APEA 3P 2026/2027 Actual Exam (Orthopedics - APEA
Testbank) - Questions & Answers with In-Depth Explanations |
Complete A+ Guide - 200 Questions and Answers Already
Graded A+ Premium Exam Tested And Verified
Subject Area Orthopedics - Advanced Physical Examination, Diagnosis, and Clinical
Reasoning
Description This rigorous examination assesses mastery of orthopedic assessment, differential
diagnosis, evidence-based management, and integration of musculoskeletal
pathophysiology. Questions are designed to test advanced clinical reasoning,
interpretation of diagnostic studies, and application of current guidelines at the
level of a practicing clinician or senior doctoral student.
Expected Grade A+
Total Questions 200
Duration 3 hours
Learning Outcomes 1. Differentiate subtle orthopedic pathologies through advanced physical
examination maneuvers and imaging interpretation.
2. Integrate pathophysiological mechanisms to explain clinical presentations and
guide management decisions.
3. Apply evidence-based, current guidelines to the diagnosis, treatment, and
referral of complex orthopedic conditions.
4. Analyze atypical presentations and avoid common diagnostic pitfalls in
musculoskeletal medicine.
Accreditation Meets or exceeds the standards for advanced clinical examinations at accredited
US universities (e.g., Ivy League, top-tier R1 institutions) and aligns with the core
competencies for nurse practitioners, physician assistants, and medical residents.
Page 1
,1. A patient presents with atraumatic shoulder pain and weakness with forward
flexion. On exam, the scapula wings laterally during active forward elevation. Which
of the following is the most specific physical examination finding to differentiate long
thoracic nerve palsy from spinal accessory nerve palsy?
A. Scapular winging that increases with arm abduction beyond 90 degrees
B. Winging that is more pronounced with pushing against a wall (wall push-up test)
C. Inability to shrug the shoulder against resistance
D. Winging that decreases when the arm is placed in internal rotation
Answer: C. Inability to shrug the shoulder against resistance
In long thoracic nerve palsy, the serratus anterior is weak, causing winging that is
accentuated with forward flexion and wall push-ups, but the trapezius (innervated by
spinal accessory nerve) remains strong, allowing a normal shoulder shrug. In spinal
accessory nerve palsy, the trapezius is weak, causing inability to shrug, and the scapula
wings with abduction. Option C is the most specific differentiating finding.
2. A patient with chronic knee pain and a history of patellar dislocation reports a
sensation of the knee 'giving way' during stair descent. On exam, the J-sign is
present, and there is apprehension with lateral patellar translation at 30 degrees of
flexion. What is the most appropriate next step in management after failed
conservative therapy?
A. Arthroscopic lateral release alone
B. Medial patellofemoral ligament reconstruction with tibial tubercle osteotomy if TT-TG
distance >20 mm
C. Proximal realignment with vastus medialis obliquus advancement
D. Patellar tendon realignment (Roux-Goldthwait procedure)
Answer: B. Medial patellofemoral ligament reconstruction with tibial tubercle
osteotomy if TT-TG distance >20 mm
For recurrent patellar instability with a high TT-TG distance (20 mm) after failed
conservative therapy, medial patellofemoral ligament reconstruction combined with
tibial tubercle osteotomy is the gold standard. Lateral release alone (A) does not
address instability. Proximal realignment (C) may be insufficient if bony malalignment
exists. The Roux-Goldthwait procedure (D) is primarily for patellar tendon realignment
in skeletally immature patients.
Page 2
,3. A patient presents with acute onset of severe low back pain radiating to the left
buttock and lateral leg, with numbness over the dorsum of the foot. Straight leg raise
is positive at 30 degrees on the left. Which nerve root is most likely compressed, and
what motor deficit would you expect?
A. L4; weakness of foot inversion
B. L5; weakness of great toe extension and foot dorsiflexion
C. S1; weakness of foot eversion and ankle plantarflexion
D. L3; weakness of hip flexion
Answer: B. L5; weakness of great toe extension and foot dorsiflexion
The dermatomal pattern (dorsum of foot, lateral leg) and reflex (none) point to L5
radiculopathy. The L5 nerve root innervates the extensor hallucis longus (great toe
extension) and tibialis anterior (foot dorsiflexion). L4 (A) affects the medial leg and foot
inversion. S1 (C) affects the lateral foot and ankle jerk. L3 (D) affects the anterior thigh
and hip flexion.
4. A patient with longstanding rheumatoid arthritis presents with acute onset of
severe right knee pain, swelling, and inability to bear weight. There is no history of
trauma. Joint aspiration reveals 85,000 WBCs/L (85% neutrophils), no crystals, and
Gram stain shows no organisms. What is the most likely diagnosis, and what is the
next step in management?
