses 'subcritical' bone loss (13.5-15%) in high-demand contact athletes where bone block may be considered, > 20-25% remains the definitive, historically validated cut-off for critical bone loss where soft tissue repair alone has an unacceptably high failure rate.

Question 16

A 52-year-old female presents with stage IIB acquired adult flatfoot deformity (posterior tibial tendon dysfunction). Clinical and radiographic evaluation demonstrates a flexible hindfoot valgus and severe forefoot abduction with >40% talonavicular uncoverage on the weight-bearing AP view. Which of the following surgical combinations is most appropriate to comprehensively correct her deformity?





Explanation

Stage IIB adult acquired flatfoot deformity is characterized by a flexible deformity with profound forefoot abduction (indicated by >40% talonavicular uncoverage). To correct this multi-planar deformity, an FDL transfer and medializing calcaneal osteotomy (which correct the hindfoot valgus) must be combined with a lateral column lengthening (Evans osteotomy) or a medial cuneiform osteotomy (Cotton) to definitively correct the forefoot abduction. Stage IIA (no significant abduction) may be treated with FDL transfer and MCO alone. Stage III (rigid) requires a triple or double arthrodesis.

Question 17

An unstable 35-year-old male is brought to the trauma bay following a high-speed motorcycle collision. His blood pressure is 80/40 mmHg. An anteroposterior pelvic radiograph reveals an APC-III pelvic ring injury (open book pelvis). A circumferential pelvic binder is ordered. To maximize the biomechanical reduction of the pelvic volume, the binder should be centered precisely over which of the following anatomical landmarks?





Explanation

To effectively reduce pelvic volume and provide hemostasis in an 'open book' (APC) pelvic ring injury, a pelvic binder or sheet must be centered directly over the greater trochanters. This directs the compressive force through the femoral heads and into the acetabula, effectively closing the anterior diastasis at the pubic symphysis and reducing the posterior sacroiliac joints. Placing the binder higher (e.g., iliac crests) can actually flare the true pelvis and exacerbate the deformity.

Question 18

A 29-year-old mountain biker falls directly onto the point of his shoulder. Radiographs reveal an acromioclavicular (AC) joint dislocation. He is diagnosed with a Rockwood Type V injury. Which of the following best describes the specific anatomical disruption and radiographic appearance that defines a Type V injury?





Explanation

The Rockwood classification of AC joint injuries is based on the degree and direction of distal clavicle displacement. Type I is a sprain; Type II involves AC rupture and CC sprain; Type III is complete rupture of AC and CC ligaments with 25-100% superior displacement. Type IV is posterior displacement into or through the trapezius. Type V is severe superior displacement (>100% and up to 300%) due to disruption of the AC ligaments, CC ligaments, and the deltotrapezial fascial attachments.

Question 19

During open reduction and internal fixation of a severe pronation-external rotation ankle fracture, the surgeon assesses the stability of the distal tibiofibular syndesmosis. The syndesmotic complex consists of several ligaments. Which of the following ligaments is biomechanically considered the strongest and provides the greatest resistance against diastasis of the syndesmosis?





Explanation

Biomechanical studies have demonstrated that the posterior inferior tibiofibular ligament (PITFL) is the strongest ligament of the syndesmotic complex, contributing approximately 42% of the resistance to fibular displacement (diastasis). The anterior inferior tibiofibular ligament (AITFL) provides about 35%, the interosseous ligament provides about 22%, and the inferior transverse ligament provides the remaining stability.

Question 20

A 28-year-old male sustains severe bilateral 'floating knee' injuries (femur and tibia fractures) in an industrial crush accident. He arrives at the trauma center intubated and requires massive transfusion. Which of the following physiologic parameters is the strongest indication to abandon Early Total Care (ETC) and instead pursue Damage Control Orthopedics (DCO) with temporary external fixation?





Explanation

Damage Control Orthopedics (DCO) is indicated in physiologically 'unstable' or 'in extremis' polytrauma patients to avoid the 'second hit' phenomenon associated with prolonged definitive surgery (like IM nailing). Established biochemical and physiologic criteria mandating DCO include: arterial pH < 7.24, core temperature < 34.0°C, serum lactate > 2.5 mmol/L (often > 4.0 mmol/L in severe shock), base deficit > 6 mEq/L, and hemodynamic instability requiring ongoing vasopressors.

Question 21

A 24-year-old male undergoes a Latarjet procedure for recurrent anterior shoulder instability with 25% glenoid bone loss. Postoperatively, he has weakness with elbow flexion and forearm supination, as well as numbness over the lateral aspect of his forearm. Which nerve was most likely injured during the procedure?





Explanation

The musculocutaneous nerve is at significant risk during the Latarjet procedure, particularly during the coracoid osteotomy and the retraction of the conjoint tendon. Injury to this nerve results in weakness of the biceps and brachialis (elbow flexion and supination) and sensory deficits in the lateral antebrachial cutaneous nerve distribution (lateral forearm).

Question 22

A 35-year-old male is brought to the trauma bay after a high-speed motorcycle crash. His blood pressure is 70/40 mmHg and heart rate is 130 bpm. An AP pelvis radiograph demonstrates an APC-III pelvic ring injury. A FAST scan is negative. A pelvic binder is appropriately applied, but he remains hemodynamically unstable despite receiving 2 units of packed RBCs and plasma. What is the most appropriate next step in management?





Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and a negative FAST scan (ruling out massive intra-abdominal hemorrhage), the bleeding is primarily venous or from pelvic arterial sources. Preperitoneal pelvic packing (PPP) and/or pelvic angiography with embolization are the treatments of choice after initial resuscitation and mechanical stabilization (binder).

Question 23

A 28-year-old female sustains a Hawkins Type II talar neck fracture following a fall from height. At 8 weeks post-injury, a radiograph of the ankle reveals a band of subchondral radiolucency within the talar dome. What does this specific radiographic finding indicate?





Explanation

This finding describes the 'Hawkins sign', which is a subchondral radiolucent band in the talar dome visible 6 to 8 weeks after a talar neck fracture. It is a sign of subchondral osteopenia secondary to hyperemia. The presence of the Hawkins sign is a highly reliable indicator that the talar body has an intact vascular supply and that avascular necrosis (AVN) is unlikely to occur.

Question 24

Which of the following best describes the fundamental biomechanical alteration achieved by the Grammont-style Reverse Total Shoulder Arthroplasty (rTSA) compared to the native glenohumeral joint?





Explanation

The Grammont design of the Reverse Total Shoulder Arthroplasty (rTSA) works by medializing and distalizing (inferior translation) the center of rotation of the glenohumeral joint. This alteration significantly increases the moment arm of the deltoid muscle and increases deltoid fiber recruitment, allowing it to compensate for a deficient rotator cuff to achieve active arm elevation.

