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Orthopedic Pathology Review | Dr Hutaif Basic Science R -...

Updated: Feb 2026 47 Views
Orthopedic Pathology Review | Dr Hutaif Basic Science R -...

Key Medical Takeaway

Discover the latest medical recommendations for ORTHOPEDIC MCQS ONLINE PATHOLOGY 017. Dedifferentiated liposarcoma is diagnosed via imaging and biopsy, often involving figures like those encountered in a pubmed question of figures. High-grade sarcomas require wide surgical resection. Radiation therapy reduces local recurrence, while chemotherapy remains investigational. This management contrasts with marginal resection for benign conditions like atypical lipomatous tumors, highlighting distinct treatment pathways based on pathology.

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ORTHOPEDIC MCQS ONLINE PATHOLOGY 017

QUESTION 1
of 100
What is the diagnosis?
1
Dedifferentiated liposarcoma
2
Intramuscular lipoma
3
Atypical lipomatous tumor
4
Myositis ossificans
QUESTION 2
of 100
The role of surgery in this condition is best described as
1
marginal resection is performed with a low likelihood of recurrence.
2
best performed after the lesion becomes “cold” on a bone scan.
3
wide resection as an indication for curative treatment.
4
not indicated.
QUESTION 3
of 100
The role of radiation treatment for this lesion is
1
proven to decrease local recurrence.
2
associated with a high rate of post-radiation sarcoma development.
3
contra-indicated for benign pathology.
4
associated with a higher risk of wound complications if given post-operatively.
QUESTION 4
of 100
Chemotherapy for this condition is
1
contraindicated when pathology is benign.
2
associated with a high risk for subsequent myelodysplastic syndrome.
3
provides dramatic survival benefits.
4
provides modest survival benefits.
QUESTION 5
of 100
Figures 5a and 5b are the radiographs of a 74-year-old man with poorly differentiated squamous cell carcinoma of the lung. He has had an uneventful recovery after undergoing a wedge resection of his left upper lobe 6 months ago. He is experiencing left lateral knee pain, and a whole-body positron emission tomography/CT scan shows no avid area other than the lateral left distal femur. This patient has needed to use a wheelchair for 3 weeks because of his pain. You discuss these treatment options: aggressive curettage, local adjuvant treatment, cementation, and prophylactic fixation vs distal femoral resection and megaprosthesis total knee arthroplasty reconstruction. You should tell him that

1
his overall disease-free survival will be no different with either procedure.
2
fixation failure may occur with cementation and prophylactic fixation but not with megaprosthesis reconstruction.
3
infection rates with megaprosthesis reconstruction are lower than with cementation after aggressive curettage.
4
radiation will not be necessary after undergoing either procedure.
QUESTION 6
of 100
Figures 6a through 6d are the radiographs and T1-weighted sagittal and fat-saturated axial MR images of an otherwise healthy 56-year-old man who has anterior knee pain and intermittent swelling after sustaining a noncontact twisting injury. Low-power and high-power hematoxylin and eosin stained histologic specimens are shown in Figures 6e and 6f. Based on the history, radiographs, CT scan, MR imaging, and histologic findings, what is the most likely diagnosis?





1
Localized pigmented villonodular synovitis (PVNS)
2
Synovial hemangioma
3
Synovial chondromatosis
4
Biphasic synovial sarcoma
QUESTION 7
of 100
Figures 7a through 7d are the radiograph, MR images, and biopsy specimen of a 35-year-old man who has a painful, slowly enlarging knee mass. Which chromosomal translocation is characteristic of this pathology?




1
t(11;22)
2
t(9;22)
3
t(x;18)
4
t(12;16)
QUESTION 8
of 100
A 45-year-old woman has a painless thigh mass that is larger than 5 cm. What is the best next step?




1
Percutaneous biopsy
2
Positron emission tomography (PET)/CT scan
3
Excisional biopsy
4
MRI of the thigh with gadolinium
QUESTION 9
of 100
What is the most likely diagnosis?
1
Osteomyelitis
2
Osteoid osteoma
3
Stress fracture
4
Adamantinoma
QUESTION 10
of 100
The most appropriate treatment of this lesion involves
1
radiofrequency ablation (RFA).
2
wide resection and hemicortical allograft reconstruction.
3
prophylactic internal fixation followed by radiation.
4
local debridement and an infectious disease consultation.
QUESTION 11
of 100
If this lesion occurred in the spine, which features would most likely be present?
1
Syrinx and paralysis
2
Spondylolisthesis and radiculopathy
3
Epidural abscess and fever
4
Scoliosis and paraspinal pain
QUESTION 12
of 100
Figures 12a and 12b are a recent radiograph and a whole-body bone scan of an 81-year-old man who has hip pain and difficulty walking. His medical history is significant for obesity, hypertension, chronic kidney disease, and coronary artery disease. An examination demonstrates
moderate tenderness with passive range of motion of the left hip and an inability to actively flex the left hip against gravity. What is the best next step?

1
Dynamic hip screw
2
Long cephalomedullary nail
3
Staging studies
4
Toe-touch weight-bearing activity for 6 weeks
QUESTION 13
of 100
Figures 13a and 13b are the radiographs of a 57-year-old man who is seen in the emergency department. He has been experiencing left thigh pain for 2 month. Four years ago he underwent laparoscopic nephrectomy and states that he has been disease free since the resection (although he has not seen a doctor in 2 years). The pathogenesis of osteolysis in renal cell carcinoma metastatic to bone includes secretion of parathyroid hormone-related peptide (PTHrP), transforming growth factor-B (TGF-B), and vascular endothelial growth factor (VEGF), which directly cause overexpression receptor activation of nuclear factor kB ligand (RANKL) on which cells?

