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Iraqi Board Orthopedic Surgery study materials
Iraqi Board Orthopedic Surgery study resources

Iraqi Board Orthopedic Surgery practice questions

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Question 1Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

During an anterior approach to the cervical spine, the surgeon must be aware that the recurrent laryngeal nerve on the right side branches from the vagus and loops around which structure before ascending toward the larynx?

  1. The subclavian artery Correct answer.
  2. The aortic arch
  3. The thyrocervical trunk
  4. The common carotid artery

Explanation

The right recurrent laryngeal nerve branches from the vagus and hooks around the right subclavian artery before ascending in the tracheoesophageal groove. The left one loops around the aortic arch distal to the ligamentum arteriosum, which is why it has a longer course and is more often injured. This asymmetry explains why a right-sided approach carries a different nerve-injury risk profile.

Question 2Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

A 24-year-old sustains a fracture through the scaphoid waist. Which vascular pattern best explains the high risk of avascular necrosis of the proximal pole?

  1. Direct supply from the anterior interosseous artery to the proximal pole
  2. Retrograde blood flow entering from the distal pole toward the proximal pole Correct answer.
  3. Dual supply from the radial and ulnar arteries equally
  4. Centrifugal flow from the intraosseous medullary system

Explanation

The scaphoid is supplied mainly by dorsal branches of the radial artery that enter distally and flow proximally in a retrograde fashion. A waist fracture interrupts this intraosseous supply and places the proximal pole at risk of avascular necrosis. This is why proximal-pole fractures carry the greatest risk.

Question 3Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

Which structure passes through the lesser sciatic foramen?

  1. The pudendal nerve Correct answer.
  2. The piriformis muscle
  3. The obturator internus tendon
  4. The superior gluteal nerve

Explanation

The pudendal nerve exits the pelvis through the greater sciatic foramen, crosses the ischial spine, and re-enters through the lesser sciatic foramen to reach the perineum. The obturator internus tendon also passes through the lesser foramen but the nerve is the classic answer tied to this foramen in surgical anatomy. Knowing this route explains pudendal block and entrapment syndromes.

Question 4Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

Which biomechanical property of bone describes its ability to deform plastically before fracture, allowing energy absorption?

  1. Stiffness
  2. Ductility Correct answer.
  3. Hardness
  4. Anisotropy

Explanation

Ductility is the capacity of a material to undergo plastic deformation before failure, which corresponds to the post-yield region of a stress-strain curve. Bone with greater ductility absorbs more energy and is less brittle. Stiffness, by contrast, describes the slope of the elastic region.

Question 5Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

A patient develops a wound infection after open reduction. Which organism is the most common cause of acute postoperative surgical site infection in orthopedic surgery?

  1. Mycobacterium tuberculosis
  2. Pseudomonas aeruginosa
  3. Bacteroides fragilis
  4. Staphylococcus aureus Correct answer.

Explanation

Staphylococcus aureus, including methicillin-resistant strains, is the leading cause of acute surgical site infection and prosthetic joint infection in orthopedics. It colonizes the skin and nares and readily contaminates wounds. Pseudomonas is more associated with specific exposures, anaerobes with gut flora, and mycobacteria with chronic granulomatous disease.

Question 6Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

Which drug is a bisphosphonate that inhibits osteoclast-mediated bone resorption by binding to hydroxyapatite?

  1. Raloxifene
  2. Teriparatide
  3. Denosumab
  4. Alendronate Correct answer.

Explanation

Alendronate is a nitrogen-containing bisphosphonate that binds hydroxyapatite and is taken up by osteoclasts, inhibiting farnesyl pyrophosphate synthase and promoting osteoclast apoptosis. This reduces bone resorption and increases bone mineral density. Teriparatide is anabolic, denosumab is a monoclonal antibody, and raloxifene is a selective estrogen receptor modulator.

Question 7Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

In the stress-strain curve of cortical bone, the area under the curve up to the fracture point represents which property?