Question 25

A 68-year-old female on long-term alendronate for osteoporosis presents with dull aching thigh pain. Radiographs demonstrate lateral cortical thickening and a transverse radiolucent line in the subtrochanteric region of the right femur. If prophylactic surgical fixation is chosen, which of the following is true regarding her management?





Explanation

Atypical femur fractures are highly associated with prolonged bisphosphonate use. Because the bone biology is altered, plate fixation has a high failure rate. Intramedullary (cephalomedullary) nailing is the preferred construct for prophylactic or definitive fixation. Bisphosphonates must be discontinued, the contralateral femur must be imaged (due to high bilateral incidence), and anabolic agents like teriparatide may actually be considered off-label to aid healing.

Question 26

A 55-year-old female presents with progressive flatfoot deformity. She has pain along the medial ankle and is unable to perform a single-leg heel rise. Examination shows a flexible hindfoot valgus and greater than 40% uncovering of the talonavicular joint on a weight-bearing AP foot radiograph. Which of the following surgical strategies is most appropriate for this stage of deformity?





Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible deformity with significant forefoot abduction (>30-40% talonavicular uncoverage). Treatment requires FDL transfer, an MDCO (to correct hindfoot valgus), and a lateral column lengthening (such as an Evans calcaneal osteotomy) to correct the severe forefoot abduction. Stage IIa lacks the severe abduction and can be treated without the lateral column lengthening.

Question 27

Historically, the anterior circumflex humeral artery was considered the primary blood supply to the humeral head. Based on current quantitative anatomical studies, which of the following structures provides the predominant arterial supply to the humeral head, and what is its path?





Explanation

Recent highly definitive anatomical and vascular injection studies (e.g., Hettrich et al.) demonstrated that the posterior circumflex humeral artery (PCHA) provides the predominant blood supply (up to 64%) to the humeral head. It enters the proximal humerus along the posteromedial aspect of the surgical neck, making it highly vulnerable in proximal humerus fractures.

Question 28

A 42-year-old male sustains a pelvic fracture in a motor vehicle collision. CT imaging of the acetabulum reveals a comminuted fracture involving the anterior column and anterior wall. A fracture line also extends across the quadrilateral plate dividing the innominate bone into two halves, with the posterior column detached from the axial skeleton. The posterior column is in a single piece and not comminuted. What is the correct Letournel classification?





Explanation

An Associated Both Column fracture is characterized by detachment of all articular segments from the intact axial skeleton. The presence of an anterior column fracture (with or without anterior wall) and a detached posterior column where no part of the articular surface remains attached to the intact ilium defines this pattern. A pathognomonic sign on the obturator oblique radiograph is the 'spur sign'.

Question 29

A 52-year-old diabetic male with severe peripheral neuropathy presents with a red, hot, swollen right foot mimicking cellulitis. Radiographs reveal extensive periarticular debris, fragmentation of the subchondral bone, and subluxation of the tarsometatarsal joints. Based on the Eichenholtz classification, what stage is this?





Explanation

Eichenholtz Stage I is the developmental or fragmentation phase of Charcot arthropathy. It is characterized clinically by a red, hot, swollen foot and radiographically by subchondral fragmentation, debris formation, and joint subluxation/dislocation. Stage II (coalescence) shows absorption of fine debris and early fusion. Stage III (remodeling) shows rounding of bone ends and sclerosis.

Question 30

A 60-year-old male presents with a massive, chronically retracted tear involving both the supraspinatus and infraspinatus tendons. Due to the medial retraction of these specific tendons, at which anatomical site is the suprascapular nerve most vulnerable to traction injury or tethering?





Explanation

The suprascapular nerve innervates the supraspinatus and infraspinatus. With massive, retracted tears of the supraspinatus, the nerve can be placed under significant traction and tethered at the suprascapular notch (proximal to its innervation of the supraspinatus). While retraction of the infraspinatus alone might tether the nerve at the spinoglenoid notch, medial retraction of massive tears (involving supraspinatus) primarily threatens the nerve at the suprascapular notch.

Question 31

A 45-year-old skier sustains a hyperflexion and varus stress injury to the knee. CT imaging shows a displaced coronal shear fracture of the posteromedial tibial plateau. Which of the following describes the most appropriate surgical approach and fixation strategy for this specific fragment?





Explanation

A posteromedial shear fracture of the tibial plateau (often seen as a variant in Schatzker IV or bicondylar injuries) requires a posteromedial approach. To effectively neutralize the vertical shear forces, a posterior buttress plate (anti-glide technique) placed directly on the posterior aspect of the medial plateau is required. Anteromedial plates cannot adequately compress or buttress a posteromedial coronal split.

Question 32

A 22-year-old football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals. What specific ligamentous structure, known as the primary stabilizer of this joint complex, is ruptured?





Explanation

The Lisfranc ligament is an interosseous ligament, but its primary functional bundle is located on the plantar aspect. It originates from the lateral aspect of the medial cuneiform and attaches to the medial base of the second metatarsal. It is the thickest and strongest ligament of the Lisfranc complex and the primary stabilizer against dorsal dislocation of the second metatarsal base.

Question 33

A 72-year-old female presents with chronic shoulder pain and limited active elevation. Radiographs show an acromiohumeral distance (AHD) of 3 mm and characteristic 'acetabularization' of the acromion. There is no evidence of glenohumeral joint space narrowing. According to the Hamada classification for cuff tear arthropathy, what grade is this?





Explanation

The Hamada classification describes the radiographic progression of massive rotator cuff tears. Grade 1: AHD > 6 mm. Grade 2: AHD < 5 mm. Grade 3: AHD < 5 mm with 'acetabularization' of the acromion (concave remodeling). Grade 4: Glenohumeral arthritis (loss of articular cartilage). Grade 5: Humeral head collapse/osteonecrosis.

Question 34

A 30-year-old male undergoes a 4-compartment fasciotomy for acute compartment syndrome of the leg following a tibial shaft fracture. Which of the following neurovascular structures is contained within the deep posterior compartment of the leg?





Explanation

The deep posterior compartment of the lower leg contains the deep flexor muscles (tibialis posterior, flexor hallucis longus, flexor digitorum longus), the posterior tibial artery and vein, the peroneal artery and vein, and the tibial nerve. Failure to adequately decompress this compartment can lead to ischemic contractures (e.g., claw toes) and tibial neuropathy.

Question 35

A 40-year-old recreational athlete sustains an acute Achilles tendon rupture. He elects for non-operative management with a modern functional rehabilitation protocol. Compared to surgical repair, high-level evidence demonstrates which of the following regarding non-operative management?





