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CAQ-Ortho practice questions

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Question 1Orthopaedic Surgery

A 24-year-old man sustains a closed tibial shaft fracture after a fall. Which finding most strongly suggests an impending compartment syndrome rather than simple fracture pain?

  1. Pain that improves after intravenous opioid analgesia
  2. Pain that is out of proportion to the injury and worsens with passive stretch of the toes Correct answer.
  3. Mild swelling of the calf that is firm to palpation
  4. Absent dorsalis pedis pulse on the affected side

Explanation

Compartment syndrome is a clinical diagnosis in which pain disproportionate to the injury and pain on passive stretch of the muscles in the involved compartment are the earliest and most reliable findings. Pulselessness is a late and inconsistent sign because compartment pressures rarely exceed arterial pressure. Opioid-responsive pain and simple swelling are nonspecific and do not exclude the diagnosis.

Question 2Orthopaedic Surgery

Which nerve is most commonly injured during a direct lateral approach to the hip for hemiarthroplasty?

  1. Sciatic nerve
  2. Obturator nerve
  3. Femoral nerve
  4. Superior gluteal nerve Correct answer.

Explanation

The superior gluteal nerve runs close to the greater sciatic notch and is at risk when the dissection extends proximally along the lateral approach, and injury produces a Trendelenburg gait from gluteus medius weakness. The sciatic nerve is at risk in posterior approaches, and the femoral and obturator nerves are not in the field of a standard lateral approach.

Question 3Orthopaedic Surgery

A 7-year-old boy has a nondisplaced supracondylar humeral fracture with a normal neurovascular examination. Which treatment is most appropriate?

  1. Skeletal traction through the olecranon for three weeks
  2. Closed reduction and percutaneous pinning in the operating theatre
  3. Open reduction through an anterior approach
  4. Long arm cast with the elbow flexed to 90 degrees and weekly radiographic review Correct answer.

Explanation

Gartland type I supracondylar fractures, which are nondisplaced and neurovascularly intact, are managed nonoperatively with immobilization and close radiographic follow-up for displacement. Pinning is reserved for displaced (type II and III) fractures, and open reduction or traction is reserved for irreducible or severely displaced injuries.

Question 4Orthopaedic Surgery

Which organism is the most frequent cause of acute hematogenous osteomyelitis in previously healthy adults?

  1. Staphylococcus aureus Correct answer.
  2. Neisseria gonorrhoeae
  3. Pseudomonas aeruginosa
  4. Salmonella species

Explanation

Staphylococcus aureus accounts for the large majority of acute hematogenous bone infections in adults and children. Salmonella is classically associated with sickle cell disease, Pseudomonas with intravenous drug use or puncture wounds, and Neisseria gonorrhoeae causes septic arthritis rather than osteomyelitis.

Question 5Orthopaedic Surgery

A 68-year-old woman has a displaced femoral neck fracture. Which factor most strongly favors internal fixation over arthroplasty?

  1. Younger age with a minimally displaced fracture and good bone stock Correct answer.
  2. Established avascular necrosis of the femoral head on radiographs
  3. Pre-existing severe osteoarthritis of the ipsilateral hip
  4. Pathological fracture through a lytic metastasis

Explanation

Internal fixation preserves the native head and is preferred in younger, higher-demand patients with minimally displaced fractures and adequate bone stock, where head-preserving surgery offers durable results. Established avascular necrosis, pathological fracture with tumor involvement, and severe pre-existing arthritis all favor replacing the joint.

Question 6Orthopaedic Surgery

Which finding on knee examination is most specific for an anterior cruciate ligament tear?

  1. A positive valgus stress test at 30 degrees of flexion
  2. A positive patellar apprehension test
  3. A positive Lachman test Correct answer.
  4. A positive McMurray test

Explanation

The Lachman test, performed at 20 to 30 degrees of flexion with an anterior tibial translation endpoint, has high sensitivity and specificity for ACL rupture. McMurray tests meniscal pathology, valgus stress tests the medial collateral ligament, and the apprehension test assesses patellar instability.

Question 7Orthopaedic Surgery

A 55-year-old man has an open tibial shaft fracture with a 6 cm wound and extensive periosteal stripping after a motorcycle crash. Which classification best describes this injury?