1
Osteoblasts
2
Osteoclasts
3
Osteoclast precursors
4
Both osteoclast precursors and the mature osteoclast
QUESTION 14
of 100
Figures 14a through 14c are the MR images of a 72-year-old man who has had a slow-growing asymptomatic mass in his thigh for more than 5 years. Cytogenetic testing on the mass reveals a ring chromosome and MDM2 expression with no 12;16 translocation. What is the most likely diagnosis?


1
Myxoid liposarcoma
2
High-grade pleomorphic liposarcoma
3
Atypical lipomatous tumor
4
Intramuscular lipoma
QUESTION 15
of 100
Figures 15a through 15c are the radiograph and MR images of a 16-year-old girl who experienced posterior knee pain after a dance recital 3 weeks ago; the pain resolved 1 week ago with ibuprofen use. What is the most appropriate treatment for this patient?



1
Image-guided core needle biopsy
2
Clinical observation and serial radiographs
3
Tc-99 whole-body bone scan
4
CT scan with sagittal and coronal reconstructions ![img](/media/upload/b8c3119c-b909-4518-9811-90a1d9f37d6d.jpg) ![img](/media/upload/00245123-7c46-4bcb-91c4-e12869c406cd.jpg) ![img](/media/upload/bcb74a6c-dd41-426d-847c-672ab52ba168.jpg)
QUESTION 16
of 100
Figures 16a through 16c are the radiograph, MR image, and biopsy specimen of a 12-year-old boy who injured his leg during a soccer game. Assuming other staging study findings are negative, what is the Musculoskeletal Tumor Society (MSTS) stage of this lesion?


1
IA
2
IB
3
IIA
4
IIB
QUESTION 17
of 100
A 57-year-old man has a bone lesion that was identified on radiograph and MR imaging (Figures 17a and 17b) that were taken to evaluate anterior knee pain. An examination reveals a positive patellar apprehension test finding. The patient brings his imaging findings to his appointment, and you learn that an image-guided core needle biopsy was performed based upon the radiologist’s interpretation of the imaging. The core needle biopsy pathology interpretation text reads, “a low-
grade cartilage consistent with either enchondroma or low-grade chondrosarcoma. Clinical and imaging correlation is recommended.” What is the best next step?




1
Fluorescent in situ hybridization analysis of the biopsy sample for the t(9;22) translocation
2
Repeat core needle biopsy, sampling a different site within the tumor
3
Observation with serial radiographs or MR imaging
4
Intercalary resection and intramedullary fixation
QUESTION 18
of 100
What is the most likely diagnosis?
1
Fibrous dysplasia
2
Metastatic carcinoma
3
Multiple hereditary exostosis
4
Multiple myeloma
QUESTION 19
of 100
Despite adequate medical management, the patient continues to experience leg pain that interferes with even the lowest demands of daily living. You recommend prophylactic intramedullary nailing of the tibia with interlocking screws. Prior to the surgery, you should recommend
1
an echocardiogram.
2
an endocrinology consultation.
3
a serum calcium level.
4
a repeat nuclear bone scan.
QUESTION 20
of 100
The most common extraskeletal manifestation of this disease is
1
café au lait macules.
2
urinary protein elevation.
3
a primary lung mass.
4
an arrhythmia.
QUESTION 21
of 100
The underlying cause of the neoplasm is
1
ALK gene rearrangement.
2
a nongerm-cell mutation of the GNAS1 gene.
3
a germline alteration in EXT1 and EXT2.
4
an abnormality arising from the translocation t(11;14)(q13;q32).
QUESTION 22
of 100
Figures 22a and 22b are the anteroposterior knee radiograph and an axial T2-weighted MR image of an 11-year-old boy who experienced knee pain following soccer practice. What is the best approach for biopsy?

1
Lateral parapatellar
2
Medial parapatellar
3
Directly medial
4
Directly anterior
QUESTION 23
of 100
Figures 23a through 23c are the MR images of a 55-year-old woman who has experienced more than 10 years of right lower extremity pain that is radiating along the sciatic nerve distribution even though she has had multiple spine decompression procedures. She cannot sit comfortably in a chair and feels a fullness in the posterior aspect of her thigh. What is the most likely diagnosis?


1
Malignant peripheral nerve sheath tumor
2
Schwannoma
3
Myxoid liposarcoma
4
Desmoid fibromatosis
QUESTION 24
of 100
Figures 24a and 24b are the right femur radiograph and bone scan of a 71-year-old man with longstanding metastatic prostate cancer who has experienced increasing right thigh pain for 2 months. The pain is worse with activity and is alleviated with rest. He experienced similar pain in his left thigh 18 months ago and subsequently sustained a left subtrochanteric femur fracture after a low-energy twisting injury. He was successfully treated with an intramedullary nail. He had been receiving zoledronic acid for 4 years prior to the fracture. This patient’s history includes heavy steroid use. His current symptoms are most likely the result of

1
a prostaglandin-secreting prostate metastasis.
2
inhibition of osteoclastic function.
3
right L4 radiculopathy secondary to prostate metastasis.
4
direct inhibition of osteoclast prenylation. _
QUESTION 25
of 100
Denosumab, the human monoclonal antibody that specifically binds and inactivates receptor activator of nuclear factor-kB ligand (RANKL), is commonly used in the setting of metastatic disease. Its cell surface receptor is expressed by
1
mature osteoclasts only.
2
mature osteoblasts only.
3
both osteoclast precursors and mature osteoclasts.
4
both osteoblast precursors and mature osteoblasts.
QUESTION 26
of 100
Figure 26 is the posteroranterior chest radiograph of a 76-year-old man with an atraumatic gradually enlarging mass overlying his left clavicle that has been present for 6 months. There are no changes in overlying skin. His only noteworthy medical history involves facial squamous cell carcinomas that have been successfully removed surgically.

