UKITE 07 ANSWERS

Question 1

The following are true about rotator cuff tears except:

A-Rotator cuff tears are more common in the elderly

B-Partial thickness tears are more painful than full thickness tears
C-Non-operative management of a rotator cuff tear can provide relief in around 50%
of patients
D-Evidence shows that early repair yields better results than delayed repair
E-Results are equally good between open, mini-open and arthroscopic technique of
rotator cuff repair

References

The incidence of rotator cuff tear increases from 5-11% in the 4th and 5th decades to
80% in the 8th decade. (1, 2)

Partial thickness tears are more painful than full thickness tears. (3)

Studies (4, 5, 6) have shown that around 50% of patients treated non-operatively had
decreased pain and improved motion, and were satisfied with the outcome.

There is no evidence of better results in early versus delayed repairs, and hence
many surgeons consider a trial of non-operative management to be appropriate. (7)

A meta-analysis of all published material relating to outcomes from rotator cuff repair
surgery showed no difference in the results between the technique of repair, and that
the outcome depends on the surgeon expertise to the choice of technique. (8)
ANS-D

Question 2

In Charcot-Marie-Tooth Disease which one of the statements below is fralse

A-Type I has autosomal dominant inheritance late onset and less severe disease
B-In type II nerve conduction could be normal.
C-Peronius brevis is normally well preserved
D-There is hindfoot varus and forefoot pronation with cavus deformity
E-Surgery rather than brace management is recommended.

References

Peronius brevis is atrophied in CMT

ANS-C

Question 3

A : Phalangeal Fracture
B : Tendon sheath infection
C : Dupuytren’s contracture
D : Rheumatoid Arthritis
E : Osteoarthritis
F : Carpal tunnel syndrome
G : Ganglion
H : Trigger finger
I : Rheumatiod nodule

1 : Which of the above diagnosis is most likely: Fixed flexion of the proximal
interphalangeal joint and hyperextension of the distal interphalangeal joint
Correct answer:
D

2 : Which of the above diagnosis is most likely: Painless inability to extend the
proximal interphalangeal joint
Correct answer:
C

3 : Which of the above diagnosis is most likely: Small firm spherical mass in line with
the flexor tendon at the proximal interphalangeal joint
Correct answer:
G

Question 4

You decided that a humeral shaft fracture needs operative Plating.

A : segmental fracture
B : open fracture
C : anterolateral approach
D : posterior approach
E : 3.5 mm plate with six cortices above and below the fracture.
F : Old age.
G : Intra-articular extension.
H : intramedullary nail.
I : Non union
J : young age.
1 : A common cause of failure of fixation

Correct answer:
E

2 : Plating is by far superior to nailing in case of

Correct answer:
G

3 : Long spiral fracture extending to proximal humerus.

Correct answer:
C

Question 5

A : Partial Wrist Fusion

B : Total Wrist Fusion
C : Extensor Synovectomy
D : Suave-Kapandji Procedure +/- Synovectomy
E : Ligamentous reconstruction of the DRUJ ligaments
F : Darrachs Procedure +/- Synovectomy
G : Wrist Arthroplasty
H : Extensor Digitorum Communis (EDC) 4 to EDC5 side to side tendon transfer
I : EDC5 repair

1 : The most appropriate procedure for the extensor digitorum communis to the little
finger and extensor digiti minimi rupture in patient with rheumatoid arthritis is

Correct answer:
H
2 : In an active rheumatoid patient with symptomatic distal radioulnar joint
involvement and subluxation of the distal ulna the most appropriate procedure is

Correct answer:
D
3 : In an active, high activity level rheumatoid patient with advanced pancarpal and
wrist arthritis the most appropriate treatment is
Correct answer:
B

Question 6

What is the most common sequale after closed treatment to simple dislocation of the
elbow.
1. Heterotrophic calcification
2. Loss of terminal extension
3. Loss of flexion
4. Redislocation
5. Nerve injury

ANS; 2, LOSS OF TERM EXTN

Question 7

Which is not a part of the mangled extremity severity score?

Glasgow coma score

Skeletal/soft tissue injury
Limb ischemia
Shock
Age

ANS; A, GCS

Question 8

A motorcyclist sustains an open fracture of the distal 1/3 of his right tibia. As part of
his management which of the following flaps would be the most appropriate for
coverage of the residual full thickness defect over the distal 1/3 of the tibia?
A-Gastrocnemius
B-Soleus
C-Free latissimus dorsi
D-Rotational semitendinosis
E-Free gracilis

In general, the soft tissue defects of the tibia can be divided into proximal, middle and
distal thirds. Gastrocnemius flaps are generally used
ANS; C, FREE LAT DORSI

Question 9

The action of osteoclasts is inhibited by which of the following hormones?

A-Parathyroid hormone
B-Glucocorticoids
C-Prostaglandins
D-Calcitonin
E-Oestrogen

Miller pp3. Calcitonin is the only one of the above hormones that acts directly on
osteoclasts. Stimulation of the calcitonin receptors on osteoclasts leads to their
inhibition.
ANS; D, CALCITONIN

Question 10

A 25-year-old man has had posterior neck discomfort for 6 months. A whole body
bone scan and a local CT scan revealed an increased activity lesion at the C7
spinous process. MRI was suggestive of multifocal involvement of the spinous
process lamina and facet. CT guided biopsy reveals an Osteoblastoma. What is the
best course of treatment.

A-Observation
B-Radiation therapy
C-Curettage
D-En-Bloc excision with stabilisation
E-Bloc excision followed by radiotherapy

En Bloc resection is recommended for Osteoblastoma. Facet removal would

necessitate fusion. Intralesional curettage has a high rate of recurrence. Radiation
therapy is not recommended and may lead to malignant transformation of the
tumour.
ANS; D, EN BLOC WTH STABN

Question 11

A : Degenerative disc disease below T8

B : Mechanical back pain
C : Cauda equina syndrome
D : Spondylolisthesis
E : Lumbar disc disease
F : Normal discs
G : Infection
H : Unrecognised fracture
I : Ankylosing spondylitis
1 : The most common cause of thoracic pain in the 4th decade
Correct answer:
A
2 : A patient with back pain, both lower limb radiation of pain, urinary retention and
saddle anaesthesia.
Correct answer:
C
3 : A patient with severe back spasm and pain with elevated CRP.
Correct answer:
G

Question 12

Which one of the following statements is false for red flag sign in the spine
They include age over 50, night pain, weight loss and history of cancer
They usually suggest serious pathology and should be investigated quickly
They could be investigated with MRI scan
They may be caused by Herpes zoster
In presence of Waddell’s signs red flag signs could be ignored

Question 13

A : Maturation Zone
B : Zone of provisional calcification
C : Primary Spongiosa
D : Secondary boney epiphysis
E : Degenerative Zone
F : Zona Reticularis
G : Reserve Zone
H : Secondary Spongiosa
I : Proliferative Zone
1 : Achondroplasia affects which zone of the growth plate?
Correct answer:
I
2 : Rickets affects which zone of the growth plate?
Correct answer:
B
3 : Acute Haematogenous Osteomyelitis affects which zone of the growth plate?
Correct answer:
C

REFS; 1. Proliferative Zone. It leads

Question 14

Which one of the following is not a structure in the posterolateral corner

Posterior cruciate ligament
Popliteus
Arcuate ligament
Fibular collateral ligament
Lateral head of the gastrocnemius

References
The posterolateral corner is made up of three layers.
Layer 1 comprises a fascial layer made up of iliotibial band and biceps femoris.
Layer 2 comprises the lateral quadriceps retinaculum, the lateral (fibular) collateral
ligament and the 2 patellofemoral ligaments.
Layer 3 comprises the joint capsule, popliteus tendon, the coronary,
fabellofibular,arcuate and popliteofibular ligaments.

Question 15

A : Technetium-indium bone scan

B : MRI
C : Technetium indium bone scan and MRI
D : Non-operative
E : Partial amputation
F : Neuropathy
G : Angiopathy
H : Surgical with amputation
I : Arthrodesis
1 : The most sensitive and specific investigation (s) to differentiate Charcot’s joint
form acute osteomyelitis.

Correct answer:
C
2 : The most profoundly influenced aetiology in Diabetic foot.
Correct answer:
F
3 : Initial treatment of Charcot foot.
Correct answer:
D

References

Less than 30% of patients with diabetic foot have decreased arterial flow. Neuropathy
(somatosensory and autonomic) involvement is the most profoundly influenced
aetiology.
In both condition (Charcot foot and osteomylitis) bone scan is hot, but Indium
leukocyte is hot in osteomyelitis and cold in Charcot. A technetium indium with MRI
correlation is the most likely study to aid differentiation with both high sensitivity and
specificity.
Management of Charcot depends on the joint affected, degree of involvement
(deformity, fragmentation and instability), and the presence of concurrent ulceration
and infection. In the stage of development, the treatment is conservative with well-
paded compressive dressing. Critiria for surgical intervention include instability of the
foot and ankle, deformity, chronic ulceration, progressive joint destruction (despite
conservative care), adequate circulation, and NO active infection. Surgical treatment
includes removing of bony prominences under ulceration, TAL, selected arthrodeses,
and amputation.