  1. Yield strength
  2. Poisson ratio
  3. Elastic modulus
  4. Toughness Correct answer.

Explanation

The area under the entire stress-strain curve up to failure represents toughness, the energy absorbed per unit volume before fracture. It combines both strength and ductility. Elastic modulus is the slope, yield strength is the stress at the yield point, and Poisson ratio describes lateral-to-axial strain.

Question 8Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

Which nerve is at greatest risk during a direct lateral approach to the hip when the interval is developed between the gluteus medius and the tensor fasciae latae?

  1. The obturator nerve
  2. The femoral nerve
  3. The sciatic nerve
  4. The superior gluteal nerve Correct answer.

Explanation

The superior gluteal nerve runs between the gluteus medius and minimus and is vulnerable during the direct lateral approach, especially if dissection extends more than about 5 cm proximal to the greater trochanter. Injury causes a Trendelenburg gait from abductor weakness. The sciatic nerve is at risk in posterior approaches, the femoral nerve in anterior approaches, and the obturator nerve is deep in the pelvis.

Question 9Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

A 65-year-old sustains a fragility fracture after a minor fall. Which cells are primarily responsible for the bone resorption seen in postmenopausal osteoporosis?

  1. Osteoclasts Correct answer.
  2. Osteoblasts
  3. Osteocytes
  4. Chondrocytes

Explanation

Osteoclasts are multinucleated cells derived from the monocyte-macrophage lineage that resorb bone through acidification and proteolytic enzymes. In postmenopausal osteoporosis, estrogen deficiency increases RANKL and cytokine signaling, driving osteoclast activity. Osteoblasts form bone, osteocytes are mechanosensors, and chondrocytes form cartilage.

Question 10Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

A patient on chronic warfarin therapy needs urgent orthopedic surgery. Which reversal strategy is most appropriate for a life-threatening bleed with an elevated INR?

  1. Prothrombin complex concentrate plus vitamin K Correct answer.
  2. Fresh frozen plasma alone
  3. Vitamin K alone
  4. Protamine sulfate

Explanation

For major bleeding or urgent surgery on warfarin, guidelines recommend four-factor prothrombin complex concentrate plus intravenous vitamin K for rapid and sustained reversal. PCC replaces the vitamin K-dependent factors more quickly and with less volume than fresh frozen plasma. Vitamin K alone acts too slowly, and protamine reverses heparin, not warfarin.

Question 11Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

Which structure is most commonly injured in a posterior dislocation of the shoulder that causes a Bankart lesion?

  1. The posterior labrum and posterior capsule Correct answer.
  2. The superior labrum from anterior to posterior
  3. The coracohumeral ligament
  4. The anterior inferior glenohumeral ligament-labrum complex

Explanation

A posterior shoulder dislocation tears the posterior labrum and posterior capsule, producing a reverse Bankart lesion, often with an impaction fracture of the anterior humeral head (reverse Hill-Sachs). The anterior inferior labroligamentous complex is injured in the far more common anterior dislocation. This distinction guides the direction of stabilization.

Question 12Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

A patient with a closed tibial fracture develops compartment syndrome. Which pathophysiological mechanism best explains the tissue injury?

  1. Capillary hypertension with increased perfusion
  2. Elevated compartment pressure reducing capillary perfusion and causing ischemia Correct answer.
  3. Venous dilation with increased oxygen delivery
  4. Direct arterial transection with distal hypoperfusion

Explanation

Compartment syndrome occurs when rising pressure within a closed fascial compartment exceeds capillary perfusion pressure, reducing blood flow and causing ischemic muscle and nerve injury. The process is microvascular, not a large-vessel transection. Prompt fasciotomy is required to restore perfusion.

Question 13Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

Which antibiotic mechanism of action is shared by vancomycin and beta-lactams such as cefazolin?