Explanation

High-level level I evidence (such as the landmark trial by Willits et al.) has demonstrated that when an early functional rehabilitation protocol is used, non-operative management of acute Achilles tendon ruptures yields equivalent re-rupture rates, strength, and functional outcomes compared to surgical repair. Furthermore, non-operative management avoids the risks of surgical complications such as deep infection and sural nerve injury.

Question 36

A 25-year-old male falls onto his shoulder apex, sustaining a Type III acromioclavicular (AC) joint dislocation. He is curious about the ruptured ligaments. Which of the following statements correctly pairs the coracoclavicular (CC) ligament bundles with their primary biomechanical restraint function?





Explanation

The CC ligaments consist of the medial conoid and the lateral trapezoid. Biomechanical studies have shown that the conoid ligament is the primary restraint against superior translation of the clavicle. The trapezoid ligament primarily resists axial compression (horizontal loading) into the acromion. The AC ligaments provide primary restraint to anterior-posterior translation.

Question 37

In a polytrauma patient with bilateral femur fractures, establishing the endpoint of resuscitation is critical prior to converting from a damage control external fixator to definitive intramedullary nailing. Which of the following laboratory parameters is the most reliable, validated indicator of adequate tissue perfusion?





Explanation

Normalization of serum lactate (typically < 2.5 mmol/L) and correction of the base deficit (approaching 0, generally > -2) are the most sensitive and validated indicators of adequate end-organ tissue perfusion. Clinical parameters like blood pressure and urine output can normalize while an occult 'oxygen debt' still exists at the tissue level, predisposing the patient to acute respiratory distress syndrome (ARDS) or multi-organ failure if subjected to major definitive surgery.

Question 38

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a Hallux Valgus Angle (HVA) of 45 degrees, an Intermetatarsal Angle (IMA) of 18 degrees, a congruent first MTP joint, and hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures provides the most reliable long-term correction?





Explanation

The Lapidus procedure (arthrodesis of the first tarsometatarsal joint) is highly indicated for patients with a severe hallux valgus deformity (IMA > 15-20 degrees) in the setting of first ray hypermobility. Distal osteotomies (like the Chevron) are inadequate for large IMA corrections. MTP arthrodesis is reserved for severe deformity combined with significant MTP degenerative joint disease.

Question 39

During a Superior Capsular Reconstruction (SCR) for an irreparable supraspinatus tear, a dermal allograft is securely attached to the superior glenoid medially and the greater tuberosity laterally. What is the primary biomechanical function of this graft in restoring shoulder kinematics?





Explanation

The primary biomechanical purpose of the Superior Capsular Reconstruction (SCR) is to act as a static spacer and superior tether. By preventing superior migration of the humeral head, it depresses the humeral head and restores a stable glenohumeral fulcrum. This allows the intact deltoid and remaining force couples of the rotator cuff to efficiently elevate the arm.

Question 40

A 34-year-old male smoker sustains a displaced intra-articular calcaneus fracture. Open reduction and internal fixation via an extensile lateral approach is planned. Which of the following intraoperative techniques is most critical for minimizing the risk of postoperative wound necrosis?





Explanation

Wound complications are famously high with the extensile lateral approach to the calcaneus, particularly in smokers. The lateral flap's blood supply relies on the lateral calcaneal artery. To preserve this vascularity, the flap must be elevated as a single full-thickness subperiosteal layer. Furthermore, a 'no-touch' technique using K-wires driven into the talus and fibula to retract the flap prevents focal tissue ischemia caused by hand-held or self-retaining retractors.

Question 41

A 28-year-old professional motocross rider sustains a Type V acromioclavicular (AC) joint dislocation. He undergoes surgical reconstruction of the coracoclavicular (CC) ligaments. Which of the following accurately describes the native anatomy and biomechanics of the CC ligaments being reconstructed?





Explanation

The coracoclavicular (CC) ligament complex consists of the conoid and trapezoid ligaments. The conoid ligament is located medial and posterior to the trapezoid ligament. It is cone-shaped and acts as the primary restraint against superior translation of the clavicle relative to the acromion. The trapezoid ligament is located anterolateral to the conoid and is the primary restraint against axial compression (driving the acromion medial towards the clavicle).

Question 42

A 45-year-old man is involved in a high-speed motor vehicle collision. Pelvic radiographs and a CT scan reveal an acetabular fracture with a 'spur sign' present on the obturator oblique radiograph. The entire articular surface is detached from the intact axial skeleton. What is the correct Letournel classification for this fracture?





Explanation

The 'spur sign' on an obturator oblique radiograph is the pathognomonic finding for an associated both column acetabular fracture. It represents the intact portion of the ilium that remains attached to the axial skeleton while the entire articular surface (both columns) is completely dissociated from the intact ilium. No portion of the articular surface remains attached to the axial skeleton in a both column fracture.

Question 43

A 30-year-old male sustains a Hawkins Type III talar neck fracture after a fall from height. Which of the following describes the dominant blood supply to the talar body that is disrupted in this injury pattern?





Explanation

The primary blood supply to the talar body is the artery of the tarsal canal, which is a branch of the posterior tibial artery. It supplies the majority of the talar body. The artery of the tarsal sinus (from the dorsalis pedis/anterior tibial and perforating peroneal arteries) and the deltoid artery (medial aspect) provide collateral supply but the artery of the tarsal canal is the most critical and is highly vulnerable to disruption in displaced talar neck fractures (Hawkins II-IV), leading to avascular necrosis (AVN).

Question 44

A 22-year-old rugby player presents with recurrent anterior shoulder instability. CT scan demonstrates 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. He undergoes a Latarjet procedure. During the coracoid transfer, which nerve is at greatest risk of injury if retractors are placed too vigorously on the medial aspect of the conjoint tendon?





Explanation

During the Latarjet procedure, the musculocutaneous nerve is at high risk of iatrogenic injury. It typically penetrates the coracobrachialis muscle approximately 5 to 8 cm distal to the coracoid tip but can enter much closer in anatomic variants. Vigorous medial retraction of the conjoint tendon can stretch or compress this nerve.

Question 45

A 34-year-old woman sustains a high-energy distal femur fracture. CT scan reveals a coronal plane fracture of the lateral femoral condyle. Which of the following surgical approaches and fixation strategies is most appropriate for addressing this specific fragment?





Explanation

The patient has a Hoffa fracture (coronal plane fracture of the femoral condyle), most commonly involving the lateral condyle. An anterior-to-posterior screw trajectory, placed perpendicular to the fracture plane via a lateral parapatellar approach (often countersunk within the articular cartilage or placed just proximal to it if the fragment size allows), provides the most biomechanically sound lag compression for a lateral Hoffa fracture.