Question 16
A : Jefferson's fracture
B : Odontoid fracture
C : Hangman's fracture
D : Wedge compression fracture
E : Burst fracture
F : "Tear drop" fracture
G : Unilateral facet dislocation
H : Bilateral facet dislocation
I : Whiplash injury
1 : Which injury is most likely to occur in the cervical spine with a combined axial
compression and flexion, an antero-inferior fragment of the vertebral body is sheared
off
Correct answer:
F
2 : Which injury is most likely to occur in the cervical spine A seat belt restrained
driver of a stationary car is rear ended from behind by another vehicle with his head
thrown backwards and hyperextension in the lower cervical spine
Correct answer:
I
3 : Which injury is most likely to occur in the cervical spine In a high speed car
accident the unrestrained passenger in the front hits his head against the dashboard
Correct answer:
C

Question 17

A 50 year old factory worker is admitted with a closed elbow injury. X-ray shows a
comminuted (Mason type III) fracture of the radial head. Clinically there is swelling
and tenderness around the medial aspect of the joint associated with valgus
instability. What is the LEAST appropriate management for this patient?
Radial head replacement
Radial head excision
Partial radial head excision
Open reduction and internal fixation of radial head
Cast immobilisation

References

Radial head fracture with a medial collateral

Question 18

What is type III SLAP lesion

Bucket handle tear of the labrum with intact biceps anchor
Bucket handle tear into the biceps insertion
Fraying, intact anchor
Detachment of the biceps anchor
Superior flap tear

References

Type I - Fraying, intact anchor

Type II - Detachment of biceps anchor
Type III - Bucket handle tear of labrum with intact biceps
Type IV - bucket handle tear into the biceps insertions.
Type V- Labral tear + SLAP
Type VI: Superior flap tear
Type VII: Capsular injury +SLAP

Question 19

Compared to patients with unilateral femoral fracture, patients with bilateral femoral
fractures are at greater risk for which complication?
Limb-length discrepancy
Malunion
Non union
Infection
ARDS

References

OKU Trauma - multiply injured patients with bilateral femoral fractures have a higher
rate of ARDS, this increased risk is not caused by femoral fractures but by the
associated multiple organ system injuries that accompany these fractures.

Question 20

With respect to Unicompartmental knee replacements (UKR) which one of the

following statements is false
10 year survival results of Unicondyler Knee Replacement (UKR) are better than
High tibial osteotomy
Revision of a UKR to another UKR has been shown to be associated with poor
results
Rheumatoid arthritis is not a contra- indication to UKR
Chondrocalcinosis is a relative contra-indication to UKR
Patello-femoral pain is a relative contra-indication to UKR

Question 21

A : Linear region of the stress strain curve

B : Toe region of the stress strain curve
C : Load at which ligament fails
D : Total energy absorbed
E : Total stress applied
F : Ultimate elongation
G : Total strain absorbed
H : Occurs in midsubstance
I : At the distal insertion of ligament
1 : When analysing the Biomechanical properties of ligament what dictates stiffness
of the ligament ?
Correct answer:
A
2 : When analysing the Biomechanical properties of ligament ultimate load is defined
as
Correct answer:
C
3 : When analysing the Biomechanical properties of ligament, the ligament failure at
higher rate of loading
Correct answer:
H

One can determine the stiffness of a ligament, or other soft tissue, by calculating the
slope in the linear region as a load is applied. When the load is initially applied,
uncoiling of the collagen will occur. This region is called the 'toe region.'
The other answers describe different ligament properties:

Ultimate load: The load at which the ligament fails

Ultimate elongation: The maximum length of the ligament before the structure fails

The rate of loading has a significant effect on the injury pattern of a ligament. With
high strain rates, the strength and tensile modulus of ligament will be increased. The
ligament will tend to fail in the mid-substance rather than the insertion sites. At slow
rates of loading, the ligament will tend to fail at the insertion site.

Question 22

Which of the pulleys of the flexor tendon are the most important in preventing
bowstring?
A2 and A4
C1 and C3
A3 and A5
C2 and C5
A2 and A5

References

There are five annular pulleys (A1, A2, A3, A4 and A5) and three cruciate pulleys
(C1, C2 and C3). The annular pulleys provide mechanical stability and the cruciate
pulleys permit flexibility at the joints. It is imperative to preserve the A2 pulley over
the proximal phalanx and the A4 pulley over the middle phalanx to prevent a
bowstring deformity. There is no C4 pulley.

Question 23

A : C8/T1 root avulsion

B : Medial cord injury
C : High ulnar nerve injury
D : Low ulnar nerve injury
E : Radial nerve injury at the elbow
F : posterior cord injury
G : Lateral cord injury
H : High median nerve injury
I : Low median nerve injury
1 : Which is the single most likely diagnosis for loss of power of elbow flexion?
Correct answer:
G
2 : Which is the single most likely diagnosis for loss of thumb IPJ flexion but
preservation of FDP power to ring and little fingers
Correct answer:
H
3 : Which is the single most likely diagnosis for weakness of all hand intrinsic
muscles with ipsilateral Horner’s syndrome
Correct answer:
A

Question 24

In fracture healing:
The most important prognostic factor is patient age.
All fractures must be immobilised.
Type I collagen is expressed early in healing process.
Head injury can decrease the osteogenic response to fracture.
Remodelling may take up many years.

Question 25

Classically physeal injuries occur through the zone of

Maturation
Profilative
Degenerative
Provisional calcification
Reserve

Question 26

A 19 year old snowboarder complains of pain in the lateral ankle after an awkward
landing. He had 2 weeks of bracing followed by 6 weeks of physiotherapy for a
suspected lateral ligament complex sprain. His persistent pain is most likely due to
Stress fracture of the distal fibula
Peroneal tendon rupture
Nutcracker fracture of the cuboid
Fracture of the lateral process of the talus
Talar neck fracture

Question 27

The knee joint receives sensory fibres from :

Sciatic and femoral nerves
Sciatic, femoral and obturator nerves
Sciatic nerve only
Femoral and obturator nerves
Femoral nerve only
Question 28

Which one of the following approaches is through true internervous plane

Anterior Smith - Petersen
Anterolateral Watson - Jones
Lateral Hardinge
Posterior Moore/Southern
Medial Ludloff

References

2- both tensor fascia lata and gluteus medius supplied by superior gluteal nerve
3- gluteus medius split (superior gluteal nerve)
4- anterior fibers of gluteus maximus split (inferior gluteal nerve)
5- both adductor longus and gracilis supplied by ant branch of obturator nerve

Question 29

In assessment of thoraco-lumbar trauma which of the following statements is true

Stability of injuries can be determined by progression of neurological injury under
abnormal physiological stresses.
Myelography is not helpful in explaining neurological deficit if there is no obvious
bony cause
Instability of vertebral fractures can not be determined by loss of vertebral height >
50%.
Anterior compression fractures are rarely associated with neurological
compromise.
There is a direct relationship between canal compromise and neurological deficit.

References

An unstable thoraco-lumbar fracture can be defined as one where normal

physiological loads cause further neurological damage, pain and unacceptable
deformity.
Myelography is seldom used in the acute trauma setting but it may be useful in cases
where the neurological deficit cannot be explained by the osseous lesion. The major
problem is the manipulation of the patient for the instillation of the dye. Recently MRI
has obviated the need for myelographic evaluation in the acute trauma setting.
Instability and hence indication for operative fixation is loss of vertebral height >40%.
There is no direct correlation between degree of canal compromise and neurological
deficit, as the neurological deficit is related to initial injury and the canal compromise
is often related to subsequent position of bony fragments.

Question 30

Which of the following statements about mallet toe deformity is true

It is commonly associated with hallux valgus
It most frequently affects the little toe
It involves a flexion deformity of the PIPJ
It is commonly found as congenital deformity and with diabetic peripheral
neuropathy
It may be treated surgically by PIPJ fusion and flexor tenotomy

References

Question 31

select the appropriate antibiotic from the folowing list

A : penicillin V
B : ciprofloxacin
C : trimethoprim
D : cefradine
E : erythromycin
F : rifampicin
G : vancomycin
H : fusidic acid
I : teicoplanin
J : ceftriaxone
1 : Inhibits DNA gyrase
Correct answer:
B
2 : Inhibits dissociation of peptidyl tRNA from ribosomes
Correct answer:
E
3 : Bacteriocidal. Prevents RNA transcription by inhibiting DNA dependant RNA
polymerase
Correct answer:
F
4 : inhibits bacterial peptidoglycan synthesis
Correct answer:
A
Your answer:
A

Question 32

A : Anterior cruciate ligament tear

B : Medial collateral ligament tear
C : Posterolateral corner injury
D : Bucket handle tear of the medial meniscus
E : Lateral meniscal cyst
F : Discoid lateral meniscus
G : Lateral collateral ligament tear
H : popliteal artery injury
I : Posterior cruciate ligament tear
1 : A 22 year old medical student presents for evaluation 1 week after injuring the left
knee. Examination of the involved knee at 30 degrees of flexion reveals increased
posterior translation, increased varus rotation, and increased tibial rotation. What is
the most likely diagnosis?
Correct answer:
C
2 : Avulsion fracture of the lateral tibial plateau on radiographs is associated with
injury to what structure?
Correct answer:
A
3 : A 18 year old skier sustains a hyperextension injury to his knee resulting in a knee
dislocation. Assuming he has an anterior and posterior cruciate injury which other
structure would you suspect to be injured in 30-50% cases?
Correct answer:
H

Question 33

An 85 year old patient, who underwent THR revision to an uncemented acetabulum

and maximum length modular femoral head, presents with recurrent dislocations and
a Trendelenberg gait. The X-rays show well fixed components with good orientation
and offset. The best option to obtain stability is:
Convert the THR to a bipolar hemiarthroplasty
Perform excision arthroplasty
Use a posterior lip augmentation devise (PLAD)
Use a constrained liner
Perform a trochanteric advancement

References

Option 1 and 2 are not appropriate as components are well fixed and well orientated;
option 3 is not correct as it is designed for cemented cups and option 5 is
inappropriate as Trendelenberg suggests abductor dysfunction in spite of good offset
of the implants.