1
Ultrasound
2
MRI with and without contrast
3
Chest CT scan and whole-body bone scan
4
Positron emission tomography (PET)
5
Presurgical radiation therapy
QUESTION 27
of 100
A 63-year-old man with right hip pain was followed 8 years ago for an incidental intraosseous lesion in the right periacetabular and ischial region that was isointense with fat on all images. He was discharged from follow-up after 3 years when no change was documented. He began experiencing pain in his hip, and a bone scan showed grade 3 uptake. New MR imaging was obtained, and an axial image at the level of the hip is shown in Figure 27. A PET/CT scan shows dramatic activity in the lesion without any other area of activity.
1
Ultrasound
2
MRI with and without contrast
3
Chest CT scan and whole-body bone scan
4
Positron emission tomography (PET)
5
Presurgical radiation therapy
QUESTION 28
of 100
Figure 28 is the MR image of a 65-year-old man with an American Joint Committee on Cancer III anterior arm pleomorphic intermediate- to high-grade sarcoma. The patient is now considering treatment options. He underwent a wide excision at an outside hospital 2 years previously. The treating surgeon recommended an amputation, and the patient is now seeking a second opinion. Imaging studies reveal no other sites of disease.

1
Ultrasound
2
MRI with and without contrast
3
Chest CT scan and whole-body bone scan
4
Positron emission tomography (PET)
5
Presurgical radiation therapy
QUESTION 29
of 100
Figure 30 is the MR image of a 29-year-old man with a large and enlarging thigh mass. Needle biopsy findings are inconclusive.

1
Marginal resection
2
Transverse incisional biopsy centered over the mass
3
Incisional biopsy centered over the mass in line with the long axis of the limb
4
Sentinel node biopsy
5
Core needle biopsy ![img](/media/upload/9e228859-1343-489b-abe1-edae9caf34c8.jpg)
QUESTION 30
of 100
Figure 31 is the sagittal MR image of a 30-year-old man with a clear-cell sarcoma of the foot. There is no evidence of disease elsewhere after standard staging of a soft-tissue sarcoma.
1
Marginal resection
2
Transverse incisional biopsy centered over the mass
3
Incisional biopsy centered over the mass in line with the long axis of the limb
4
Sentinel node biopsy
5
Core needle biopsy
QUESTION 31
of 100
Figures 32a through 32d are the radiographs and MR images of a 13-year-old girl with new posterolateral knee pain following a fall. What is the best next step?




1
Percutaneous biopsy
2
Open curettage and grafting
3
Referral to a musculoskeletal oncologist
4
Observation with follow-up radiographs ![img](/media/upload/bf1b72e3-4a3a-4958-b6a7-57d32a9dd832.jpg) ![img](/media/upload/e74eb4fa-28aa-4677-9365-dd7ca7c80e9d.jpg) ![img](/media/upload/d9115559-269e-4037-a70e-65831c608062.jpg) ![img](/media/upload/932c5ec5-debb-4106-904a-1eeea3ea7d86.jpg)
QUESTION 32
of 100
Figures 33a through 33d are the radiograph, MR images, and biopsy specimen of a 66-year-old woman with a several-month history of an enlarging thigh mass after “pulling a muscle” while playing softball. Several weeks ago her physician aspirated the cyst, but the result is no change. Treatment of this lesion should include




1
embolization.
2
reaspiration and observation.
3
radiation therapy alone.
4
radiation therapy and surgery. ![img](/media/upload/2e226d6b-3b7d-47f0-9ebd-37988f4f8f21.jpg) ![img](/media/upload/02799520-1e12-43e5-a981-75c06f7142b5.jpg) ![img](/media/upload/bcc482a6-2584-4b11-8a04-be80adee0bb7.jpg) ![img](/media/upload/bcd794db-c28a-438b-beab-68545d9b2997.jpg)
QUESTION 33
of 100
A 79-year-old woman is seen for follow-up of a right arm posterior compartment high-grade soft-tissue sarcoma after undergoing wide resection of the tumor with preservation of the radial nerve
and minimal stripping of the posterior humeral periosteum. She then received 70 Gy of postsurgical radiation. Local recurrence occurred 4 years later, and she was treated with re-resection and adjuvant doxorubicin and ifosfamide chemotherapy. At that time, she learned she had osteoporosis and was treated with alendronate. She experienced an atraumatic fracture 2 years later without evidence of local recurrence. Which treatment poses highest risk for fracture in this scenario?