Question 46

A 25-year-old soccer player complains of a snapping sensation behind his lateral malleolus during push-off. Examination reveals subluxation of the peroneal tendons with resisted dorsiflexion and eversion. Which of the following structures is the primary restraint to this subluxation?





Explanation

The superior peroneal retinaculum (SPR) is the primary restraint to peroneal tendon subluxation. It originates from the posterolateral ridge of the fibula and inserts onto the lateral calcaneal wall. Injury to the SPR, often through forced dorsiflexion and inversion causing an avulsion from the fibula, results in peroneal tendon instability.

Question 47

In evaluating a 4-part proximal humerus fracture for the risk of avascular necrosis (AVN) of the humeral head, which of the following radiographic findings is considered the most reliable predictor of subsequent ischemia according to Hertel's criteria?





Explanation

According to Hertel's classic criteria, the most reliable predictors of ischemia (and subsequent AVN) in proximal humerus fractures include a posteromedial metaphyseal head extension (calcar segment) of less than 8 mm, disruption of the medial hinge (>2 mm of displacement), and anatomic neck fracture patterns. A short calcar length attached to the articular segment means the ascending branch of the anterior humeral circumflex artery and endosteal supply are compromised.

Question 48

A 50-year-old pedestrian is struck from the side by a car. Pelvic radiographs show a transverse fracture of the pubic rami and a posterior iliac wing fracture that extends into the sacroiliac joint. What is the Young-Burgess classification of this injury, and what is the primary deforming force?





Explanation

This is a Lateral Compression Type II (LC-II) pelvic ring injury. It is characterized by an anterior ring injury (e.g., transverse pubic rami fractures) combined with a crescent fracture of the posterior ilium extending into the SI joint. The primary deforming force in lateral compression injuries is internal rotation of the hemipelvis.

Question 49

A 60-year-old female presents with dorsal midfoot pain and stiffness in her great toe. Radiographs show a preserved plantar joint space but significant dorsal osteophytes and joint space narrowing at the first MTP joint. She has pain at the extremes of motion but not in the mid-range. What is the most appropriate surgical management if conservative care fails?





Explanation

This patient has Grade 2 hallux rigidus according to the Coughlin and Shurnas classification (preserved plantar joint space, pain only at extremes of motion, prominent dorsal osteophytes). The standard surgical treatment for Grades 1 and 2, when conservative measures fail, is a dorsal cheilectomy. Arthrodesis is generally reserved for advanced disease (Grades 3 and 4) with diffuse pain throughout the range of motion and global joint space loss.

Question 50

A 28-year-old male volleyball player presents with insidious onset posterior shoulder pain and weakness in external rotation. Exam reveals atrophy of the infraspinatus with a normal appearing supraspinatus. MRI demonstrates a paralabral cyst. At which of the following anatomical locations is the cyst most likely compressing the suprascapular nerve?





Explanation

Isolated atrophy and weakness of the infraspinatus indicate compression of the suprascapular nerve after it has innervated the supraspinatus. This occurs at the spinoglenoid notch. Compression at the more proximal suprascapular notch would cause weakness and atrophy in both the supraspinatus and infraspinatus. Paralabral cysts associated with posterior labral tears frequently track into the spinoglenoid notch.

Question 51

A 35-year-old farmer sustains an open tibial shaft fracture after his leg is caught in a tractor mechanism. The wound is 12 cm long with significant periosteal stripping, but adequate soft tissue coverage is possible. According to the most recent evidence-based guidelines for severe agricultural open fractures, which empiric antibiotic regimen should be initiated upon arrival to the emergency department?





Explanation

For severe open fractures (Gustilo-Anderson Type III) sustained in an agricultural setting or highly contaminated with soil, standard guidelines recommend an expanded spectrum of coverage. This typically includes a first-generation cephalosporin (Cefazolin) for Gram-positive coverage, an aminoglycoside (Gentamicin) for Gram-negative coverage, and high-dose Penicillin to cover anaerobic organisms, specifically Clostridium perfringens, which can cause gas gangrene.

Question 52

In a patient with Stage II posterior tibial tendon dysfunction (PTTD), tearing or attenuation of the spring ligament complex is frequently observed. Which component of the spring ligament complex is the thickest, most frequently torn, and acts as the primary static stabilizer of the talonavicular joint?





Explanation

The spring ligament complex (calcaneonavicular ligament) has three main components: superomedial, inferoplantar, and medioplantar. The superomedial calcaneonavicular ligament is the thickest and most crucial static stabilizer of the talar head. It is the component most frequently attenuated or torn in conjunction with posterior tibial tendon dysfunction (acquired flatfoot deformity).

Question 53

A 21-year-old male cyclist falls and sustains a midshaft clavicle fracture. Which of the following radiographic or clinical criteria is considered the strongest relative indication for operative fixation to decrease the risk of symptomatic nonunion?





Explanation

Significant displacement (>100% translation) and shortening (>2 cm) are the strongest predictors of nonunion and poor functional outcomes in midshaft clavicle fractures. Operative fixation in this setting significantly decreases the nonunion rate and improves early functional outcomes compared to non-operative management.

Question 54

A 29-year-old male sustains a high-energy, vertically oriented femoral neck fracture (Pauwels Type III). He undergoes closed reduction and internal fixation. Which of the following construct modifications would best resist the high shear forces inherent to this fracture pattern?





Explanation

Pauwels Type III fractures (>50 degrees) are highly vertically oriented, resulting in immense shear forces that often lead to varus collapse, nonunion, and failure of multiple cannulated screw constructs. Biomechanical studies demonstrate that a fixed-angle device, such as a sliding hip screw (SHS) combined with a derotational screw, provides vastly superior resistance to shear forces and varus collapse compared to three cannulated screws.

Question 55

A 24-year-old football player sustains a hyperplantarflexion injury to his foot resulting in a subtle Lisfranc injury. During surgical exploration, you identify a tear of the primary Lisfranc ligament. What are the correct anatomical attachments of this ligament?





Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the primary and strongest stabilizer of the second tarsometatarsal joint; notably, there is no direct intermetatarsal ligament between the first and second metatarsal bases.

Question 56

A 32-year-old weightlifter feels a 'pop' in his anterior axilla while performing a heavy bench press. MRI confirms a complete rupture of the pectoralis major tendon. During surgical repair, an understanding of the insertional anatomy is critical. Which of the following best describes the normal footprint of the pectoralis major on the humerus?