Question 34

Poor or incomplete resolution of symptoms following first dorsal compartment release

for De Quervain's stenosing tenosynovitis would most likely occur as a result of:
Early return to activity
Superficial radial sensory nerve injury
Abductor pollicis longus laceration
Incomplete release
Pseudoaneurysm in the radial artery

References

The most common reason for recurrent or persistent symptoms of first dorsal
compartment stenosis is failure to recognize and release a separate extensor pollicis
brevis subsheath. The superficial radial sensory nerve may be injured in surgery for
De Quervain disease, but the resulting neuroma is often more painful than the
original symptoms and is of a different character. Abductor pollicis longus laceration
would result in loss of radial abduction of the thumb. Early motion of the thumb is
recommended following release of the first dorsal compartment.

Question 35
Which of the following statements is true regarding osteogenesis imperfecta
It is a disorder of Type II collagen
The most common type of osteogenesis imperfecta is Type 3
Histological examination bone is characterized by increased diameters of Haversian
canals and osteocyte lacunae
The gene responsible is COL1A3
Radiographs demonstrate thickened cortices with generalized osteopenia

References

prevalence 1 in 20000 children

Genetic, collagen type 1, gene - collagen 1A1 on chromosome 7q or mutation 1A2on
chromosome 17q, mild mutation quantitative defect or abnormal type of collagen
molecule is formed.
Sillence Classification
Type 1 mild blue sclera quantitative - 1A normal teeth 1B dentinogenesis imperfecta
50% deafness
Type 2 lethal abnormal collagen or severe quantitative
Type 3 severe white sclera abnormal collagen dentinogenesis imperfecta
Type 4 moderate white sclera abnormal collagen 4A normal teeth 4B dentinogenesis
imperfecta
Medical treatment - Bisphosphonates and vit D
Surfical treatment - plaster, nailing, Sofield technique, scoliosis treatment

Question 36

Which of the following does not predispose to hallux rigidus.

Long first metatarsal
Metatarsus adductus
Flat or chevron-shaped metatarsophalangeal joint
Osteochondral fracture
Hallux Valgus Interphalangeus

Question 37

A : Tension pneumothorax
B : Flail chest
C : Open pneumothorax
D : Massive haemothorax
E : Cardiac tamponade
F : Commotio cordis
G : Blunt cardiac injury
H : Aortic distruption
1 : 26 years old male brought to Casualty department following a high-deceleration
injury. He is haemodynamically unstable. Some of the CXR findings are; fractures of
the first and second ribs, deviation of the oesophagus (NG tube present) to the right
and obliteration of the aortic knob. What is the most likely diagnosis?
Correct answer:
H
2 : Results in sudden death following a blow to the chest by a ball in previously
healthy people. Usually does not respond to resuscitation. What is the most likely
diagnosis?
Correct answer:
F

3 : In this injury some of the findings are increased venous and decreased arterial
pressure and muffled heart sounds. What is the most likely diagnosis?
Correct answer:
E

Question 38

A : Ankylosing spondylitis
B : Carpal tunnel syndrome
C : Gout
D : Ulnar nerve compression
E : Joint sepsis
F : Trauma
G : Osteoarthritis
H : Psoriatic arthritis
I : De Quervain's tendinitis
1 : A 45 year old man who suffers form insulin dependent diabetes mellitus presents
with pain and tingling sensation affecting the thumb, index and middle fingers.
Correct answer:
B

2 : A 73 year old woman with rheumatoid arthritis on immuno-suppressive drugs

presents with systemic malaise and fever. She has red, hot, swollen wrist.
Correct answer:
E
3 : A 43 year old domestic worker woman presents with pain and swelling proximal to
the radial styloid for several weeks. She has no systemic symptoms.
Correct answer:
I

Question 39
Which one of the following statements is true for osteosarcoma
Is a malignant spindle cell sarcoma of bone
Is composed of small round cells in a sparse intracellular stroma
Has a chondroid matrix surrounding malignant chondrocytes with a characteristic
clear cytoplasm
Is usually unresponsive to neo-adjuvant chemotherapy
Patients with pulmonary metastasis have a 5 year survival rate of 10%

References

The histology of osteosarcoma is characterised by highly malignant spindle cells

producing osteoid and is the most common primary malignant tumour of bone
excluding myeloma. Ewing’s sarcoma is characterised by small round cells in a
sparse intracellular stroma and the histological appearance described in option 3
typifies chondrosarcoma. Neoadjuvant chemotherapy has dramatically improved the
prognosis of patients with osteosarcoma but when pulmonary metastasis develop
after completion of therapy the metastasis can be resected a survival rate of 20-40%
can be expected

Question 40

Which of the following statements regarding osteoporosis is true?

It is defined by WHO as a bone density equal to or less than 2.5 standard deviations
below the mean for age matched normal subjects.
NICE recommends bisphosphonates for secondary prevention in women with
osteoporotic fracture over the age of 75 without further investigation.
Dietary calcium supplementation is unnecessary if bisphosphonates are used as
therapy.
Calcium and vitamin D supplementation alone do not reduce fracture risk.
Thyroid abnormailites are a rare association

References

WHO definition is less than not equal to 2.5 standard deviation below peak bone
mass in 25 year old women.
NICE guidelines suggest bisphosphonates are recommended for secondary
prevention.

Question 41
Which one of the following is not a branch of of the posterior cord of the brachial
plexus?
Radial nerve
Axillary nerve
Dorsal scapular nerve
Lower subscapular nerve
Thoracodorsal nerve

References

Dorsal scapular (Nerve to rhomboidus) is a branch of C5 root.

Question 42

The greatest increase in compartment pressure during reamed intramedullary nailing

of tibial shaft fracture occurs with the use of
A tourniquet
A large IM nail
Continuous traction
Entry into medullary canal with an awl
A static locking construct

References
Effect of acute reamed versus undreamed intramedullary nailing on compartment
pressure when treating closed tibial shaft fractures; a randomized prospective study.
J ortho Trauma 2000 Nov 14(8):554-8.
OKU 7 ch 42
RESULTS: Compartment syndrome did not occur in any patient. Peak average
pressures were obtained during reaming in the reamed group (30.0 millimeters of
mercury anterior compartment, 34.7 millimeters of mercury deep posterior
compartment) and during nail insertion in the unreamed group (33.9 millimeters of
mercury anterior compartment, 35.2 millimeters of mercury deep posterior
compartment). The average pressures quickly returned to less than thirty millimeters
of mercury and remained there for the duration of the study. The deep posterior
compartment pressures were lower in the reamed group than in the unreamed group
at ten, twelve, fourteen, sixteen, eighteen, twenty, twenty-two, and twenty-four hours
postoperatively (p < 0.05 at each of these times. A statistically significant difference
between anterior compartment pressures could not be shown with the numbers
available. The deltaP values were greater than thirty millimeters of mercury at all
times after nail insertion in both the reamed and unreamed groups. CONCLUSION:
These data support acute (within three days of injury) reamed intramedullary nailing
of closed, displaced tibial shaft fractures without the use of a fracture table.
logbook help

Question 43

Which factor is most indicative of progression in an adolescent idiopathic scoliosis?

Risser sign 0
A lumbar curve
Male gender
Risser sign 5
Concomitant Marphan's syndrome

References

RISSER CLASSIFICTION IS DEGREE OF OSSIFICATION OF THE ILIAC

APOPHYSES. ‘0’ INDICATES NO ILIAC APOPHYSES OSSIFIED AND HENCE A
GROWING CHILD. LIKELIHOOD OF PROGRESSION IS RELATED TO GROWTH.

Question 44
A : Hyperparathyroidism
B : Renal Osteodystrophy
C : Rickets
D : Postmenopausal Osteoporosis
E : Scurvy
F : Pagets disease
G : Osteopetrosis
H : Pseudohypoparathyoidism
I : Hypoparathyroidism
1 : Vitamin C deficiency leading to defective collagen synthesis
Correct answer:
E
2 : Decreased Oestrogen levels leading to reduce bone mass
Correct answer:
D
3 : Genetic disorder caused by a lack of effect of parathyroid hormone at the target
cells
Correct answer:
H

Question 45

Which one of the following is considered a contraindication to cement injection

techniques, such as Kyphoplasty or vertebroplasty, in the treatment of osteoporotic
compression fractures?
Patient age more than 85 years
Retropulsion of the posterior vertebral wall
Acute fracture in the hospitalised patient
Prior compression fracture
Fracture age of 4 months

References

When retropulsion of the posterior wall is present, nothing prohibits the cement from
following the path of least resistance into the canal or from pushing a bone fragment
further into the canal. Patient age itself is not a contraindication as long as no
medical contraindication to surgery. An acute fracture in a patient who remains
immobile and hospitalised because of pain may be a good indication for such a
technique. Prior or old fractres are not contraindications, but pain relief may be less
predictable.