  1. Gustilo-Anderson type IIIB Correct answer.
  2. Gustilo-Anderson type I
  3. Gustilo-Anderson type IIIC
  4. Gustilo-Anderson type IIIA

Explanation

Gustilo-Anderson type IIIB denotes an open fracture with extensive soft-tissue loss and periosteal stripping that requires a local or free flap for coverage. Type IIIA has adequate soft-tissue coverage without flap, type IIIC has an associated arterial injury requiring repair, and type I is a clean wound under 1 cm.

Question 8Orthopaedic Surgery

Which radiographic finding is characteristic of developmental dysplasia of the hip in a 6-month-old infant?

  1. Coxa valga with lateral bowing of the proximal femur
  2. Premature closure of the greater trochanteric apophysis
  3. A widened or asymmetric acetabular index with lateral and superior displacement of the femoral head Correct answer.
  4. A shortened, thickened femoral neck with coxa magna

Explanation

In DDH the acetabulum is shallow and steep, producing an increased acetabular index, and the femoral head is displaced laterally and proximally with a disrupted Shenton line. Coxa magna and neck thickening follow Perthes disease or infection, and coxa valga is a separate deformity.

Question 9Orthopaedic Surgery

Which nerve is most at risk during a volar approach to the distal radius for internal fixation?

  1. Median nerve Correct answer.
  2. Radial sensory nerve
  3. Posterior interosseous nerve
  4. Ulnar nerve

Explanation

The median nerve lies directly beneath the flexor carpi radialis and flexor pollicis longus in the carpal tunnel region and is the structure most commonly endangered during a volar plate application to the distal radius. The ulnar nerve is on the ulnar side, the superficial radial nerve is dorsal, and the posterior interosseous nerve is dorsal and proximal.

Question 10Orthopaedic Surgery

A 35-year-old runner has lateral knee pain that worsens with downhill running and is tender over the lateral femoral epicondyle. Which diagnosis is most likely?

  1. Patellofemoral syndrome
  2. Medial collateral ligament sprain
  3. Popliteal cyst
  4. Iliotibial band syndrome Correct answer.

Explanation

Iliotibial band syndrome produces lateral knee pain with tenderness over the lateral epicondyle and is aggravated by repetitive flexion-extension such as downhill running. Patellofemoral pain is anterior, a popliteal cyst causes posterior swelling, and MCL sprain follows a valgus injury with medial tenderness.

Question 11Orthopaedic Surgery

Which statement about the blood supply to the femoral head is most accurate?

  1. The obturator artery supplies the majority of the adult femoral head
  2. The medial circumflex femoral artery provides the dominant supply in adults Correct answer.
  3. The lateral circumflex femoral artery is the main supply after skeletal maturity
  4. The artery of the ligamentum teres supplies most of the adult femoral head

Explanation

After skeletal maturity, the medial circumflex femoral artery, via the lateral epiphyseal branches, provides the dominant blood supply to the femoral head. The artery of the ligamentum teres contributes only a small amount, and the obturator and lateral circumflex arteries are not the principal sources in adults.

Question 12Orthopaedic Surgery

A 70-year-old woman with osteoporosis has a Colles fracture. Which deformity is expected on examination?

  1. Radial head subluxation with a shortened forearm
  2. Dorsal angulation and dorsal displacement of the distal fragment Correct answer.
  3. Volar angulation and volar displacement of the distal fragment
  4. Ulnar angulation without displacement

Explanation

A Colles fracture is a distal radius fracture with dorsal angulation and dorsal displacement of the distal fragment, often producing a dinner-fork deformity. Volar displacement describes a Smith fracture, and radial head subluxation with forearm shortening suggests a Monteggia-type injury.

Question 13Orthopaedic Surgery

Which finding best distinguishes septic arthritis from transient synovitis of the hip in a child?

  1. Inability to bear weight with a fever above 38.5 C and an elevated C-reactive protein Correct answer.
  2. An ESR of 20 mm/h
  3. Mild pain that improves with rest and NSAIDs
  4. A history of recent upper respiratory infection

Explanation

Kocher criteria, including non-weight-bearing, fever above 38.5 C, elevated ESR, and elevated CRP or white cell count, help distinguish septic arthritis from transient synovitis. Transient synovitis typically causes milder pain, a lower fever, and modest inflammatory markers, and recent URI is common in both.