Explanation

The pectoralis major tendon twists 180 degrees before inserting onto the lateral lip of the bicipital groove. Because of this twist, the lower fibers (sternocostal head) insert superior and deep (posterior) to the upper fibers (clavicular head). The clavicular head inserts inferiorly and superficially. Most tears in weightlifters involve the sternal head selectively or the entire tendon.

Question 57

A 27-year-old male develops impending compartment syndrome of the lower leg after a tibial shaft fracture. You plan a four-compartment fasciotomy. Which of the following muscle combinations is located entirely within the deep posterior compartment?





Explanation

The deep posterior compartment of the leg contains the tibialis posterior, flexor digitorum longus (FDL), flexor hallucis longus (FHL), and the popliteus (proximally). It also houses the tibial nerve and the posterior tibial and peroneal vessels. Failure to adequately release this specific compartment is a common cause of poor outcomes in leg fasciotomies.

Question 58

A 42-year-old recreational athlete sustains an acute Achilles tendon rupture. He is debating between operative repair and non-operative management. Based on the most recent high-quality randomized controlled trials utilizing early functional rehabilitation protocols, which of the following statements regarding outcomes is most accurate?





Explanation

Recent high-quality level I evidence (such as the Willits trial and more recent meta-analyses) demonstrates that when functional rehabilitation with early weight-bearing and range of motion is employed, there is no statistically significant difference in re-rupture rates between operative and non-operative management of acute Achilles tendon ruptures. Operative management carries higher risks of complications such as infection and nerve injury.

Question 59

A 55-year-old female with poorly controlled type 1 diabetes presents with insidious onset of profound shoulder stiffness and pain. She is diagnosed with adhesive capsulitis (frozen shoulder). Histological and biochemical analysis of the capsule in this condition is most likely to show an upregulation of which of the following cytokines?





Explanation

Adhesive capsulitis is characterized by chronic inflammation and severe fibrosis of the joint capsule. Histologically, it resembles Dupuytren's disease, showing dense fibroblastic proliferation. This fibrotic cascade is driven heavily by pro-fibrotic cytokines, particularly Transforming Growth Factor-beta (TGF-b) and Platelet-Derived Growth Factor (PDGF).

Question 60

A 26-year-old male presents with a grossly deformed foot after a fall from a ladder. Radiographs reveal a medial subtalar dislocation without associated fractures. Which of the following structures is most likely to block closed reduction of this specific dislocation pattern?





Explanation

In a medial subtalar dislocation, the foot is displaced medially, forcing the talar head to protrude laterally. The structures that commonly block closed reduction of a medial subtalar dislocation include the extensor digitorum brevis (EDB) muscle, the extensor retinaculum, or the talonavicular joint capsule impinging on the talar head. Conversely, in a lateral subtalar dislocation, the posterior tibial tendon (PTT) frequently blocks reduction by looping around the medially prominent talar neck.

Question 61

A 55-year-old male presents with chronic shoulder pain and weakness. Clinical examination demonstrates a positive external rotation lag sign and a positive Hornblower's sign. MRI reveals a massive, irreparable tear of the posterosuperior rotator cuff with significant fatty infiltration of the infraspinatus and teres minor. The subscapularis is intact. If a tendon transfer is planned, which of the following provides the most biomechanically appropriate line of pull to restore external rotation in this patient?





Explanation

A lower trapezius transfer, often augmented with an Achilles tendon allograft, most closely replicates the anatomic vector of the infraspinatus. It is highly effective for restoring external rotation in patients with irreparable posterosuperior cuff tears and an intact subscapularis, especially when there is a pronounced external rotation deficit (positive lag and Hornblower's signs). While latissimus dorsi transfers are also used for massive posterosuperior tears, its vector is less parallel to the infraspinatus compared to the lower trapezius.

Question 62

A 35-year-old male is involved in a high-speed motor vehicle collision. Radiographs and CT demonstrate a posterior hip dislocation with an associated posterior wall acetabular fracture. There is a distinct area of marginal impaction of the articular cartilage. What is the most appropriate management of the marginal impaction during open reduction and internal fixation?





Explanation

Marginal impaction is common in posterior wall acetabular fractures. Failure to recognize and elevate this impacted articular cartilage leads to joint incongruity and rapid post-traumatic arthritis. The standard of care is to disimpact and elevate the articular segment to match the femoral head, fill the resulting subchondral/metaphyseal void with cancellous bone graft, and then reduce and fix the posterior wall over it to act as a buttress.

Question 63

A 58-year-old diabetic female with peripheral neuropathy presents with a warm, swollen, and erythematous left foot. Radiographs demonstrate coalescing of previously seen fracture fragments, absorption of fine bone debris, and early sclerosis of the midfoot bones. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?





Explanation

The Eichenholtz classification divides Charcot arthropathy into three main clinical/radiographic stages (plus Stage 0). Stage 0 represents clinical inflammation with normal radiographs. Stage I (Development/Fragmentation) is characterized by acute inflammation, osteopenia, joint subluxation, and bony fragmentation/debris. Stage II (Coalescence) is marked by decreased inflammation, absorption of fine debris, early sclerosis, and fusion of fragments. Stage III (Reconstruction/Remodeling) shows decreased sclerosis and remodeling of bone ends.

Question 64

A 25-year-old male sustains a Pauwels Type III (vertical) femoral neck fracture. Which of the following internal fixation constructs provides the greatest biomechanical stability against the high vertical shear forces inherent to this fracture pattern?





Explanation

Pauwels Type III fractures (>50 degrees) are inherently unstable due to high vertical shear forces. Biomechanical studies consistently demonstrate that fixed-angle devices, such as a sliding hip screw (SHS), combined with a derotational screw to control rotational forces, provide superior stability and higher load-to-failure compared to multiple parallel cannulated screws for vertical femoral neck fractures in young adults.

Question 65

A 22-year-old rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals an 'inverted pear' glenoid with 28% anterior inferior bone loss. What is the most appropriate surgical management?





Explanation

Anterior glenoid bone loss exceeding 20-25% ('inverted pear' glenoid) is an absolute indication for a bone block augmentation procedure, as soft tissue repairs (like an arthroscopic Bankart) have unacceptably high failure rates in this setting. The Latarjet procedure (transferring the coracoid process with the attached conjoint tendon to the anterior glenoid) provides a triple blocking effect (bone block, sling effect of the conjoint tendon, and capsular repair) and is the treatment of choice.

Question 66

In recent randomized controlled trials comparing operative versus nonoperative management for acute Achilles tendon ruptures, when utilizing early functional rehabilitation protocols for both groups, which of the following correctly describes the outcomes?





