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Part of the Master Guide

Orthopedic Prometric MCQs - Chapter 3 Part 1

Orthopedic Prometric MCQs - Chapter 3 Part 21

25 Apr 2026 37 min read 2 Views
Orthopedic Prometric MCQs - Chapter 3 Part 21

Welcome to Chapter 3 Part 21 of our comprehensive Orthopedic Prometric Exam Simulator. This interactive test features 20 high-yield multiple-choice questions designed to help you prepare for the Saudi Prometric (SCFHS), DHA, HAAD, SLE, and OMSB orthopedic surgery exams.

Use the Study Mode to view detailed explanations instantly, or switch to Exam Mode to test your speed and accuracy under simulated testing conditions.

Prometric Exam Simulator


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Question 1

A 48-year-old man presents with a closed head injury requiring intubation and isolated bilateral facet dislocation. The next appropriate step is:





Explanation

The patient has a severe closed head injury and is unable to tolerate a close reduction maneuvers with Gardner-Wells tongs. Emergent magnetic resonance imaging should be obtained to evaluate the potential presence of a disk herniation at the dislocation. Should a disk herniation be present, anterior approach and diskectomy should be performed prior to reduction maneuvers.

Question 2

A major indication for surgical decompression of an L1 burst fracture is:





Explanation

Generalized treatment algorithms for burst fractures involving upper lumbar spine have relative indications for surgery that include 50% loss of height, 25% of kyphosis, and 50% canal compromise. Absolute indications for decompression include neurological deficits including a potential conus injury. Post-void residual of > 450 mL is suggestive of sacral root injury at the level of conus. Bradford suggests that anterior decompression of this injury has favorable outcome with frequent resolution or improvement of symptoms.

Question 3

An injury associated with a type 1 fracture of the odontoid is:





Explanation

Type 1 fractures are a rare entity. They are frequently treated with immobilization with a hard collar if isolated. There have been numerous reports in the literature of a type 1 fracture of the odontoid being associated with an atlanto-occipital dislocation, and this injury must be suspected. The potential for missing atlanto-occipital dislocation may lead to a fatal outcome.

Question 4

A type 3 traumatic spondylolisthesis of the axis, as classified by Levine and Edwards, is best treated with which of the following:





Explanation

The Levine classification of traumatic spondylolisthesis or Hangman fractures involving C 2 in the type 3 injury has a combined bilateral facet dislocation at C 2-C 3 as well as the traumatic spondylolisthesis of the axis. Closed reduction could not be performed secondary to the traumatic spondylolisthesis at the C 2 isthmus.

Question 5

A type 3 Anderson and Montensano fracture of the occipitocondyle is best described as:




Explanation

) An occipital condyle-axial dislocation A type 3 fracture of the occipital condyle is an avulsion fracture from traction of the alar ligament. This usually results from a rotation, lateral bending moment, or combined injury. If the injury is severe, both alar ligaments may be involved and occipitocervical instability may occur. Treatment for a type 3 injury would include a rigid or collar orthosis for 8 to 12 weeks, possible halo mobilization, and, if ligamentous instability has occurred, posterior cervical fusion.

Question 6

An 8-year-old boy has had torticollis for approximately 5 weeks. He has undergone immobilization with a cervical collar without success. The patient has not undergone traction and now has atlantoaxial rotatory subluxation. The best treatment for this patient should be:





Explanation

The treatment protocol for atlantoaxial rotatory subluxation is based on the onset and length of time of deformity. Soft collar treatment for this deformity is best if treated within 1 week of onset. For deformities lasting up to 1 month, in-house hospitalization with traction is warranted. However, the success of this treatment declines markedly after 1 month, at which time posterior C 1-C 2 fusion is warranted.

Question 7

During posterior cervical plating, several techniques can be employed. The recommended lateral mass screw position is:





Explanation

Surgical technique for cervical lateral mass fixation as described by An and colleagues is 30° of Lateral angulation and 15° of angulation cephalad to the facet joint.. This has been described as the safest recommended technique for lateral mass screw placement.

Question 8

A 35-year-old man presents 3 years after a motor vehicular trauma. It is now 3 years following operative stabilization of the spine at C 7. He complained of mild weakness in his right upper extremity at the biceps level and has corresponding parasthesias in the right thumb. The next step in the evaluation of this patient is:





Explanation

The patient is a 35-year old man has been stable since his injury. The most important evaluation for this individual would be magnetic resonance imaging to rule out potential cervical cord syrinx that has occurred given new onset weakness and sensory changes proximal to his injury.