Question 14Orthopaedic Surgery

Which muscle-tendon unit is most commonly affected in de Quervain tenosynovitis?

  1. Extensor pollicis longus
  2. Flexor carpi ulnaris
  3. Abductor pollicis longus and extensor pollicis brevis Correct answer.
  4. Extensor carpi radialis brevis

Explanation

De Quervain tenosynovitis involves the first dorsal compartment, containing the abductor pollicis longus and extensor pollicis brevis tendons, and produces radial wrist pain with a positive Finkelstein test. Extensor pollicis longus occupies the third compartment, and the other muscles listed are not involved.

Question 15Orthopaedic Surgery

A 45-year-old man has a complete spinal cord injury at T10 after a fall. Which bowel and bladder function is most likely preserved?

  1. Loss of anal sphincter tone with continuous dribbling
  2. Reflex detrusor contraction with an upper motor neuron bladder Correct answer.
  3. Absent bulbocavernosus reflex with flaccid bladder
  4. Acontractile lower motor neuron bladder requiring Credé maneuver

Explanation

Injuries above the conus medullaris (T10 is above the sacral segments) produce an upper motor neuron pattern with reflex detrusor contraction and spastic sphincter function. A lower motor neuron, acontractile bladder occurs with conus or cauda equina lesions, and loss of anal tone and the bulbocavernosus reflex indicates sacral involvement.

Question 16Orthopaedic Surgery

Which radiographic feature is characteristic of osteoarthritis rather than rheumatoid arthritis?

  1. Uniform symmetric joint space loss with marginal erosions
  2. Pencil-in-cup deformity of the phalanges
  3. Periarticular osteopenia with soft-tissue swelling
  4. Asymmetric joint space narrowing with subchondral sclerosis and osteophytes Correct answer.

Explanation

Osteoarthritis produces asymmetric narrowing in the load-bearing compartment with subchondral sclerosis, cysts, and osteophytes. Rheumatoid arthritis causes symmetric diffuse narrowing with marginal erosions and periarticular osteopenia, and pencil-in-cup deformity is seen in psoriatic arthritis.

Question 17Orthopaedic Surgery

A 30-year-old woman has a displaced midshaft clavicle fracture with 2.5 cm of shortening. Which treatment is most appropriate?

  1. Closed reduction with a spica cast
  2. Sling immobilization alone with early range of motion
  3. Open reduction and plate fixation Correct answer.
  4. Figure-of-eight bandage for six weeks

Explanation

Displaced midshaft clavicle fractures with significant shortening, usually greater than 2 cm, or with comminution or skin tenting have improved union and function with operative plate fixation. Sling or figure-of-eight treatment is reserved for minimally displaced fractures, and spica casting is not used for the clavicle.

Question 18Orthopaedic Surgery

Which structure is most commonly injured in an ankle sprain caused by inversion?

  1. Anterior talofibular ligament Correct answer.
  2. Anterior inferior tibiofibular ligament
  3. Deltoid ligament
  4. Calcaneofibular ligament

Explanation

An inversion ankle sprain first ruptures the anterior talofibular ligament, followed by the calcaneofibular ligament in more severe injuries. The deltoid ligament is injured with eversion, and the anterior inferior tibiofibular ligament is injured in a high ankle sprain from external rotation.

Question 19Orthopaedic Surgery

A 60-year-old man has a complete rotator cuff tear with pseudoparalysis and superior migration of the humeral head. Which finding on examination is most consistent with this injury?

  1. Increased external rotation strength in abduction
  2. Painless full active elevation against resistance
  3. Normal drop-arm test result
  4. Weakness of active elevation with preserved passive forward elevation Correct answer.

Explanation

A massive rotator cuff tear with pseudoparalysis produces profound weakness of active elevation while passive elevation remains full, and the drop-arm test is typically positive. Preserved active elevation against resistance and normal strength argue against a complete tear.

