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1. A 3 8.year-old marathon runner has had Achilles tendon pain for the past 2 months. Examination reveals that the tendon is thickened and tender proximal to the calcaneal insertion. The tendon sheath is not thickened or tender. The pathophysiology of the tendon is best described as 1-Acute inflammation. 2- Chronic inflammation. 3- Partial tendon rupture. 4- Anaerobic degeneration. 5- Impaired collagen cross-linking. 2. A 14-year-old boy with a history of cerebral palsy has a clawed hallux, cavus foot deformity, and associated pain. Examination reveals pain under the first metatarsal head and a rigid first tarsometatarsal joint. Treatment should consist of 1- extensor hallus longus lengthening. 2- midfoot osteotomy. 3- first metatarsal osteotomy. 4- transfer of the extensor hailucis longus to the neck of the first metatarsal, 5- transfer of the extensor hallucis longus to the neck of the first metatarsal with first metatarsal osteotomy. 3. A 30-year-old man has chronic pain, joint stiffness, and symmetrical polyarthropathy but no significant synovitis. Examination reveals enlargement of the second and third metatarsal heads, Radiographs show chondrocalcinosis of the ankles and bony enlargement of the midfoot; no marginal erosions are evident at the metatarsophalangeal level. What is the most likely diagnosis? I- Osteoarthritis 2- Rheumatoid arthritis 3 Hemochromatosis 4- Reiter’s syndrome 5- Pseudogout calciumpyrophosphate deposition disease) 4- A Trendelenburq qait is most lik:ely to be seen in association with 1— a central disk herniation at L3—L4. 2— an psilateral paracentral disk herniation at L:3—L4, 3— an psilateral paracentral disk herniation at L4—L. 4— an ipsilateral paracentral disk herniation at L5—S1 5— an ipsilateral far lateral disk herniation at L4—L5 1 5- A 35-year-old man sustained a posterior dislocation of the hip with a shearing fracture of the femoral head. The most critical factor in minimizing the risk of osteonecrosis of the femoral head is the 1) 2) 3) 4) 5) interval between injury and reduction of the dislocation surgical approach chosen for internal fixation of the fracture type of internal fixation used for the fracture presence of other musculoskeletal injuries type of femoral head fracture 6- In a retroperitoneal approach to the lumbar spine, what structure runs along the medial aspect of the psoas and along the lateral border of the spine? 1— Ilioinquinal nerve 2— Genitofemoral nerve 3— Sympathetic trunk 4— Ureter 5— Aorta 7- If a laminectomy for spiral stenosis is performed, which of the following is an indication for concomitant arthrodesis at that level? 1— Prior laminectomy at an adjacent level 2— Ten degrees cf degenerative scoliosis 3— Removal of 25% of each facet joint at surgery 4— Degenerative spondylolisthesis at the level of the laminectomy 5— Forreminal stenosis at the level of the laminectomy 8- A 27—year—old man sustained a gunshot wound to the lumbar spine and undergoes an exploratory laparatomy . An injury to the cecum is identified and treated. Management should now include 1—no antibiotics. 2— oral broad—spectrum antibiotics for 7 days, 3— intravenous broad—spectrum antibiotics for 45 hours. 4— intravenous broad—spectrum antibiotics for 7 days. 5— intravenous antibiotics specific for Staphylococcus for 7 days 2 9- Five weeks after undergoing a successfull L4—L5 diskectomy, with complete relief of his preoperative sciatica, a 36-year-old man has severe, relentless back and buttock pain. Examination and laboratory studies are unremarkable with the exception of an erythrocyte sedimentation rate (ESR) of 90 mm/h. What is the next most appropriate step in management? 1- Broad-spectrum-intravenous antibiotics 2- AP, lateral, and flexion-extension lateral radiographs 3- MRI with gadolinium 4- Open biopsy of the surgical disk space 5- Anterior debridement and interabody fusion 10- A 45-year-old women sustained a closed, minimally displaced midshaft fracture of the humerus. She had no associated injuries. The best management for this fracture is 1) 2) 3) 4) 5) a hanging arm cast a Velpeau dressing a shoulder spica cast a functional brace an intramedullary nail 11- What nerve is most likely to develop a traumatic neuroma following open reducation and internal fixation of a talar neck fracture via a posterolateral approach? I - Dorsal intermediate cutaneous 2- Sural 3- Saphenous 4- Medial plantar 5- Lateral plantar (Baxter) 12- A 32-year-old construction worker reports a persistent burning, tingling sensation on the dorsum of his right foot and significant sensitivity on the plantar surface after a 500-lb steel beam dropped on it 8 weeks ago. Initial radiographs revealed no fractures, and the skin remained intact at the time of injury. Physical therapy, antiinflammatory drugs. and a serotonin reuptake inhibitor have failed to provide relief. What is the next most appropriate step in management? 