Multiple Choice Questions
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39. Which of the following structures is disrupted in patients with an acute medial subtalar dislocation:
A) Lisfranc ligament
B) Long plantar ligament
E) Anterior talofibular ligament
C) Talocalcaneal ligament
D) Calcaneonavicular ligament
38. A 22-year-old collegiate basketball player presents for treatment of a stress fracture of the base of the fifth metatarsal at the junction of the metaphysis and diaphysis. The fracture was treated operatively, and the patient returned to playing basketball. Three months later, it was apparent that a repeat fracture was present. The fracture was treated with screw removal and a repeat screw fixation. Four months later, after a successful basketball season, he sustained a repeat stress fracture of the metatarsal. On examination, he has a mild cavovarus foot configuration with normal ankle range of motion. Inversion is 15° and eversion is 5°. The base of the fifth metatarsal is prominent.
The most likely cause for the repeat fracture is:
A) Abnormal ankle biomechanics
B) Chronic unrecognized ankle instability
C) A varus heel
D) Bone sclerosis of the fifth metatarsal base
E) Chronic avascularity of the fifth metatarsal base
37. A 23-year-old man sustains an injury to his foot when falling off a ladder. The foot is grossly twisted inward, and the talonavicular joint is dislocated with the talar head penetrating through the extensor brevis muscle. The dislocation is reduced.
The likelihood of this resulting in avascular necrosis of the talus is:
36. A 43-year-old construction worker sustained a work-related injury to his foot 7 months ago. He was initially treated with cast immobilization and limited weight bearing. He has lateral foot pain and inability to walk comfortably. He has limited walking endurance. Upon examination, pain is present laterally along the course of the peroneal tendons, and no motion of the subtalar joint is present.
The recommendation is:
A) Physical therapy followed by job modification
B) Shoe modification and orthotic support
C) Nonsteroidal medication, and ankle foot orthoses
D) Injection of the peroneal tendons with cortisone
E) Subtalar arthrodesis
35. A patient presents for treatment in your emergency department following an injury that he sustained 4 hours earlier. His foot was run over by a piece of heavy industrial equipment. On examination, he has pain in the foot, a displaced fracture of the second metatarsal, a 3-cm area of severe contusion over the forefoot, and numbness of the dorsal surface of the foot.
The next examination that you recommend is:
A) Measurement of compartment pressures in the foot
B) Magnetic resonance imaging of the tarsometatarsal joint
C) Computerized axial tomography of the midfoot
D) Doppler evaluation of the foot pulses
E) Laser Doppler flowmetry
34. 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%
33. A glenoid profile radiograph of a 21-year-old male rugby player with multiple traumatic anterior shoulder dislocations is presented:
Which of the following is the preferred treatment:
A) Sling for a period of 6 weeks
B) Physiotherapy emphasizing strengthening of dynamic shoulder stabilizers
C) Capsular shift
D) Bankart reconstruction
E) Coracoid transfer procedure
32. All of the following factors have been used to explain why exertional compartment syndrome is more common in the lower leg when compared to the upper arm except:
A) Muscle straining that occurs in the lower leg seldom occurs in the upper arm.
B) Muscle compartments of the upper arm blend anatomically with the shoulder girdle making it less likely that bleeding would be confined to the compartment of the upper extremity.
C) The brachialis fascia is less taut than the crural fascia.
D) The brachialis fascia yields more to increased intracompartmental pressure as compared to the crural fascia.
E) The pulse pressure of the lower extremity is greater than that of the upper extremity.
31. In the setting of chronic anterior cruciate ligament (ACL) deficiency, which of the following meniscal tear patterns is most common:
A) Peripheral posterior horn tears of the medial meniscus
B) Peripheral posterior horn tears of the lateral meniscus
C) Peripheral anterior horn tears of the medial meniscus
D) Peripheral anterior horn tears of the lateral meniscus
E) Central posterior horn tears of the medial meniscus
30. A 15-year-old female volleyball player twisted her knee while planting her foot. She states she felt her knee give out. She had immediate swelling and was unable to continue participation. She denies hearing a pop. Physical examination reveals a large effusion with a range of motion from full extension to 80° flexion. She has marked tenderness along the medial retinaculum of her knee. She has no joint line tenderness. There is no pathologic laxity involving the collateral or cruciate ligaments.