  1. Inhibition of bacterial protein synthesis at the 30S subunit
  2. Inhibition of bacterial cell wall synthesis Correct answer.
  3. Inhibition of DNA gyrase
  4. Disruption of the bacterial cell membrane

Explanation

Both vancomycin and beta-lactams inhibit cell wall synthesis, although at different steps: beta-lactams inhibit transpeptidase cross-linking, while vancomycin binds the D-Ala-D-Ala terminus and blocks elongation. This shared target explains their bactericidal effect against growing organisms. Protein synthesis inhibitors, gyrase inhibitors, and membrane disruptors act elsewhere.

Question 14Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

Which anatomical structure is most at risk during a proximal tibial osteotomy performed just below the tibial tuberosity?

  1. The saphenous nerve
  2. The tibial nerve
  3. The popliteal artery
  4. The common peroneal nerve Correct answer.

Explanation

The common peroneal nerve winds around the fibular neck and lies close to the lateral aspect of the proximal tibia and fibula, making it vulnerable during proximal tibial osteotomy or fibular surgery. Injury produces foot drop and sensory loss over the dorsum of the foot. The tibial nerve and popliteal artery are more posterior and central.

Question 15Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

Which type of collagen predominates in hyaline articular cartilage and provides tensile strength?

  1. Type III
  2. Type I
  3. Type II Correct answer.
  4. Type IV

Explanation

Hyaline articular cartilage is composed mainly of type II collagen, which forms a fibrillar network that traps proteoglycans and provides tensile strength and load distribution. Type I dominates bone, tendon, and skin, type III is found in reticular fibers, and type IV is in basement membranes. Loss of type II integrity is central to osteoarthritis.

Question 16Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

A patient is scheduled for elective arthroplasty and takes aspirin for secondary prevention. Which pharmacologic consideration is most relevant preoperatively?

  1. Aspirin acts primarily by inhibiting cyclooxygenase-2 in platelets
  2. Aspirin reverses heparin anticoagulation
  3. Aspirin has no effect on platelet function
  4. Aspirin irreversibly inhibits cyclooxygenase-1 and impairs platelet aggregation for the platelet lifespan Correct answer.

Explanation

Aspirin acetylates cyclooxygenase-1 irreversibly, blocking thromboxane A2 production and platelet aggregation for the life of the platelet, roughly 7 to 10 days. This is why some surgeons stop aspirin before major elective surgery, though many continue it for cardiac protection. Platelets lack nuclei and cannot synthesize new enzyme.

Question 17Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

Which structure forms the medial boundary of the femoral triangle and is a key landmark for femoral nerve block?

  1. The sartorius
  2. The rectus femoris
  3. The inguinal ligament
  4. The adductor longus Correct answer.

Explanation

The femoral triangle is bounded by the inguinal ligament superiorly, the sartorius laterally, and the adductor longus medially. The femoral nerve lies lateral to the femoral artery within this triangle, which guides the landmark femoral nerve block. Correct boundary knowledge prevents needle misdirection.

Question 18Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

A patient has a chronic prosthetic joint infection with a sinus tract. Which biofilm-related principle best explains the difficulty of eradicating this infection with antibiotics alone?

  1. Biofilm bacteria lack cell walls and are inherently resistant
  2. Planktonic bacteria are protected by the glycocalyx
  3. Biofilm formation increases bacterial replication rate
  4. Sessile bacteria in biofilm are metabolically slow and resistant to antibiotics and host defenses Correct answer.

Explanation

Biofilm bacteria adhere to implants, secrete a glycocalyx, and enter a slow-growing sessile state that reduces antibiotic susceptibility and shields them from phagocytes. This is why implant removal is often required for chronic prosthetic joint infection. Planktonic bacteria are the free-floating, more susceptible form.

Question 19Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

Which muscle-tendon unit is most commonly affected in de Quervain tenosynovitis at the radial styloid?