1- Continued physical therapy 2- Alteration of medication to include an anti-epileptic 3- Tarsal tunnel release 4- Sympathetic blocks 5- Neurostimulation 3 13- Which of the following structures are found in the anterior tarsal tunnel? 1- Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve 2- Extensor hallucis longus, tibialis anterior, extensor digitorurn longus, dorsalis pedis artery, superficial peroneal nerve 3— Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve, superficial peroneal nerve 4- Extensor hallucis brevis, extensor hallucis longus, extensor digitorun-i Iongus, dorsalis pedis artery, deep peroneal nerve 5- Dorsalis pedis artery, deep peroneal nerve, superficial peroneal nerve 14. An 11-year-old boy stepped on a nail and sustained a puncture to the right forefoot 6 days ago. He was wearing tennis shoes at the time of injury. Treatment in the emergency department consisted of local debridement and tetanus prophylaxis; a radiograph was negative for foreign body, chondral defect, or fracture. He was discharged with a 3-day prescription of amoxicillin and calvulanate. The patient now has increasing pain and tenderness at the puncture site. What is the best course of action? 1- Change the antibiotic to ciprofloxacin 2- Initiate gentamicin 3- Resume the prescription for amoxicillin and clavulanate 4- Observation and follow-up in 48 hours 5- Surgical debridement 15-A patient who has recalcitrant medial plantar heel pain and pain directly over the medial side of the heel undergoes open release of the plantar fascia. After releasing a portion of the plantar fascia, the deep fascia of the abductor hallucis muscle is released to relieve pressure on which of the following structures? I- Lateral plantar artery 2- Tibial nerve 3- First branch of the lateral plantar nerve 4- Sural nerve 5- Flexor hallucis brevis muscle 16- The Lisfranc ligament connects the base of the 1- first metatarsal and the medial cuneiform. 2- first metatarsal and the base of the second metatarsal. 3- first metatarsal and the middle cuneiform. 4- second metatarsal and the medial cuneiform. 5- second metatarsal and the middle cuneiform. 4 17- A 20—year—old man sustained a closed tibial fracture and is treated with a reamed intramedullary nail. What is the most common complication associated with this treatment? 1—nonunioni 2— malunion 3— Infection 4— knee paint 5— Compartment syndrome 18- Tibial tubercle transfer is indicated in all the followings except: 1) Recurrent dislocation of the patella. 2) Recurrent subluxation will give way in the knee joint. 3) Internal rotation of the tibia. 4) Flat lateral femoral condy1. 5) Hypoplasia of the patella. 19- A 4--year—old girl sustains an isolated spiral femoral fracture after falling from her tricycle, Management should consist of 1— external fixation. 2— plate fixation. 3— skeletal traction for S weeks. 4— immediate spica cast immobilization, 5—flexible nailing with titanium nails. 20- An 18—month--old child sustains a crush amputation of the tip of the index finqer. bone is exposed, but the nail is intact, Management should consist of 1— dressing changes and healing by secondary intention. 2— a split—thickness skin graft. 3- a full-thickness skin graft. 4— a thennar flap. 5— a V—Y flap. 21- An otherwise healthy 25—year—old man sustained a wound with a 1—cm by 1.5— cm soft—tissue loss over the volar aspect of the middle phalanx of his middle finger After appropriate debnidernent and irrigation, the flexor digitorum profundus tendon and neurovascular bundles are visible. The wound should be treated with a 1- split-thickness skin graft. 2- thennar flap. 3- cross-finger flap. 4— lateral arm flap. 5— Moberg (vol.ar advancerrient flap. 5 22- A 20-year old women involved in a motor vehicle accident sustained multiple injuries, including ipsilateral femoral neck and shaft fractures. The most appropriate treatment for this patient's orthopaedic injuries is 1) skeletal traction until the patient's is stable, then internal fixation of the femoral neck fracture and locked intramedullary nailing of the femoral shaft fracture 2) skeletal traction until the patient's is stable, then fixation of femoral neck and shaft fracture with a femoral reconstruction nail 3) immediate fixation of femoral neck and shaft fracture with multiple screws and Enders' nails 4) immediate fixation of the femoral neck and shaft