,CONTENT
Section 1: General Orthopaedics
Section 2: Shoulder
Section 3: Elbow and Forearm
Section 4: Hand and Wrist
Section 5: Hip and Thigh
Section 6: Knee and Lower Leg
Section 7: Foot and Ankle
Section 8: Spine
Section 9: Pediatric Orthopaedics
,SECTION 1: GENERAL ORTHOPAEDICS — Test
Bank (20 MCQs)
Principles of Musculoskeletal Evaluation (Questions
1–4)
1. [Principles of Musculoskeletal Evaluation] A 67-year-old man presents with
progressive right knee pain for 18 months. He reports stiffness that lasts 10–15
minutes in the morning and pain worsening with activity; exam shows crepitus,
minimal effusion, and varus deformity. Plain radiographs show joint space
narrowing medially and osteophytes. Which finding most strongly supports a
diagnosis of primary osteoarthritis rather than an inflammatory arthropathy?
A. Elevated ESR and CRP
B. Prolonged morning stiffness (>60 minutes)
C. Asymmetric joint space narrowing with osteophyte formation
D. Symmetric small joint involvement (MCP, PIP) with subluxation
Answer: C
Rationale: Primary OA typically presents with activity-related pain, short
morning stiffness, and asymmetric joint space narrowing with osteophyte
formation on imaging. Elevated inflammatory markers and prolonged morning
stiffness (>60 min) point toward inflammatory arthropathies like RA. Small
symmetric MCP/PIP involvement with subluxation is characteristic of RA rather
than OA. The combination of clinical pattern and radiographic osteophytes best
supports OA.
,Key words: osteoarthritis, asymmetric narrowing, osteophytes, morning
stiffness, radiograph
2. [Principles of Musculoskeletal Evaluation] A 34-year-old manual laborer c/o
lateral elbow pain for six months worsened by gripping and resisted wrist
extension. On exam, resisted wrist extension reproduces his pain; passive wrist
flexion with the elbow extended reproduces symptoms. Which physical test is
being described and what structure is most likely involved?
A. Cozen test — common extensor tendon (lateral epicondyle)
B. Mill’s test — common flexor tendon (medial epicondyle)
C. Finkelstein test — abductor pollicis longus and extensor pollicis brevis tendons
D. Tinel test — ulnar nerve at the elbow
Answer: A
Rationale: Resisted wrist extension reproducing lateral elbow pain describes the
Cozen test, indicating involvement of the common extensor tendon at the lateral
epicondyle (tennis elbow). Mill’s test also implicates lateral structures but is
performed by passive stretching. Finkelstein assesses de Quervain’s
tenosynovitis (thumb tendons). Tinel’s sign tests nerve irritation (ulnar nerve)
and is not tendon-specific. The clinical vignette (gripping, resisted extension)
matches lateral epicondylitis.
Key words: lateral epicondylitis, Cozen, resisted wrist extension, common
extensor tendon, tennis elbow
3. [Principles of Musculoskeletal Evaluation] A patient presents after a fall with
immediate knee swelling and inability to bear weight. On exam, Lachman test is
subtly positive, but the patient is very guarded. Plain radiographs show no
,fracture. Which next step best balances diagnostic accuracy and expediency for
confirming an ACL tear in the acute setting?
A. Immediate diagnostic arthroscopy under anesthesia
B. MRI of the knee once acute pain and swelling permit clearer imaging
C. Rely on Lachman and return to clinic in 6 weeks for reassessment
D. Ultrasound of the knee to visualize ACL fibers
Answer: B
Rationale: MRI is the noninvasive imaging modality of choice to confirm ACL
tears and associated intra-articular injuries. While arthroscopy is diagnostic and
therapeutic, it is invasive and not the first-line diagnostic step. Immediate
reliance on a single physical test may miss concurrent injuries; ultrasound is not
reliable for ACL visualization. MRI should be obtained once the patient can
tolerate it (often in the acute setting is still feasible) to guide management
(operative vs nonoperative).