1
Chronic oral bisphosphonate use
2
Doxorubicin and ifosfamide chemotherapy
3
Timing and dose of radiation
4
Surgical periosteal stripping
QUESTION 34
of 100
A neoplasm that involves rearrangements of 1p13 involving the colony-stimulating factor 1 (CSF1) gene which, when expressed, causes proliferation of neoplastic cells and the recruitment of monocyte-macrophage non-neoplastic cells is
1
a tenosynovial giant-cell tumor.
2
a nodular fasciitis.
3
an infantile fibrosarcoma.
4
an inflammatory myofibroblastic tumor.
QUESTION 35
of 100
This tumor has been recently treated in phase 1 trials with molecularly targeted therapies including a conformation-specific inhibitor of CSF1 receptor (CSF1R), resulting in at least a 50% reduction of tumor volume in some patients. This type of inhibitor is further defined as
1
a tyrosine kinase inhibitor.
2
a substrate binding synthetic molecule.
3
an anti-CSF1R antibody.
4
an anti-CSF1 antibody
QUESTION 36
of 100
What is the neoplastic cell of origin for this tumor?
1
Lymphocyte
2
Monocyte
3
Macrophage
4
Mononuclear phagocyte
QUESTION 37
of 100
Figures 38a and 38b are the radiographs of a 12-year-old girl with a slowly enlarging mass on her posterior elbow. She has an unremarkable medical history. The mass is nontender, soft, and mobile with respect to the underlying bone. Her elbow motion is supple and unrestricted. What is the most likely cause of this condition?

1
Inherited abnormality of phosphate metabolism
2
Inherited abnormality of calcium metabolism
3
Renal disease with chronic renal insufficiency
4
Chronic hyperparathyroidism
QUESTION 38
of 100
Figures 39a through 39c are the radiographs and MR image of a 14-year-old boy who has intermittent knee swelling and pain exacerbated by activity. What is the most likely diagnosis?


1
Vascular malformation
2
Synovial chondromatosis
3
Diffuse pigmented villonodular synovitis (PVNS)
4
Lipoma arborescens
QUESTION 39
of 100
A 21-year-old man learned he had Ewing sarcoma of the right distal femur at age 13. He underwent treatment with neoadjuvant chemotherapy, surgical resection with distal femoral replacement, and adjuvant chemotherapy. He completed treatment at age 14, and subsequent surveillance imaging has shown no evidence of recurrence. He has noted increasing fatigue during the last 3 months, however, and bleeding when he brushes his teeth. An examination is unremarkable with the exception of bilateral pretibial bruising for which the patient does not recall trauma. Which tests will aid in diagnosis?
1
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
2
Serum protein electrophoresis
3
Complete blood count (CBC) with a peripheral smear
4
Platelet aggregation testing and bleeding time
QUESTION 40
of 100
Figures 41a through 41d are the radiograph, MR images, and biopsy specimen of a 35-year-old woman with pain and progressive paresthesias in her left arm. Staging shows no other lesions. Appropriate local control for this condition requires



1
forequarter amputation.
2
Tikhoff-Linberg limb salvage resection.
3
contaminated wide resection with a postsurgical radiotherapy boost.
4
chemotherapy and radiotherapy alone.
QUESTION 41
of 100
Figures 42a through 42d are the radiograph, CT scans, and biopsy specimen of a 38-year-old man who arrived at the emergency department with urinary retention. He has no other symptoms. What is the most appropriate treatment for this lesion?



1
Surgery alone
2
Surgery and radiation therapy
3
Surgery, radiation therapy, and chemotherapy
4
Radiation therapy alone
QUESTION 42
of 100
Which treatment regimen for Ewing sarcoma most effectively controls disease?
1
Chemotherapy alone
2
Chemotherapy plus wide surgical resection
3
Chemotherapy plus radiation therapy
4
Surgery plus radiation therapy
QUESTION 43
of 100
Figures 44a through 44c are the clinical photograph and radiographs of a 59-year-old man who has a 4-year history of metastatic renal cell carcinoma to the brain, lungs, and bones. He has been referred for a painful left proximal femur metastasis. Axial MR images are shown in Figures 44d and 44e. Presurgical embolization, en bloc resection, and proximal femur replacement are performed. The resection specimen and a postsurgical radiograph are shown in Figures 44f and 44g. Compared with intramedullary nail fixation, this treatment strategy






1
entails a higher perioperative mortality risk.
2
improves overall survival.
3
poses lower risk for local treatment failure.
4
is associated with less complete pain relief.
QUESTION 44
of 100
Figures 45a and 45b are the radiographs of a previously asymptomatic 10-year-old girl who fell off of her bike. Treatment of this lesion should consist of


1
observation.
2
MRI with and without contrast.
3
curettage and bone grafting.
4
open biopsy. ![img](/media/upload/b386cd41-9e37-4bf7-bd9e-ef5e257ba362.jpg) ![img](/media/upload/af31c767-94a6-4651-ada2-f8d8fa620ad2.jpg)
QUESTION 45
of 100
Figure 46a is the lateral radiograph of a 54-year-old man who has had a painless soft-tissue mass on his right foot that has been growing slowly for about 1 year. MR sequences are shown in Figures 46b through 46e. A biopsy is performed, and a low-power hematoxylin and eosin photomicrograph is seen in Figure 46f. The most appropriate treatment for this lesion is







1
a diet that reduces uric acid production.
2
wide local resection followed by radiotherapy.
3
marginal excision.
4
excision and radiotherapy after the mineralization matures. ![img](/media/upload/c7b719b0-ca1c-4344-aafc-b97c64cdc725.jpg) ![img](/media/upload/bf00440e-1f4e-4860-935f-740c618cda01.jpg) ![img](/media/upload/ed9f3d6b-86ac-4f45-ad57-d5924d605fe0.jpg) ![img](/media/upload/556099ee-dacb-4880-8d4f-261bf3a94e4b.jpg) ![img](/media/upload/76fef3ed-d1e1-466b-a122-93db533ef28c.jpg) ![img](/media/upload/aca8932d-1f6d-4c10-a4bb-c9ff90900db3.jpg) ![img](/media/upload/26a1ad67-4714-4474-a1df-c10b48ff774f.jpg)
QUESTION 46
of 100
Figures 47a and 47b are the radiograph and axial CT section of a 73-year-old woman with metastatic lung cancer who has a painful left periacetabular lesion. She is a high-risk surgical candidate because of a prior pneumonectomy and progressive metastatic disease of her remaining lung. Palliative radiation is recommended. Two regimens are being considered: a single fraction of 8 Gy or 15 fractions of a 30-Gy cumulative dose over 3 weeks. Compared to the multifraction regimen, the 8-Gy single fraction is associated with

1
inferior pain relief.
2
higher cost.
3
superior pain relief.
4
equivalent pain relief.
QUESTION 47
of 100
Figures 48a through 48e are the MR image, radiograph, CT scan, and biopsy specimens of a 14-year-old boy with right shoulder pain without antecedent trauma. What is the most likely diagnosis?