Question 9

A 55-year-old man with ankylosing spondylitis has a minor fall and is suffering with neck pain. Anteroposterior and lateral radiographs are negative with no evidence of fracture. He has no neurologic loss and has normal strength with the exception of severe restricted motion. Twelve hours following injury, he is found to have bilateral bicep and tricep weakness. The appropriate management and the work up of this individual is:





Explanation

The patient is within 12 hours of having normal cervical spine films. Approximately one third of patients with ankylosing spondylitis incur occult injuries to the cervical spine that are not identified by plain films prior to kyphotic progression. A bone scan would delineate a fracture after 72 hours. However, the presence of progressive weakness should raise suspicion of a potential epidural hematoma. For this reason, magnetic resonance imaging would better delineate epidural hematoma.

Question 10

A 2-year-old boy with a congenital heart anomaly has a 40° thoracolumbar curvature. Standing posteroanterior and lateral radiographs reveal vertebral anomalies indicative of congenital scoliosis. Which of the following patterns of congenital scoliosis has the worst prognosis for progression?





Explanation

Congenital spinal deformity is caused by structural abnormalities in the vertebrae that can result in asymmetric growth, such as scoliosis or kyphosis. It has been classified in 2 types. Type I involves defects of formation and type II involves defects of segmentation. However, in many instances, deformities can be a mixture of both. Defects of formation include segmented or unsegmented hemivertebrae and wedge vertebrae. Defects of segmentation include block vertebrae, unilateral bars, or unilateral bars with hemivertebrae. The potential for progression is dependent on the growth potential of the anomalies. The presence of healthy-appearing disks between the hemivertebra and its normal counterparts indicates good growth potential and risk for progression. A unilateral bar on the opposite side of a segmented hemivertebra acts as a tether on the concave side of the curve and has the most likelihood for progression. Children with congenital scoliosis also have a significant incidence of associated anomalies, both intraspinal and other organ systems. About 30% have a spinal dysraphism such as diastematomyelia, meningocele or lipoma. Other associated anomalies include Klippel-Feil syndrome (25%), genitourinary tract abnormalities (30%), cardiac defects (12%), and Sprengelâ s deformity (10%).

Question 11

Six months ago, an 11-year-old premenarchal girl with adolescent idiopathic scoliosis had a right thoracic curve from T5 to T12 measuring 20°. Her physical examination was normal. She returned to the office and a standing posteroanterior radiograph demonstrates a 28° right thoracic curve from T5 to T12; she is Risser stage 0. A lateral radiograph shows a thoracic kyphosis of 10°. At this time, you recommend:





Explanation

In skeletally immature patients with adolescent idiopathic scoliosis and curves approaching 30° with documented progression, bracing may be effective at preventing further progression of the curve. Risk of progression in adolescent idiopathic scoliosis is related to curve magnitude and remaining growth potential. The risk of further progression in this patient is 68%, and bracing is indicated. Electrical stimulation and physical therapy have not been shown to affect the natural history of scoliosis. Surgery may be indicated in patients with more severe curves. In the sagittal plane, hypokyphosis is usually present in adolescent idiopathic scoliosis.

Question 12

A 15-year-old boy with adolescent idiopathic scoliosis has a right thoracic curve from T5 to T11 measuring 45° and a left thoracolumbar curve from L1 to L4 measuring 32°. He is Risser stage 2 and has a hypokyphotic thoracic spine. Bending films demonstrate moderate flexibility in the lumbar curve. He was prescribed a thoracolumbosacral orthosis since age 14, but his scoliosis has progressed. His physical exam reveals a prominent right rib hump and mild right shoulder elevation. His head is centered above his pelvis. His neurological examination is normal. You recommend:





Explanation

This patient has a right thoracic curve with a compensatory left lumbar curve pattern of adolescent idiopathic scoliosis. There has been documented progression into the surgical range despite bracing, and he still has some growth remaining. Surgical intervention is indicated. This curve pattern (King II, Lenke D) can be approached posteriorly with thoracic fusion alone to the neutral and stable vertebra and instrumentation to obtain and maintain correction. The unfused lumbar curve will spontaneously correct to balance the fused thoracic curve. Care must be taken to avoid fusion into the lower lumbar spine and preserve motion segments.