Question 20Orthopaedic Surgery

Which of the following is the most appropriate initial management of a hemodynamically unstable patient with a pelvic ring fracture from blunt trauma?

  1. Skeletal traction of both lower extremities
  2. Immediate definitive open reduction and internal fixation of the pelvis
  3. Elective angiography after 24 hours of observation
  4. Application of a pelvic binder and activation of a massive transfusion protocol Correct answer.

Explanation

In an unstable patient with a pelvic ring injury, temporary pelvic binder placement, hemorrhage control with blood product resuscitation, and early angioembolization or preperitoneal packing are priorities. Definitive internal fixation and elective delayed angiography are inappropriate during active hemorrhage.

Question 21Orthopaedic Surgery

Which tumor is the most common primary malignant bone tumor in children and adolescents?

  1. Multiple myeloma
  2. Osteosarcoma Correct answer.
  3. Chondrosarcoma
  4. Ewing sarcoma

Explanation

Osteosarcoma is the most common primary malignant bone tumor in children and adolescents, typically arising in the metaphysis of long bones around the knee. Ewing sarcoma is less common, chondrosarcoma occurs in older adults, and multiple myeloma is a disease of older adults.

Question 22Orthopaedic Surgery

A 25-year-old man has a posterior hip dislocation after a dashboard injury. Which complication should be specifically assessed and documented before and after reduction?

  1. Sciatic nerve function Correct answer.
  2. Femoral artery pulse
  3. Obturator nerve sensation
  4. Superior gluteal nerve function

Explanation

Posterior hip dislocation places the sciatic nerve at risk, and its function must be documented before and after reduction because a deficit changes management and prognosis. The femoral artery, obturator nerve, and superior gluteal nerve are not the structures primarily endangered by a posterior dislocation.

Question 23Orthopaedic Surgery

Which biomechanical principle best explains why a short oblique fracture of the midshaft femur is treated with an intramedullary nail rather than a plate?

  1. Plates allow immediate full unprotected weight bearing
  2. An intramedullary nail acts as a load-sharing device with a more favorable lever arm for early weight bearing Correct answer.
  3. Intramedullary nails eliminate the need for fracture reduction
  4. A plate provides superior torsional stiffness in the diaphysis

Explanation

An intramedullary nail is placed along the mechanical axis of the bone, giving a short lever arm and load-sharing behavior that permits early weight bearing and low rates of refracture compared with plates. Plates are load-bearing and do not offer superior torsional stiffness for diaphyseal fractures, and reduction is still required.

Question 24Orthopaedic Surgery

A patient has a suspected Achilles tendon rupture. Which clinical test is most useful?

  1. Lachman test
  2. Finkelstein test
  3. McMurray test
  4. Thompson (Simmonds) calf squeeze test Correct answer.

Explanation

The Thompson test squeezes the calf and looks for absent plantar flexion, indicating a disrupted Achilles tendon. Finkelstein tests for de Quervain tenosynovitis, McMurray for meniscal tears, and Lachman for ACL rupture.

Question 25Orthopaedic Surgery

Which of the following best describes the role of the anterolateral ligament complex in the knee?

  1. It contributes to rotational stability and is increasingly addressed in some ACL reconstruction techniques Correct answer.
  2. It is the primary restraint to anterior tibial translation in extension
  3. It is the primary restraint to knee hyperextension
  4. It is the main restraint to valgus stress at 30 degrees of flexion

Explanation

The anterolateral ligament complex provides secondary rotational restraint, and injury to it may contribute to residual pivot shift after ACL reconstruction, which is why some surgeons add lateral extra-articular tenodesis. The ACL is the primary restraint to anterior translation, and the MCL resists valgus stress.

Question 26Orthopaedic Surgery

A 24-year-old man sustains a displaced femoral shaft fracture and is treated with an intramedullary nail. Which principle best explains why reamed intramedullary nailing is preferred over plate fixation for this fracture pattern?

