Multiple Choice Questions
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65. An 11-year-old boy sustains a fall while jumping on a trampoline. He has moderate back pain, an L-5 radiculopathy, and weakness of the right extensor hallucis longus. Radiographs and a computerized tomography scan of the lumbar spine demonstrate a slipped vertebral apophysis.
The recommended treatment is:
A) Laminectomy and excision of annulus and vertebral bony margin
B) Bed rest
C) Thoracolumbosacral orthosis
D) Physical therapy
E) Spinal traction
64. A 12-year-old girl presents to the clinic with scoliosis detected by school screening. Her past medical history includes ophthalmologic observation for Lisch nodules of the iris. She has just started her menstrual periods. On physical exam, she has axillary freckles and normal neurological function. Standing radiographs of the spine illustrate a 32° right thoracic curve from T4 to T10 and rib pencilling. In the sagittal plane, she has a thoracic kyphosis of 30°.
The most likely diagnosis is:
A) Adolescent idiopathic scoliosis
B) Congenital kyphoscoliosis
C) Neurofibromatosis-1 (NF-1)
D) Neurofibromatosis-2 (NF-2)
E) Stickler disease
63. What is the most common site of pelvic avulsion fracture in a skeletally immature athlete?
A) Anterior inferior iliac spine (AIIS)
B) Ischial tuberosity
C) Anterior superior iliac spine (ASIS)
D) Iliac crest
E) Pubic symphysis
62. Which of the following conditions does not occur in the valgus of a 4-year-old child:
A) Physiologic valgus
B) Prior proximal metaphyseal fracture
C) Multiple exostoses
D) Chondroectodermal dysplasia
E) Infantile Blount disease
61. In which muscle does Ely’s test detect spasticity or contracture:
A) Biceps femoris
B) Rectus femoris
60. A 1-year-old patient presents with a pseudarthrosis of the left clavicle. Which of the following conditions is most likely to coexist with pseudarthrosis of the left clavicle:
B) Proteus syndrome
C) Osteogenesis imperfecta
D) Fibrous dysplasia
59. All of the disorders listed below are examples of osteochondrosis except:
A) Legg-Calvé-Perthes disease
B) Scheuermann’s disease
C) Osgood Schlatter disorder
D) Gorham’s disease
E) Blount disease
58. The parameter most often recommended to follow the reciprocal relationship of the femoral head to the acetabulum in patients with cerebral palsy is known as the:
A) Migration index
B) Epiphyseal extrusion index
C) Stulberg index
D) Acetabular index
E) Tonnis index
57. Which population of patients with cerebral palsy is at greatest risk of neuromuscular hip subluxation:
B) Spastic hemiplegics
C) Spastic diplegics
56. Which of the following iliac osteotomies provides the greatest freedom of mobilization of the acetabular segment:
A) Salter osteotomy
B) Pemberton osteotomy
C) Steel osteotomy
D) Chiari osteotomy
E) Ganz osteotomy
55. Which of the following conditions does not have a risk of cervical deformity greater than the general population
B) Larsen syndrome
C) Diastrophic dysplasia
E) Down syndrome
54. In the absence of surgery, which of the following gait parameters in children with cerebral palsy tends to remain static with increasing age:
A) Knee range of motion
B) Ankle range of motion
C) Normalized walking velocity
D) Femoral anteversion
E) Knee stiffness
53. Macrodactyly is associated with all of the following syndromes except:
B) Proteus syndrome
C) Klippel-Trenaunay syndrome
D) Marfan syndrome
E) Multiple enchondromatosis
52. Klippel-Trenaunay syndrome is characterized by cutaneous capillary venous malformation, varicose veins, and which of the following:
A) Multiple enchondromas
B) Multiple osteochondromas
C) Limb hypertrophy
D) Seizure disorder
E) Congenital pseudarthrosis of the tibia
51. Which of the following conditions is least commonly seen in patients with congenital dislocation of the patella:
A) Fibrosis of the vastus lateralis
B) Contracture of the iliotibial band
C) Hypoplasia of the vastus medialis
D) Enlarged patella
E) Flexion contracture
50. A mutation in type II collagen is responsible for all of the following conditions except:
A) Stickler syndrome
B) Spondyloepiphyseal dysplasia congenita
C) Kniest syndrome
D) Strudwick dysplasia
49. According to National Institutes of Health (NIH) criteria, what is the minimum number of 15-mm café-au-lait macules required as a diagnostic criterion for neurofibromatosis in postpubertal patients:
48. The protein neurofibromin normally acts in which of the following ways:
A) Inhibits fibroblast growth factor
B) Promotes proteoglycan assembly
C) Down regulates Ras protein
D) Causes nerve cells to divide
E) Promotes tumor formation
47. What is the histological difference between avascular necrosis of the femoral head in children versus adults:
A) Children have less creeping substitution than adults
B) Children do not demonstrate osseous collapse.