fracture with multiple screws and retrograde intramedullary nailing 5) immediate fixation of the femoral neck and shaft fracture with multiple screws and antegrade intramedullary nailing 23- A 12—year--old boy sustains open comminuted midshaft tibial and fibular fractures while playing indoor soccer, The wound is grossly clean and measures 7 cm with some periosteal stripping .Antibiotics and tetanus toxoid are administered immediately in the emergency department. Following irrigation and debridement of the wound in the operating room, treatment should include 1- a long leg cast. 2- a reamed nail. 3— an unreamed nail, 4- an external fixator, 5— plates and screws 24- Which of the following is an advantage of unrearmed nailing of the tibia compared to reamed nailing? 1— Less surgical time 2—Lower risk of nonunion 3— Lower rate of malunion 4— Faster time to union 5— Less secondary procedures to achieve union 25- An otherwise healthy 35—year—old woman reports dorsal wrist pain and has trouble extending her thumb after sustaining a minimally displaced fracture of the distal radius 3 months ago. what is the next most appropriate step in management? 1— Neuropliysiologic test to evaluate the posterior interosseous nerve 2— Transfer of extensor inidicis proprius to the extensor pollicis longus tendon 3— Interphalangeal joint arthrodesis cf the thumb 4— Extension splinting of the thumb 5— Fine cut CT of the distal radius to evaluate Lister’s tubercle 6 26- What is the major difference in outcome following open reduction and internal fixation of the tibial plafond at 2 to 5 days versus 10 to 20 days? 1— Improved ankle range of motion 2— Increased risk of wound complications 5— Decreased ankle pain 4— Decreased risk of nerve injures 5— Decreased risk of development of traumatic arthritis 27- A 7-year—old boy has a swollen and deformed right arm after falling off his bicycle Radiographs reveal a completely displaced posterolateral supracondylar humeral fracture. Examination reveals ,a warm, pink hand and forearm but absent pulses. What is the next most appropriate step in management ? 1— Angiography 2— Immediate closed reduction and casting in extension 3— Surgical exploration and repair of the artery, followed by skeletal stabilization 4— Closed reduction and pinning, followed by reassessment of the vascular status 5— Magnetic resonance angiography MRA 28- A55—year—old woman fell and sustained an elbow dislocation with . coronoid fracture and a radial head fracture. The elbow is reduced and splinted. What is the most common early complication? 1— Brachial artery intimal tear 2— Recurrent dislocation 3— Forearm compartment syndrome 4— Posterior interosseous nerve injury 5—ulnar nerve palsy 29- A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most rehable method of predicting a tear of the interosseous membrane? 1- Level of the fibular fracture 2- Lauge-Hansen fracture class 3- Intraoperative stress testing 4- Widening of the medial clear space 5- Talar dislocation 30- When performing a flexor tendon repair of a digit other than the thumb, what structures of the flexor tendon sheath should be preserved? 1- Al. and A pulleys 2- Al. and A3 pulleys 3- A2 and A3 pulleys 4- A2 and A4 pulleys 5- C1. and C2 pulleys 7 31- A distal radius fracture in an elderly man is strongly predictive for what subsequent injury? I.- Another distal radius fracture 2- Insufficiency fracture of the spine 3- Insufficiency fracture of the pelvis 4- Hip fracture 5- Proximal humerus fracture 32- In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by 1- a posterior-lateral approach. 2- a lateral approach. 3- a medial approach. 4- an anterior-medial approach. 5- rigid cast immobilization. 33- A 54-year-old man sustained a small superficial abrasion over the left acromioclavicular joint after falling from his bicycle. Examination reveals no other physical findings. Radiographs show a displaced fracture of the lateral end of the clavicle distal to a line drawn vertically to the coracoid process. Management should consist of 1- open reduction and plate fixation. 2- a figure-of-8 bandage for 4 to 8 weeks. 3- a sling for comfort, followed by physical therapy when pain-free. 4- excision of the outer end of the clavicle. 5- a tension band and Kirschner wires. 34- An adult with a distal humeral fracture underwent open reduction and internal fixation. What is the most common postoperative complication? 1- Loss of elbow range of motion 2- Nonunion 3- Malunlon 4- Infection 5- Ulnar nerve dysfunction 35- A 25—year—old woman undergoes surgical treatment of a displaced proximal humeral fracture via a deltopectoral approach. At the first postoperative visit, she reports a tingling numbness along the anterolateral aspect of the forearm. What structure is most likely injured? 