  1. The nail compresses the fracture gap directly, producing primary bone healing without callus
  2. The nail preserves periosteal blood supply better than any extramedullary device
  3. The nail shares load along the mechanical axis and resists bending and torsion through a small entry portal Correct answer.
  4. The nail eliminates the need for postoperative weight-bearing restriction

Explanation

An intramedullary nail acts as a load-sharing internal splint positioned near the mechanical axis, so bending moments are small and the device tolerates high cyclical loads while permitting early weight bearing. Reaming also deposits bone graft at the fracture site and improves stability. Plate fixation requires a larger exposure and creates a load-bearing construct with a stress riser at the plate end.

Question 27Orthopaedic Surgery

A 68-year-old woman falls on an outstretched hand and cannot actively extend the wrist or fingers. Sensation is diminished over the dorsum of the first web space. Which injury pattern explains these findings?

  1. Ulnar nerve injury at the cubital tunnel
  2. Posterior interosseous nerve palsy from a distal humerus fracture
  3. Radial nerve palsy associated with a humeral shaft fracture Correct answer.
  4. Median nerve contusion at the carpal tunnel

Explanation

A humeral shaft fracture can injure the radial nerve in the spiral groove, producing wrist drop and sensory loss over the dorsal first web space. The posterior interosseous nerve supplies finger and thumb extension but not wrist extension and has no cutaneous sensory territory. Median and ulnar lesions do not cause wrist drop.

Question 28Orthopaedic Surgery

Which finding on physical examination is most consistent with a developmental dysplasia of the hip in a 3-month-old infant?

  1. Limited abduction of the affected hip with asymmetric thigh creases Correct answer.
  2. Painful restricted internal rotation of the hip
  3. Fixed flexion contracture with positive Thomas test
  4. Audible clunk with hip extension and external rotation

Explanation

In an infant with developmental dysplasia, the femoral head is displaced superolaterally, so hip abduction is limited and skin creases are asymmetric. Ortolani and Barlow maneuvers are used for screening in the newborn period but become less reliable after a few months as contractures develop. Pain and fixed flexion contractures suggest other diagnoses such as septic arthritis or psoas abscess.

Question 29Orthopaedic Surgery

A 58-year-old man has a closed distal radius fracture treated with a volar locking plate. Two weeks later he reports numbness and tingling in the thumb, index, and middle fingers that worsens at night. Which structure is most likely compressed?

  1. Anterior interosseous nerve in the forearm
  2. Radial sensory nerve over the radial styloid
  3. Median nerve within the carpal tunnel Correct answer.
  4. Ulnar nerve in Guyon canal

Explanation

Volar plating of the distal radius places the median nerve at risk from hematoma, edema, or hardware prominence within the carpal tunnel, producing nocturnal numbness in the median distribution. Carpal tunnel syndrome is a recognized complication after distal radius fractures and their fixation. Ulnar and radial sensory involvement would produce different distributions.

Question 30Orthopaedic Surgery

A 42-year-old woman has a firm, painful mass over the dorsal wrist that fluctuates in size with wrist flexion. Which structure is the most likely origin of this lesion?

  1. Extensor carpi radialis brevis tendon sheath
  2. Dorsal radiocarpal joint capsule Correct answer.
  3. Flexor carpi radialis tendon sheath
  4. Scapholunate interosseous ligament

Explanation

A dorsal wrist ganglion typically arises from the dorsal radiocarpal joint capsule and communicates with the joint through a stalk, which explains fluctuation in size with wrist position. Ganglia are mucin-filled cysts lined by synovium-like cells. Tendon sheath ganglia occur but are more typical on the volar wrist or digits.

Question 31Orthopaedic Surgery

A 19-year-old athlete has recurrent anterior shoulder instability with a bony Bankart lesion involving 25 percent of the glenoid. Which factor most strongly predicts failure of arthroscopic soft-tissue stabilization in this patient?

  1. Presence of a small Hill-Sachs lesion
  2. Glenoid bone loss reducing the effective articulating arc Correct answer.
  3. Younger age at first dislocation
  4. History of more than one dislocation episode

Explanation

Glenoid bone loss decreases the width of the glenoid arc available to resist humeral head translation, so soft-tissue repair alone has a high failure rate once loss exceeds roughly 20 percent. Bone augmentation procedures such as a Latarjet or bone graft are considered in that setting. Age and recurrence number increase risk but are weaker predictors than structural bone loss.