C) Large areas of fibrovascular tissue do not form in children.
D) There is no osteoclastic resorption in children.
E) Children do not have any residual changes after 2 years.
46. Polyostotic fibrous dysplasia is caused by a mutation in which of the following genes:
A) GNAS 1
B) EXT 1
C) Fibroblast growth factor receptor protein
45. The result of treatment of developmental dysplasia of the hip with Salter osteotomy is is worse with which of the following:
A) A higher degree of the dislocation before treatment (Tonnis grade)
C) Higher preoperative acetabular index
D) Increased age at surgery
E) Performing open reduction at a separate surgery than the osteotomy
44. Chronic recurrent multifocal osteomyelitis is caused by which of the following:
A) Staphylococcus epidermidis
C) Spirochetal infection
D) Viral infection
E) No organism has been isolated
43. Which of the following is found less often in children with lumbosacral agenesis as compared to controls:
A) Cervical spine anomalies
B) Maternal diabetes
C) Hip dislocation
D) Spina bifida
E) Genu recurvatum
42. Which of the following by itself is not an indication for surgery in a child with acute hematogenous osteomyelitis:
A) Fever higher than 38.5°
B) Subperiosteal abscess
C) Presence of a sequestrum
D) Intramedullary abscess
E) Adjacent septic arthritis
41. A 13-year-old girl is seen in clinic for bunion. She is asymptomatic but has a hallux valgus angle of 29°, an intermetatarsal angle of 15°, and a medial prominence over the first metatarsal head. The family asks whether anything can be done to prevent future problems with the foot.
A) Osteotomy of the first metatarsal base
B) Hemiepiphyseodesis of the medial physis of the first metatarsal
C) Double osteotomy of the first metatarsal
D) Mitchell osteotomy
E) Shoe modifications if symptoms develop
40. Which of the following symptoms is not characteristic of McCune-Albright’s syndrome:
A) Café-au-lait spots with irregular borders
B) Café-au-lait spots with smooth borders
C) Precocious puberty
D) Diabetes mellitus
39. After the bone age of 15 years, boys will achieve the most growth from which of the following regions:
A) Distal femoral epiphysis
B) Proximal tibial epiphysis
C) Distal tibial epiphysis
D) Ilium and pelvis
38. In evaluating infants for Blount disease, which diagnostic parameter allows correct classification of the greatest number of children:
A) Langenskjold rating
B) Tibiofemoral angle
C) Tibial metaphyseal-diaphyseal (M-D) angle
D) Femoral M-D angle divided by tibial M-D angle
E) Femoral intercondylar distance divided by height
37. Nine days after surgery, a 16-year-old boy with idiopathic scoliosis has a temperature of 39.5° C. Wound aspiration reveals gram-positive cocci in clusters.
Your next step in management is:
A) Begin intravenous cephalosporin and monitor the response
B) Begin intravenous vancomycin and monitor the response
C) Begin hyperbaric oxygen and intravenous antibiotics
D) Open and debride the wound, leaving the instrumentation in place
E) Open and debride the wound, and remove the instrumentation
36. Which of the following events typically occurs first in adolescent girls:
A) Risser sign turning to 1
B) Peak height velocity
D) Skeletal maturity
E) Tanner sign of 3
35. Homeobox genes are best characterized by which of the following descriptions:
A) Homeobox genes regulate fracture healing.