The most likely diagnosis is:
A) Partial anterior cruciate ligament tear
B) Posterior cruciate ligament tear
C) Medial collateral ligament sprain
D) Patellar subluxation
E) Peripheral medial meniscal tear
29. A 16-year-old male high school football player was making a tackle when he felt sudden pain in his right long finger. He has swelling and tenderness along the volar aspect of the injured digit. He is unable to actively flex the distal interphalangeal joint of the injured digit. Radiographs are negative for fracture.
Recommended treatment should include:
B) Splinting of the distal interphalangeal joint in extension
C) Splinting of the distal interphalangeal joint in flexion
D) Immediate active range of motion exercises
E) Surgical repair
28. 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
27. After landing awkwardly on his flexed knee, a 22-year-old basketball player has immediate onset of pain and difficulty bearing weight. With the knee flexed 30°, examination reveals increased varus, external rotation, and posterior translation which decreases when the knee is flexed to 90°.
The patient most likely has injured what structures:
A) Posterolateral complex
B) Posterolateral complex and posterior cruciate ligament
C) Posterior cruciate ligament
D) Lateral collateral ligament
E) Posterior cruciate ligament and medial collateral ligament
26. The most common cause of an indirect injury to the Lisfranc joint occurs through which mechanism:
C) Axial load of a plantarflexed foot
D) Supination and external rotation
E) Pronation and adduction
25. Distal one-third clavicle fractures constitute what percentage of all clavicle fractures:
24. A 25-year-old soccer player sustained a closed tibia fracture when his planted leg was struck by another player.
Which of the following would be the most common fracture pattern and mechanism:
A) Short spiral fracture — torsion
B) Oblique fracture — uneven bending
C) Transverse fracture — pure bending
D) Oblique fracture with a butterfly fragment — bending and compression
E) Segmental fracture — four-point bending
23. Following a traumatic nerve injury, in which time period would a physician find denervation activity with fibrillation and positive sharp waves in the affected muscles:
A) Immediately following the injury
B) 7 to 10 days following injury
C) 2 to 5 weeks following injury
D) 6 to 8 weeks following injury
E) 12 weeks following injury
22. 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.
21. 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
20. 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
19. A 46y old man fell 20 feet and sustained the injury shown in the figure attached. The injury is closed; however, the soft tissues are swollen and ecchymotic with blisters.
The most appropriate initial management should consist of
A) long leg cast.
B) a short leg cast.
C) immediate open reduction and internal fi xation.
D) a temporizing spanning external fi xator.
E) primary ankle fusion.
18. A collegiate golfer sustained a hook of the hamate #. After 12 wks of splinting and therapy, the hand is still symptomatic.
What is the most appropriate management to allow return to competitive activity?
A) Continued observation
B) Open reduction and internal fi xation of the fracture
C) Excision of the hook of the hamate
D) Carpal tunnel release
E) Guyon canal release
17. 20y old man sustained a closed tibial # and is treated with a reamed intramedullary nail.
What is the most common complication associated with this treatment?
D) Knee pain
E) Compartment syndrome
16. What is the most likely complication following treatment of the humeral shaft fracture shown in the figure attached?
B) Shoulder pain
D) Elbow injury
E) Radial nerve injury
15. 36y woman sustained a tarsometatarsal joint fracture-dislocation in a motor vehicle accident. The patient is treated with ORIF.
What is the most common complication?
A) Posttraumatic arthritis
C) Fixation failure
14. What is the most appropriate indication for replantation in an otherwise healthy 35y old man?
A) Isolated transverse amputation of the thumb through the middle of the nail bed
B) Isolated transverse amputation of the index fi nger through the proximal phalanx
C) Isolated transverse amputation of the ring fi nger through the proximal phalanx
D) Isolated transverse amputation of the hand at the level of the wrist
E) Forearm amputation with a 10-hour warm ischemia time
13. 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
12. In patients with displaced radial neck fractures treated with ORIF with a plate and screws, the plate must be limited to what surface of the radius to avoid impingement on the proximal ulna?