Question 32Orthopaedic Surgery

A 65-year-old man has a displaced femoral neck fracture and is independently mobile. Which treatment is most appropriate?

  1. Cannulated screw fixation
  2. Total hip arthroplasty Correct answer.
  3. Dynamic hip screw fixation
  4. Proximal femoral locking plate

Explanation

For displaced intracapsular femoral neck fractures in older patients, arthroplasty is preferred because internal fixation carries a high rate of nonunion and avascular necrosis. Total hip arthroplasty is favored over hemiarthroplasty in patients who were independently mobile and have a reasonable life expectancy. Screw fixation and extramedullary devices are suited to different fracture patterns.

Question 33Orthopaedic Surgery

A 32-year-old man has a closed tibial shaft fracture treated in a cast. Six hours later he reports severe pain out of proportion to the injury, and passive stretch of the toes is painful. Which action is most appropriate next?

  1. Elevate the limb above heart level and reassess in two hours
  2. Prescribe escalating opioid analgesia and observe
  3. Obtain repeat radiographs to exclude fracture displacement
  4. Remove the cast and perform urgent fasciotomy if compartment pressures are elevated Correct answer.

Explanation

Pain out of proportion and pain on passive stretch are the earliest reliable signs of acute compartment syndrome. The constricting cast must be removed immediately, and if compartment pressures remain elevated, urgent fasciotomy is required to prevent muscle and nerve necrosis. Delay causes irreversible ischemic injury.

Question 34Orthopaedic Surgery

Which organism is the most common cause of acute hematogenous osteomyelitis in children beyond the neonatal period?

  1. Salmonella species
  2. Streptococcus pyogenes
  3. Staphylococcus aureus Correct answer.
  4. Haemophilus influenzae

Explanation

Staphylococcus aureus accounts for the majority of acute hematogenous osteomyelitis in children and adults. Salmonella is classically associated with sickle cell disease, and Haemophilus influenzae has become rare since widespread vaccination. Streptococcus species occur but are less frequent.

Question 35Orthopaedic Surgery

A 47-year-old woman has a firm, slowly enlarging mass in the proximal tibia. Radiographs show a lytic lesion with a sclerotic margin and no periosteal reaction. Which feature most supports a benign rather than malignant process?

  1. Presence of a soft-tissue mass
  2. Narrow zone of transition with sclerotic rim Correct answer.
  3. Cortical breakthrough
  4. Wide zone of transition

Explanation

A narrow zone of transition with a well-defined sclerotic margin indicates slow growth and a benign process. Malignant lesions grow rapidly, producing a wide zone of transition, cortical destruction, and aggressive periosteal reactions such as Codman triangle or sunburst patterns. Soft-tissue extension also favors malignancy.

Question 36Orthopaedic Surgery

A 55-year-old man develops a deep vein thrombosis after total knee arthroplasty. Which prophylaxis strategy is most effective in reducing this complication?

  1. Aspirin alone started after discharge
  2. Mechanical compression alone without pharmacologic agents
  3. Bed rest for the first 48 hours after surgery
  4. Combined pharmacologic prophylaxis with early mobilization Correct answer.

Explanation

Risk of venous thromboembolism after major lower limb arthroplasty is reduced by pharmacologic prophylaxis, often with low-molecular-weight heparin or a direct oral anticoagulant, combined with mechanical measures and early mobilization. Bed rest and mechanical prophylaxis alone are less effective.

Question 37Orthopaedic Surgery

A 28-year-old woman has a complete Achilles tendon rupture while playing badminton. Which examination finding best supports the diagnosis?

  1. Positive anterior drawer of the ankle
  2. Positive Thompson squeeze test with absent plantarflexion Correct answer.
  3. Inability to dorsiflex the ankle
  4. Tenderness over the medial malleolus

Explanation

In a complete Achilles rupture, squeezing the calf fails to produce plantarflexion because the musculotendinous unit is discontinuous, which is the Thompson test. A palpable gap may also be present. Ankle dorsiflexion is preserved because it is driven by the anterior compartment muscles.

Question 38Orthopaedic Surgery

A 62-year-old man has lumbar spinal stenosis with neurogenic claudication. Which clinical feature best distinguishes this from vascular claudication?