A. Pseudogout; treat with colchicine
B. Septic arthritis; start empiric antibiotics and await culture results
C. Acute flare of rheumatoid arthritis; increase disease-modifying antirheumatic drug dose
D. Hemarthrosis; perform arthroscopic drainage
Answer: B. Septic arthritis; start empiric antibiotics and await culture results
Inflammatory arthritis patients are at high risk for septic arthritis, which presents with
acute monoarthritis, high WBC count (>50,000, predominantly neutrophils), and
negative crystals. Gram stain can be negative in up to 50% of cases. Empiric antibiotics
should be started immediately after cultures. Pseudogout (A) would show calcium
pyrophosphate crystals. Rheumatoid flare (C) typically has lower WBC counts.
Hemarthrosis (D) is unlikely without trauma.
Page 3
, 5. A patient with insidious onset of bilateral hand stiffness and pain that improves
with activity, along with swelling of the proximal interphalangeal joints and
metacarpophalangeal joints, is found to have positive rheumatoid factor and
anti-CCP antibodies. Which of the following is the most appropriate first-line
disease-modifying antirheumatic drug (DMARD) according to current guidelines?
A. Hydroxychloroquine monotherapy
B. Methotrexate with folic acid supplementation
C. Tumor necrosis factor inhibitor (e.g., adalimumab) as monotherapy
D. Leflunomide with a loading dose
Answer: B. Methotrexate with folic acid supplementation
Current ACR/EULAR guidelines recommend methotrexate as the first-line DMARD
for moderate-to-high disease activity rheumatoid arthritis due to its efficacy, safety, and
cost. Hydroxychloroquine (A) is used for mild disease. Biologics (C) are reserved for
inadequate response to methotrexate. Leflunomide (D) is an alternative but not
first-line.
6. A patient presents with a painful, swollen left knee after a twisting injury. On
exam, the knee is locked in 30 degrees of flexion and cannot be fully extended.
McMurray test is positive for a click with pain. Which of the following is the most
likely diagnosis, and what is the definitive management?
A. Anterior cruciate ligament tear; reconstruction with hamstring autograft
B. Medial meniscus bucket-handle tear; arthroscopic partial meniscectomy or repair
C. Posterior cruciate ligament tear; conservative management with quadriceps strengthening
D. Patellar dislocation; closed reduction and immobilization
Answer: B. Medial meniscus bucket-handle tear; arthroscopic partial
meniscectomy or repair
A bucket-handle tear of the medial meniscus often causes mechanical locking (inability
to fully extend) and a positive McMurray test. Arthroscopic surgery is indicated to
unlock the knee and either repair (if in vascular zone) or partial meniscectomy. ACL
tear (A) typically presents with hemarthrosis and anterior drawer sign, not locking.
PCL tear (C) presents with posterior sag. Patellar dislocation (D) presents with a
laterally displaced patella.
Page 4
Testbank) - Questions & Answers with In-Depth Explanations |
Complete A+ Guide - 200 Questions and Answers Already
Graded A+ Premium Exam Tested And Verified
Subject Area Orthopedics - Advanced Physical Examination, Diagnosis, and Clinical
Reasoning
Description This rigorous examination assesses mastery of orthopedic assessment, differential
diagnosis, evidence-based management, and integration of musculoskeletal
pathophysiology. Questions are designed to test advanced clinical reasoning,
interpretation of diagnostic studies, and application of current guidelines at the
level of a practicing clinician or senior doctoral student.
Expected Grade A+
Total Questions 200
Duration 3 hours
Learning Outcomes 1. Differentiate subtle orthopedic pathologies through advanced physical
examination maneuvers and imaging interpretation.
2. Integrate pathophysiological mechanisms to explain clinical presentations and
guide management decisions.
3. Apply evidence-based, current guidelines to the diagnosis, treatment, and
referral of complex orthopedic conditions.
4. Analyze atypical presentations and avoid common diagnostic pitfalls in
musculoskeletal medicine.
Accreditation Meets or exceeds the standards for advanced clinical examinations at accredited
US universities (e.g., Ivy League, top-tier R1 institutions) and aligns with the core
competencies for nurse practitioners, physician assistants, and medical residents.
Page 1
,1. A patient presents with atraumatic shoulder pain and weakness with forward
flexion. On exam, the scapula wings laterally during active forward elevation. Which
of the following is the most specific physical examination finding to differentiate long
thoracic nerve palsy from spinal accessory nerve palsy?
A. Scapular winging that increases with arm abduction beyond 90 degrees
B. Winging that is more pronounced with pushing against a wall (wall push-up test)
C. Inability to shrug the shoulder against resistance
D. Winging that decreases when the arm is placed in internal rotation
Answer: C. Inability to shrug the shoulder against resistance
In long thoracic nerve palsy, the serratus anterior is weak, causing winging that is
accentuated with forward flexion and wall push-ups, but the trapezius (innervated by
spinal accessory nerve) remains strong, allowing a normal shoulder shrug. In spinal
accessory nerve palsy, the trapezius is weak, causing inability to shrug, and the scapula
wings with abduction. Option C is the most specific differentiating finding.
2. A patient with chronic knee pain and a history of patellar dislocation reports a
sensation of the knee 'giving way' during stair descent. On exam, the J-sign is
present, and there is apprehension with lateral patellar translation at 30 degrees of
flexion. What is the most appropriate next step in management after failed
conservative therapy?
