ABOS Orthopaedic Surgery Part II common mistakes
ABOS Orthopaedic Surgery Part II · Understand the traps and how to avoid them.
Committing to a surgical plan for an adult hip or knee complaint before confirming the diagnosis with appropriate imaging and labs, e.g., recommending arthroplasty for a painful hip in a patient whose radiographs show only mild changes and whose pain is actually referred from the lumbar spine.
Candidates pattern-match the most familiar reconstructive diagnosis ('hip OA', 'knee OA') to a presentation and stop gathering data, because the reconstructive section rewards decisive operative answers and the clock pressures quick closure.
What to do instead
For every reconstructive stem, explicitly list the differential and the discriminating test (plain films plus ESR/CRP and aspiration for suspected periprosthetic infection, MRI for avascular necrosis or soft-tissue pathology, spinal exam for referred pain) before selecting an operation; if the stem lacks the data, choose the next diagnostic step rather than the procedure.
Choosing the wrong antibiotic or duration for periprosthetic joint infection by defaulting to 'IV vancomycin for six weeks' regardless of organism, culture timing, or whether DAIR versus two-stage exchange is indicated.
Basic science and reconstruction content overlap here, and candidates memorize one protocol instead of reasoning from organism identity, biofilm maturity, symptom duration, and implant stability.
What to do instead
Anchor on a decision framework: symptom duration and implant stability determine DAIR versus exchange; organism and sensitivity determine agent; chronicity determines duration. Practice stems that vary one variable at a time so the framework, not a memorized regimen, drives the answer.
Missing the ankle or hindfoot component of a foot and ankle problem, e.g., treating a chronic lateral ankle sprain as an isolated ligament issue without assessing for peroneal tendon pathology, osteochondral lesion, or hindfoot malalignment on the stem's described exam.
Candidates focus on the named structure in the question and under-weight the biomechanical chain, and foot and ankle anatomy is tested less frequently than knee and shoulder, so recall is thinner.
What to do instead
For every foot and ankle stem, run a fixed checklist: ligaments, tendons, cartilage, alignment, and neurovascular status. Read the exam findings for clues to a second lesion before selecting treatment.
Mishandling the vascular status or zone of injury in a hand or digit replantation/amputation stem, e.g., selecting replantation for a severely crushed, avulsed, or multiply injured digit without addressing the warm ischemia time and expected functional outcome.
Candidates equate 'amputated part' with 'replant it,' and microvascular indications are memorized as absolutes rather than weighed against mechanism, ischemia time, and patient factors.
What to do instead
For replantation stems, systematically state mechanism, ischemia time, level, and patient factors, then justify the choice against published indications and contraindications. Practice contrasting sharp versus avulsion injuries so the reasoning generalizes.
Failing to stage a musculoskeletal tumor before biopsy, e.g., proceeding to 'incisional biopsy' or 'excisional biopsy' of a bone lesion without ordering staging imaging or without considering whether the lesion is a candidate for neoadjuvant therapy.
Candidates treat biopsy as a simple diagnostic step and under-recall that biopsy route and timing are dictated by the presumed diagnosis and planned resection.
What to do instead
For every oncology stem, recite the sequence: imaging and staging first, then biopsy planned along the definitive resection corridor by the treating surgeon. Eliminate any answer that biopsied before staging or that used a biopsy tract inconsistent with later resection.
Applying adult fracture principles to pediatric bone, e.g., recommending anatomic reduction and internal fixation for a displaced pediatric forearm or femur fracture that is better treated closed, or ignoring physeal Salter-Harris classification when choosing treatment.
Candidates carry adult trauma habits into pediatric stems and under-recall remodeling potential, growth plate behavior, and the different tolerance for displacement by age and location.
What to do instead
For pediatric trauma stems, first classify the injury (including Salter-Harris type), then state the child's age and remaining growth, then choose the least invasive treatment consistent with acceptable alignment. Practice paired adult/pediatric stems of the same fracture to highlight the contrast.
Selecting the wrong shoulder or elbow procedure for the diagnosis, e.g., recommending reverse total shoulder for an intact-rotator-cuff arthritis or recommending anatomic replacement when cuff deficiency and pseudoparalysis are described.
Candidates memorize procedures by name without linking them to the specific prerequisite (cuff integrity, bone stock, glenoid version, age, function) that makes each implant appropriate.
What to do instead
For each shoulder/elbow stem, write the prerequisite the implant depends on before choosing it: cuff status for reverse versus anatomic, glenoid bone for augmented components, and functional demand for hemiarthroplasty. Answer only after matching the stem's described prerequisites to the implant.
Ignoring red flags or neurologic progression in a spine stem, e.g., treating a disc herniation or stenosis nonoperatively when the stem describes progressive motor deficit, cauda equina symptoms, or bowel/bladder change.
Candidates focus on the degenerative diagnosis and default to conservative care, missing that the stem's exam findings are the actual decision driver.
What to do instead
For every spine stem, scan first for red flags (progressive deficit, saddle anesthesia, bowel/bladder change, fever, trauma, cancer history). If present, the answer is urgent evaluation or decompression, not observation. Build a red-flag checklist and apply it before reading the treatment options.
Recommending surgery for a sports medicine condition that should be treated nonoperatively first, e.g., proceeding to ACL reconstruction or rotator cuff repair without documenting a trial of rehabilitation, or missing that the stem describes an in-season athlete or a partial tear with good function.
Candidates associate named sports injuries with their definitive operation and skip the nonoperative pathway and return-to-play reasoning the exam tests.
What to do instead
For sports stems, state the nonoperative options and their expected course before considering surgery, and identify the specific finding that would make surgery indicated (complete tear, instability, failed rehab). Choose nonoperative care when the stem lacks that finding.
Committing to definitive fixation of a polytrauma or damage-control patient before resuscitation and physiologic stabilization, e.g., choosing immediate intramedullary nailing for a femur fracture in a hemodynamically unstable patient with a borderline physiologic profile.
Candidates equate femur fracture with 'nail it now' and under-recall damage-control orthopaedics and the concept of the borderline patient.
What to do instead
For trauma stems, first assess physiology (hemodynamics, lactate/base deficit, associated injuries, temperature), then choose timing: early total care versus damage control with temporary stabilization. Practice stems that vary only the physiologic status so timing, not the fracture, drives the answer.
Answering professionalism or practice-based stems with the clinically 'best' outcome rather than the ethically or system-correct action, e.g., choosing to operate on a patient whose consent process or conflict-of-interest disclosure is incomplete because the surgery is indicated.
Candidates treat professionalism items as clinical vignettes and default to the treatment answer, under-weighting informed consent, disclosure, documentation, and systems-based practice.
What to do instead
For professionalism stems, identify the ethical or systems principle at stake (consent, disclosure, error reporting, resource stewardship) before reading the options, and eliminate any answer that bypasses that principle even if clinically attractive.