  1. Absent pedal pulses
  2. Symptoms relieved by standing still
  3. Symptoms relieved by leaning forward or sitting Correct answer.
  4. Symptoms worse with walking uphill

Explanation

Neurogenic claudication from lumbar stenosis is classically relieved by lumbar flexion, such as leaning forward over a shopping cart or sitting, because flexion increases the spinal canal diameter. Vascular claudication is relieved simply by standing still and is not position dependent. Pedal pulses are typically normal in spinal stenosis.

Question 39Orthopaedic Surgery

A 35-year-old man has a displaced transverse patella fracture with a disrupted extensor mechanism. Which treatment is most appropriate?

  1. Patellectomy
  2. Tension-band wiring or screw fixation with repair of the retinaculum Correct answer.
  3. Total knee arthroplasty
  4. Cylinder cast immobilization alone

Explanation

Displaced patella fractures with loss of active extension require operative fixation to restore the extensor mechanism and articular surface. Tension-band wiring or screw constructs are standard for transverse patterns. Nonoperative treatment is reserved for undisplaced fractures with an intact extensor mechanism.

Question 40Orthopaedic Surgery

Which statement about the anatomy of the rotator cuff is most accurate?

  1. The infraspinatus and teres minor are external rotators inserting on the greater tuberosity Correct answer.
  2. The supraspinatus tendon inserts on the lesser tuberosity
  3. The long head of the biceps passes through the subscapular recess
  4. The subscapularis is a primary external rotator of the shoulder

Explanation

The infraspinatus and teres minor arise from the posterior scapula and insert on the greater tuberosity, acting as external rotators. The supraspinatus also inserts on the greater tuberosity, while the subscapularis inserts on the lesser tuberosity and internally rotates. The long head of the biceps runs in the bicipital groove.

Question 41Orthopaedic Surgery

A 45-year-old woman has a Colles fracture with dorsal angulation after a fall. Which deformity is expected on examination?

  1. Radial head subluxation
  2. Dinner-fork deformity with dorsal displacement Correct answer.
  3. Forked appearance caused by volar angulation
  4. Volar displacement of the distal fragment

Explanation

A Colles fracture is a distal radius fracture with dorsal displacement and angulation of the distal fragment, producing the classic dinner-fork deformity. A Smith fracture has volar displacement instead. Radial head subluxation is unrelated to distal radius fractures.

Question 42Orthopaedic Surgery

A 70-year-old woman with osteoporosis sustains a fragility fracture of the distal radius. Which intervention most reduces her risk of subsequent fractures?

  1. Annual radiographs of the wrist
  2. Calcium supplementation alone
  3. Activity restriction to avoid falls
  4. Bisphosphonate therapy with vitamin D and calcium Correct answer.

Explanation

After a fragility fracture, pharmacologic treatment with an antiresorptive agent such as a bisphosphonate, together with vitamin D and calcium, substantially reduces the risk of further fractures. Calcium alone is insufficient. Activity restriction does not treat underlying bone loss and may worsen function.

Question 43Orthopaedic Surgery

A 25-year-old man has a posterior hip dislocation after a dashboard injury. Which structure is most at risk of injury because of its blood supply?

  1. Femoral neck, from the artery of the ligamentum teres
  2. Greater trochanter, from the lateral circumflex femoral artery
  3. Lesser trochanter, from the obturator artery
  4. Femoral head, from disruption of the medial circumflex femoral artery Correct answer.

Explanation

Posterior hip dislocation can stretch and tear the medial circumflex femoral artery, which provides the dominant blood supply to the femoral head through the retinacular vessels. This can lead to avascular necrosis, particularly with delayed reduction. The artery of the ligamentum teres contributes only a minor supply.

Question 44Orthopaedic Surgery

A 50-year-old man has a complete spinal cord injury at the T6 level. Which autonomic complication should be anticipated during episodes of bladder distension?

  1. Loss of pain sensation below the lesion
  2. Hyperreflexia limited to the lower limbs
  3. Neurogenic shock with hypotension and bradycardia
  4. Autonomic dysreflexia with hypertension and bradycardia Correct answer.