A) 2 cm distal to the articular surface of the radial head
B) 1 cm distal to the articular surface of the radial head
C) Within a 90° arc or safe zone
D) Within a 120° arc or safe zone
E) Within a 180° arc or safe zone
11. 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
10. Regarding an open tibial shaft fracture in a patient presenting to a hospital without onsite plastic surgery available. The best cause of an action is:
A) Resuscitation of the patient and early (within 6 hours) debridement of the wound without stabilisation and Plastics review of the patient at an elective clinic
B) Resuscitation and early transfer of the patient to an appropriate specialist centre for combined Plastics and Orthopaedic intervention
C) Resuscitation of the patient, debridement and skeletal stabilisation with no plan in place for definitive soft tissue coverage
D) Washout with 2L saline and hydrogen peroxide within resus and plan for formal debridement by Plastic surgeons available within 24 hours
E) Debridement and skeletal stabilisation at local centre with plan in place for transfer to centre with Plastics for definitive soft tissue coverage within 72 hours
9. A 34 year old male is being resuscitated in Accident & Emergency department following a road traffic accident.
What is the most important test to assess adequacy of fluid replacement resuscitation?
A) Lactic acid < 2 mmol/L
B) Urine output of 0.25 ml/kg/hr
C) Stability of Glasgow Coma Score
D) Decreased pulse pressure
E) Increased heart rate
8. A 25 years old man was assaulted with a knife in the axillary region. He presented with weakness of shoulder abduction. Which nerve branch of the brachial plexus is most likely to have been transacted?
A) Thoracodorsal nerve of the posterior cord
B) Musculocutaneus nerve of the lateral cord
C) Ulnar nerve of the medial cord
D) Suprascapular nerve of the superior trunk
E) Axillary nerve of the posterior cord
7. A 55 -years-old man sustains an open fracture of the radius which was treated with open reduction and internal fixation. This operation was complicated with radial nerve injury which did not improve at follow up.
Which of the following treatments will best restore function?
A)Transfer of pronator teres to extensor carpi radialis brevis
B)Transfer of deltoid to triceps
C)Transfer of the flexor carpi radialis to extensor digitorum and the palmaris longus to the extensor pollicis longus
D)Transfer of pectoralis major to biceps
E)Transfer of common flexors tendon to the humerus
6. A football player fell on his flexed knee with the foot in plantar flexion. On examination, he has a positive quadriceps active test .
Which knee ligament in most likely injured in this patient?
A) Anterior cruciate ligament (ACL)
B) Posterior cruciate ligament (PCL)
C) Lateral collateral ligament (LCL)
D) Medial collateral ligament (MCL)
E) Posterolateral corner complex (PLC)
5. A 13 year-old boy sustains a tibia fracture following a fall from a swing. The fracture is reduced and placed in an above knee back slab in the accident and emergency department.
What is considered to be the most important early indicating symptom of a developing compartment syndrome of the leg?
A) Decreased sensation in the foot
B) Pain out of proportion to injury
C) Decreased pulses in the foot
D) Inability to move the toes
E) Pale appearance of the foot
4. A 33 years old female basketball player felt a pop and sustained non contact pivoting injury when to her knee when she landed from a rebound. She is complaining of knee pain immediate clinical examination shows haemoarthrosis.
What is the most likely damaged structure?
A) Patella dislocation
B) Anterior cruciate ligament tear
C) Posterior cruciate ligament tear
D) Posterolateral complex
E) Lateral collateral ligament
3 . A 28 years old man was involved in a motorbike road traffic accident sustaining head injury resulting in a coma and hip fracture.
Indomethacin is indicated here to prevent which complication?
A) Non union
C) Vascular compromise
D) Pressure ulcers
E) Heterotopic ossification
2. 25 years old rugby player sustained posterior hip dislocation when several players landed on his back with the hip flexed to 90 degrees, resulting in posterior hip dislocation.
What is the most common complication of hip dislocation?
A) Posttraumatic arthritis
B) Avascular necrosis
C) Sciatic nerve injury
D) Recurrent dislocation
E) Femoral artery occlusion