,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
Focus: Principles of musculoskeletal evaluation; Lower-extremity amputations;
Anesthesia for orthopedic surgery; Osteoarthritis; Complementary & alternative
therapies for OA.
1. A 68-year-old woman presents with gradually worsening right knee pain for 2
years. Pain is worse with activity and improves with rest. She reports morning
stiffness lasting about 10 minutes. On exam there is crepitus, reduced AROM
and a small effusion. What finding on plain radiography most strongly supports
osteoarthritis as the diagnosis?
A. Periarticular osteopenia and marginal erosions
B. Uniform joint space narrowing with periarticular osteophytes
C. Subluxation with central erosions and juxta-articular osteoporosis
D. Diffuse soft tissue calcification around the joint?
Answer: B
Rationale: Radiographic features of OA classically include asymmetric (often
focal) joint space narrowing due to cartilage loss, osteophyte formation,
subchondral sclerosis and subchondral cysts. Option B captures osteophytes
with joint space narrowing consistent with OA. Periarticular osteopenia and
marginal erosions (A, C) are more typical of inflammatory arthritides such as RA.
Diffuse soft tissue calcification (D) suggests other entities (e.g., CPPD or tumoral
calcinosis). The clinical features (activity-related pain, brief morning stiffness)
also support OA.
,Key words: osteophyte, joint space narrowing, subchondral sclerosis,
osteoarthritis, radiograph
2. A 45-year-old male worker twisted his ankle at work and now has increasing
pain and paresthesia in the forefoot, with tense swelling, pain on passive stretch
of the toes, and pain out of proportion to exam. Distal pulses are present. What is
the most appropriate next step?
A. Apply elevation and ice and re-examine in 4 hours
B. Obtain MRI of the foot to evaluate soft tissue injury
C. Perform urgent compartment pressure measurement and prepare for
fasciotomy if elevated
D. Start oral NSAIDs and schedule outpatient orthopaedic follow-up next week?
Answer: C
Rationale: The history and exam are classic for acute compartment syndrome —
pain out of proportion, pain on passive stretch, tense swelling, and neurovascular
symptoms. This is an urgent surgical limb-threatening condition; compartment
pressure measurement can confirm but clinical suspicion alone is sufficient to
proceed to fasciotomy in many settings. Elevation and ice (A) or outpatient
management (D) would dangerously delay treatment. MRI (B) is not appropriate
in an acute emergent setting and delays decompression.
Key words: compartment syndrome, pain out of proportion, passive stretch,
fasciotomy, emergent
,3. During a musculoskeletal evaluation of a patient with suspected ACL rupture,
which physical test has the highest diagnostic value when performed properly
and why?
A. McMurray test because it evaluates meniscal injury that coexists with ACL
tears
B. Anterior drawer test because it is reliable regardless of muscle guarding
C. Lachman test because it assesses anterior translation with the best sensitivity
and specificity
D. Pivot-shift test because it is most comfortable for the awake patient?
Answer: C
Rationale: The Lachman test is widely regarded as the most sensitive and
specific physical exam maneuver for diagnosing ACL rupture because it
evaluates anterior tibial translation with the knee at ~20–30° flexion, minimizing
hamstring guarding. The anterior drawer test (B) is less sensitive, especially
when performed acutely with guarding. Pivot-shift (D) is specific but often painful
and difficult to perform in the acute setting. McMurray (A) assesses meniscal
pathology but is not diagnostic for isolated ACL tears.
Key words: Lachman, ACL, sensitivity, specificity, anterior translation
4. A 72-year-old man with peripheral arterial disease and chronic ischemic rest
pain of the foot undergoes angioplasty but has persistent nonhealing forefoot
ulcers with exposed bone and recurrent infection despite antibiotics. He is
nonambulatory with severe calf muscle atrophy. What is the most appropriate
definitive surgical consideration?