1— Medial cord of the brachial plexus 2— Radial nerve 3— Median nerve 4— Axillary nerve 5— Musculocutaneous nerve 8 36- A 5 0—years—old man sustained a non displaced extra—articular fracture of the proximal aspect of the third metatarsal after dropping a heavy object on his left foot. Management should consist of 1— open reduction and internal fixation. 2— external bone stimulation 3— percutaneous pin fixation, 4— weight bearing in a walking boot or walking cast. 5— open reduction and internal fixation and primary tarsormetatarsal joint fusion. 37- A 52—year—old woman sustained a closed, displaced talar neck fracture in a motor vehicle accident. Which of the flowing is an avoidable complication of surgical treatment? 1— Posttraumatic .arthrit of the subtalar joint 2— Posttraumatic arthritis of the ankle joint 3— Malunon of the talus 4— Osteorperosis of the talus 5— Complex regional pain syndrome 38- A 34-year-old man sustained a tibial fracture in a motorcycle accident. What perioperative variable is associated with the greatest relative risk for reoperation to achieve bone union? 1- Gender 2- Delay in initial surgical treatment 3- Use of nonsteroidal anti-inflammatory drugs 4- Smoking 5- cortical contact of less than or equal to 50% 39- A 30—year--old woman sustains a transverse amputation of the distal phalanx of the index finger ,leaving exposed bone What is the most appropriate management of the soft—tissue defect? 1— Dressing changes and healing by secondary intention 2— Split—thickness skin grafting 3— V—y advancement flap 4— Moberg volar advancement flap) 5— First dorsal metacarpal artery—island pedicled flap 9 40- A 35—year—old man sustains a closed Monteggia fracture Examination reveals that sensation, vasnular status, and finger flexion are normal. When he extends his wrist, it deviates radially , and he is unable to extend his fingers or thumb . After reduction of the fracture, what is the next step in treatment for the extensor deficits of the thumb and fingers? 1— Exploration of the radial nerve 2— Exploration of the median nerve 3— Nerve conduction velocity studies 4— Tendon transfers after the fracture is stabilized 5— Observation 41- An 3—year—old girl sustained a displaced fracture at the base of the femoral neck in a motor vehicle accident, Management should consist of 1— closed reduction and spice cast immobilization. 2— closed reduction and fixation of the femoral fracture with smooth pins across the physis 3— open reduction and fixation with screws across the fracture and short of the growth plate, and a spice cast, 4— skeletal traction in a90— 90 position. 5— temporary traction until fixation with a specially ordered pediatric hip screw is possible 42- Long bone fracture repair following intramedullary stabilization occurs primarily through which of the following healing mechanisms? 1— Haversiani remodelinq 2— endosteal ossification only 3— Intramernbranous ossificatiorl only 4— Endochondral ossification only 5— intramernbranous and endochondral ossification 43- Nutritional rickets is associated with which of the following changes in chemical blood level? 1- Low Vitamin D levels 2- High to normal calcium levels 3- High phosphate levels 4- Decreased PTH 5- Decreased alkaline phosphatase levels 10 44- A 30—year—old man reports pain and weakness in his right arm, Examination reveals grade 4 strength in wrist flexion and elbow extension, decreased senisation over the middle finger ,decreased triceps reflex, These symptoms are most compatible with impingement on what nerve root? 1— CS 2— C6 3—C7 4— C8 5— T1 45- A 25—year--old man is brought to the emergency department following a motor vehicle accident, Extrication time was 2 hours, and in the field he had .A systolic blood pressure by palpation of 90 mm Hg. Intravenous therapy was started, and or arrival in the emergency department he has a systolic: blood pressure of 90 mm Hq with a pulse rate of 130. Examination reveals a flail chest and a femoral diaphyseal fracture. Ultrasound of the abdomen is positive. The trauma surgeons take him to the operating room for an exploratory laparotomy. At the conclusion of the procedure, he has a systolic pressure of 100 mm Hg with a pulse rate of 110. Oxygen saturation is 90% on 100% oxygen, and he has a temperature of 95.0 degrees F (35 degrees 0). What is the recommended treatment of the femoral fracture at this time? 1— Reamed intramedullary nail 2—unreamed intramedullary nail 3— Percutaneous plate fixation 4— Skeletal traction 5— External fixation 46- Figures 9a and 9b show the radiographs of a 60-year-old man who was struck by an automobile 24 hours ago. Examination reveals palpable dorsalis pedis and posterior tibial pulses, active flexion and extension of the toes, normal sensation, and no pain on passive flexion or extension of the toes. Figures 9c and 9d show clinical photographs of the leg. Immediate treatment should include: 1- application of sterile dressings, followed by external fixation. 