Question 46

Regarding SUFE, which of the following is false?

There is a male preponderance
It more commonly affects Polynesian children.
According to Southwick classification, difference of 30 to 50 degrees in Southwick
angle between normal and affected side is classified as moderate slip.
According to Wilson classification, moderate slip is between 33 to 50% femoral head
displacement as a percentage of the femoral neck diameter.
Both hips are reported to be involved in 5% of cases

References

25 to 40% cases are bilateral

Question 47

A : MESS value of 7 or more

B : MESS value of between 4 and 6
C : MESS value of 4 or less
D : MESS value of 6 or more
E : MESS value of 8
F : MESS value of between 3 and 7
G : MESS value of 10 or more
H : MESS value of 1
I : MESS value of between 2 and 5
1 : A 59 year old man is found 7 hours after sustaining a comminuted fracture of his
left tibia secondary to a high velocity gun shot wound. He is hypotensive on site ( syst
BP <90) but responds well to IV fluids. He has a weak DP pulse but good Cap Refill.
What is the patient’s MESS value?
Correct answer: is actually 8 age2 , bp 1, energy 3, perfusion 1 doubled to 2
G

2 : What MESS value has been associated with a 100% amputation rate?
Correct answer:
A

3 : What MESS value has been associated with a 100% salvage rate?
Correct answer:
C

Skeletal / soft-tissue injury

Low energy (stab; simple fracture; pistol gunshot wound) 1
Medium energy (open or multiple fractures, dislocation) 2
High energy (high speed MVA or rifle GSW) 3
Very high energy (high speed trauma + gross contamination) 4
Limb ischemia
Pulse reduced or absent but perfusion normal 1*
Pulseless; paresthesias, diminished capillary refill 2
Cool, paralyzed, insensate, numb 3*
Shock
Systolic BP always > 90 mm Hg 0
Hypotensive transiently 1
Persistent hypotension 2
Age (years)
< 30 0
30-50 1
> 50 2

* Score doubled for ischemia > 6 hours

logbook help

Question 48

A : Renal Cell metastasis

B : Chondroblastoma.
C : Aneurysmal bone cyst
D : Osteosarcoma.
E : Osteioid osteoma.
F : Enchondroma
G : Osteoblastoma
H : Ewing’s Sarcoma
1 : The pre-operative use of arterial embolization in order to decrease blood loss at
time of resection is commonly used in the treatment of:
Correct answer:
A
2 : Intra-arterial cis-platin is used as adjuvant chemotherapy in the treatment of:
Correct answer:
D
3 : Radio frequency ablation can be used as the primary treatment of:
Correct answer:
E

Question 49

A : McMurray's test
B : Appley's test
C : Lachman test
D : Anterior drawer test
E : J sign
F : Pivot shift test
G : Clark's test
H : Dial test
I : Quadriceps active test
1 : What is the most sensitive test for ACL injury?
Correct answer:
C

2 : Negative in isolated PCL injury but positive in combined PCL and Posterolateral
corner injury.
Correct answer:
H

3 : Negative in isolated posterolateral corner injury but positive in PCL injury

Correct answer:
I

References

The lists of tests to assess ligament stability of the knee are long and can be
confusing. Lachman, Anterior draw, Finacetto and Pivot tests are tests to assess the
ACL injury. Lachman’s test is the most reliable of them as per following tables:

Although, PCL and posterolateral corner instability are often co-exist, however, they
can be isolated and it is quite helpful to be able to differentiate them clinically. I found
the following table is quite helpful.

Dial test is negative in (isolated) PCL injury but positive in combined injury or isolated
posterolateral corner injury. Contrary to the Quadriceps active test, which is positive
in PCL (isolated or combined) injury and negative in poster lateral corner.

McMurray and Apley’s tests are for meniscal injuries mainly, while Clark’s and J tests
are related to patelofemoral joints.

Question 50

With reference to spinal stenosis which of the following statements is true

There is an equal sex distribution between male & female and is solely age
related.
Spinal claudication can differ from vascular claudication in that sitting and riding a
bike will provoke symptoms consist with spinal stenosis.
Symptoms are progressive in the over 70 age group
Surgical treatment should involve decompression and fusion if there is evidence of
spondylo-listhesis.
Investigations should include plain radiographs, CT and Gadolinium enhanced
MRI

References

Men are more commonly affected due to the fact that their spinal canals are more
narrow at L3-L5 and the commonest sites are L4/L5 & L3/L4 segments.
Spinal claudication is excentuated by uphill walking produces late symptoms, relief
with sitting or bending and no relation to cycle exercise.
Several small studies have implied that in the majority of pts (>60%) there is no
deterioration in the symptoms.
Current indications for surgical management include spinal fusion with
decompression if there is either pre-operative instability related to spondylo-listhesis
or if instability is likely as a result of resection of facet joint.
Current investigations include X-rays, CT to delineate bony component and plain MRI
to ascertain contribution from soft tissue hypertrophy.

Question 51
Lower limb anatomy
A : A The medial femoral circumflex artery
B : B The inferior gluteal nerve
C : C The femoral nerve
D : D The superior gluteal nerve
E : E The sciatic nerve
F : F The obturator artery
G : G The lateral femoral circumflex artery
H : H The inferior gluteal artery
I : I The superior gluteal artery
J : J The femoral artery
1 : During a direct lateral (Hardinge) approach to the hip, which neurovascular
structure may be injured by excessive retraction of the gluteus medius muscle?
Correct answer:
D

2 : The artery of the ligamentum teres (foveal artery) is a branch of which vessel?
Correct answer:
F

3 : The anterior (Smith-Petersen) approach to the hip utilises the internervous plane
between muscles supplied by the superior gluteal nerve and which other nerve?
Correct answer:
C

Question 52
Antegrade femoral nailing in polytrauma patients with chest injuries should be:
Performed without reaming
Performed with reaming
Avoided acutely
Delayed until the pulmonary injury has completely resolved
None of above

References

Reamed femoral nailing in a patient with an acute pulmonary injury does not add to
pulmonary complications or the incidence of acute respiratory distress syndrome
(ARDS). Stabilize the fracture and mobilize the patient with any available technique.
Studies from Germany show an approximate 35% incidence of ARDS in polytrauma
patients who undergo antegrade reamed femoral nailing. Studies from the United
States have not corroborated these results, and show a 5% to 8% incidence of
ARDS.

Question 53

Transeverse fracture of humeral shaft in adults

2)sling is better than coller and cuff.
3)Body mass index does influence the management.
4)Radial nerve palsy is contraindication for conservative management.
5) malunion is more of a problem than nonunion.
Hanging cast is recommended to align the fracture.

Question 54

All these are examples of Benign tumours except:

Osteochondroma
Fibrous histiocytoma
Adamantinoma
Chondroblastoma.
Aneurysmal Bone cyst.

Question 55

Dropped finger in Rheumatoid arthritis is due to:

Volar subluxation of the metacarpophalageal joint
Avulsion of the central slip of the extensor tendon
Rupture of the extensor tendon at the level of the wrist
Subluxation of the extensor tendon over the metacarpophalangeal joint

Rupture of the extensor tendon at the level of the metacarpophalangeal joint

Question 56
The following is not a cause of intrinsic muscle shortening (Intrisic Plus deformity):
Ulnar nerve palsy
Post traumatic scarring
Volar subluxation of the metacarpophalangeal joints
Cerebral palsy
Ischaemia

Question 57

A 32 year old butcher accidentally amputates the 3rd digit of his dominant hand.
What is the proper sequence for repairing the structures during surgical re-
implantation?
(1) Nerves, (2) arteries, (3)bone, (4)veins, (5)extensor tendon, (6)flexor tendons
(1) bone, (2) extensor tendon, (3)flexor tendons, (4)arteries, (5)nerves, (6)veins

(1) bone, (2) arteries, (3)nerves, (4)veins, (5)flexor tendons, (6)extensor tendons
(1) bone, (2) extensor tendon, (3)flexor tendons, (4)arteries, (5)veins, (6)nerves
(1) arteries, (2)bone, (3)flexor tendons, (4)extensor tendon, (5)veins, (6)nerves

References

The proper sequence for repair during digital re-implantation is : (1) locate and tag
vessels and nerves, (2) debride necrotic tissues, (3) shorten and fix the bone,
(4)repair extensor tendons, (5) repair flexor tendons, (6) artery anastomosis, (7)
repair the nerves, (8) vein anastomosis, (9) skin coverage. Bony stability must be
established before vessel repair, so anastomoses are not disrupted during bone
repair. Definitive bone length must be established before tendon repair so
appropriate resting length can be set.