  1. The flexor carpi radialis
  2. The abductor pollicis longus and extensor pollicis brevis Correct answer.
  3. The extensor carpi radialis brevis
  4. The extensor pollicis longus

Explanation

De Quervain tenosynovitis involves the first dorsal compartment, containing the abductor pollicis longus and extensor pollicis brevis tendons. Inflammation at the radial styloid causes pain with thumb motion and a positive Finkelstein test. The extensor pollicis longus occupies the third compartment and is not involved.

Question 20Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

A 70-year-old with a distal radius fracture fixed with a volar plate develops flexor pollicis longus rupture. Which mechanism best explains this complication?

  1. Systemic corticosteroid-induced tendon weakening
  2. Infection spreading from the fracture site
  3. Ischemic necrosis of the tendon from tourniquet use
  4. Attritional wear of the tendon against a prominent plate edge Correct answer.

Explanation

Volar plating of the distal radius places the flexor pollicis longus tendon close to the plate; a prominent distal edge or screw can cause attritional friction and eventual rupture. This is a mechanical, not ischemic or infectious, process. Careful plate placement and intraoperative tendon inspection reduce the risk.

Question 21Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

Which structure is the primary stabilizer against anterior translation of the tibia on the femur at 30 degrees of knee flexion?

  1. The medial collateral ligament
  2. The posterior cruciate ligament
  3. The lateral collateral ligament
  4. The anterior cruciate ligament Correct answer.

Explanation

The anterior cruciate ligament is the primary restraint to anterior tibial translation, especially near 30 degrees of flexion where it is most isometric and tested by the Lachman maneuver. The posterior cruciate ligament resists posterior translation. Collateral ligaments primarily control varus and valgus stability.

Question 22Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

A young athlete has a chronic avulsion injury at the ischial tuberosity. Which muscle group originates there and would be affected?

  1. The gluteus medius
  2. The hamstrings Correct answer.
  3. The quadriceps
  4. The adductors

Explanation

The hamstrings, including the biceps femoris, semitendinosus, and semimembranosus, originate from the ischial tuberosity, so avulsion there impairs hip extension and knee flexion. The quadriceps originates from the anterior pelvis and femur, the adductors from the pubis, and the gluteus medius from the ilium. This anatomy explains the functional deficit after such injuries.

Question 23Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

In a patient with osteogenesis imperfecta, which molecular defect most directly explains the bone fragility?

  1. Deficiency of vitamin D receptors
  2. Defective type II collagen in cartilage
  3. Absent osteoclast function
  4. Defective type I collagen synthesis or structure Correct answer.

Explanation

Osteogenesis imperfecta results from mutations in the COL1A1 or COL1A2 genes, producing abnormal or insufficient type I collagen, the main structural protein of bone. This reduces bone tensile strength and causes recurrent fractures. Type II collagen defects affect cartilage, and osteoclast or vitamin D defects cause different disorders.

Question 24Basic sciences applied to orthopedics (anatomy, biomechanics, pathology, microbiology, pharmacology)

A patient with a chronic osteomyelitis of the tibia has a sequestrum. Which pathophysiological feature best characterizes a sequestrum?

  1. A devitalized piece of bone isolated from the blood supply by the inflammatory process Correct answer.
  2. A fluid-filled cavity within the medullary canal
  3. A fibrous membrane surrounding the infected bone
  4. A vascularized fragment of new bone formed around the infection

Explanation

A sequestrum is a segment of necrotic, devitalized bone that has lost its blood supply and become separated from surrounding viable bone by infection. Because antibiotics cannot penetrate it, surgical debridement is usually required. The reactive new bone that forms around it is called the involucrum.

Question 25Trauma and fracture management (including polytrauma and damage control orthopedics)

In a multiply injured patient, which parameter is the most reliable trigger for switching from early total care to damage control orthopedics?

  1. Presence of a closed femoral shaft fracture
  2. A single systolic blood pressure reading below 90 mmHg in the emergency room
  3. Patient age above 40 years
  4. Serum lactate above 2.5 mmol/L persisting after initial resuscitation Correct answer.