2-application of sterile dressings and a long-leg walking cast. 3- debridement of the fracture blisters, skin grafting, and internal fixation with Ender nails. 4- debridement of the fracture blisters, skin grafting, and internal fixation with interlocking nail. 5- open reduction and internal fixation with a plate and screws, and delayed primary closure of the wound, 11 12 47- Figures 10a and 10b show the hand of a 50-year-old man with insulin-dependent diabetes who has increasing pain, tenderness, and swelling of the palm. Examination reveals tenderness over the palm and thenar eminence and pain on attempts at active flexion of the thumb and index finger. The diagnosis most likely is infection of the: 1-midpalmar space. 2- thenar compartment. 3- thenar space. 4- flexor tendon sheath of the thumb. 5- flexor tendon sheath of the index finger. 48- Peroneal nerve palsy secondary to total knee replacement is most common in patients who have which of the following preoperative deformities? 1- Varus 2- Valgus 3- Flexion 4-Flexion and valgus 5- Flexion and varus 49- In pigmented villonodular synovitis: 1. 2. 3. 4. 5- The condition typically presents in elderly females. The condition is typically rapidly progressive. Involvement of the knee occurs in about 80% of cases. The condition is polyarticular in the majority of cases. The erythrocyte sedimentation rate is typically elevated. 13 50- The following statements are correct concerning metastatic deposits in bone: 1. Carcinoid lung tumours tend to produce sclerotic secondaries. 2. The same primary tumour cannot simultaneously produce both lytic and sclerotic secndaries. 3. Secondaries fràm thyroid carcinoma tend to expand bone. 4. Alkaline phosphate usually increase. 5. A secondary deposit in a digital phalanx is most likely to be due to a bronchial carcinoma. 51- In Brodie’s abscess: 1. 2. 3. 4. 5. A sclerotic margin is usually seen. There is a characteristic appearance at angiography. The appearances on plain radiography may mimic an osteoid osteoma. The lesion is typically sited in the epiphysis. The lower limb is more commonly involved. 52-The following are correct associations: 1. 2. 3. 4. 5. Monteggia fracture—oblique ulnar shaft fracture with anterior dislocation of the radial head. Smith’s fracture—distal radial fracture with dorsal angulations of the distal fragment. Barton’s fracture—a marginal posterior radial fracture involving the articular surface. Bennett’s fracture—a fracture of the proximal end of the first metacarpal which extends into the first carpometacarpal joint. Salter—Harris type II fracture—fracture through the growth plate and the metaphysic 53- Teratologic dislocation of the hip characterized by the following features except: 1. 2. 3. 4. 5. Dislocations occur before birth. Are not reducible on examination. Has significant limited ROM. Usually associated with other neuromuscular syndromes. Usually treated by Pavlik Harness 54- The most common muscle to be involved in calcifying tendinitis is : 1. 2. 3. 4. 5. supraspinatus infraspinatus teres minor subscapularis biceps 55- Giant cell tumour of bone: 1. 2. 3. 4. 5. Accounts for approximately 5% of primary bone tumours. Typically has a well-defined sclerotic margin. Is best treated by curettage followed by radiotherapy. Typically exhibits periosteal reaction. Affecting the spine usually involves the posterior elements. 14 56- Recognized features of osteomalacia include all except 1. 2. 3. 4. 5. Increased quantity of normally mineralized bone. Poor callus formation. Accentuation of the cortical outline of the vertebral bodies. Looser’s zones. Protrtisio acetabuli. 57- Osteochondromas 1. a Are a characteristic feature of Maffucci’s syndrome. 2. Originate in the metaphysis. 3. Are due to the presence of aberrant epiphyseal cartilage. 4. That show punctate calcification in the cartilage cap have stopped growing. 5. When solitary rarely undergo malignant degeneration. 58- In metastatic bone disease 1. A solitary bone metastasis is more common than a primary malignant neoplasm of bone in patients over 50 years of age. 2. The axial skeleton is most often affected. 3. Vascular invasion is the main mode Of spread from the primary tumour. 