Question 13

A 1-year-old male infant is referred by his pediatrician for evaluation of possible scoliosis. Otherwise, he is healthy. His physical exam reveals normal neurologic function, plagiocephaly and a flexible thoracic curve. Radiographs reveal a left thoracic curve with a C obb angle of 36° and no vertebral anomalies. The apical ribs are in Phase I, and the rib-vertebral angle difference is 18°. At this time, management should include:





Explanation

Infantile idiopathic scoliosis is rare in this country and not well understood. It is more common in Europe, occurs more frequently in boys, and left thoracic curves predominate. Plagiocephaly, or a flattening of the posterior skull on the convex side of the spinal curvature, is frequently found in these patients, suggesting a postural cause of both. There are 2 types of infantile idiopathic scoliosis: resolving and progressive. Distinguishing between the 2 types has obvious consequences regarding prognosis and treatment. Prior to Mehtas work, identification of the type of infantile idiopathic scoliosis was difficult, because it was not related to curve magnitude, age at onset, rate of progression, or degree of rotation. Mehta showed that the 2 groups were distinguishable by the relationship of the ribs to the apical vertebral body on the posteroanterior radiograph. Ribs that do not overlap the vertebral body are in Phase I, and ribs that do overlap the vertebral body on the convexity of the curve are in Phase II. The rib- vertebral angle is constructed by the intersection of a line perpendicular to the apical vertebral endplate with a line drawn along the long axis of the corresponding rib. The rib-vertebral angle (RVA) difference is the difference of the RVA of the concave and convex ribs of the apical vertebra. In scoliosis, the convex ribs form a more acute angle than the concave ribs, so this difference is >0. Mehta concluded that curves in which the ribs are in Phase I and the RVA difference is < 20° have a better prognosis (resolving type) and require just observation. Treatment for progressive curves includes serial body casts, orthoses, or surgery for severe curves. Various surgical approaches include posterior spinal fusion, instrumentation without fusion to allow spinal growth, or anterior convex hemiepiphysiodesis with posterior hemiarthrodesis.

Question 14

The most appropriate indication, after scoliosis curve progression, for a posterior spinal fusion with segmental instrumentation to the pelvis in a severely involved spastic quadriplegic child with cerebral palsy is:





Explanation

Patients with a spastic quadriplegic pattern of cerebral palsy have higher than 25% incidence of scoliosis. This neuromuscular scoliosis differs from that of idiopathic scoliosis in that it is usually a long C -shaped thoracolumbar curve that may involve the pelvis. Frequently, posterior spinal fusion from T1 to the sacrum is required with rigid segmental instrumentation with stabilization to the pelvis (a unit rod). Indications for fusion in these patients include curve progression and loss of function. This can include loss of sitting ability, poor pulmonary function due to poor pulmonary toiletting, and recurrent infection such as decubitus ulcers. These children are most often non-ambulators and are dependent on wheelchair sitting supports for postural control.

Question 15

A 12-year-old boy with Duchenne muscular dystrophy has a 25° curve in the thoracolumbar spine with moderate pelvic obliquity. His pulmonary function tests are 70% of predicted function. He uses a wheelchair for ambulation, but is able to stand for transfers. Management should include:





Explanation

Scoliosis in patients with Duchenne muscular dystrophy typically becomes progressive when ambulation ceases. For curves >20°, posterior spinal fusion with instrumentation is indicated. Fixation to the pelvis is necessary to improve sitting if pelvic obliquity is present. Severe, collapsing scoliosis can result without operative intervention and can result in diminishing pulmonary function and loss of sitting ability. Surgery can be safely undertaken if pulmonary function remains >40% of predicted function, but anterior surgery causes morbidity on an already compromised pulmonary system. Nonoperative treatment such as orthoses or trunk supports offer little in the way of controlling progression and are generally not well tolerated by these patients.

Question 16

A 6-year-old girl with a lumbar level paraplegia secondary to myelomenigocele presents with a rapidly progressive thoracolumbar scoliosis. The most accurate test to determine the etiology of the spinal deformity is:





Explanation

Children with myelodysplasia are at risk for scoliosis, but a rapidly progressive curve should alert the physician to aggressively investigate the etiology. Causes include: Tethered cord Syringomyelia Shunt failure Progressive hydromyelia Arnold-C hiari malformation All of these conditions can be readily diagnosed by a magnetic resonance imaging scan of the brain and spinal cord. Radiologic imaging such as radiographs, computerized tomography scans, or bone scans for bony lesions is rarely helpful. Cerebrospinal fluid analysis is unlikely to reveal an answer regarding scoliosis. In the presence of a working ventriculoperitoneal shunt, the most likely etiology in this child is a tethered cord. Increased lumbar lordosis, back pain, or an increase in lower root level spasticity should alert the clinician to the possible presence of a tethered cord.