Question 58

Which one of the following statements is true regarding paediatric supracondylar

fractures of the humerus.
Peak incidence occurs in those over 11 years of age
Neurological injuries occur in over 20% of fractures
Anterior interosseus nerve function is assessed by testing power of flexion at the
interphalangeal joint of the thumb and the DIP joint of the little finger
The Gartland Classification is based on the degree of fracture displacement
Injury is suspected radiographically if the posterior humeral line does not bisect the
capitellum

Question 59

A : Developmental dysplasia of hip

B : Congenital coxa vara
C : Slipped upper femoral epiphysis
D : Osteomyelitis of the hip
E : Transient synovitis
F : Legg - Calve - Perthes Disease
1 : Southwicks Angle of greater than 15 degrees
Correct answer:
C

2 : Triangular ossification defect in inferomedial femoral neck

Correct answer:
F no B

3 : Acetabular index of less than 25 degrees

Correct answer:
A

Question 60

In hallux valgus which one of the following statements is false

Interphalangeal angle of 7 degrees is normal
Hallux valgus angle is between long axis of 1st metatarsal and a line trough base of
distal articular cap of the metetarsal
Intermetatarsal angle calculates angle between long axis of 1st metatarsal and the
2nd metatarsal and should be normally less than 10 degrees
phalengeal articular angle is important for Akin osteotomy
Common complication of corrective surgery is recurrence

Hallux valgus angle is between long axis of proximal phalanx and long axis of 1st MT
and is normally less than 15 degrees.

Question 61

With regards to fractures of the distal radius and percutaneous k wire fixation.
A : Anterior interosseous nerve
B : Posterior interosseous nerve
C : Ulnar nerve
D : Radial nerve
E : Flexor pollicis longus
F : Extensor pollicis longus
G : Superficial radial nerve
H : Recurrent motor branch of the median nerve
I : Median nerve
1 : 6 weeks post MUA & k wiring a patient presents with sensory disturbance in the
first web space
Correct answer:
G

2 : 6 weeks post MUA & k wiring a patient presents with reduced range of active
thumb movement
Correct answer:
F

3 : Which nerve is frequently compromised in acute distal radius fractures

Correct answer:
I
Question 62

Which of the following is true regarding embolisation in the management of pelvic

fractures with associated bleeding?
It is the first choice procedure in most cases
It is useful in only about 10% of cases
It is useful in the management of venous bleeding
It is a rapid means of obtaining haemodynamic control
If unsuccessful, a pelvic ex fix should be applied

References

Embolisation is not first choice, and an ex fix should always be applied first. It is only
useful for a major vessel bleed rather than from the venous plexus, and is not a rapid
procedure.

Question 63

In a fit adult patient with Class II circulatory shock (15 to 30% blood loss) vital signs
will indicate:
Normal blood pressure and a decreased pulse pressure
Normal blood pressure and an increased pulse pressure
Hypotension and a decreased pulse pressure
Hypotension and an increased pulse pressure
Hypotension and a normal pulse pressure

Question 64

The Sanders classification of Calcaneal fractures is based upon:

Position of secondary fracture line on lateral radiograph
Position of secondary fracture line on Harris axial radiograph
Number and location of articular fragments on sagital CT scan
Position of primary fracture line on lateral radiograph
Number and location of articular fragments on coronal CT scan

References

Sanders Classification (1993) is based on the number and location of articular

fragments on Coronal CT scan. There are 4 types, based on the number of
fragments of the posterior facet, with displacement of 2mm considered significant.

Question 65

Which of the following is considered the lowest level that a standard

thoracolumbosacral orthosis (TLSO) can immobilise?
T9 -10
T11-12
L1-2
L3-4
L5 -S1

References

Without more distal immobilisation such as a thigh extension, the lower two lumbar
segments generally show the same or even increased mobility with a TLSO.

Question 66

2. A fifteen year old football player scored a goal during a teacher versus pupil match
at school. As soon as he kicked the ball he felt a sudden pain in his groin and had
painful weightbearing. He was seen in A&E soon after the injury. There was some
bruising in his groin. He had difficulty flexing his hip, but there was full range of
passive movement. X- Ray reveals a tiny bony avulsion from the Anterior Inferior Iliac
Spine. What muscle is he likely to have injured?
Sartorius
Reflected head of rectus femoris
Straight head of rectus femoris
Pectineus
None of the above

References

Straight head of rectus femoris. This is the only muscle attached to the AIIS.
Sartorius is attached to the ASIS. Reflected head of rectus femoris originates from a
shallow concavity above the acetabulum. Pectineus originates from the pectineal line
on the pubis.
Last’s Anatomy

Question 67

A : Degenerative plantar fasciitis

B : Ankylosing spondylitis
C : Haglund deformity
D : Inflammatory arthropathy
E : Tibialis anterior tenosynovits
F : Deep peroneal nerve entrapment
G : All
H : Medial 2/3rd
I : Medial 1/3rd
1 : A 40 year old man presented to the clinic with 6 month history of plantar foot pain.
If he also had history of back pain and stiffness along with tendonitis and restriction
of hip and chest movements most likely diagnosis is
Correct answer:
B

2 : For central heel pain (stone bruise) which condition should be ruled out
Correct answer:
D
3 : In plantar fascia release for plantar fasciitis surgeon should release how much of
plantar fascia
Correct answer:
I

4 : Posterior heel pain due to retrocalcaneal bursitis is associated with

Correct answer:
C

Question 68

The only Intrinsic tendon associated with the first MTP joint is:
Extensor halllucis longus
Extensor digitorum brevis
Flexor hallucis brevis
Flexor hallucis longus.
Peronus brevis.

Question 69

A : Total knee arthroplasty

B : Unicondyler knee arthroplasty
C : Patellofemoral arthroplasty
D : High tibial osteotomy
E : ACL reconstruction
F : microfracture/OATS
G : Knee arthrodesis
H : Revision knee arthroplasty
I : Above knee amputation
1 : A 42 year old man with ACL deficient knee without symptoms of instability, medial
degenerative changes and a partially correctable varus deformity complaining of
significant medial knee pain but no instability.
Correct answer:
D

2 : A 60 year old woman with rheumatoid arthritis with ‘bone on bone’ medial
compartment degenerative change with no flexion deformity and no evidence of
patello-femoral or lateral compartment degenerative change.
Correct answer:
A

3 : A 35 year old man with a localised chondral defect on the medial femoral condyle
noticed at arthroscopy
Correct answer:
F

References

1. Young patient (too young for TKR), incompletely correctable varus deformity (UKR
contra-indicated). Instability not a problem (Address pain first with HTO, if instability
subsequently a problem can address ACL)
2. Unicompartmental disease but inflammatory arthritis contra-indication for UKR.

3.

Question 70

A : Osteoarthritis
B : Rheumatoid arthritis
C : Osteonecrosis
D : Seronegative arthropathy
E : Septic arthritis
F : Gout
G : Diabetes
H : Haemophilia
I : Pigmented villonodular synovitis
1 : Which of the above is associated with a painless, massive destruction of the knee
joint
Correct answer:
G

2 : Which of the above rarely affects the knee joint, but has a predilection for smaller
synovial joints and is more common in men
Correct answer:
F

3 : Which of the above conditions symptoms may be controlled by desmopressin

Correct answer:
H

Question 71

Following through knee amputation, which prosthesis would you recommend to the
following patients?
A : Polycentric Knee
B : Stance-Phase Control Knee
C : Fluid control knee
D : Constant-Friction knee
E : Cadence control lnee
F : Manual locking knee
G : Manual fluid control knee
H : Polycentric locking knee
I : Flex Foot prosthesis
J : Trans tibial prosthesis
1 : A 12 year old male
Correct answer:
D

2 : A blind 80 year old

Correct answer:
F

3 : A bilateral amputee
Correct answer:
A

Question 72

A 45 year old postal worker with diabetes prsents with a 3cm ulcer below his first
metatarsal head. Flexor tendons are visible, but no erythema, swelling or fluctuance
is noted beyond the edge of the ulcer. Xrays reveal no evidence of bony involvement.
What is the most appropriate management?
A Oral Antibiotics and elevation
B Total Contact Cast
C Intravenous Antibiotics
D Leech Therapy
E Surgical Debridement and IV antibiotics

Question 73

After how many weeks in utero do osteoblasts normally form the primary ossification
centres in long bones?
6 weeks
8 weeks
9 weeks
10 weeks
12 weeks

References

At 6 weeks, embryonic long bones have formed from mesenchymal anlage. At 8

weeks, vascular buds invade the mesenchymal model, bringing in osetoprogenitor
cells which differentiate into osteoblasts leading to formation of the primary
ossification centre. By 9 weeks, irruption canals bring capillaries into the primary
ossification centres. At 10 weeks, epiphyseal arteries are formed.

Question 74

Open reduction and internal fixation for fracture clavicle is indicated in all of the
following except:
Non union
Neuro-vascular injury
Open fracture
Epileptic patient
Floating shoulder

References

The only absolute indication for open reduction and internal fixation is probably the
neuro-vascular injury because it poses a significant threat to life and limb. Stabilising
the fracture reduces this risk significantly. However, there is a consensus that non-
union, open fracture and floating shoulder are other good indications for ORIF. Some
authorities regarded epilepsy an indication for open reduction and fixation of clavicle
fractures because it might interfere with shoulder immobilisation. This is not widely
accepted and it is always worth giving a chance for non-operative treatment.