Explanation

Persistent lactate elevation after resuscitation reflects ongoing hypoperfusion and predicts intolerance of prolonged definitive surgery, so it is a widely used trigger for damage control. Isolated single readings, fracture pattern alone, or age alone are weaker discriminators.

Question 26Trauma and fracture management (including polytrauma and damage control orthopedics)

The classic 'lethal triad' that drives death in major trauma consists of which combination?

  1. Anemia, thrombocytosis, and hyperthermia
  2. Hypothermia, acidosis, and coagulopathy Correct answer.
  3. Hypoxia, hypercapnia, and hypotension
  4. Hyperkalemia, acidosis, and renal failure

Explanation

The lethal triad is hypothermia, metabolic acidosis, and coagulopathy, each amplifying the others in exsanguinating trauma. Recognizing it underpins damage control resuscitation and abbreviated surgery.

Question 27Trauma and fracture management (including polytrauma and damage control orthopedics)

Which is the preferred initial skeletal stabilization for a hemodynamically unstable polytrauma patient with a femoral shaft fracture?

  1. Immediate plate fixation through an open approach
  2. Traction through a Thomas splint for two weeks
  3. Intramedullary nailing under the same anesthetic as laparotomy
  4. Rapid application of a bridging external fixator Correct answer.

Explanation

Damage control orthopedics favors quick, low-blood-loss stabilization with a bridging external fixator in the unstable patient. Conversion to definitive fixation occurs once physiology is restored.

Question 28Trauma and fracture management (including polytrauma and damage control orthopedics)

In damage control resuscitation of major trauma, what is the recommended initial approach to crystalloid administration?

  1. Permissive hypotension with minimized crystalloid and early balanced blood products Correct answer.
  2. Colloid infusion until hemoglobin normalizes
  3. Large-volume crystalloid to restore normal blood pressure before blood products
  4. Hypertonic saline as the primary resuscitation fluid

Explanation

Modern damage control resuscitation minimizes crystalloid, permits lower blood pressure until hemorrhage control, and gives balanced blood products early. Excess crystalloid worsens coagulopathy, acidosis, and edema.

Question 29Trauma and fracture management (including polytrauma and damage control orthopedics)

A patient with an open tibial fracture is brought in six hours after injury with gross contamination. Which factor most strongly increases the risk of infection?

  1. The use of a tourniquet during debridement
  2. The time elapsed since injury and degree of contamination Correct answer.
  3. The patient's blood group
  4. The fracture being in the distal third of the tibia

Explanation

Delay to debridement and the degree of wound contamination are the dominant predictors of infection in open fractures. Early thorough debridement and antibiotics reduce this risk.

Question 30Trauma and fracture management (including polytrauma and damage control orthopedics)

Which antibiotic regimen is most appropriate as initial prophylaxis for a Gustilo-Anderson type III open tibial fracture?

  1. No antibiotics until culture results are available
  2. Intravenous cefazolin plus an aminoglycoside, with penicillin added for soil contamination Correct answer.
  3. Oral flucloxacillin alone
  4. Topical antibiotic powder only

Explanation

Type III open fractures require broad Gram-negative cover in addition to anti-staphylococcal cover, so a cephalosporin plus an aminoglycoside is standard, with penicillin added for farm or soil contamination. Antibiotics should start promptly, not await cultures.

Question 31Trauma and fracture management (including polytrauma and damage control orthopedics)

Which statement best describes the role of the 'second hit' concept in polytrauma care?

  1. A second operation should always be performed within 48 hours
  2. The second hit refers to a second fracture in the same limb
  3. Secondary insults such as surgery or sepsis can precipitate organ failure after initial priming Correct answer.
  4. A second injury always occurs within 24 hours of the first

Explanation

The first hit of trauma primes the immune system; a second hit such as major surgery, infection, or hypotension can trigger systemic inflammatory response and organ failure. This underpins timing of definitive fixation.