B) Homeobox genes are involved in immune system regulation.
C) Homeobox genes are a series of genes that regulate limb genesis.
D) Homeobox genes regulate spinal development.
E) Homeobox genes regulate vascular invasion of the physis.
34. Which of the following is known about the genetics of multiple hereditary exostosis (MHE):
A) There is no genetic pattern for this condition.
B) MHE follows an x-linked inheritance pattern.
C) MHE follows an autosomal recessive pattern.
D) MHE involves a defect in biosynthesis of heparan sulfate.
E) MHE involves a defect in fibroblast growth factor.
33. Which of the following best predicts the risk of nonaccidental injury in young children who sustain a fracture of the femur:
A) The fracture pattern
B) The location of the fracture
C) The socioeconomic status of the family
D) Whether the child was previously able to walk
E) Coexistence of other disabilities
32. A patient with L4 level myelomeningocele has developed a full-thickness pressure sore on the heel that has a central necrosis and is draining. While undergoing debridement in the local emergency department, the patient develops labored respiration and a nondetectable blood pressure.
The most likely cause is:
A) Latex allergy
B) Aortic dissection
C) Septic shock
D) Spontaneous tension pneumothorax
E) Shunt failure
31. A 12-year-old boy with achondroplasia has a gradual 40° thoracolumbar kyphosis. He is unable to walk more than two blocks. Magnetic resonance imaging reveals spinal stenosis, and the patient is scheduled to undergo posterior decompression from T12-S1.
In addition to this procedure, you recommend:
A) Observation with serial radiographs every 4 months
B) Postoperative brace for 6 months
C) In situ fusion with bone graft
D) Posterior fusion across the kyphosis with instrumentation
E) Anterior corpectomy and fusion of T12
30. Which of the following conditions is not associated with an increased risk of congenital vertical talus?
A) Cerebral palsy
D) Nail patella syndrome
E) Larsen syndrome
29. Pleiotropy is demonstrated by which of the following examples:
A) Patients with osteogenesis imperfecta differ in the number of fractures they have received.
B) Patients with hemophilia A have different target joints.
C) Hurler syndrome is usually not present in prior generations of an affected patient.
D) Some patients with Marfan syndrome have scoliosis or pectus carinatum, while other patients with Marfan syndrome do not.
E) Patients with Ollier disease often have more involvement on one side of the body.
28. Morquio syndrome is caused by a deficiency in:
D) Fibroblast growth factor receptor protein
E) Sulfate transport protein
27. A 12-year-old girl is referred because of a positive school scoliosis screen. She has a curve of 16° from T5 to T12, convex to the right. She also complains of mild back pain over the region of the curve several times per week. Neurologic examination is normal.
Recommended treatment includes:
A) Magnetic resonance imaging
B) Technetium bone scintigraphy with SPECT
C) Treatment with a thoracolumbosacral orthosis
D) Computed tomography of the thoracic spine
E) Home exercises and re-examination in follow-up
26. Which of the following is a true statement regarding the results of surgery for a contracted joint in arthrogryposis:
A) The joint range of motion can easily be doubled.
B) The joint cannot be changed.
C) The beginning and end of the range may change, but the total amount of motion remains about the same.
D) The joint usually becomes stiffer.
E) There is not an indication for such surgery.
25. Which of the following conditions is not associated with an increased risk of congenital vertical talus?
A) Sacral agenesis
B) Cerebral palsy
E) Nail patella syndrome
24. A 6-year-old girl with osteogenesis imperfecta has severe bowing of both femurs. The family is interested in surgery to correct the condition.
This method will give her the longest interval between procedures in the future:
A) Closed osteoclasis and cast application
B) Multiple osteotomies and realignment over a single smooth rod
C) Multiple osteotomies and realignment over parallel rods
D) Multiple osteotomies and realignment over telescoping rods
E) Excision of the abnormal bone and replacement with allograft
23. Prior to treatment, this pathologic finding characterizes clubfoot:
A) The talar head and neck are deviated medially.