A. Below-knee (transtibial) amputation to preserve knee function if perfusion
,allows healing
B. Forefoot (toe) amputation only to remove infected tissue and preserve limb
length
C. Above-knee amputation because it reduces the risk of stump infection the
most
D. Conservative debridement and long-term suppressive antibiotics only?
Answer: A
Rationale: In chronic critical limb ischemia with failed revascularization and
nonhealing infected wounds with exposed bone, below-knee (transtibial)
amputation is often the preferred definitive surgery if tissue perfusion at that level
is adequate for healing. It preserves the knee joint, which significantly improves
prosthetic rehabilitation and energy expenditure compared to above-knee
amputation. Forefoot amputation (B) may be insufficient if infection and ischemia
extend proximally. Above-knee amputation (C) sacrifices knee function and
should be reserved when healing potential for a transtibial stump is poor. Long-
term suppressive antibiotics (D) without addressing nonviable tissue is
insufficient.
Key words: critical limb ischemia, nonhealing ulcer, below-knee amputation, limb
salvage, prosthesis
5. A 59-year-old woman with severe knee OA and coronary artery disease is
scheduled for total knee arthroplasty. She takes aspirin 81 mg daily and
clopidogrel for a drug-eluting stent placed 6 months ago. What is the best
anesthesia plan balancing bleeding and cardiac risk?
A. Proceed with neuraxial (spinal) anesthesia after stopping clopidogrel 5 days
,preoperatively and continuing aspirin per cardiology guidance
B. Perform spinal anesthesia without stopping antiplatelet therapy to minimize
cardiac risk
C. Use general anesthesia because neuraxial anesthesia is absolutely
contraindicated with recent stent placement
D. Delay surgery until the patient is off all antiplatelet agents for 10 days?
Answer: A
Rationale: Perioperative management requires balancing thrombotic risk from
stent vs bleeding risk from neuraxial anesthesia. For a drug-eluting stent placed
6 months ago, cardiology often recommends continuing dual antiplatelet therapy
for at least 6–12 months; however, neuraxial anesthesia is contraindicated with
recent clopidogrel use due to bleeding risk/epidural hematoma. Stopping
clopidogrel 5–7 days before neuraxial block (after cardiology consultation) while
continuing aspirin (often acceptable) is a common compromise. Performing
neuraxial anesthesia without stopping antiplatelet therapy (B) risks spinal
hematoma. General anesthesia (C) is an option but neuraxial is not absolutely
contraindicated given appropriate timing. Delaying until off all agents for 10 days
(D) may significantly increase stent thrombosis risk and is not advised without
cardiology input.
Key words: neuraxial anesthesia, antiplatelet, clopidogrel, aspirin, stent,
perioperative management
6. A 55-year-old female with knee OA asks about glucosamine and chondroitin
supplementation. Which of the following statements best reflects the evidence
and counseling you should provide?
, A. Glucosamine and chondroitin are proven to reverse cartilage loss and should
replace NSAIDs.
B. Some trials show modest symptom benefit for certain formulations of
glucosamine sulfate; results are mixed and they are not disease-modifying for all
patients.
C. Glucosamine and chondroitin are associated with high rates of serious
adverse events and should be avoided.
D. They have definitive structural benefits shown on serial MRI and therefore
delay arthroplasty in most patients?
Answer: B
Rationale: Evidence for glucosamine and chondroitin is mixed. Some studies,
particularly with pharmaceutical-grade glucosamine sulfate, show modest
symptomatic benefit in some patients, but overall results are inconsistent and
there is no definitive proof of disease-modifying effects across populations. They
are generally safe with low rates of serious adverse events (contrary to C). They
do not consistently reverse cartilage loss or reliably delay arthroplasty (contrary
to A and D). Counseling should emphasize modest potential benefit, variable
product quality, cost, and possible interactions (e.g., glucosamine with warfarin
monitoring).
Key words: glucosamine, chondroitin, complementary therapy, evidence,
counseling
7. A 38-year-old runner presents with lateral knee pain. On exam there is focal
tenderness just proximal to the lateral joint line and pain reproduced by resisted
external rotation of the knee. Which component of the musculoskeletal evaluation
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
Focus: Principles of musculoskeletal evaluation; Lower-extremity amputations;
Anesthesia for orthopedic surgery; Osteoarthritis; Complementary & alternative
therapies for OA.