Question 32Trauma and fracture management (including polytrauma and damage control orthopedics)

A patient presents with a pulseless limb and a displaced supracondylar humeral fracture in a child. What is the most appropriate immediate management?

  1. Immediate exploration and repair of the brachial artery before reduction
  2. Application of a backslab and outpatient review in one week
  3. Observation with analgesia and reassessment in 24 hours
  4. Immediate closed reduction and restoration of alignment with reassessment of the pulse Correct answer.

Explanation

In supracondylar fractures with vascular compromise, urgent closed reduction and stabilization often restores flow by relieving the fracture's tethering effect on the brachial artery. Vascular exploration is reserved for limbs that remain ischemic after reduction.

Question 33Trauma and fracture management (including polytrauma and damage control orthopedics)

Which finding is most consistent with compartment syndrome of the leg?

  1. Pain out of proportion to injury, worsened by passive stretch of the compartment muscles Correct answer.
  2. Bradycardia and hypertension as the classic early picture
  3. Absent distal pulses as the earliest sign
  4. Immediate complete sensory loss in the entire leg

Explanation

The earliest and most reliable sign of compartment syndrome is disproportionate pain aggravated by passive stretch of the muscles in the affected compartment. Pulselessness is a late finding, and sensory changes occur later.

Question 34Trauma and fracture management (including polytrauma and damage control orthopedics)

What is the definitive treatment for acute compartment syndrome of the leg?

  1. Urgent complete fasciotomy of all affected compartments Correct answer.
  2. Compression bandaging and serial pressure checks
  3. Elevation above heart level and observation
  4. Manitol infusion alone

Explanation

Acute compartment syndrome is a surgical emergency requiring urgent full-length fasciotomy of all involved compartments. Delay leads to muscle necrosis and Volkmann contracture.

Question 35Trauma and fracture management (including polytrauma and damage control orthopedics)

Which fracture pattern is most characteristic of a high-energy pelvic ring injury with hemodynamic instability?

  1. Anterior-posterior compression type I with a stable ring
  2. Isolated pubic ramus fracture in an elderly patient
  3. Vertical shear injury with posterior displacement of the hemipelvis Correct answer.
  4. Avulsion of the anterior superior iliac spine

Explanation

Vertical shear injuries disrupt the posterior pelvic complex and can cause major retroperitoneal hemorrhage with instability. They require prompt stabilization, often with a pelvic binder followed by external or internal fixation.

Question 36Trauma and fracture management (including polytrauma and damage control orthopedics)

In the acute management of a hemodynamically unstable patient with a suspected pelvic fracture, which maneuver is recommended first?

  1. Immediate open reduction and internal fixation
  2. Insertion of a chest drain before pelvic binding
  3. Angioembolization before any mechanical stabilization
  4. Application of a pelvic binder at the level of the greater trochanters Correct answer.

Explanation

A pelvic binder applied at the greater trochanter level closes the pelvic volume and provides temporary mechanical stabilization, reducing bleeding. It is a rapid bedside maneuver that precedes definitive fixation or embolization.

Question 37Trauma and fracture management (including polytrauma and damage control orthopedics)

Which clinical feature best distinguishes a hip dislocation from a displaced femoral neck fracture?

  1. Femoral neck fractures always produce limb lengthening
  2. The limb is shortened and externally rotated in both conditions
  3. Hip dislocation never causes pain on movement
  4. Posterior dislocation typically produces shortening, adduction, and internal rotation Correct answer.

Explanation

Posterior hip dislocation classically presents with a shortened, adducted, and internally rotated limb, whereas a displaced femoral neck fracture gives shortening and external rotation. This distinction guides urgent imaging and reduction.

Question 38Trauma and fracture management (including polytrauma and damage control orthopedics)

A patient has a knee dislocation with an absent dorsalis pedis pulse that does not return after closed reduction. What is the next most appropriate step?