Question 75

Which of the following does not contribute to the blood supply of the femoral
neck/head?
Medial Femoral Circumflex Artery
Lateral Femoral Circumflex Artery
Inferior Gluteal Artery
Posterior Branch of the Obturator Artery
Internal Pudendal Artery

Question 76

Which of the following surgically important microorganisms do the statements most

accurately apply?
A : Pasteurella multocida
B : Staphylococcus aureus
C : Haemophilus Influenzae
D : Pseudomonas aeruginosa
E : Salmonella species
F : Neisseria gonorrhoeae
G : Bartonella hensela
H : Clostridium tetani
I : Mycobacterium tuberculosis
J : Staphylococcus epidermidis
1 : The most common pathogen from a cat bite?
Correct answer:
A

2 : A cause of septic arthritis in a 2 year old unimmunised child?

Correct answer:
C

3 : The most common pathogen in infection of a Total Hip Replacement?

Correct answer:
J

Question 77

A : Developmental dysplasia of the hip

B : Slipped capital femoral epiphysis
C : Achondroplasia
D : Down's Syndrome
E : Turner's Syndrome
F : Coxa Plana
G : Coxa Vara
H : Tibial torsion
I : Femoral anteversion
1 : A child with trident hand inability to approximate extended middle and ring fingers
Correct answer:
C

2 : 6 year old boy with hip pain and decreased abduction and internal rotation.
Crescent sign on radiograph
Correct answer:
F

3 : 2 year old child with in-toeing gait and internal rotation of feet with patella facing
forwards
Correct answer:
H

Question 78

Which one of the following statements is true about surgical approaches to the elbow
joint
Kaplan’s interval is between extensor carpi radialis brevis and extensor digitorum
Kaplan’s interval can safely be extended distally to expose the proximal radius
Kocher’s approach utilises the interval between extensor carpi ulnaris and
anconeus.
Olecranon osteotomy gives inadequate exposure of the distal humerus for fracture
management.
Olecranon osteotomy precludes primary arthroplasty in the treatment of distal
humeral fractures

References

Kaplan’s interval is between extensor carpi radialis longus and extensor digitorum.
The posterior interosseus nerve is at risk if Kaplan’s interval is extended distally.
Olecranon osteotomy gives good exposure of the distal humeral articular surface and
does not preclude primary arthroplasty.

Question 79

A : Slipped upper femoral epiphysis

B : Perthes disease
C : Developmental dysplasia of the hip
D : Adolescent ideopathic scoliosis
E : Supracondyler fracture of the humerus
F : Lateral mass fracture of the distal humerus
G : Club foot
H : Tibia Vara
I : Coxa Vara
1 : The radiographic measurement of Baumann angle is useful for which condition?
Correct answer:
E

2 : The radiographic measurement of Cobb's angle is useful for which condition?

Correct answer:
D
D
3 : The radiographic measurement of centre edge angle of Wiberg is useful for which
condition?
Correct answer:
C

Question 80

To which of the following organs do sarcoma’s commonly metastasise

Kidney
Lung
Liver
Bones
Brain

References

Soft tissue sarcomas most commonly metastasize to the lungs. Plain chest
radiographs may not reveal small lesions. Computerized tomography of the chest is
the most sensitive method to detect small nodules that are 3 mm to 15 mm in
diameter. Other sites of metastases include other bones and visceral organs, such as
the liver, spleen, and kidneys.

Question 81

Which of the following surgically important microorganisms do the statements most

accurately apply?
A : Pasteurella multocida
B : Staphylococcus aureus
C : Haemophilus Influenzae
D : Pseudomonas aeruginosa
E : Salmonella species
F : Neisseria gonorrhoeae
G : Bartonella hensela
H : Clostridium tetani
I : Mycobacterium tuberculosis
J : Borrelia species
1 : The most common cause of acute monoarticular septic arthritis in a sexually
active 21 year old man?
Correct answer:
F

2 : Classically would produce a bullseye rash at the site of infection and present with
generalised arthralgia.
Correct answer:
J

3 : The most characteristic organism from a puncture of a nail through the sole of a
shoe in a non diabetic patient.
Correct answer:
D
References

Question 82

A : Impingement syndrome
B : Supraspinatus lesion
C : Infraspinatus/Posterior supraspinatus lesion
D : subscapularis lesion
E : posterior subluxation
F : Inferior laxity or instability
G : SLAP lesion
H : Bicipital tendinosis
I : Thoracic outlet syndrome
1 : Positive Crank test will differentiate which pathology from others?
Correct answer:
G

2 : Positive Wright's test will differentiate which pathology from others?

Correct answer:
I

3 : Positive Belly press test will differentiate which pathology from others?
Correct answer:
D

References

1) Crank test: pain on full abduction, humeral loading and rotation- SLAP lesion also
+ve are Active compression test and Anterior slide test.
2) Wright’s test: Loss of pulse and reproduction of symptoms on Extension-Abduction
and ER of arm with neck rotated away- Thoracic Outlet syndrome.
3) Belly push test: Inability to hold elbow forward when elbow held anteriorly with
abdominal pressure- Subscapularis lesion. Also +ve are Lift-off test and modified lift
off test.

Question 83

Which of the following describes the appearance on T1 and T2 weighted images of a

lipoma.
Gray (T1) / Dark (T2)
Dark (T1) / Dark (T2)
Bright (T1) / Bright (T2)
Dark (T1) / Bright (T2)
Bright (T1) / Gray (T2)

References

Lipomas are homogeneous and they exactly follow the subcutaneous fat on all
sequences. With fat suppression techniques, lipomas turn completely dark.
Remember, fat suppression turns the fat from its high signal to low signal.
It is important to remember the appearances of every lesion on both T1 and T2
weighted images:
T1 weighted T2 weighted
Fat High Moderate
Tendons Low Low
Ligaments Low Low
Fascial layers Low Low
Cortical bone Low Low
Muscle Moderate Moderate
Normal marrow High Moderate
Soft tissue sarcomas Low High
Fluid (ganglions, effusions) Low High
Pigmented villonodular synovitis† Very low Very low

Question 84

A 41 year old farmer complains of pain in his first metatarsophalangeal joint. Pain
has recurred following a dorsal cheilectomy 3 years previously. Radiographs shows
severe osteoarthritis in his first MTPJ. The next most appropriate procedure is
Repeat dorsal cheilectomy
Sialistic 1st MTPJ arthroplasty
Ceramic 1st MTPJ arthroplasty
1st MTPJ fusion
Excision of the 1st metatarsal head

References

In high demand patients, where chielectomy has failed, with severe symptomatic
arthritis the options are arthroplasty, fusion or excision.
Silastic and Ceramic arthroplasty are options in low demand patients due to risk of
early failure, and resection arthroplasty is associated with lower push off strength,
hence is unsutable for this patient.

Question 85

The most common organism cultured from septic arthritis is?

Neisseria gonorrhoea
Strep pyogenes
Staph epidermidis
Staph aureus
E. coli

References

Staph aureus is the most common cause overall. Neisseria gonorrhoea is the most
common in young sexually active patients accounting for 75% in this group. Staph
epidermidis is a common contaminant in infective samples.

Question 86
A : Extensor indicis
B : Extensor pollicis longus
C : Flexor carpi radialis
D : Palmaris brevis
E : Flexor pollicis longus
F : Flexor carpi ulnaris
G : Opponens pollicis
1 : Is used for a brunelli repair following scapho-lunate dissociation
Correct answer:
C

2 : Is most commonly ruptured following a distal radius fracture

Correct answer:
B

3 : Is most commonly used for extensor pollicis longus repair

Correct answer:
A

Question 87

Which of the following zones of the physis is implicated in Slipped capital femoral
epiphysis?
Reserve Zone
Hypertrophic Zone
Maturation Zone
Degenerative Zone
Zone of provisional calcification

References

Miller pp 15: The hypertrophic zone is believed to be involved in slipped upper capital
epiphysis (SCFE), except SCFE associated with renal failure, in which the slip occurs
through the metaphyseal spongiosa.

Question 88

With respect to management of osteoarthritis of the knee with osteotomy which one
of the following statements is true
Results of high tibial osteotomy are similar at 5 and 10 year follow up.
In High Tibial Osteotomy (HTO) the aim is to over-correct the deformity by 3-4
degrees.
The complication of non-union is common.
A varus tibial osteotomy is performed for a valgus knee.
High tibial osteotomies are indicated for patients over 60 years of age.

Question 89

What nerve innervates the pronator quadratus muscle?