1. A 68-year-old woman presents with gradually worsening right knee pain for 2
years. Pain is worse with activity and improves with rest. She reports morning
stiffness lasting about 10 minutes. On exam there is crepitus, reduced AROM
and a small effusion. What finding on plain radiography most strongly supports
osteoarthritis as the diagnosis?
A. Periarticular osteopenia and marginal erosions
B. Uniform joint space narrowing with periarticular osteophytes
C. Subluxation with central erosions and juxta-articular osteoporosis
D. Diffuse soft tissue calcification around the joint?
Answer: B
Rationale: Radiographic features of OA classically include asymmetric (often
focal) joint space narrowing due to cartilage loss, osteophyte formation,
subchondral sclerosis and subchondral cysts. Option B captures osteophytes
with joint space narrowing consistent with OA. Periarticular osteopenia and
marginal erosions (A, C) are more typical of inflammatory arthritides such as RA.
Diffuse soft tissue calcification (D) suggests other entities (e.g., CPPD or tumoral
calcinosis). The clinical features (activity-related pain, brief morning stiffness)
also support OA.
,Key words: osteophyte, joint space narrowing, subchondral sclerosis,
osteoarthritis, radiograph
2. A 45-year-old male worker twisted his ankle at work and now has increasing
pain and paresthesia in the forefoot, with tense swelling, pain on passive stretch
of the toes, and pain out of proportion to exam. Distal pulses are present. What is
the most appropriate next step?
A. Apply elevation and ice and re-examine in 4 hours
B. Obtain MRI of the foot to evaluate soft tissue injury
C. Perform urgent compartment pressure measurement and prepare for
fasciotomy if elevated
D. Start oral NSAIDs and schedule outpatient orthopaedic follow-up next week?
Answer: C
Rationale: The history and exam are classic for acute compartment syndrome —
pain out of proportion, pain on passive stretch, tense swelling, and neurovascular
symptoms. This is an urgent surgical limb-threatening condition; compartment
pressure measurement can confirm but clinical suspicion alone is sufficient to
proceed to fasciotomy in many settings. Elevation and ice (A) or outpatient
management (D) would dangerously delay treatment. MRI (B) is not appropriate
in an acute emergent setting and delays decompression.
Key words: compartment syndrome, pain out of proportion, passive stretch,
fasciotomy, emergent
,3. During a musculoskeletal evaluation of a patient with suspected ACL rupture,
which physical test has the highest diagnostic value when performed properly
and why?
A. McMurray test because it evaluates meniscal injury that coexists with ACL
tears
B. Anterior drawer test because it is reliable regardless of muscle guarding
C. Lachman test because it assesses anterior translation with the best sensitivity
and specificity
D. Pivot-shift test because it is most comfortable for the awake patient?
Answer: C
Rationale: The Lachman test is widely regarded as the most sensitive and
specific physical exam maneuver for diagnosing ACL rupture because it
evaluates anterior tibial translation with the knee at ~20–30° flexion, minimizing
hamstring guarding. The anterior drawer test (B) is less sensitive, especially
when performed acutely with guarding. Pivot-shift (D) is specific but often painful
and difficult to perform in the acute setting. McMurray (A) assesses meniscal
pathology but is not diagnostic for isolated ACL tears.
Key words: Lachman, ACL, sensitivity, specificity, anterior translation
4. A 72-year-old man with peripheral arterial disease and chronic ischemic rest
pain of the foot undergoes angioplasty but has persistent nonhealing forefoot
ulcers with exposed bone and recurrent infection despite antibiotics. He is
nonambulatory with severe calf muscle atrophy. What is the most appropriate
definitive surgical consideration?