Explanation

Recent high-quality RCTs have demonstrated that when an early functional rehabilitation protocol (including early weight-bearing in a functional orthosis) is utilized, the re-rupture rates between operative and nonoperative management are statistically equivalent. However, operative management continues to carry a higher risk of soft-tissue complications, such as infection and wound breakdown.

Question 67

A 42-year-old female sustains a high-energy Schatzker IV tibial plateau fracture involving a large posteromedial fragment. The surgeon plans a direct posteromedial approach for optimal buttress plating. This approach utilizes an internervous/intermuscular plane between which two structures?





Explanation

The posteromedial approach to the tibial plateau is indicated for coronal plane fractures with a posteromedial fragment. The superficial dissection involves utilizing the interval between the medial head of the gastrocnemius (retracted laterally/posteriorly) and the pes anserinus (retracted medially/anteriorly). This exposes the popliteus, which can be partially elevated to safely access the posteromedial plateau.

Question 68

During surgical reconstruction of a severe acromioclavicular (AC) joint separation, precise knowledge of the coracoclavicular (CC) ligament insertions is required. Which of the following best describes the normal anatomic footprint of the CC ligaments on the clavicle?





Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid is medial and posterior, inserting approximately 4.5 cm from the distal end of the clavicle. The trapezoid is lateral and anterior, inserting approximately 3.0 cm from the distal clavicle. Mnemonic: 'Conoid is Cone-shaped, medial, and posterior.' Accurate tunnel placement requires knowing these distances.

Question 69

A 30-year-old male falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the pathomechanics and vascular risk associated with this specific injury pattern?





Explanation

The Hawkins classification for talar neck fractures: Type I is nondisplaced (AVN 0-15%). Type II involves subtalar subluxation/dislocation (AVN 20-50%). Type III involves dislocation of both the subtalar and tibiotalar joints (extruded talar body), with an AVN risk near 100%. Type IV (added by Canale/Kelly) involves subtalar, tibiotalar, and talonavicular dislocation.

Question 70

A 40-year-old male is brought into the trauma bay with an APC-III (Anteroposterior Compression) pelvic ring injury and severe hemodynamic instability. A non-invasive pelvic binder is applied to reduce pelvic volume. To achieve maximal reduction of the symphyseal diastasis and control hemorrhage, over which anatomic landmark should the binder be centered?





Explanation

Pelvic binders are a critical first step in managing hemodynamically unstable pelvic ring injuries, particularly open book (APC) patterns. To correctly apply vector force that effectively closes the pelvic ring and reduces the symphyseal diastasis, the binder must be centered directly over the greater trochanters. Placement too high (e.g., over the iliac crests or ASIS) is a common error and is ineffective at reducing pelvic volume.

Question 71

A 75-year-old female undergoes a reverse total shoulder arthroplasty (RTSA) for a severely displaced 4-part proximal humerus fracture. Compared to a hemiarthroplasty performed for the same indication, RTSA provides which primary functional advantage?





Explanation

In elderly patients with complex proximal humerus fractures, hemiarthroplasty outcomes are heavily dependent on tuberosity healing; failure of tuberosities to heal leads to pseudoparalysis. Reverse total shoulder arthroplasty (RTSA) relies on the deltoid for forward elevation and is biomechanically independent of tuberosity healing, providing more predictable pain relief and active forward elevation, although tuberosity repair is still attempted to improve external rotation.

Question 72

The Tillaux-Chaput fracture is an important component of complex ankle fractures. It represents an avulsion fracture caused by tension from the anterior inferior tibiofibular ligament (AITFL). From which specific bony structure does this fragment avulse?





Explanation

The anterior inferior tibiofibular ligament (AITFL) connects the anterolateral distal tibia to the anteromedial distal fibula. An avulsion fracture of its tibial attachment is the Tillaux-Chaput fragment (anterolateral distal tibia). An avulsion of its fibular attachment is the Wagstaffe-Le Fort fragment. The posterior inferior tibiofibular ligament (PITFL) avulses the posterolateral tibia, known as the Volkmann fragment.

Question 73

The Lower Extremity Assessment Project (LEAP) study prospectively evaluated thousands of patients with severe lower extremity trauma. Which of the following was a primary conclusion of the LEAP study regarding the presence of an insensate plantar foot at the time of initial clinical presentation?





Explanation

Historically, an insensate plantar foot at presentation was considered an absolute indication for amputation. However, the LEAP study definitively demonstrated that initial absence of plantar sensation is not predictive of long-term functional outcome, and many patients regain sensation or function well regardless. Therefore, it is no longer considered an absolute indication for primary amputation.

Question 74

A 28-year-old male presents with shoulder weakness and a dull ache following a severe blunt trauma to the base of his posterior neck during a wrestling match. Physical examination reveals a drooping shoulder and lateral winging of the scapula that worsens with shoulder abduction. The winged scapula is translated laterally and superiorly. Injury to which nerve is most likely responsible?





Explanation

Lateral winging of the scapula, accompanied by a drooping shoulder, is the hallmark of trapezius muscle paralysis, which is innervated by the spinal accessory nerve (CN XI). This contrasts with medial winging of the scapula, which is caused by serratus anterior paralysis (long thoracic nerve injury) and is classically accentuated by asking the patient to push against a wall.

Question 75

A 22-year-old collegiate football player sustains a high-energy axial load to a plantarflexed foot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. There is no evidence of compartment syndrome. What is the most appropriate definitive management?





Explanation

A 3 mm diastasis between the 1st and 2nd metatarsal bases indicates an unstable Lisfranc injury. Because the interosseous ligament is disrupted, anatomic reduction is essential. In an active athletic patient with a purely ligamentous or displaced bony Lisfranc injury >2mm, operative intervention (ORIF or primary arthrodesis) is required to restore anatomy and prevent post-traumatic midfoot collapse and arthritis.

Question 76

A 40-year-old male sustains an isolated, closed transverse fracture of the femoral shaft in a motor vehicle accident. Reamed intramedullary nailing is planned. What is the primary physiological and clinical benefit of reaming the medullary canal prior to nail insertion compared to an unreamed technique?





Explanation

Multiple large randomized trials (e.g., the SPRINT trial data, though SPRINT was tibia, femoral studies heavily concur) and meta-analyses have shown that reamed intramedullary nailing of closed femoral shaft fractures yields significantly higher union rates and lower rates of hardware failure compared to unreamed nailing. Reaming allows for a larger, stiffer nail and generates autologous bone graft at the fracture site, outweighing the transient destruction of the endosteal blood supply.

Question 77

A 25-year-old baseball pitcher undergoes shoulder arthroscopy for chronic shoulder pain. He is diagnosed with a Type II SLAP (Superior Labrum Anterior to Posterior) tear. What is the defining anatomical characteristic of a Type II SLAP lesion?