1
Unicameral bone cyst
2
Eosinophilic granuloma
3
Chondrosarcoma
4
Chondroblastoma
QUESTION 48
of 100
What is the likelihood of this patient’s children having a similar condition?
1
No different than the likelihood among the general population
2
25% only if her partner is similarly affected; if not, no different than the population average
3
50%
4
100%
QUESTION 49
of 100
Germline alterations associated with this condition


1
affect proteins exostosin-1 (EXT1) and exostosin-2 (EXT2).
2
encode the alpha subunit of the stimulatory G-protein-coupled receptor, Gsa.
3
cause neoplastic cells to express vimentin, CD99, and FLI-1.
4
produce the WWTR1-CAMTA1 fusion.
QUESTION 50
of 100
Based on imaging alone, what does this bone lesion most closely resemble?
1
Multiple myeloma
2
Implant-associated osteolysis
3
Metastatic renal cell carcinoma
4
Enchondroma
QUESTION 51
of 100
Figures 52a through 52c show the biopsy of this lesion. Based on the clinical history, radiograph, and biopsy, which diagnosis is most likely?



1
Enchondroma
2
High-grade osteosarcoma
3
Metastatic renal cell carcinoma
4
Dedifferentiated chondrosarcoma ![img](/media/upload/a6444fbc-651f-4b3d-b012-f08835750635.jpg) ![img](/media/upload/54242fc4-9fad-477d-89c5-a841613fdd6d.jpg) ![img](/media/upload/40457423-d365-4d76-bb93-6c76da769557.jpg)
QUESTION 52
of 100
Staging for patients with this diagnosis necessitates which study or studies?
1
CT scan of the chest and a bone scan
2
Skeletal survey
3
Bone marrow aspirate
4
Bone marrow biopsy
QUESTION 53
of 100
Which local treatment option is most appropriate?
1
Radiation and wide surgical resection
2
Extended curettage with adjuvants
3
Wide surgical resection
4
Revision knee arthroplasty
QUESTION 54
of 100
Figures 55a through 55d are the MR images, intraoperative photograph, and biopsy specimen of a 33-year-old man with progressive knee pain and recurrent effusions. What is the most likely diagnosis?



1
Lipoma arborescens
2
Synovial osteochondromatosis
3
Pigmented villonodular synovitis (PVNS)
4
Intra-articular hemangioma
QUESTION 55
of 100
A disadvantage associated with presurgical (vs postsurgical) radiation therapy for soft-tissue sarcoma is a
1
larger radiation field.
2
lack of formation of a “pseudocapsule” to facilitate resection.
3
higher local recurrence rate.
4
higher wound complication rate.
QUESTION 56
of 100
Figures 57a and 57b are the close-up femur radiographs of a 73-year-old man with nonsmall-cell carcinoma of the lung with visceral metastases. He has localized thigh pain at rest and with any
range of motion of the ipsilateral hip or knee. A bone scan shows multiple areas of increased uptake. Other femur images in 2 views show no other lesions. The medical oncologist predicts a survival of 3 months. What is the best next step?

1
Needle biopsy of the femur to confirm the diagnosis
2
Cephalomedullary femur nailing
3
Palliative radiation only
4
Curettage and cementation with plate fixation of the involved femur
QUESTION 57
of 100
Figures 58a through 58c are the radiograph, MR image, and sagittal CT scan of a 13-year-old boy with a 5-month history of a left hip injury. He has no current pain, but substantial, progressive limitations in hip flexion are present. What is the most likely diagnosis?






1
Extraskeletal osteosarcoma
2
Myositis ossificans
3
Chondrosarcoma
4
Pelvic osteosarcoma
QUESTION 58
of 100
What is the diagnosis?
1
Radiation-associated insufficiency fracture
2
Postradiation osteosarcoma
3
Postradiation sclerosis
4
Metastatic colorectal cancer
QUESTION 59
of 100
The best treatment is
1
chemotherapy and wide surgical resection.
2
bisphosphonate treatment with or without sacroplasty.
3
gabapentin or similar pharmacologic therapy.
4
radiation therapy.
QUESTION 60
of 100
The prognosis for this condition is
1
influenced by the latent time to presentation.
2
generally favorable.
3
variable, with periodic flares and remissions.
4
relatively poor.
QUESTION 61
of 100
Figures 62a and 62b are the radiographs of a 69-year-old woman who is seen for follow-up of a right arm posterior compartment high-grade soft-tissue sarcoma. She previously underwent wide resection of the tumor with preservation of the radial. She experienced an atraumatic fracture 2 years after completion of all treatment. There is no evidence of recurrence on MR imaging. The patient desires treatment because of pain and instability at the fracture site. What is the most reliable treatment option?