A. Below-knee (transtibial) amputation to preserve knee function if perfusion
,allows healing
B. Forefoot (toe) amputation only to remove infected tissue and preserve limb
length
C. Above-knee amputation because it reduces the risk of stump infection the
most
D. Conservative debridement and long-term suppressive antibiotics only?
Answer: A
Rationale: In chronic critical limb ischemia with failed revascularization and
nonhealing infected wounds with exposed bone, below-knee (transtibial)
amputation is often the preferred definitive surgery if tissue perfusion at that level
is adequate for healing. It preserves the knee joint, which significantly improves
prosthetic rehabilitation and energy expenditure compared to above-knee
amputation. Forefoot amputation (B) may be insufficient if infection and ischemia
extend proximally. Above-knee amputation (C) sacrifices knee function and
should be reserved when healing potential for a transtibial stump is poor. Long-
term suppressive antibiotics (D) without addressing nonviable tissue is
insufficient.
Key words: critical limb ischemia, nonhealing ulcer, below-knee amputation, limb
salvage, prosthesis
5. A 59-year-old woman with severe knee OA and coronary artery disease is
scheduled for total knee arthroplasty. She takes aspirin 81 mg daily and
clopidogrel for a drug-eluting stent placed 6 months ago. What is the best
anesthesia plan balancing bleeding and cardiac risk?
A. Proceed with neuraxial (spinal) anesthesia after stopping clopidogrel 5 days
,preoperatively and continuing aspirin per cardiology guidance
B. Perform spinal anesthesia without stopping antiplatelet therapy to minimize
cardiac risk
C. Use general anesthesia because neuraxial anesthesia is absolutely
contraindicated with recent stent placement
D. Delay surgery until the patient is off all antiplatelet agents for 10 days?
Answer: A
Rationale: Perioperative management requires balancing thrombotic risk from
stent vs bleeding risk from neuraxial anesthesia. For a drug-eluting stent placed
6 months ago, cardiology often recommends continuing dual antiplatelet therapy
for at least 6–12 months; however, neuraxial anesthesia is contraindicated with
recent clopidogrel use due to bleeding risk/epidural hematoma. Stopping
clopidogrel 5–7 days before neuraxial block (after cardiology consultation) while
continuing aspirin (often acceptable) is a common compromise. Performing
neuraxial anesthesia without stopping antiplatelet therapy (B) risks spinal
hematoma. General anesthesia (C) is an option but neuraxial is not absolutely
contraindicated given appropriate timing. Delaying until off all agents for 10 days
(D) may significantly increase stent thrombosis risk and is not advised without
cardiology input.
Key words: neuraxial anesthesia, antiplatelet, clopidogrel, aspirin, stent,
perioperative management
6. A 55-year-old female with knee OA asks about glucosamine and chondroitin
supplementation. Which of the following statements best reflects the evidence
and counseling you should provide?
, A. Glucosamine and chondroitin are proven to reverse cartilage loss and should
replace NSAIDs.
B. Some trials show modest symptom benefit for certain formulations of
glucosamine sulfate; results are mixed and they are not disease-modifying for all
patients.
C. Glucosamine and chondroitin are associated with high rates of serious
adverse events and should be avoided.
D. They have definitive structural benefits shown on serial MRI and therefore
delay arthroplasty in most patients?
Answer: B
Rationale: Evidence for glucosamine and chondroitin is mixed. Some studies,
particularly with pharmaceutical-grade glucosamine sulfate, show modest
symptomatic benefit in some patients, but overall results are inconsistent and
there is no definitive proof of disease-modifying effects across populations. They
are generally safe with low rates of serious adverse events (contrary to C). They
do not consistently reverse cartilage loss or reliably delay arthroplasty (contrary
to A and D). Counseling should emphasize modest potential benefit, variable
product quality, cost, and possible interactions (e.g., glucosamine with warfarin
monitoring).
Key words: glucosamine, chondroitin, complementary therapy, evidence,
counseling
7. A 38-year-old runner presents with lateral knee pain. On exam there is focal
tenderness just proximal to the lateral joint line and pain reproduced by resisted
external rotation of the knee. Which component of the musculoskeletal evaluation