A. Arthroscopic lateral release alone
B. Medial patellofemoral ligament reconstruction with tibial tubercle osteotomy if TT-TG
distance >20 mm
C. Proximal realignment with vastus medialis obliquus advancement
D. Patellar tendon realignment (Roux-Goldthwait procedure)
Answer: B. Medial patellofemoral ligament reconstruction with tibial tubercle
osteotomy if TT-TG distance >20 mm
For recurrent patellar instability with a high TT-TG distance (20 mm) after failed
conservative therapy, medial patellofemoral ligament reconstruction combined with
tibial tubercle osteotomy is the gold standard. Lateral release alone (A) does not
address instability. Proximal realignment (C) may be insufficient if bony malalignment
exists. The Roux-Goldthwait procedure (D) is primarily for patellar tendon realignment
in skeletally immature patients.
Page 2
,3. A patient presents with acute onset of severe low back pain radiating to the left
buttock and lateral leg, with numbness over the dorsum of the foot. Straight leg raise
is positive at 30 degrees on the left. Which nerve root is most likely compressed, and
what motor deficit would you expect?
A. L4; weakness of foot inversion
B. L5; weakness of great toe extension and foot dorsiflexion
C. S1; weakness of foot eversion and ankle plantarflexion
D. L3; weakness of hip flexion
Answer: B. L5; weakness of great toe extension and foot dorsiflexion
The dermatomal pattern (dorsum of foot, lateral leg) and reflex (none) point to L5
radiculopathy. The L5 nerve root innervates the extensor hallucis longus (great toe
extension) and tibialis anterior (foot dorsiflexion). L4 (A) affects the medial leg and foot
inversion. S1 (C) affects the lateral foot and ankle jerk. L3 (D) affects the anterior thigh
and hip flexion.
4. A patient with longstanding rheumatoid arthritis presents with acute onset of
severe right knee pain, swelling, and inability to bear weight. There is no history of
trauma. Joint aspiration reveals 85,000 WBCs/L (85% neutrophils), no crystals, and
Gram stain shows no organisms. What is the most likely diagnosis, and what is the
next step in management?
A. Pseudogout; treat with colchicine
B. Septic arthritis; start empiric antibiotics and await culture results
C. Acute flare of rheumatoid arthritis; increase disease-modifying antirheumatic drug dose
D. Hemarthrosis; perform arthroscopic drainage
Answer: B. Septic arthritis; start empiric antibiotics and await culture results
Inflammatory arthritis patients are at high risk for septic arthritis, which presents with
acute monoarthritis, high WBC count (>50,000, predominantly neutrophils), and
negative crystals. Gram stain can be negative in up to 50% of cases. Empiric antibiotics
should be started immediately after cultures. Pseudogout (A) would show calcium
pyrophosphate crystals. Rheumatoid flare (C) typically has lower WBC counts.
Hemarthrosis (D) is unlikely without trauma.
Page 3
, 5. A patient with insidious onset of bilateral hand stiffness and pain that improves
with activity, along with swelling of the proximal interphalangeal joints and
metacarpophalangeal joints, is found to have positive rheumatoid factor and
anti-CCP antibodies. Which of the following is the most appropriate first-line
disease-modifying antirheumatic drug (DMARD) according to current guidelines?
A. Hydroxychloroquine monotherapy
B. Methotrexate with folic acid supplementation
C. Tumor necrosis factor inhibitor (e.g., adalimumab) as monotherapy
D. Leflunomide with a loading dose
Answer: B. Methotrexate with folic acid supplementation
Current ACR/EULAR guidelines recommend methotrexate as the first-line DMARD
for moderate-to-high disease activity rheumatoid arthritis due to its efficacy, safety, and
cost. Hydroxychloroquine (A) is used for mild disease. Biologics (C) are reserved for
inadequate response to methotrexate. Leflunomide (D) is an alternative but not
first-line.
6. A patient presents with a painful, swollen left knee after a twisting injury. On
exam, the knee is locked in 30 degrees of flexion and cannot be fully extended.
McMurray test is positive for a click with pain. Which of the following is the most
likely diagnosis, and what is the definitive management?
A. Anterior cruciate ligament tear; reconstruction with hamstring autograft
B. Medial meniscus bucket-handle tear; arthroscopic partial meniscectomy or repair
C. Posterior cruciate ligament tear; conservative management with quadriceps strengthening
D. Patellar dislocation; closed reduction and immobilization
Answer: B. Medial meniscus bucket-handle tear; arthroscopic partial
meniscectomy or repair
A bucket-handle tear of the medial meniscus often causes mechanical locking (inability
to fully extend) and a positive McMurray test. Arthroscopic surgery is indicated to
unlock the knee and either repair (if in vascular zone) or partial meniscectomy. ACL
tear (A) typically presents with hemarthrosis and anterior drawer sign, not locking.
PCL tear (C) presents with posterior sag. Patellar dislocation (D) presents with a
laterally displaced patella.
Page 4