1
Injection of platelet-rich plasma and transcutaneous electrical stimulation
2
Debridement of the nonunion site, plate fixation of the fracture, and autologous bone grafting
3
Cemented long-stem proximal humerus replacement
4
Intramedullary humeral nail with bone morphogenetic protein-2 application
QUESTION 62
of 100
Figures 63a through 63d are the radiograph, CT scan, MR image, and biopsy specimen of a 20-year-old rower who has a several-month history of low-back pain. He has lost 10 pounds, but has no other constitutional symptoms. There is no bowel or bladder incontinence, and he does not have neurologic symptoms. Which medication can be used to treat this condition?



1
Methotrexate
2
Nonsteroidal anti-inflammatory drugs (NSAIDs)
3
Denosumab
4
Adriamycin
QUESTION 63
of 100
Which blastic metastases to bone are most common?
1
Breast and prostate carcinomas
2
Renal cell and thyroid carcinomas
3
Cervical and bladder carcinomas
4
Lung and liver carcinomas
QUESTION 64
of 100
Figures 65a and 65b are the axial and coronal MR images of a 72-year-old woman who underwent a right knee arthroplasty 14 years ago. She has been referred by her primary care provider for evaluation and management of a right medial knee mass. What is the next best step?

1
Open surgical biopsy
2
Bone scan
3
Right knee radiographs
4
Staging CT scan of chest
QUESTION 65
of 100
Figures 66a and 66b are the clinical photographs of an 86-year-old man with a high-grade undifferentiated pleomorphic sarcoma of the right thigh. He is pictured during preparations for wide surgical excision. What is a favorable prognostic factor?

1
Superficial location with ulceration
2
Appendicular, lower extremity location
3
Histological evidence of extensive necrosis
4
Local inflammatory reaction to tumor
QUESTION 66
of 100
Figures 67a and 67b are the fused positron emission tomography/CT scans of a calf lesion at groin level in a 36-year-old woman with a soft-tissue mass. Her biopsy specimen is shown in Figure 67c. Staging studies reveal no other lesions. Using the American Joint Committee on Cancer (AJCC) staging system, the stage is most likely


1
IA (G1 T2b N0 M0).
2
IIB (G1 T2b N0 M0).
3
III (G3 T2b N1 M0).
4
IV (G3 T2b N1 M1).
QUESTION 67
of 100
Figure 68a is the clinical photograph of a 59-year-old woman who has had a long-standing fungating ulcer on her left lower leg. She states that the ulcer began as a small reddened area and gradually enlarged during the last 4 years. Anteroposterior (AP) and lateral radiographs of her left leg are shown in Figures 68b and 68c. A whole-body bone scan is shown in Figure 68d. An axial T1-weighted MR image is shown in Figure 68e. A CT scan of the pelvis at the level of the groin is shown in Figure 68f. A histologic specimen is shown in Figure 68g. Based on the clinical, radiographic, and histologic information, the diagnosis is









1
poorly differentiated squamous carcinoma.
2
dermatofibrosarcoma protuberans.
3
melanoma.
4
locally advanced osteomyelitis.
QUESTION 68
of 100
Which treatment will most likely improve this patient’s condition?
1
Broad-spectrum intravenous antibiotics
2
High-dose corticosteroids
3
Resuscitation and oxygen
4
Anticoagulation with heparin
QUESTION 69
of 100
Which prophylactic measures may decrease risk for this postsurgical complication?
1
Distal femoral venting, perioperative hydration, and oxygenation
2
Presurgical antibiotics and antibiotic redosing
3
Perioperative normothermia with a forced-air warming device
4
Neuraxial or regional anesthesia
QUESTION 70
of 100
Figures 71a through 71d are the radiographs, MR images, and biopsy specimen of a 15-year-old boy with a several-month history of right hip pain with no history of injury. This condition is associated with increased activity of which gene product?



1
FGFR3
2
Ga stimulatory protein
3
COMP
4
EXT-1
QUESTION 71
of 100
Figures 72a through 72d are the radiograph, MR images, and biopsy specimen of a 42-year-old man with an insidious onset of left hip pain. Further imaging reveals no other lesions. What is the most appropriate initial treatment?



1
Bisphosphonate or denosumab and observation with cementoplasty for refractory pain
2
Chemotherapy and wide surgical resection
3
Wide surgical resection alone
4
Extended intralesional curettage and grafting
QUESTION 72
of 100
Figures 73a through 73c are the radiographs of a 68-year-old woman with a pathologic left femur fracture. A clinical examination demonstrates a large soft-tissue mass at the fracture site. CT scans of the chest, abdomen, and pelvis reveal numerous enlarged lymph nodes. Frozen section analysis at open biopsy reveals relapsed lymphoma. What is the most appropriate treatment?


1
Antegrade reconstruction nail
2
Antegrade reconstruction nail and distal femur plate fixation
3
Retrograde femoral nail
4
Retrograde femoral nail and proximal femur plate fixation
QUESTION 73
of 100
Survival estimation in guiding surgical decision-making in metastatic spine disease includes scores that include
1
visceral metastases, multiple bone metastases, and tumor types with poorer prognosis.
2
body mass index, lower hemoglobin levels, older age, and visceral metastases.
3
peripheral vascular disease, diabetes, and visceral metastases.
4
disease confined to only adjacent vertebrae.
QUESTION 74
of 100
A 52-year-old woman with a medical history that includes type 1 diabetes mellitus and rheumatoid arthritis has a painless right thigh mass that increased in size during the preceding year. Ultrasound was “consistent with lipoma,” and the patient underwent uneventful resection. Final pathology revealed high-grade undifferentiated sarcoma. Figures 75a and 75b are the clinical photograph and postresection MR image. The treatment rendered prior to referral to a sarcoma center most likely will result in increased

1
likelihood for amputation.
2
likelihood for flap coverage.
3
overall mortality.
4
need for radiation therapy.
QUESTION 75
of 100
A 16-year-old boy with a high-grade conventional osteosarcoma of the right proximal tibia has completed neoadjuvant chemotherapy. A restaging radiograph and MR image are shown in Figures 76a and 76b. Wide resection with limb salvage is planned. Which muscle will provide the primary protective margin for the tibial nerve and popliteal vessels?