4. A skeletal radionuclide scan is the investigation of choice in the assessment of the extent of bony involvement. 5. Bony sclerosis is due to the production of tumorous bone in most cases. 59- Osteonecrosis of the femoral head is a recognized complication of 1. Haemophilia. 2. polycythaemia rubra vera. 3. Gaucher’s disease. 4. Multiple myeloma. 5. Cushing syndrome 60- absolute criteria for primary amputation in Mangled Extremity injuries include all of the following except one : 1. 2. 3. 4. 5. warm ischemia time of > 6 hr in lower limb injuries gas gangrene complete limb avulsion major soft tissue loss bone loss of > 1 cm 61- Starting Allopurinol treatment is indicated in all of the following patients, except: 1. 2. 3. 4. 5. Acute gouty attack Tophi. Chronic gouty arthritis. Very high uric acid levels. Associated uric acid stones. 15 62- Following an anterior approach to the hip for joint replacement , a patient complains of numbness over the lateral thigh, The structure in the figure most likely to have been injured during the operative procedure is 1) 2) 3) 4) 5) B C D E F 63- After undergoing intramedullary nailing for a fracture of the femur , a patient complains of numbness in the scrotum. The structure in the figure most likely to have been injured is 1) 2) 3) 4) 5) G H I J K 64- In the anterior approach to the proximal third of the radius, the deep muscle incised to gain access to the bone is innervated by which nerve 1) 2) 3) 4) 5) Radial Median Posterior interosseous Ulnar Musculocutaneous 16 65- In the anterolateral approach to the ankle, dissection should proceed in the interval between the 1) 2) 3) 4) 5) Extensor digitorum longus and peroneus tertius Extensor digitorum longus and tibialis anterior Extensor digitorum longus and peroneus brevis Peroneus tertius and peroneus bervis Peroneus bervis and peroneus longus 66- The structure(s) LEAST likely to cause compression of the posterior interosseous nerve is (are) the 1) 2) 3) 4) 5) Fibrous bands anterior to the radial head Recurrent radial vessels Extensor carpi radialis longus Arcade of Frohse Distal border of the supinator 67- All the following statements regarding Sprengel's deformity are true EXCEPT that 1) the affected scapula is abnormally high 2) an omohyoid bone may be attached to the vertebral border of the affected scapula 3) the affected scapula is usually smaller than the unaffected scapula 4) the trapezius on the affected side is usually defective 5) operative treatment is usually unnecessary 68- The most common pattern of degenerative arthritis encountered in the wrist is 1) 2) 3) 4) 5) 69- triscaphe arthritis scapholunate advanced collapse (SLAC) scapholunate arthritis triquetrolunate arthritis capitolunate arthritis The muscles most severely affected in Volkmann's ischemic contracture in the wrist is 1) 2) 3) 4) 5) flexor digitorum superficialis and flexor carpi radialis flexor digitorum superficialis and flexor pollicis longus flexor carpi ulnaris and pronator teres flexor digitorum profundus and flexor pollicis longus flexor digitorum profundus and flexor carpi radialis 17 70- A 56-year-old man has had 1 month of persistent lower back pain and radiculopathy. The most appropriate treatment is 1) activity as tolerated, with strengthening and flexibility exercises 2) laminectomy and disk excision 3) appropriate imaging studies and chemonucleolysis if the disk is not sequestrated 4) appropriate imaging studies and percutaneous aspiration of the disk if it is not sequestrated 5) appropriate imaging studies and microdiskectomy 18 71- The changes in the fibula in the figure are most likely caused by A) B) C) D) E) 72- The bone at the tip of the arrow in the figure is most likely A) B) C) D) E) 73- Tumor bone Fracture callus An involucrum A sequestrum Viable endochondral bone Two months following avascular necrosis of the entire femoral head in a 32- year-old man, histologic examination of the center of the necrotic area would most often reveal 1) 2) 3) 4) 5) 74- Parosteal osteosarcoma Ewing's sarcoma Osteogenesis imperfecta Tuberculous osteomyelitis Hematogenous osteomyelitis Viable fatty marrow Osteoclastic activity along the necrotic trabeculae Osteoblasts lining the necrotic trabeculae No evidence of cellular activity Fibrous tissue within the marrow spaces On histologic examination , an aneurysmal bone cyst can most easily be confused with 1) 2) 3) 4) 5) An osteogenic sarcoma A nonossifying fibroma A chondroblastoma A hemangioendothelioma A giant cell tumor 19 75- Following total knee arthroplasty, patient with venograms positive for deep venous thrombosis should be anticoagulated with therapeutic doses of 1) 2) 3) 4) 5) 76- The most common site