  1. Discharge with a knee brace and outpatient review
  2. Application of a compression bandage and elevation
  3. Urgent vascular imaging and vascular surgery consultation Correct answer.
  4. Repeat closed reduction after 24 hours

Explanation

Knee dislocation carries a high risk of popliteal artery injury, and an absent pulse after reduction mandates urgent vascular assessment, usually CT angiography. Delay risks limb loss.

Question 39Trauma and fracture management (including polytrauma and damage control orthopedics)

Which of the following is a recognized indication for urgent operative fixation of a fracture in a polytrauma patient?

  1. A chronic stress fracture of the metatarsal
  2. A stable closed distal radius fracture
  3. An open fracture with ongoing hemorrhage Correct answer.
  4. An undisplaced pubic ramus fracture

Explanation

Open fractures with ongoing hemorrhage require urgent surgical control of bleeding and debridement. Stable closed fractures and chronic injuries can be managed electively.

Question 40Trauma and fracture management (including polytrauma and damage control orthopedics)

In the management of a mangled extremity, which scoring system is commonly used to help decide between limb salvage and amputation?

  1. Ranson criteria
  2. MESS (Mangled Extremity Severity Score) Correct answer.
  3. Glasgow Coma Scale
  4. Wells score

Explanation

The MESS score incorporates skeletal and soft tissue injury, limb ischemia, shock, and age to support the salvage versus amputation decision, though it is an adjunct rather than an absolute rule. The other scores assess consciousness, pancreatitis, and thrombosis risk respectively.

Question 41Trauma and fracture management (including polytrauma and damage control orthopedics)

Which statement about fat embolism syndrome after long bone fractures is correct?

  1. It usually presents within the first hour with isolated hypertension
  2. It occurs only with open fractures
  3. It is confirmed by the presence of fat globules in the urine alone
  4. It typically presents with hypoxemia, petechiae, and neurological changes 24 to 72 hours after injury Correct answer.

Explanation

Fat embolism syndrome classically develops 24 to 72 hours after long bone fractures with a triad of respiratory distress, petechial rash, and neurological dysfunction. Early stabilization of fractures reduces its incidence.

Question 42Trauma and fracture management (including polytrauma and damage control orthopedics)

A patient with a tibial plateau fracture develops a tense swollen calf with pain on passive stretch two days after surgery. What is the most appropriate next step?

  1. Order an elective MRI in one week
  2. Apply ice and compression
  3. Remove the cast or dressing and measure compartment pressures urgently Correct answer.
  4. Increase opioid analgesia and reassess in 12 hours

Explanation

Suspected compartment syndrome after tibial plateau surgery requires immediate release of constricting dressings and urgent compartment pressure measurement. If pressure is elevated, fasciotomy must follow without delay.

Question 43Trauma and fracture management (including polytrauma and damage control orthopedics)

Which of the following best describes 'permissive hypotension' in hemorrhagic shock?

  1. Using vasopressors as first-line therapy before blood products
  2. Maintaining systolic pressure around 80 to 90 mmHg until hemorrhage is controlled in patients without head injury Correct answer.
  3. Deliberately lowering blood pressure below 60 mmHg in all trauma patients
  4. Withholding all intravenous fluids indefinitely

Explanation

Permissive hypotension targets a lower systolic pressure until surgical or endovascular hemorrhage control, avoiding clot disruption, and is generally avoided in traumatic brain injury where perfusion pressure must be maintained.

Question 44Trauma and fracture management (including polytrauma and damage control orthopedics)

Which fracture in a polytrauma patient is most associated with the development of acute respiratory distress syndrome?

  1. Isolated distal phalanx fracture
  2. Femoral shaft fracture with intramedullary instrumentation during instability Correct answer.
  3. Ankle sprain without fracture
  4. Isolated radial head fracture

Explanation

Femoral shaft fractures, particularly with intramedullary reaming during physiological instability, are associated with fat embolism and ARDS. Timing of fixation is therefore critical in polytrauma.

Question 45Trauma and fracture management (including polytrauma and damage control orthopedics)

Which factor most strongly predicts mortality in an elderly patient with a hip fracture?