1
Soleus
2
Popliteus
3
Medial gastrocnemius
4
Lateral gastrocnemius
QUESTION 76
of 100
Figures 77a and 77b are the recent knee radiographs of a 53-year-old man whose history includes tobacco use and secondary polycythemia. He is now experiencing bilateral knee pain, knee swelling, and increasing discomfort with ambulation. All efforts at nonsurgical treatment have failed. What is the most reasonable next treatment option?






1
Core biopsy
2
Knee arthroplasty with postsurgical radiation therapy
3
Knee arthroplasty
4
Debridement with intravenous antibiotics
QUESTION 77
of 100
This patient should be told that
1
he has developed a prosthetic joint infection with purulence on biopsy.
2
he has developed a metal-on-metal pseudotumor reaction.
3
the tumor has recurred with transformation to a higher grade.
4
the tumor has recurred in a similar manner.
QUESTION 78
of 100
Definitive treatment for this tumor likely will necessitate
1
irrigation and debridement with single vs 2-stage prosthetic exchange and i.v. antibiotics.
2
chemotherapy and radiotherapy.
3
hemipelvectomy.
4
revision to a metal-on-highly crosslinked polyethylene construct.
QUESTION 79
of 100
Figure 80a is the radiograph of a 5-year-old girl who has experienced 8 weeks of shoulder pain that is mostly relieved with nonsteroidal anti-inflammatory drugs. Her MR images are shown in Figures 80b through 80f. Histology is shown in Figures 80g through 80i. The most likely diagnosis is









1
aneurysmal bone cyst.
2
Ewing sarcoma.
3
giant-cell tumor.
4
osteoblastoma.
QUESTION 80
of 100
A 32-year-old man underwent distal femur resection and endoprosthetic replacement at age 15 for high-grade conventional osteosarcoma. He was treated with neoadjuvant and adjuvant cisplatin, doxorubicin, and methotrexate. There has been no evidence of recurrent osteosarcoma, and he has been otherwise active and well. He is scheduled to undergo exchange of the polyethylene liner and bushings in his prosthesis because of wear that has caused recurrent effusions and a sensation of instability. Which study is most important to assess his perioperative medical risk?
1
Pulmonary function tests
2
24-hour creatinine clearance
3
Hepatic transaminases
4
Echocardiogram
QUESTION 81
of 100
Figures 82a and 82b are the histopathology of an otherwise healthy 50-year-old man who had a growing mass marginally excised from his shoulder with local anesthetic and no presurgical imaging. The mass includes the deep fascia and muscle and is larger than 5 cm. Postsurgical MR imaging was obtained, and T2 and T1+C images are shown in Figures 82c and 82d. What is the best local treatment option?









1
Observation
2
Radiation only
3
Chemotherapy only
4
Reexcision and radiation
QUESTION 82
of 100
The optimal initial treatment of this pathologic fracture is
1
spanning external fixation with continuation of neoadjuvant chemotherapy.
2
above-knee amputation with postsurgical adjuvant chemotherapy determined by the histologic findings from the specimen.
3
cast immobilization of the fracture with continuation of neoadjuvant chemotherapy.
4
immediate limb-sparing resection and endoprosthetic reconstruction with adjuvant chemotherapy determined by histologic findings from the specimen.
QUESTION 83
of 100
A series of axial T1-weighted MR images is shown in Figure 84. The postfracture MRI reveals tissue contamination by fracture hematoma. Based upon the MRI findings, which aspect of limb-sparing resection and reconstruction will be most challenging?
1
Preserving sciatic, tibial, and common peroneal nerve function
2
Obtaining adequate fixation of the distal femur component
3
Soft-tissue coverage of the endoprosthesis
4
En bloc extra-articular resection of the knee joint
QUESTION 84
of 100
The patient ultimately undergoes rotationplasty. What is the most likely etiology of early limb loss after rotationplasty for sarcoma?
1
Vascular compromise
2
Wound infection
3
Local recurrence
4
Fixation failure
QUESTION 85
of 100
When compared to patients who undergo endoprosthetic reconstruction, patients who undergo rotationplasty are more likely to
1
have difficulty obtaining gainful employment.
2
participate in high-impact exercise and sports.
3
require revision surgery at some point in their lifetime.
4
experience problems with psychosocial adjustment.
QUESTION 86
of 100
Figures 87a through 87d are radiographs of both knees of a 75-year-old man who is experiencing bilateral knee pain and stiffness. The gross appearance of the lesions in the suprapatellar pouch is seen in Figure 87e. The histologic finding that would best determine this process is osteoarthritic in nature and not neoplastic is the absence of




1
chondrocyte cloning.
2
synovial metaplasia.
3
cords of eosinophilic cells in myxoid stroma.
4
multinucleated giant cells.
QUESTION 87
of 100
Figures 88a through 88d are the radiographs and biopsy specimens of a 65-year-old woman with a history of breast cancer who has been experiencing 6 weeks of increasing left hip pain. She denies any injury. What is the most likely diagnosis?