Explanation

Autonomic dysreflexia occurs with cord lesions above T6, where a noxious stimulus such as bladder distension triggers sympathetic outflow causing severe hypertension, often with reflex bradycardia and headache. It is a medical emergency requiring removal of the stimulus. Neurogenic shock occurs acutely after injury, not with bladder distension.

Question 45Orthopaedic Surgery

A 30-year-old man has a closed, displaced midshaft tibia and fibula fracture with intact compartments and good alignment after reduction. Which treatment is most appropriate?

  1. Nonoperative casting with immediate full weight bearing
  2. Intramedullary nailing Correct answer.
  3. Above-knee amputation
  4. External fixation for six weeks

Explanation

Intramedullary nailing is the standard treatment for displaced tibial shaft fractures because it provides stable fixation, allows early motion, and has a lower infection rate than open plating. It permits controlled weight bearing and reliable union. Casting with immediate full weight bearing risks displacement and nonunion.

Question 46Orthopaedic Surgery

A 60-year-old woman has a painful, swollen knee and a history of recent dental work. Joint aspiration shows a white cell count of 25,000/mm3 with 85 percent neutrophils. Which diagnosis is most likely?

  1. Osteoarthritis flare
  2. Gouty arthritis
  3. Septic arthritis Correct answer.
  4. Hemarthrosis

Explanation

A joint aspirate with a white cell count above 50,000/mm3 and a high neutrophil percentage strongly suggests septic arthritis; counts in the 25,000 to 50,000 range are indeterminate but concerning in the right clinical setting. Recent bacteremia sources such as dental work support hematogenous seeding. Gram stain and culture guide treatment.

Question 47Orthopaedic Surgery

A 14-year-old boy has anterior knee pain that worsens with activity and improves with rest. Examination shows tenderness over the tibial tubercle. Which diagnosis is most likely?

  1. Osgood-Schlatter disease Correct answer.
  2. Patellar dislocation
  3. Meniscal tear
  4. Sinding-Larsen-Johansson syndrome

Explanation

Osgood-Schlatter disease is traction apophysitis at the tibial tubercle insertion of the patellar tendon, common in active adolescents during growth spurts. It causes localized tenderness over the tibial tubercle with pain on resisted knee extension. Sinding-Larsen-Johansson syndrome affects the inferior pole of the patella instead.

Question 48Orthopaedic Surgery

A 40-year-old man has a forearm fracture treated with a cast. He develops severe pain, pallor, and paresthesias in the hand. Which diagnosis should be suspected first?

  1. Acute compartment syndrome of the forearm Correct answer.
  2. Complex regional pain syndrome
  3. Carpal tunnel syndrome
  4. Radial nerve palsy

Explanation

The combination of pain out of proportion, pallor, and paresthesias after cast application suggests acute compartment syndrome or vascular compromise in the forearm. Immediate removal of constricting material and urgent evaluation are required. Delay risks Volkmann ischemic contracture.

Question 49Orthopaedic Surgery

A 55-year-old woman has a distal radius fracture with a volar tilt of -20 degrees on the lateral radiograph. What does this measurement indicate?

  1. Excessive volar angulation
  2. Dorsal angulation of the distal fragment Correct answer.
  3. Normal volar tilt
  4. Neutral alignment

Explanation

Normal distal radius volar tilt is about 11 degrees. A value of -20 degrees indicates dorsal angulation of the distal fragment, typical of a Colles-type fracture. This malalignment affects wrist biomechanics and may require reduction or operative fixation.

Question 50Orthopaedic Surgery

A 68-year-old man has a chronic rotator cuff tear with superior migration of the humeral head and pseudoparalysis. Which treatment is most appropriate?

  1. Corticosteroid injection and observation
  2. Physical therapy alone
  3. Arthroscopic subacromial decompression alone
  4. Reverse total shoulder arthroplasty Correct answer.

Explanation

In older patients with a chronic, irreparable rotator cuff tear and pseudoparalysis, reverse total shoulder arthroplasty restores elevation by using the deltoid as the motor and compensating for cuff deficiency. Decompression alone does not address the loss of active elevation. Therapy and injections are supportive but do not restore function.