The radial nerve
The ulnar nerve
The posterior interosseous nerve
The anterior interosseous nerve
The distal motor branch of the median nerve

Question 90

In the management of compartment syndrome

A : Anterior compartment
B : Lateral compartment
C : Superficial posterior compartment
D : Deep posterior compartment
E : Measurement of compartment pressures
F : Measurement of post-exercise compartment pressures
G : Administration of high doses of intravenous morphine
H : Immediate fasciotomies via a single incision
I : Immediate fasciotomies via two incisions
J : Immediate fasciotomies via three incisions
1 : Which is the most commonly involved compartment in acute compartment
syndrome of the leg?
Correct answer:
A

2 : Which is the most appropriate management for an acute compartment syndrome

of the leg following a tibial fracture?
Correct answer:
I

3 : What is the most appropriate management for an athlete complaining of exercise

induced leg pain?
Correct answer:
F

Question 91

In ligament balancing for knee replacement

A : Lateral capsular release
B : Downsize the femur
C : Ilio-tibial band release
D : Popliteus tendon release
E : Lateral collateral ligament release
F : release deep menisco-tibial ligament
G : release posteromedial corner ans semimembranosus
H : Cut more proximal tibia
I : Cut more distal femur
1 : In knee replacement procedure - If the knee is well balanced for collaterals but
flexion gap is smaller than extension gap
Correct answer:
B

2 : In knee replacement procedure - knee has flexion gap more than extension gap -
tight in extension.
Correct answer:
I

3 : In replacement procedure for valgus knee - after release of the lateral capsule for
the exposure which is the next release for ligament balancing
Correct answer:
C

1. Check and correct posterior slope of tibia. Could also redo femoral cuts to smaller
size with anterior referencing or recess PCL.

2. Cut more distal femur. Could also release posterior capsule.

3. After initial lateral capsular release from the tibia, ITB is released from the Gerdy's
tubercle, then popliteus tendon if tight in flexion from insetion on the femur and finally
the lateral collateral ligament off the femoral attachment.
Whiteside et al CORR 1999

Question 92

A : 1 year
B : less than 1 %
C : 6 months
D : 65%
E : 40%
F : 2 weeks
G : 10%
H : 100%
I : 8 weeks
1 : With regard to a Hawkins type II fracture of the talar neck When would you expect
to first see the Hawkins sign following successful open reduction and internal
fixation?
Correct answer:
I

2 : With regard to a Hawkins type II fracture of the talar neck What is the incidence of
avascular necrosis?
Correct answer:
E

3 : With regard to a Hawkins type II fracture of the talar neck What is the incidence of
sub-talar arthrosis in long term?
Correct answer:
D

Hawkin’s sign is the appearance of subchondral atrophy in the dome of the talus
representing disuse osteopenia. This only occurs if there is blood supply and
indicates revascularisation.

Hawkin’s classification:

I Undisplaced
II Displaced (disloc. subtalar jt.)
III Displaced + dislocation of the body (disloc. ankle jt)
IV (added by Terry and Canale later) Displaced + dislocation of both body and neck
(disloc. T-N jt.)
Hawkins AVN Non-union Subtalar Arthrosis
Type I 10% 2% 25%
Type II 40% 8% 65%
Type III 90% 10% 65% (ankle 70%)

Question 93

In acute haematogenous osteomyelitis:

The organism is usually Streptococcus pneumoniae.
Patient with sickle cell disease are prone to infection with Haemophilus
influenzae.
In adults the commonest site of infection is thoracolumbar vertebrae.
Blood culture is positive in every case of proven infection.
Early mobilisation of the affected limb is desirable.

Question 94

Concerning the shoulder joint which one of the following statements is true
The scapula lies in the coronal plane
The tendon of subscapularis is partially intrasynovial.
The glenoid is anteverted approximately 7 degrees relative to the axis of the
scapula.
The posterior approach to the shoulder utilises the internervous plane between
supraspinatus and infraspinatus.
The suprascapular nerve passes superficial to the transverse scapula ligament which
separates it from the vessels.

References

The scapula lies 30 degrees anterior to the coronal plane. The superior border of
subscapularis tendon is intra-articular. The glenoid is retroverted relative to the
scapula. The internervous plane is between infraspinatus and teres minor. The
suprascapular nerve passes deep to the ligament and is vulnerable to compression
at this site.

Question 95

A : Dynamic hip screw

B : Total hip resurfacing
C : Total hip replacement
D : Non-union
E : Hemiarthroplasty
F : Cannulated screw fixation
G : Thromboembolism
H : Infection
I : Osteonecrosis
1 : A previously fit and well 40 year old male presents with a intertrochanteric fracture
neck of femur. What is the most appropriate treatment of this injury?
Correct answer:
A
2 : A 85 year old lady falls in the street and sustains a displaced intracapsular
fracture neck of femur. What is the most appropriate method of treatment?

Correct answer:
E

3 : A very active 65 year old lady had a fall whilst running for a bus. Her hip
radiograph shows displaced intracapsular fractured neck of femur with presence of
osteophytes and subchondral sclerosis of the hip joint. She had painful hip joint
before fall. What is the most appropriate method of treatment for this patient?
Correct answer:
C

Question 96

PIPJ fusion may be performed as part of the correction of which one of the following
lesser ray foot deformities:
Fixed hammer toe
Mallet toe
Crossover toe
Flexible hammer toe
Flexible claw toe

Question 97

In Hallux valgus after failure of conservative treatment.

A : Modification of the footwear/toe spacer
B : Bunionectomy
C : Dorsal cheilectomy
D : Keller's arthroplasty
E : Lateral soft tissue release
F : Medial soft tissue tightening
G : Akin osteotomy
H : Scarf osteotomy
I : Basal first metatarsal osteotomy
J : Amputation of the great toe
1 : A 68 year old woman with rheumatoid arthritis, has painful hallux valgus, with
underriding great toe
Correct answer:
D

2 : A 38 year old male accountant with painful bunion, intermetatarsal angle of 18

degrees, and slightly increased distal metatarsal articular angle with minimal
arthrosis
Correct answer:
H

3 : A 68 year old lady with prominent painful bunion, intermetarsal angle of 12

degrees and hallux valgus angle of 40 degrees, with arthritis of the big toe MTP joint
Correct answer:
D
Rheumatoid feet with hallux valgus should have 1st MTP fusions to provide a stable
post for the lesser toes or could have excision arthroplasty.
The indications for a scarf osteotomy are painful bunion, minimal arthrosis, and IMA
up to 24 degrees, so the 38 yo man needs a scarf osteotomy.
Painful arthritic severe hallux valgus in the elderly can be successfully treated with
excision arthroplasty.

Question 98

Which of the following statements is false

Developmental dysplasia is commonly seen in females
Slipped upper femoral epiphysis is seen commonly in children of caucasian origin
compared to african origin
Forefoot adductus is a component of clubfoot
Radiographs are helpful in over 3 month old child with developmental dysplasia of
the hip
Kohler's disease involves the navicular bone

References

DDH COMMONLY SEEN IN FEMALES(85%)

SCFE SEEN COMMONLY IN AFRICAN AMERICAN
FOREFOOT ADDUCTUS IS A COMPONENT OF CLUBFOOT
FEMORAL HEAD OSSIFIES AT ABOUT 3 MONTHS
KOHLER’S DISEASE IS OSTEONECROSIS OF THE NAVICULAR

Question 99
Which of the following statement regarding calcium homeostasis is false?
The dietary requirement of calcium is higher in adolescents.
Calcitonin has its principal effect directly on the osteoclast.
Parathyroid hormone exerts its effect through an intracellular receptor complex.
Vitamin D is a steroid hormone.
Vitamin D undergoes hydroxylation in the liver and kidney to its active form.

References

Dietary requirement of calcium is greatest in pregnancy and growth spurt.

Parathyroid hormone works through membrane receptor activating adenylyl cyclase
consequently increasing cyclic AMP.

Question 100

A : Dorsal Intercalated Segment Instability (DISI)

B : 30-60°
C : Carpal Instability Non-Dissociative (CIND)
D : Piano Key Sign
E : 10-40°
F : Volar Intercalated Segment Instability (VISI)
G : Signet Ring Sign
H : Thurston Holland Sign
I : less than 30 degrees
1 : A 20 year old female falls on an outstretched hand. She complains of pain in her
wrist. Examinations suggest a possible scapholunate injury. What is the normal
range/value of the scapholunate angle on the lateral wrist X-Ray?
Correct answer:
B

2 : A 30 year old male has a history of wrist injury 18 months ago. He complains of
wrist pain and intermittent clicking. What X-Ray feature of a chronic DISI deformity
suggests flexion of the Scaphoid?
Correct answer:
G

3 : A 25 year old male presents with a 6 month history of left wrist pain and clicking.
He does not recall any injury. Examination is unhelpful. A lateral wrist X-Ray reveals
a scapholunate angle of 10°. What form of carpal instability does he have?
Correct answer:
F

References

Brinker’s Review of Orthopaedic Trauma

Normal rangeof scapholunate angle is 30-60 °. The average is 47°. > 70° = DISI. <
30° = VISI
Signet ring sign is caused by flexion of the Scaphoid on the AP Wrist X-Ray. Piano
key sign is found clinically in distal radioulnar joint instability. Thurston Holland sign
relates to the metaphyseal fragment in a type II Salter Harris physeal injury.
CIND would not result in a scapholunate angle change from normal.

Question 101

With regard to RA in the Hand and Wrist following statements are true except one
The most common flexor tendon rupture is flexor pollicis longus.
The most common tendon rupture is extensor digiti minimi
Within 2 years of diagnosis over 2/3rds of patients have wrist symptoms.

Methotrexate should be stopped prior to surgery.

Rheumatoid Nodules are seen in approximately 25% of patients.