Key words: ACL tear, MRI, Lachman, intra-articular injury, imaging
4. [Principles of Musculoskeletal Evaluation] A 45-year-old woman presents
with low back pain radiating to both legs, new urinary urgency, saddle
paresthesia, and progressive bilateral foot weakness. Which feature on physical
examination most specifically raises concern for cauda equina syndrome
requiring urgent evaluation?
A. Positive straight-leg raise test on the right
B. Unilateral ankle dorsiflexion weakness
C. Loss of anal sphincter tone on rectal exam
D. Hyporeflexia of the patellar reflex
Answer: C
,Rationale: Loss of anal sphincter tone indicates S2–S4 sacral nerve root
compromise and is a specific and urgent sign of cauda equina syndrome, which
requires immediate neurosurgical/orthopaedic evaluation. While SLR, unilateral
weakness, or hyporeflexia can occur with radiculopathy, they are not specific for
cauda equina. Saddle anesthesia and bladder/bowel dysfunction plus decreased
anal tone are red flags for urgent imaging and possible decompression.
Key words: cauda equina, anal sphincter tone, saddle anesthesia, red flag,
urgent MRI
Amputations of the Lower Extremity (Questions 5–
8)
5. [Amputations — Level Selection & Vascular Considerations] A 72-year-old
diabetic patient with peripheral arterial disease has a nonhealing plantar forefoot
ulcer with osteomyelitis limited to the first and second metatarsals despite
revascularization attempts. The limb is otherwise viable proximally. Which
surgical option best balances infection control and preservation of function?
A. Below-knee (transtibial) amputation
B. Syme (ankle disarticulation) amputation
C. Transmetatarsal amputation preserving posterior tibial function
D. Hip disarticulation
Answer: C
Rationale: When infection is limited to the forefoot (metatarsals) and sufficient
viable tissue remains, a transmetatarsal amputation preserves limb length and
plantar-flexion lever arm, improving prosthetic and shoe options and patient
function compared with more proximal levels. Transtibial or ankle disarticulations
are more morbid and used when disease is more proximal or when
,transmetatarsal level cannot be safely healed. Hip disarticulation is excessive and
reserved for catastrophic proximal disease. Optimal level selection balances
infection control and functional preservation.
Key words: transmetatarsal, limb salvage, osteomyelitis, level selection, function
6. [Amputations — Prosthetic & Functional Outcomes] Compared with
transfemoral amputation, which statement best describes the typical functional
and metabolic consequences of a well-healed transtibial (below-knee)
amputation in an otherwise healthy adult?
A. Transtibial amputation requires more energy for ambulation than
transfemoral.
B. Transtibial amputation preserves the knee joint and generally requires less
metabolic cost for ambulation than transfemoral.
C. Transtibial amputees cannot be fit with a modern prosthesis capable of near-
normal gait.
D. Transtibial amputation always results in poorer prosthetic control compared
with transfemoral.
Answer: B
Rationale: Preservation of the native knee (transtibial level) allows better
prosthetic control and typically results in lower metabolic energy expenditure
and superior functional outcomes compared with transfemoral (above-knee)
amputations. Transfemoral amputations generally increase energy cost and
reduce gait efficiency. Modern prostheses can offer good function for transtibial
amputees; thus option B correctly summarizes outcomes.
Key words: transtibial, energy expenditure, knee preservation, prosthetic
function, gait
,7. [Amputations — Neuroma & Pain Management] A patient with a painful
distal tibial stump after below-knee amputation has focal, reproducible
lancinating pain at the stump scar consistent with a neuroma. Which surgical
strategy has shown the most promise to decrease both neuroma pain and
phantom limb pain in contemporary limb salvage practice?
A. Simple traction neurectomy with ligation and skin closure only
B. Primary burying of the nerve end under local fat without reinnervation
C. Targeted muscle reinnervation (TMR) or regenerative peripheral nerve
interface (RPNI) on identified sensory nerves
D. Conservative measures only (analgesics and desensitization) with no surgical
options
Answer: C
Rationale: Contemporary evidence supports targeted muscle reinnervation
(TMR) and regenerative peripheral nerve interface (RPNI) techniques to decrease
neuroma formation and reduce phantom limb pain by providing regenerating
axons a physiologic target, improving pain outcomes compared with simple
traction neurectomy or burial alone. Conservative measures can help but surgical
nerve-targeting techniques are increasingly preferred when neuroma pain is
refractory and specific nerve pathology is identified.