Question 17

An 11-year-old girl presents with low back pain for 2 monthsâ duration. She is an elite gymnast and has missed 2 meets because of the pain. Physical exam reveals pain with hyperextension of the lumbar spine. Her neurological exam is normal. Radiographs of the lumbar spine, including oblique views, are normal. The recommendation is:





Explanation

Athletes involved in sports requiring repetitive hyperextension or rotation of the lumbar spine are susceptible to stress fractures of the pars interarticularis or spondylolysis. Two months of insidious back pain warrants a diagnostic work up, and radiographs may be nondiagnostic in the early period. A bone scan with single photon emission computed tomography will confirm the diagnosis in a patient with a history and physical findings of spondylolysis. Magnetic resonance imaging is rarely helpful in the diagnosis of this bony lesion, but it may be the next diagnostic modality if the bone scan was negative and the pain continued. Rest with immobilization is usually the first line of treatment for spondylolysis. In cases of refractory pain, controversy exists in the surgical management of this condition. Some authors favor repair of the lytic defect and others prefer a posterolateral fusion.

Question 18

An 8-year-old girl presents with back pain and an abnormal gait. She walks with externally rotated feet and limited hip flexion. She has a palpable step-off at the lumbosacral junction and hamstring tightness. Radiographs of the lumbosacral spine demonstrate a dysplastic spondylolisthesis with a slip angle of 55° and slippage of 60% of L5 on S1. The recommended course of treatment is:





Explanation

Spondylolisthesis is the forward slipping of 1 vertebra on the next caudal vertebra. Spondylolisthesis in children can be classified into 2 types: isthmic and dysplastic. Isthmic spondylolisthesis is an entity in which there is a lesion in the pars interarticularis that permits forward slippage; the articular facets are normal. Dysplastic or congenital spondylolisthesis implies that there is a congenital deficiency in the L5-S1 facet that allows forward slipping. There is no defect or elongation in the pars. Growing children, particularly females, with dysplastic spondylolisthesis are at risk for further progression. This patients abnormal gait is due to hamstring tightness, probably due to the lumbosacral instability and nerve root irritation. With a grade III slip, back pain, and an abnormal gait, this patient is a candidate for an in situ posterolateral spinal fusion. Use of instrumentation is controversial, especially because the long-term results of in situ noninstrumented fusions are superior.

Question 19

The following can be found in the examination and radiographs of a child with Scheuermann disease:





Explanation

Scheuermann disease is increased thoracic kyphosis, usually rigid, occurring in adolescent males. The etiology is unknown, but has included theories dealing with avascular necrosis of the ring apophysis, growth plate abnormalities, biologic and mechanical causes. The classic definition is increased thoracic kyphosis (>45°) with 5° or more of anterior wedging at 3 sequential vertebrae. Other radiographic abnormalities include: Endplate irregularities Spondylolysis C ompensatory lumbar hyperlordosis Schmorlâ s nodes Hamstring tightness and rigid thoracic kyphosis is noted on physical examination, and neurological function is normal. Treatment consists of bracing in skeletally immature patients with a thoracolumbosacral orthosis, but many adolescent male patients are noncompliant with bracing. In the skeletally mature patient with pain and severe deformity (>65° of kyphosis), posterior spinal fusion with instrumentation is indicated. Occasionally, anterior diskectomy and interbody fusion with posterior fusion and instrumentation are required for severe deformity correction. Postural kyphosis is also common in adolescent males, but the vertebral changes are not present, and the deformities are usually more supple. Treatment is hyperextension exercises.

Question 20

The natural history of which of the following spinal deformities in children carries with it the highest risk of paraplegia?





Explanation

Congenital kyphosis, if left alone, is the most likely cause of paraplegia of all noninfectious spinal deformities. Defects of formation are more progressive than defects of segmentation, and paraplegia is common with defects that have an apex at T4-T9, the watershed area of spinal cord blood flow. Treatment is usually surgical. There is no evidence of successful nonoperative treatment for congenital kyphosis. An early, limited posterior fusion, coupled with anterior growth, may result in a slow correction of the kyphosis. For kyphosis >55° in children older than 5 years of age, anterior and posterior spinal fusions are necessary. The tethering structures anteriorly must be released (anterior longitudinal ligament, annulus fibrosus) and distraction anteriorly is maintained by autogenous strut grafts. Posteriorly, compression instrumentation is required with fusion. If neurological compromise exists preoperatively, magnetic resonance imaging is necessary to delineate the area of compression so that an anterior cord decompression may be performed successfully.

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Dr. Mohammed Hutaif
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