B) The dome of the talus is flattened.
C) The navicular is positioned more laterally than normal.
D) The foot has a rocker deformity.
E) The tendoachilles inserts in a more lateral position than normal.
22. A 15-year-old basketball player has mild scoliosis, pes planus, pectus carinatum, and long slender fingers. In order to determine if he has Marfan syndrome and should be allowed to continue playing basketball, it is most useful to order a:
A) Cardiac echo
B) Magnetic resonance image of the lumbosacral spine
C) Slit lamp examination
D) Chest radiograph
E) Dermal fibroblast assay
21. A 12-year-old boy presents to the emergency department after being struck by a car. His only complaint at the time of presentation is right ankle pain. After obtaining an excellent reduction and casting the leg, the risks of a future growth disturbance through the involved physis must be discussed with the family. What are the chances of a significant growth disturbance of his leg:
A) < 1%
B) 2% to 3%
C) 10% to 15%
D) 45% to 55%
E) 80% to 90%
20. Which ancillary test is not helpful in the diagnosis of Charcot-Marie-Tooth disease (CMT):
A) Electromyography (EMG)
B) Nerve conduction velocity (NCV)
C) Nerve biopsy
D) Muscle biopsy
E) Muscle enzymes
19. A 7-year-old boy presents with bilateral high arches. His parents report that they are having difficulty finding shoes that comfortably fit him. The patient denies any foot pain. The father had similar problems with his feet and was diagnosed with a “mild” neurologic condition. On exam, the child has bilateral pes cavus with a supple hindfoot. Treatment of the feet at this time should consist of:
A) Soft tissue procedures alone
B) Soft tissue procedures and calcaneal osteotomy
C) Triple arthrodesis
18. Following tibial eminence fractures in skeletally-immature patients, all of the following sequelae have been described except:
A) Residual anterior cruciate ligament laxity
B) Lengthening of the tibial spine
C) Loss of knee flexion
D) Hypertrophy of the tibial spine
E) Loss of terminal knee extension
17. Placing a highly tensioned soft tissue graft across the open femoral physis during anterior cruciate ligament reconstruction results in which of the following outcomes
A) Premature closure of the physis
B) No growth disturbance
C) Development of femoral varus
D) Development of femoral valgus
E) Femoral overgrowth
16. A genetic mutation accounts for the manifestations of achondroplasia. Which of the following proteins has a genetic mutation that has been linked to achondroplasia:
A) Fibroblast growth factor (FGF) receptor 3
B) Type I collagen
D) Type II collagen
E) Cartilage oligomeric matrix protein (COMP)
15. 13y old boy injured his knee playing basketball and is now unable to bear weight. Examination reveals tenderness and swelling at the proximal anterior tibia, with a normal neurologic examina-ption. AP and lateral radiographs are shown in figures attached.
Management should consist of
B) a long leg cast.
C) fasciotomy of the anterior compartment.
D) open reduction and internal fixation.
E) patellar advancement.
14. A 6y old child sustained a closed nondisplaced proximal tibial metaphyseal fracture 1 year ago. She was treated with a long leg cast with a varus mold, and the fracture healed uneventfully. She now has a 15° valgus deformity.
What is the next step in management?
A) Proximal tibial/fibular osteotomy with acute correction and pin f xation
B) Proximal tibial/fi bular osteotomy with gradual correction and external fi xation
C) MRI of the proximal tibial physis
D) Medial proximal tibial hemiepiphysiodesis
E) Continued observation
13. A 6y old girl is referred for the elbow injury seen in figure atrached. What is the most appropriate treatment?
A) Immobilization in a long arm cast for 3 weeks
B) Immobilization in a long arm cast for 8 weeks
C) Open reduction and immobilization in a long-arm cast for 3 weeks
D) Open reduction and internal fixation with smooth pins
E) Open reduction and internal fixation with a screw
12. A 9y old child sustains a proximal tibial physeal fracture with a hyperextension mechanism.
What structure is at most risk for serious injury?