Key words: neuroma, TMR, RPNI, phantom limb, nerve management
8. [Amputations — Surgical Level & Rehabilitation] In a patient with severe
distal femur trauma that spares the femoral condyles but leaves the knee joint
nonfunctional, which amputation level can preserve maximal femoral length and
provide a stable weight-bearing end with potential for good prosthetic fit?
A. Above-knee (transfemoral) amputation with long femoral stump
, B. Knee (through-knee or disarticulation) amputation
C. Hip disarticulation
D. Through-knee amputation is never recommended because it prevents
prosthetic fitting
Answer: B
Rationale: Knee disarticulation (through-knee) preserves maximal femoral
length and offers a bulbous end that can be weight-bearing in selected patients;
it may provide better limb length and lever arm for prosthetic control compared
with a high transfemoral amputation. It is an accepted option when the distal
femur condyles are preserved but the knee joint is nonfunctional. Hip
disarticulation is excessive and reserved for more proximal problems. Modern
prosthetics can accommodate through-knee stumps, so option D is incorrect.
Key words: knee disarticulation, through-knee, femoral length, prosthetic fit,
weight bearing
Anesthesia for Orthopedic Surgery (Questions 9–
12)
9. [Anesthesia — Regional vs General Anesthesia Benefits] For elective total
knee arthroplasty in a reasonably healthy 65-year-old, which of the following is
the most evidence-supported advantage of using neuraxial or regional
anesthesia (e.g., spinal/epidural or peripheral nerve blocks) instead of general
anesthesia?
A. Eliminates all risks of postoperative pulmonary complications
B. Provides superior immediate postoperative analgesia and reduces early opioid
consumption
Section 1: General Orthopaedics
Section 2: Shoulder
Section 3: Elbow and Forearm
Section 4: Hand and Wrist
Section 5: Hip and Thigh
Section 6: Knee and Lower Leg
Section 7: Foot and Ankle
Section 8: Spine
Section 9: Pediatric Orthopaedics
,SECTION 1: GENERAL ORTHOPAEDICS — Test
Bank (20 MCQs)
Principles of Musculoskeletal Evaluation (Questions
1–4)
1. [Principles of Musculoskeletal Evaluation] A 67-year-old man presents with
progressive right knee pain for 18 months. He reports stiffness that lasts 10–15
minutes in the morning and pain worsening with activity; exam shows crepitus,
minimal effusion, and varus deformity. Plain radiographs show joint space
narrowing medially and osteophytes. Which finding most strongly supports a
diagnosis of primary osteoarthritis rather than an inflammatory arthropathy?
A. Elevated ESR and CRP
B. Prolonged morning stiffness (>60 minutes)
C. Asymmetric joint space narrowing with osteophyte formation
D. Symmetric small joint involvement (MCP, PIP) with subluxation
Answer: C
Rationale: Primary OA typically presents with activity-related pain, short
morning stiffness, and asymmetric joint space narrowing with osteophyte
formation on imaging. Elevated inflammatory markers and prolonged morning
stiffness (>60 min) point toward inflammatory arthropathies like RA. Small
symmetric MCP/PIP involvement with subluxation is characteristic of RA rather
than OA. The combination of clinical pattern and radiographic osteophytes best
supports OA.
,Key words: osteoarthritis, asymmetric narrowing, osteophytes, morning
stiffness, radiograph
2. [Principles of Musculoskeletal Evaluation] A 34-year-old manual laborer c/o
lateral elbow pain for six months worsened by gripping and resisted wrist
extension. On exam, resisted wrist extension reproduces his pain; passive wrist
flexion with the elbow extended reproduces symptoms. Which physical test is
being described and what structure is most likely involved?