Explanation

Snyder classification of SLAP tears: Type I is degenerative fraying with an intact biceps anchor. Type II is detachment of the superior labrum and the biceps anchor from the superior glenoid (most common, often requires repair or tenodesis). Type III is a bucket-handle tear of the superior labrum with an intact biceps anchor. Type IV is a bucket-handle tear of the superior labrum that extends into the long head of the biceps tendon.

Question 78

A 50-year-old obese female presents with a progressive flatfoot deformity. Clinically, she has pain along the medial ankle and is unable to perform a single-leg heel rise on the affected side. Weight-bearing radiographs show uncovering of the talonavicular joint, but clinical examination reveals the hindfoot deformity remains fully flexible and correctable. What stage of Posterior Tibial Tendon Dysfunction (PTTD) does this represent?





Explanation

Johnson and Strom classification of PTTD: Stage I is tenosynovitis with pain and swelling, but normal alignment and a positive single-leg heel rise. Stage II involves tendinosis/rupture with a flexible flatfoot deformity and inability to perform a single-leg heel rise. Stage III is characterized by a rigid, fixed flatfoot deformity (fixed hindfoot valgus). Stage IV (added by Myerson) involves deltoid ligament compromise leading to rigid ankle valgus.

Question 79

In bridge plating of a highly comminuted distal femur fracture using a lateral locked plate, the surgeon must balance construct stiffness to promote secondary bone healing. Which of the following mechanical choices most significantly decreases construct stiffness to allow the micro-motion necessary for robust callus formation?





Explanation

In bridge plating, the 'working length' is the distance between the two closest screws on either side of the fracture. Increasing the working length (by leaving holes empty near the fracture) decreases the stiffness of the construct, allowing for interfragmentary strain and micro-motion. This micro-motion is essential for secondary bone healing via callus formation. Constructs that are too stiff (short working length, filling every hole) suppress callus and contribute to nonunion.

Question 80

A 32-year-old elite weightlifter feels a sudden "pop" in his anterior axilla while bench pressing. He presents with extensive ecchymosis and loss of the anterior axillary fold. An acute rupture of the pectoralis major is suspected. At its normal humeral insertion, what is the anatomical relationship of the sternal head relative to the clavicular head?





Explanation

The pectoralis major has a unique, twisted insertion on the lateral lip of the bicipital groove. The tendon undergoes a 180-degree twist so that the lower/inferior fibers (sternal head) insert deep and superior to the upper/superior fibers (clavicular head). The sternal head is typically the first part to rupture under maximal eccentric load during activities like bench pressing.

Question 81

A 70-year-old woman undergoes a reverse total shoulder arthroplasty (rTSA) for cuff tear arthropathy. At her 2-year follow-up, radiographs show a Grade 2 scapular notching. Which of the following surgical design factors or techniques is most effective in minimizing the risk of scapular notching in rTSA?





Explanation

Scapular notching is a common complication of reverse total shoulder arthroplasty, caused by mechanical impingement of the humeral component against the inferior scapular neck during arm adduction. Inferior placement of the baseplate with an inferior tilt, lateralization of the center of rotation, and using a larger glenosphere can help minimize this impingement.

Question 82

A 32-year-old man sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. Which of the following vascular structures, representing the primary blood supply to the talar body, is most likely disrupted in this injury?





Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, supplies the majority of the blood to the talar body. In a Hawkins Type III fracture (fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints), the blood supply from the artery of the tarsal canal, artery of the tarsal sinus, and branches of the neck are disrupted, leading to a near 100% risk of avascular necrosis (AVN).

Question 83

During an ilioinguinal approach to the acetabulum for a transverse fracture, the surgeon encounters massive bleeding over the posterior aspect of the superior pubic ramus. This bleeding is most likely originating from an anastomosis between which of the following vascular systems?





Explanation

The corona mortis ('crown of death') is a vascular anastomosis between the external iliac system (usually via the inferior epigastric vessels) and the obturator system. It is located on the posterior aspect of the superior pubic ramus, approximately 4-7 cm from the pubic symphysis, and must be carefully identified and ligated during an anterior approach to the acetabulum.

Question 84

A 58-year-old poorly controlled diabetic patient presents with a swollen, erythematous, and warm left foot. Radiographs demonstrate joint effusion, soft tissue edema, osteopenia, and periarticular fragmentation with early subluxation. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?





Explanation

Eichenholtz Stage I is the Developmental or Fragmentation stage. It is characterized clinically by a red, hot, swollen foot and radiographically by joint effusion, bone fragmentation, debris formation, and subluxation/dislocation. Stage II (Coalescence) shows absorption of debris and early fusion, while Stage III (Consolidation) shows remodeling and stable deformity.

Question 85

Historically, the anterior humeral circumflex artery was thought to be the primary blood supply to the humeral head. Based on modern quantitative perfusion studies, which vessel actually provides the majority of the blood supply to the humeral head?





Explanation

Recent quantitative anatomical studies (e.g., Hettrich et al.) have demonstrated that the posterior humeral circumflex artery provides the vast majority (approximately 64%) of the blood supply to the humeral head, challenging the classic teaching that the arcuate branch of the anterior humeral circumflex artery was the dominant supplier.

Question 86

A 25-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 hemodynamic measurements provides the most reliable indication for performing a four-compartment fasciotomy?





Explanation

The delta P (diastolic blood pressure minus compartment pressure) is the most reliable threshold for diagnosing acute compartment syndrome. A delta P of less than 30 mmHg is an absolute indication for fasciotomy. Absolute pressure thresholds (e.g., 30 mmHg) can lead to overtreatment in hypotensive patients and undertreatment in hypertensive patients.

Question 87

According to the Lauge-Hansen classification, in a pronation-external rotation (PER) ankle injury, what is the first anatomic structure to fail?





Explanation

In the Lauge-Hansen system, the first word denotes the position of the foot, and the second denotes the force applied. For Pronation-External Rotation (PER): Stage 1 is rupture of the deltoid ligament or a transverse medial malleolus fracture. Stage 2 is rupture of the AITFL. Stage 3 is a high fibular fracture (above the syndesmosis). Stage 4 is rupture of the PITFL or a posterior malleolus fracture.

Question 88

A 30-year-old competitive weightlifter feels a sudden 'pop' in his anterior shoulder while performing a heavy bench press. Examination reveals a loss of the anterior axillary fold. When a pectoralis major rupture occurs, which of the following describes the most common pathoanatomic failure pattern?