  1. The side of the fracture
  2. The type of anaesthesia used exclusively
  3. The choice of implant material
  4. The patient's pre-injury functional status and comorbidities Correct answer.

Explanation

Pre-injury mobility, cognitive status, and comorbidity burden are the strongest predictors of mortality after hip fracture. Early surgery and orthogeriatric care improve outcomes but do not override baseline reserve.

Question 46Trauma and fracture management (including polytrauma and damage control orthopedics)

A patient with a floating knee (ipsilateral femoral and tibial shaft fractures) is hemodynamically stable. What is the preferred definitive treatment?

  1. Amputation of the limb
  2. Traction for six weeks for both fractures
  3. Intramedullary nailing of both the femur and the tibia Correct answer.
  4. External fixation of the femur only

Explanation

In the stable patient, intramedullary nailing of both the femur and tibia allows early mobilization and union with good functional results. Damage control external fixation is reserved for the unstable patient.

Question 47Trauma and fracture management (including polytrauma and damage control orthopedics)

Which of the following is the most appropriate initial immobilization for a suspected unstable cervical spine injury in a polytrauma patient?

  1. Immediate removal of all immobilization to assess range of motion
  2. Soft foam collar and early mobilization
  3. Traction applied without imaging
  4. Rigid cervical collar with manual in-line stabilization and log-roll precautions Correct answer.

Explanation

Suspected cervical spine injury requires a rigid collar with manual in-line stabilization during airway management and transfers to prevent secondary neurological injury. Imaging determines definitive management.

Question 48Trauma and fracture management (including polytrauma and damage control orthopedics)

Which statement about open fracture debridement timing is most consistent with current evidence?

  1. Debridement should always be performed in the operating theatre after 48 hours
  2. Debridement is unnecessary if antibiotics are given within one hour
  3. Debridement can be safely delayed beyond 24 hours for all open fractures
  4. Debridement should be performed as soon as feasible, with urgency greatest for heavily contaminated or vascularly compromised wounds Correct answer.

Explanation

Current evidence supports early debridement, with the greatest urgency for grossly contaminated wounds, vascular compromise, and farm injuries, rather than a rigid six-hour rule for all fractures. Antibiotics remain an essential adjunct but do not replace surgical debridement.

Question 49Trauma and fracture management (including polytrauma and damage control orthopedics)

In a patient with a suspected Achilles tendon rupture, which clinical test is most useful?

  1. McMurray test
  2. Lachman test
  3. Finkelstein test
  4. Simmonds-Thompson squeeze test Correct answer.

Explanation

The Simmonds-Thompson squeeze test detects absent plantar flexion when the calf is squeezed, indicating Achilles discontinuity. The other tests assess meniscal, ligamentous, and tendon pathology elsewhere.

Question 50Trauma and fracture management (including polytrauma and damage control orthopedics)

A 24-year-old man is brought to the emergency department after a high-speed motorcycle crash. He is confused, has a systolic blood pressure of 85 mmHg and a heart rate of 140/min, and has an unstable pelvis on examination. According to damage control orthopedics, which sequence of priorities is most appropriate?

  1. Hemorrhage control and physiological resuscitation first, with temporary skeletal stabilization and delayed definitive fixation Correct answer.
  2. Immediate definitive internal fixation of all long bone fractures before abdominal assessment
  3. Immediate transfer to the operating theatre for intramedullary nailing of the femur before pelvic binding
  4. Rapid fluid loading to a systolic pressure above 120 mmHg followed by total care in the intensive care unit

Explanation

Damage control orthopedics prioritizes control of hemorrhage and correction of the lethal triad (hypothermia, acidosis, coagulopathy) before definitive fracture care. Temporary stabilization with an external fixator or traction, together with pelvic binding, limits ongoing bleeding and the 'second hit' of surgery. Definitive fixation is then performed once physiology has been restored.