A. Cozen test — common extensor tendon (lateral epicondyle)
B. Mill’s test — common flexor tendon (medial epicondyle)
C. Finkelstein test — abductor pollicis longus and extensor pollicis brevis tendons
D. Tinel test — ulnar nerve at the elbow
Answer: A
Rationale: Resisted wrist extension reproducing lateral elbow pain describes the
Cozen test, indicating involvement of the common extensor tendon at the lateral
epicondyle (tennis elbow). Mill’s test also implicates lateral structures but is
performed by passive stretching. Finkelstein assesses de Quervain’s
tenosynovitis (thumb tendons). Tinel’s sign tests nerve irritation (ulnar nerve)
and is not tendon-specific. The clinical vignette (gripping, resisted extension)
matches lateral epicondylitis.
Key words: lateral epicondylitis, Cozen, resisted wrist extension, common
extensor tendon, tennis elbow
3. [Principles of Musculoskeletal Evaluation] A patient presents after a fall with
immediate knee swelling and inability to bear weight. On exam, Lachman test is
subtly positive, but the patient is very guarded. Plain radiographs show no
,fracture. Which next step best balances diagnostic accuracy and expediency for
confirming an ACL tear in the acute setting?
A. Immediate diagnostic arthroscopy under anesthesia
B. MRI of the knee once acute pain and swelling permit clearer imaging
C. Rely on Lachman and return to clinic in 6 weeks for reassessment
D. Ultrasound of the knee to visualize ACL fibers
Answer: B
Rationale: MRI is the noninvasive imaging modality of choice to confirm ACL
tears and associated intra-articular injuries. While arthroscopy is diagnostic and
therapeutic, it is invasive and not the first-line diagnostic step. Immediate
reliance on a single physical test may miss concurrent injuries; ultrasound is not
reliable for ACL visualization. MRI should be obtained once the patient can
tolerate it (often in the acute setting is still feasible) to guide management
(operative vs nonoperative).
Key words: ACL tear, MRI, Lachman, intra-articular injury, imaging
4. [Principles of Musculoskeletal Evaluation] A 45-year-old woman presents
with low back pain radiating to both legs, new urinary urgency, saddle
paresthesia, and progressive bilateral foot weakness. Which feature on physical
examination most specifically raises concern for cauda equina syndrome
requiring urgent evaluation?
A. Positive straight-leg raise test on the right
B. Unilateral ankle dorsiflexion weakness
C. Loss of anal sphincter tone on rectal exam
D. Hyporeflexia of the patellar reflex
Answer: C
,Rationale: Loss of anal sphincter tone indicates S2–S4 sacral nerve root
compromise and is a specific and urgent sign of cauda equina syndrome, which
requires immediate neurosurgical/orthopaedic evaluation. While SLR, unilateral
weakness, or hyporeflexia can occur with radiculopathy, they are not specific for
cauda equina. Saddle anesthesia and bladder/bowel dysfunction plus decreased
anal tone are red flags for urgent imaging and possible decompression.
Key words: cauda equina, anal sphincter tone, saddle anesthesia, red flag,
urgent MRI
Amputations of the Lower Extremity (Questions 5–
8)
5. [Amputations — Level Selection & Vascular Considerations] A 72-year-old
diabetic patient with peripheral arterial disease has a nonhealing plantar forefoot
ulcer with osteomyelitis limited to the first and second metatarsals despite
revascularization attempts. The limb is otherwise viable proximally. Which
surgical option best balances infection control and preservation of function?
A. Below-knee (transtibial) amputation
B. Syme (ankle disarticulation) amputation
C. Transmetatarsal amputation preserving posterior tibial function
D. Hip disarticulation
Answer: C
Rationale: When infection is limited to the forefoot (metatarsals) and sufficient
viable tissue remains, a transmetatarsal amputation preserves limb length and
plantar-flexion lever arm, improving prosthetic and shoe options and patient
function compared with more proximal levels. Transtibial or ankle disarticulations
are more morbid and used when disease is more proximal or when
,transmetatarsal level cannot be safely healed. Hip disarticulation is excessive and
reserved for catastrophic proximal disease. Optimal level selection balances
infection control and functional preservation.