A) Tibial nerve
B) Popliteal artery
C) Common peroneal nerve
D) Posterior cruciate ligament
E) Popliteus muscle
11. In obstetric Brachial plexus injury, return of which of the following by 3 months is considered an indicator of plexus recovery:
10. An 18 month old boy is brought with clawing deformity of his right hand. The parent’s informed that he was born full term after a difficult delivery by shoulder dystocia. The patient had right clavicle fracture. A week later the parents noticed the child did not flex the fingers of his right hand. After 2 years the child is brought to you. On Examination, his right hand has extension at all the metacarpophalangeal joint of the fingers while his PIP and DIP joints are flexed. His thumb is adducted and is difficult to passively bring it to full abduction. There is obvious wasting of the hand and Forearm. The child is able to move the arm well with no abnormalities of the shoulder, elbow and wrist. There is no evidence of horner’s syndrome, diaphragmatic palsy and absent grasp reflex.
The diagnosis of the boy’s condition is:
A) Erb’s Palsy
B) Cerebrovascular Accident
C) Klumpke’s palsy
D) Ulnar and Median combined nerve injury
9. A 10 year old boy presents with a mobile, soft painless mass over the posteromedial aspect of his knee. MRI Shows a Simple cyst.
How do you manage this patient?
A) Contrast CT
B) Bone Scan
D) Radical Excision
8. The ACL is mostly deficient in which of the following abnormalities:
B) Proximal Femoral Focal Deficiency
C) Congenital Radial Head Dislocation
D) Apert Syndrome
E) Cleidocranial dyslexia
7. Which is most important function that needs to be restored in Brachial plexus injury?
A) Shoulder Abduction
B) Elbow Flexion
C) Shoulder Elevation
D) Wrist Extension
E) Wrist Flexion
6. A mother brought her 7 month old infant with a history congenital dislocation of knee. The infant was previously treated with serial casting in Flexion to 15°.Currently the patient presented with Recurrent Grade III Congenital Dislocation of Knee (CDK).
What is the next step in the treatment?
A) Serial Above knee casting in extension for 4 weeks.
B) Serial above knee casting in Flexion for 4 weeks.
C) Percutaneous Quadriceps recession, followed by above knee casting.
D) Open VY Quadriceps platy, followed by above- knee casting.
E) Arthroscopic ACL Division, followed by above knee casting.
5. A 15 year old boy presents with increasing foot deformity. The boy was diagnosed with cavovarus deformity associated with Charcot Marie Tooth Disease. Coleman block test reveals Correctable Hindfoot deformity and Achilles reflex is diminished bilaterally.
Which procedure is associated with improved clinical outcome in patients with the above described condition?
A) Triple athrodesis
B) Split Tibialis Anterior Transfer to Lateral column
C) Transfer of peroneus brevis to peroneus longus
D) Lateral column lengthening calcaneal osteotomy
E) Posterior tibial tendon transfer through the interosseous membrane to dorsum of the foot
4. A 18 year old male patient presented with progressive foot deformity for one year. Has pain along the lateral border of the foot while walking. His father had similar problems with both feet throughout his life. On examination his foot showed cavo-varus deformity.
Proper management includes evaluating for?
A) Cervical Stenosis
B) Acetabular Dysplasia
D) Hypoplastic thumb
3. A 12-year-old boy presented with the complaints of his knees knocking together and recurrent falls while running. Examination revealed separation of the medial malleoli by 3 inches when standing with the knees in contact with each other and the feet directed forwards.
The probable diagnosis is :
A) Coxa Vara
B) Bilateral Flat foot
C) Genu varum.
D) Talipes calcaneovalgus.
E) Genu Valgum
2. All of the following are treatment for genu valgum excluding :
A) Osteoclasis of Tibia
B) Wedged shoes.
C) Night splints.
D) Mc’Ewans Osteotomy of Femur
1. The clinical features of coxa vara include the following except :
A) Shortening, adduction and eversion of the limb.
B) Raising of the greater trochanter above Nelaton’s line.
C) Limitation of all movements of the hip.
D) Positive Trendelenburg’s sign.
E) Limping and difficulty in kneeling, riding and separating the legs.