of terminal bony overgrowth in children with acquired amputations is the 1) 2) 3) 4) 5) 77- Humerus Radius Femur Tibia Fibula A 16-year- old baseball player has had 2 weeks of aching low back pain during athletic activities. Examination was normal except for mild paraspinal muscle spasm . radiographs showed bilateral spondylolysis at L5 , with no spondylolisthesis . the most appropriate initial treatment is 1) 2) 3) 4) 5) 78- heparin for 3 weeks heparin for 3 months heparin for 6 months warfarin ( coumadin )for 3 weeks warfarin ( coumadin )for 3 months Bed rest for 2 weeks Cessation of athletic activities for 3 months Immobilization in a cast or brace Limitation of activity as determined by symptoms Posterior spinal fusion A 15-year-old wrestler noted the sudden, atraumatic onset of shoulder pain and felt as though he had " lost control " of his shoulder . examination showed weakness of his deltoid , biceps, triceps, and wrist extensors . the most likely diagnosis is 1) Dislocation of the shoulder with injury to the axillary nerve 2) Dislocation of the shoulder with injury to the musculocutsneous nerve 3) Acute brachial neuropathy 4) Thoracic outlet syndrome 5) Acute herniation of a cervical disk 20 79- A 3-year-old girl recovering from an upper respiratory tract infection suddenly refused to walk. Examination revealed the right hip to be held in flexion and external rotation, and any attempt at motion caused severe pain. Her temperature was 39°C (102.2°F), WBC 17,000/mm³ , and erythrocyte sedimentation rate (ESR) 75 mm/h. The next step in management should be 1) 2) 3) 4) 5) 80- A 15½-year-old boy had a nonprogressive inequality of leg lengths of 2 cm. The most appropriate treatment is 1) 2) 3) 4) 5) 81- use of a heel lift on the shorter leg epiphysiodesis of the distal femur of the longer leg epiphysiodesis of the distal tibia of the longer leg closed femoral shortening of the longer leg one-stage femoral lengthening of the shorter leg Which of the following statements regarding developmental coxa vara is correct? 1) 2) 3) 4) 5) 82- a CT scan of the hip an MRI scan of the hip a bone scan aspiration of the hip surgical drainage of the hip The incidence is greater in females Hip pain is usually present Bilateral involvements is usual The deformity corrects spontaneously with growth Epiphysiodesis of the greater trochanter is not recommended treatment In a 4-year-old with infantile tibia vara, radiographs demonstrated a stage III Langenskiold lesion and a tibiofemoral angle of 25° varus. The most appropriate treatment is 1) 2) 3) 4) 5) Observation Application of an orthosis at night Application of a full-time orthosis Hemiepiphysiodesis Tibial osteotomy 21 83- All the following may be neurofibromatosis EXCEPT 1) 2) 3) 4) 5) 84- with Fibromolluscum Elephantiasis Focal gigantism Subperiosteal bone proliferation Scoliosis elevating the limb and performing serial examinations univalving the cast bivalving the cast and dividing the cast padding removing the cast measuring intracompartmental pressure Closed reduction and application of an above-elbow cast A collar and cuff Skeletal traction Open reduction and internal fixation Excision of the fracture fragment Nine months following treatment of a Salter type II distal femoral fracture in a 9-year-old boy, routine radiographs reveal "tenting" of the physis. You suspect a central growth arrest. The best imaging modality to confirm this impression is 1) 2) 3) 4) 5) 87- association The most appropriate treatment for a 6-year-old boy with a displaced fracture of the lateral humeral condyle is 1) 2) 3) 4) 5) 86- in Three hours after closed reduction and above-knee casting for a tibial shaft fracture, a 25-year-old patient complained of increasing pain in the leg. Capillary refill was sluggish and passive motion of the toes caused pain in the leg. The most appropriate initial management of this patient is 1) 2) 3) 4) 5) 85- seen Oblique radiography of the knee Polytomography Hypocycloidal motion tomography CT MRI Radiographs of a 4-year-old boy seen 7 days following an elbow injury revealed posterior and medial displacement of the proximal radius and ulna relative to the distal humerus. Optimal treatment is 1) 2) 3) 4) 5) Cast immobilization Closed reduction Closed reduction and percutaneous pinning Open reduction and percutaneous pinning A sling that allows motion of the elbow 22 88- In the treatment of a mid-shaft fracture of the femur in a 7years-old child in skeletal traction, the traction pin should be inserted in the 1) 2) 3) 4) 5) 89- Proximal tibia with the knee fully extended Proximal tibia with the knee flexed 90 ° Distal femur with the knee fully extended