Key words: transmetatarsal, limb salvage, osteomyelitis, level selection, function
6. [Amputations — Prosthetic & Functional Outcomes] Compared with
transfemoral amputation, which statement best describes the typical functional
and metabolic consequences of a well-healed transtibial (below-knee)
amputation in an otherwise healthy adult?
A. Transtibial amputation requires more energy for ambulation than
transfemoral.
B. Transtibial amputation preserves the knee joint and generally requires less
metabolic cost for ambulation than transfemoral.
C. Transtibial amputees cannot be fit with a modern prosthesis capable of near-
normal gait.
D. Transtibial amputation always results in poorer prosthetic control compared
with transfemoral.
Answer: B
Rationale: Preservation of the native knee (transtibial level) allows better
prosthetic control and typically results in lower metabolic energy expenditure
and superior functional outcomes compared with transfemoral (above-knee)
amputations. Transfemoral amputations generally increase energy cost and
reduce gait efficiency. Modern prostheses can offer good function for transtibial
amputees; thus option B correctly summarizes outcomes.
Key words: transtibial, energy expenditure, knee preservation, prosthetic
function, gait
,7. [Amputations — Neuroma & Pain Management] A patient with a painful
distal tibial stump after below-knee amputation has focal, reproducible
lancinating pain at the stump scar consistent with a neuroma. Which surgical
strategy has shown the most promise to decrease both neuroma pain and
phantom limb pain in contemporary limb salvage practice?
A. Simple traction neurectomy with ligation and skin closure only
B. Primary burying of the nerve end under local fat without reinnervation
C. Targeted muscle reinnervation (TMR) or regenerative peripheral nerve
interface (RPNI) on identified sensory nerves
D. Conservative measures only (analgesics and desensitization) with no surgical
options
Answer: C
Rationale: Contemporary evidence supports targeted muscle reinnervation
(TMR) and regenerative peripheral nerve interface (RPNI) techniques to decrease
neuroma formation and reduce phantom limb pain by providing regenerating
axons a physiologic target, improving pain outcomes compared with simple
traction neurectomy or burial alone. Conservative measures can help but surgical
nerve-targeting techniques are increasingly preferred when neuroma pain is
refractory and specific nerve pathology is identified.
Key words: neuroma, TMR, RPNI, phantom limb, nerve management
8. [Amputations — Surgical Level & Rehabilitation] In a patient with severe
distal femur trauma that spares the femoral condyles but leaves the knee joint
nonfunctional, which amputation level can preserve maximal femoral length and
provide a stable weight-bearing end with potential for good prosthetic fit?
A. Above-knee (transfemoral) amputation with long femoral stump
, B. Knee (through-knee or disarticulation) amputation
C. Hip disarticulation
D. Through-knee amputation is never recommended because it prevents
prosthetic fitting
Answer: B
Rationale: Knee disarticulation (through-knee) preserves maximal femoral
length and offers a bulbous end that can be weight-bearing in selected patients;
it may provide better limb length and lever arm for prosthetic control compared
with a high transfemoral amputation. It is an accepted option when the distal
femur condyles are preserved but the knee joint is nonfunctional. Hip
disarticulation is excessive and reserved for more proximal problems. Modern
prosthetics can accommodate through-knee stumps, so option D is incorrect.
Key words: knee disarticulation, through-knee, femoral length, prosthetic fit,
weight bearing
Anesthesia for Orthopedic Surgery (Questions 9–
12)
9. [Anesthesia — Regional vs General Anesthesia Benefits] For elective total
knee arthroplasty in a reasonably healthy 65-year-old, which of the following is
the most evidence-supported advantage of using neuraxial or regional
anesthesia (e.g., spinal/epidural or peripheral nerve blocks) instead of general
anesthesia?
A. Eliminates all risks of postoperative pulmonary complications
B. Provides superior immediate postoperative analgesia and reduces early opioid
consumption