1
Metastatic breast cancer
2
Myeloma
3
Fibrous dysplasia
4
Osteosarcoma
QUESTION 88
of 100
Figures 89a through 89g are the radiographs, MR images, and biopsy specimen of a 32-year-old man who has chronic left thigh and knee pain and recent knee swelling with no specific trauma or injury. The pain is exacerbated with activity but is also present at rest and at night. What is the most appropriate treatment?











1
Surgical wide resection and endoprosthetic reconstruction
2
Chemotherapy followed by wide surgical resection and reconstruction
3
Aggressive curettage with allograft placement
4
Aggressive debridement, antibiotic bead placement, and intravenous (IV) antibiotics
QUESTION 89
of 100
What is the most likely diagnosis?
1
Desmoid tumor
2
High-grade pleomorphic sarcoma
3
Synovial sarcoma
4
Extraskeletal Ewing sarcoma
QUESTION 90
of 100
Immunohistochemical analysis of this lesion will be characterized by expression of
1
CD99.
2
epithelial membrane antigen.
3
estrogen receptor.
4
S100.
QUESTION 91
of 100
Figures 92a and 92b are the reconstruction radiographs of a 16-year-old boy with a high-grade conventional osteosarcoma of his right proximal tibia. He has completed neoadjuvant
chemotherapy. Wide resection, endoprosthetic proximal tibia replacement, a medial gastrocnemius flap, and a split-thickness skin graft were performed. The preferred postsurgical knee rehabilitation regimen is

1
therapist-directed passive and active assisted range of motion exercises from 0 to 90 degrees.
2
immobilization in full extension for 6 weeks with therapist-directed gait training and isometric exercises.
3
use of an immediate continuous passive motion machine set at 0 to 90 degrees followed by outpatient physical therapy.
4
use of a knee immobilizer for 2 weeks followed by home use of a continuous passive motion machine (set at 0 to 90 degrees).
QUESTION 92
of 100
Figures 93a through 93f are radiographs, selected MR imaging sequences, and biopsy specimens of the left humerus of a 76-year-old woman who has experienced long-term left arm pain. She has received previous treatment for osteoarthritis of her left shoulder with nonsteroidal anti-inflammatory drugs and an intra-articular corticosteroid injection for her rotator cuff arthropathy. Recent staging studies show no evidence of metastatic disease. What is the most appropriate next treatment?





1
Neoadjuvant chemotherapy followed by wide resection
2
Presurgical radiation therapy followed by wide resection
3
Wide resection and endoprosthetic reconstruction
4
Systemic chemotherapy and local radiation
QUESTION 93
of 100
Figures 94a through 94f are the radiographs and MR images of a 16-year-old boy who experiences left ankle pain with activity. What is the most likely diagnosis?





1
Aneurysmal bone cyst (ABC)
2
Fibrous dysplasia
3
Simple bone cyst
4
Ewing sarcoma
QUESTION 94
of 100
A patient undergoes excision of a presumed lipoma of the superficial thigh. Final pathology reveals synovial sarcoma without reference to the margins. What is the recommendation for definitive treatment?
1
Observation
2
External beam radiation therapy alone
3
Wide resection of the tumor bed and radiation therapy
4
Radiation therapy and chemotherapy
QUESTION 95
of 100
Figures 96a and 96b are the MRI sections of the symptomatic left knee of a 28-year-old man with left anterior knee pain 18 months after undergoing an allogenic bone marrow transplant for acute myelogenous leukemia. His intraoperative fluoroscopy images are shown in Figures 96c and 96d. What is most critical when obtaining a diagnosis for this patient?



1
Sampling from the periphery of the lesion
2
Immediate formalin fixation
3
Sending unfixed fresh tissue
4
Fixation with ribonucleic acid (RNA) stabilization solution
QUESTION 96
of 100
Figures 97a through 97d are the radiographs and MR images of a 21-year-old man with symptoms of a left medial thigh mass. Upon examination, you palpate a firm, fixed, deep, nontender mass of the medial proximal left thigh. No other masses are found during the examination. The patient fears metastatic disease. What is the risk for malignant transformation throughout this patient’s lifetime?



1
0%
2
Less than 1%
3
Less than 15%
4
More than 15%
QUESTION 97
of 100
Figures 98a and 98b are the radiograph and biopsy specimen of a 20-year-old man who is being evaluated for the first time for foot pain. Treatment should include


1
first-ray amputation.
2
extended curettage and grafting or cementation.
3
extended curettage, radiation, and chemotherapy.
4
wide resection and chemotherapy.
QUESTION 98
of 100
What are the most common primary sites for carcinomas metastatic to bone?
1
Lung, breast, prostate, kidney, and thyroid
2
Lung, cervical, prostate, breast, and kidney
3
Breast, lung, prostate, bladder, and adrenal
4
Prostate, lung, breast, bladder, and cervical
QUESTION 99
of 100
Figures 100a through 100c are the select T1 and T2 axial and T2 sagittal MR images of a 26-year-old-woman who has had intermittent left thigh pain for 6 months that is exacerbated by activity. Left femur radiographs are unremarkable. Initial treatment should include


1
observation.
2
sclerotherapy.
3
open biopsy.
4
wide resection.
Dr. Mohammed Hutaif
Written & Medically Reviewed by
Dr. Mohammed Hutaif
Consultant Orthopedic & Spine Surgeon
Keywords
Prof. Mohammed Hutaif Orthopedic Surgeon Yemen abstract at pubmed pmid view abstract pubmed pmid view review pubmed pmid
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