Distal femur with the knee flexed 90 ° Distal femur and proximal tibia A 12-year-old boy sustained a complete, midsubstance rupture of the anterior cruciate ligament (ACL) and an avulsion of the medial collateral ligament (MCL) from its tibial insertion. The knee is grossly unstable to valgus and anteroposterior stresses. The most appropriate treatment is 1) Application of a knee immobilizer; early knee motion 2) Application of an above-knee cast for 6 weeks; vigorous rehabilitation 3) Surgical repair of the MCL; rehabilitation for the ACL 4) Surgical repair of the MCL; intraarticular reconstruction of the ACL 5) Surgical repair of the MCL; extraarticular reconstruction of the ACL 23 90- Six months following closed reduction and casting of a tibial shaft fracture, an 18-year-old man had pain when he ambulated more than 30 min at a time. Radiographs of his tibia are shown below. All the following forms of treatment could be justified in this patient EXCEPT 1) 2) 3) 4) 5) resection of 2 cm of fibula posterolateral bone grafting pulsed electromagnetic field stimulation reamed intramedullary nailing take-down of the nonunion site, with plating and bone grafting 24 91- The posterior approach to the shoulder is most safely and easily accomplished by dissection 1) 2) 3) 4) 5) 92- Along the inferior border of the teres major Between the teres major and the teres minor Between the teres minor and the infraspinatus Between the infraspinatus and the supraspinatus Between the long lateral heads of the triceps All the following are important consideration for a successful metacarpophalangeal (MCP) arthoplasty EXCEPT 1) The functional status of the proximal and distal interphalangeal joints 2) The functional status of the wrist joints 3) Release of MCP capsular contracture 4) Release of intrinsic contracture 5) Amount of osteopenia in the hand 93- Which of the following is most important in the early management of cervical radiculopathy ? 1) 2) 3) 4) 5) 94- The most common initial manifestation of rheumatoid disease in the forefoot is 1) 2) 3) 4) 5) 95- Immobilization Traction Nonsteroidal anti-inflammatory drugs (NSAIDs) Exercises to strengthen the paravertebral musculature Trigger-point injection dorsal tenosynovitis lateral deviation of the toes fusiform swelling of the toes tender callosities over the PIP joints metatarsalgia Optimal management of severe disuse osteopenia with hypercalcemia is 1) mechanical compressive treatment; maintenance of water and electrolyte balance 2) calcium and phosphate supplements 3) calcitonin or diphosphonates ; maintenance of water and electrolyte balance 4) phosphate supplements; mechanical compressive treatment 5) immobilization 25 96- Five weeks after treatment of an extra articular fracture of the distal radius in a below-elbow cast, a 70 year-old woman was suddenly unable to extend her thumb. The most likely diagnosis is : 1) 2) 3) 4) 5) 97- Deep wound infection following primary total hip arthroplasty occurs in approximately 1) 2) 3) 4) 5) 98- 1 percent of cases, of which 15 percent develop after 24 months 2 percent of cases, of which 25 percent develop after 24 months 3 percent of cases, of which 35 percent develop after 24 months 4 percent of cases, of which 45 percent develop after 24 months 5 percent of cases, of which over 50 percent develop after 24 months Third-generation bisphosphanates exert most of their effect by: 1) 2) 3) 4) 5) 99- Compression of the posterior interosseous nerve. Rupture of the extensor pollicis longus . Displacement of the fracture . Compartment syndrome in the forearm. Osteoarthritis of the basilar joint of the thumb. Increasing osteoblast production of primary spongiosa. Increasing osteoclast resorptive fronts. Decreasing osteoblast production of secondary spongiosa. Decreasing osteoclastic resorption. Inhibiting matrix vesicle dissolution. Loosening of the tibial component following total knee arthroplasty has been associated primarily with 1) 2) 3) 4) 5) Poor surgical technique Poor prosthetic design Marked preoperative varus deformity Marked preoperative valgus deformity preoperative recurvatum deformity 100- An 18-year-old wrestler sustained a posterolateral dislocation of the elbow. Examination after reduction of the elbow revealed that the elbow could be easily redislocated. Radiographs obtained after reduction showed a concentric reduction with anatomic alignment. Further treatment should consist of 1) 2) 3) 4) 5) immobilization at 90° for 1 week immobilization at 90° for 3 week immobilization at 90° for 6 week operative repair of the medial collateral ligament operative repair of the medial and lateral collateral ligament 26 27 28