Explanation

The pectoralis major tendon undergoes a 180-degree twist before inserting onto the lateral lip of the bicipital groove. The sternal head twists to insert proximal and deep to the clavicular head. During eccentric loading with the arm extended and externally rotated (e.g., bench press), the deep sternal head is under maximal tension and is typically the first or only part to rupture.

Question 89

A 35-year-old male sustains a vertically oriented femoral neck fracture (Pauwels Type III) after falling from a roof. To minimize the risk of varus collapse and nonunion, which internal fixation construct provides the most biomechanically superior stability against shear forces?





Explanation

Pauwels Type III fractures are vertically oriented (>50 degrees) and experience high shear forces, leading to a high risk of varus collapse. Biomechanical studies have shown that a fixed-angle device, such as a sliding hip screw (often combined with a derotational screw), provides superior stability against vertical shear forces compared to multiple cancellous screws.

Question 90

A 21-year-old track athlete presents with insidious onset of vague dorsal midfoot pain. A CT scan reveals a nondisplaced, incomplete stress fracture in the central third of the navicular. What is the most appropriate initial management?





Explanation

Navicular stress fractures typically occur in the central third, which is a relative watershed area for blood supply. For nondisplaced and incomplete fractures, the gold standard initial treatment is strict non-weight-bearing in a short leg cast for 6 to 8 weeks to allow for healing and minimize the risk of nonunion.

Question 91

A 24-year-old collegiate baseball pitcher presents with 'dead arm' syndrome and posterior shoulder pain during the late cocking phase of throwing. MRI reveals a Snyder Type II SLAP tear. What is the defining pathoanatomic feature of a Type II SLAP lesion?





Explanation

According to the Snyder classification: Type I is degenerative fraying; Type II is detachment of the superior labrum and biceps anchor from the superior glenoid tubercle; Type III is a bucket-handle tear of the labrum with an intact biceps anchor; Type IV is a bucket-handle tear that extends into the long head of the biceps tendon.

Question 92

A 40-year-old farmer sustains a Gustilo-Anderson Type IIIB open tibia fracture heavily contaminated with soil and manure. Based on current guidelines, which of the following prophylactic antibiotic regimens is most appropriate?





Explanation

For a heavily contaminated farm injury (Type III open fracture), the standard antibiotic prophylaxis includes a first-generation cephalosporin (for Gram-positive coverage), an aminoglycoside (for Gram-negative coverage), and the addition of high-dose penicillin to specifically cover anaerobic organisms, most notably Clostridium species.

Question 93

The Sanders classification is widely used to categorize intra-articular calcaneus fractures based on coronal CT images. This classification relies specifically on the number and location of fracture lines through which articular facet?





Explanation

The Sanders classification evaluates intra-articular calcaneal fractures by assessing the number and location of primary fracture lines through the posterior facet of the calcaneus on the widest semicoronal CT image. The posterior facet is the largest and most critical weight-bearing surface of the subtalar joint.

Question 94

A 28-year-old elite volleyball player presents with vague posterior shoulder pain and isolated weakness in external rotation. Physical examination reveals noticeable atrophy of the infraspinatus fossa, while the supraspinatus fossa appears completely normal. At which anatomic location is the nerve most likely entrapped?





Explanation

The suprascapular nerve innervates the supraspinatus muscle after passing through the suprascapular notch, and then travels through the spinoglenoid notch to innervate the infraspinatus. Entrapment at the spinoglenoid notch (commonly by a paralabral cyst in overhead athletes) results in isolated infraspinatus weakness and atrophy, sparing the supraspinatus.

Question 95

A 65-year-old woman on alendronate for 12 years presents with insidious lateral thigh pain. Radiographs reveal lateral cortical thickening and a transverse radiolucent line in the subtrochanteric femur. What is the primary cellular mechanism leading to this atypical femur fracture?





Explanation

Long-term bisphosphonate use severely suppresses osteoclast-mediated bone remodeling. Physiologic bone remodeling is required to repair everyday microdamage. When suppressed, microcracks accumulate and coalesce, causing the bone to become brittle. This leads to atypical femur fractures, which characteristically begin as a transverse cortical stress reaction on the tension (lateral) side of the subtrochanteric or diaphyseal femur.

Question 96

A 32-year-old recreational basketball player sustains an acute, closed Achilles tendon rupture. In discussing treatment options, what is the most scientifically supported advantage of open surgical repair compared to conservative management with functional rehabilitation?





Explanation

Historically and in recent meta-analyses, the primary advantage of surgical repair for an Achilles tendon rupture is a significantly lower rate of re-rupture compared to non-operative treatment. However, this comes at the cost of higher surgical complications, such as wound infection, skin breakdown, and potential sural nerve injury.

Question 97

A 22-year-old male falls directly onto his shoulder tip. Radiographs demonstrate 100% superior displacement of the clavicle relative to the acromion. Based on the Rockwood classification for acromioclavicular (AC) joint injuries, a Type III separation involves complete rupture of which ligaments?





Explanation

In the Rockwood classification: Type I is an AC ligament sprain; Type II is an AC ligament tear with a CC ligament sprain; Type III is a complete rupture of both the AC ligaments and the CC ligaments (conoid and trapezoid), resulting in superior displacement of the clavicle between 25% and 100%.

Question 98

A 45-year-old driver sustains a posterior wall acetabular fracture in a head-on collision. Which of the following findings is an absolute indication for operative fixation of the posterior wall?





Explanation

Absolute indications for open reduction and internal fixation of a posterior wall acetabular fracture include hip joint instability (often seen when >20-40% of the wall is involved), the presence of an incarcerated intra-articular osteochondral fragment, and progressive sciatic nerve deficit following a closed reduction.

Question 99

The stability of the midfoot relies heavily on the Lisfranc ligament complex. The primary Lisfranc ligament is an interosseous band that connects which two specific osseous structures?





Explanation

The Lisfranc ligament is a strong interosseous ligament extending obliquely from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. There is no direct ligamentous connection between the bases of the first and second metatarsals, making the Lisfranc ligament critical for midfoot stability.

Question 100

A 26-year-old man presents with recurrent anterior shoulder instability. An MRI arthrogram reveals a HAGL lesion. What is the specific pathoanatomy defining this lesion?





Explanation

HAGL stands for Humeral Avulsion of the Glenohumeral Ligament. It describes the complete detachment of the inferior glenohumeral ligament (IGHL) complex from its insertion site on the anatomical neck of the humerus. This causes a loss of the 'sling' effect of the IGHL, leading to severe anterior or anteroinferior shoulder instability. It is an important lesion to recognize, as it requires a specific surgical repair distinct from a standard Bankart repair.

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Dr. Mohammed Hutaif
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