References

1. The most common flexor tendon rupture is FPL – True (56% of flexor tendon
ruptures)
Reference: Mannerfelt L, Norman O: Attrition ruptures of flexor tendons in
rheumatoid arthritis caused by bony spurs in the carpal tunnel: Aclinical and
radiological study. J Bone Joint Surg Br 1969;51:270-277
2. The most common tendon rupture is EDM true
EDM most common due to its position over the ulnar head which subluxes dorsally
and causes attrition rupture)
Reference: Miller M, (2000) Review of Orthopaedics 3rd ed Saunders Philidelphia
3. Within 2 years of diagnosis over 2/3rds of patients have wrist symptoms – True
Reference: Hamalainen M, Kammonen M, Lehtimaki M, et al: Epidemiology of wrist
involvement in rheumatoid arthritis Rheumatol 1992;17:1-7.
4. Methotrexate should be stopped prior to surgery - False
Reference: Methotrexate and early postoperative complications in patients with
rheumatoid arthritis undergoing elective orthopaedic surgery. Annals of Rheumatic
Disease Grennan DM, Gray J, Loudon J, Fear S.
A prospective randomised study of postoperative infection or surgical complications
occurring within one year of surgery in patients with RA who underwent elective
orthopaedic surgery. CONCLUSION: Continuation of methotrexate treatment does
not increase the risk of either infections or of surgical complications occurring in
patients with RA within one year of elective orthopaedic surgery. Thus methotrexate
treatment should not be stopped in patients whose disease is controlled by the drug
before elective orthopaedic surgery.
5. Rheumatoid Nodules are seen in approximately 25% of patients – True
Reference: Miller M, (2000) Review of Orthopaedics 3rd ed Saunders Philidelphia
logbook help

Question 102

In assessing an acetabular fracture the following are true EXCEPT

An AP Pelvis X-ray acts as a screening test
The Iliac oblique view assesses the posterior column and anterior wall
The Pelvic inlet view is NOT a standard view for acetabular fracture assessment
The Obturator oblique view assesses the posterior column and anterior wall

The Iliopectineal line represents the anterior column

References

The standard views for acetabular fracture assessment are AP Pelvis, Iliac Oblique
and Obturator Oblique. The first view acts as a screening view. The second assesses
the posterior column and anterior wall. The last view assesses the anterior column
and posterior wall. The Iliopectineal line represents the anterior column and the
Ilioischial line the posterior column
(See Miller’s Review of Orthopaedics)

Question 103

An 80 year old woman with osteoporosis presents with a fagility fracture of the hip.
Which of the following statements are true?
BMD T score would be around -1
She would be on HRT for prevention of fragility fractures
Hip fracture is the most common fragility fracture
Treatment with bisphosphonates would be appropriate.
She is unlikely to of had a previous fragility fracture
References

Blue book

Question 104

With regard to RA in the Cervical Spine which one of the following statements is true
Involvement of the C-Spine in patients with RA is less than 10%
Lateral subluxation of C1 on C2 is the most common direction of subluxation–
Atlantoaxial impaction/ Cranial setting is less likely to cause neurological compromise
than Atlantoaxial subluxsation
Neurological symptoms are more common than neck pain
A diagnosis of atlantoaxial impaction can be made by identifying protusion of the
odontoid tip more than 4.5mm proximal to McGregor’s line

References

1. Involvement of the C-Spine in patients with RA is less than 10% - False

17-86% of patients with RA have C-Spine involvement
Reference: Rawlins BA, Girardi FP, Boachie- Adjei O: Rheumatoid arthritis of the
cervical spine. Rheum DisClin North Am 1998;24:55-65.
2. Lateral subluxation of C1 on C2 is the most common direction of subluxation–
False
Anterior subluxation is most common
Reference: Morizono Y, Sakou T, KawaidaH: Upper cervical involvement in
rheumatoid arthritis. Spine 1987;12:721-725.
3. Atlantoaxial impaction/ Cranial setting is less likely to cause neurological
compromise than Atlantoaxial subluxsation - False
Atlantoaxial impaction is the most common cause of neurological compromise in
cervical RA
Reference: Rheumatoid arthritis in the cervical spine. J Am Acad Orthop Surg. 2005
Nov;13(7):463-74Kim DH, Hilibrand AS.
4. Neurological symptoms are more common than neck pain – False
Neck pain, decreased ROM and crepitus are more common than neurological
compromise
Reference: Rheumatoid arthritis in the cervical spine. J Am Acad Orthop Surg. 2005
Nov;13(7):463-74Kim DH, Hilibrand AS.
5. A diagnosis of atlantoaxial impaction can be made by identifying protusion of the
odontoid tip more than 4.5mm proximal to McGregor’s line – True
Diagnosis is >4.5mm proximal to McGregor’s line. Diagnosis can also be made by
identifying protusion of the odontoid tip proximal to McRae’s line.
Reference: Riew KD, Hilibrand AS, Palumbo MA, Sethi N, Bohlman HH: Diagnosing
basilar invagination in the rheumatoid patient: The reliability of radiographic criteria. J
Bone Joint Surg Am 2001;83:194-200.)

Question 105

In obstetric brachial plexus injury, the return of biceps function within how many
months is considered to be a better prognostic indicator
3 months
9 months
12 months
18 months
24 months

References

Gilbert and Tassin (1) were the first to indicate the importance of monitoring the
return of biceps function as an indicator of brachial plexus recovery, which was
subsequently confirmed by other studies (2, 3, 4) in that if normal biceps function
failed to return by 3 months of age, the outcome at 2 years of age was not normal.

logbook help

Question 106

Which one of the following is not true about Sprengel's deformity?

Most common deformity of the shoulder in the children
Hyperplastic and narrow scapula
Associated with Klippel-Feil syndrome
Associated with scoliosis and kidney disease
Leads to decreased abduction

References

Most common deformity of shoulder in children. Scapula is hypoplastic,

undescended, medially rotated and wide with omovertebral connections (30%).
Associated with Klippel-Feil syndrome, kidney disease, scoliosis and
diastematomyelia. Surgery is required for cosmesis and functional deformity
(Decreased abduction) in the form of distal advancement of associated muscles and
scapula. Clavicle osteotomy is needed to avoid brachial plexus injury due to stretch.
Surgery is best done at 3-8 years old.

Question 107

In the anterior approach to C5, what structure is less vulnerable from the left side
than from the right?
The thoracic duct
The recurrent laryngeal nerve
The sympathetic chain
The carotid sheath
The superior laryngeal nerve

Question 108
Which of the following findings is a prerequisite for a high tibial valgus osteotomy for
medial compartment osteoarthritis?
Narrowing of lateral compartment
Ligamentous instability
Inflammatory arthritis
Preoperative range of motion of at least 90 degrees
Lateral Tibial subluxation

References

The indications for high tibial valgus osteotomy include physiologically young age,
arthritis confined to the medial compartment, 10-15 degrees of varus alignment on
weight-bearing radiographs and a preoperative range of motion of at least 90
degrees.

Question 109

A : Splintage
B : MRI arthrogram
C : X-ray imaging
D : Ultrasound imaging
E : Conservative management
F : Closed reduction and splintage
G : Open reduction and splintage
H : Repeat clinical examination
I : Open reduction and acetabular osteotomy
1 : A 5 week old baby with a positive Ortolani test is best assessed with which
imaging?
Correct answer:
D

2 : Primary treatment of dislocations presenting at the age of 18 months should be

Correct answer:
F

3 : A 14 year old child presenting with painless bilateral dislocations should have
treatment with
Correct answer:
E
logbook help

Question 110

The popliteus muscle receives its motor innervation from:

Peroneal branch of the sciatic nerve
Terminal branch of the obturator nerve
Saphenous nerve
Tibial branch of the sciatic nerve
Femoral nerve

Question 111

During primary total knee arthroplasty, the trial components are in place. The
extensor space is tight, but flexion space is normal. What is the best gap balancing
solution?
Resect additional distal femur and proximal tibia
Upsize the femoral component and distally augment the femur
Resect additional distal femur
Decrease the thickness of the tibial insert
Resect the proximal tibia and distally augment the femoral component

References

The first rule of total knee arthroplasty is to restore the joint line to its original
location.This will ensure optimal patellofemoral biomechanics and will facilitate
ligament balancing. Changes on the tibial side affect both the flexion and extension
gaps equally. Changes in the femoral component sizing or position affect the flexion
gap only.Tibial changes affect both flexion and extension gaps. To convert a tight
extension gap to a normal flexion gap, more distal femur needs to be resected.

Question 112

Which one of the following statements regarding ACL reconstruction is true?

ACL reconstruction decreases the progression of degenerative changes in the
knee
Hamstring tendon grafts have better results than bone patella bone grafts
Ultimate tensile load of the native ACL ligament is more than 2000 Newtons

Femoral tunnel placement should be in the anterior half of the Blumensaat's line on
the lateral x-ray
Femoral tunnel placement in the left knee should be in the 11 o'clock position

References

A No evidence exists to confirm this statement

B Level 1 evidence to suggest equivalent results between two grafts in terms of
patient satisfaction and activity level.
C Ultimate tensile load is approximately 2160N
D Anatomical placement of the femoral insertion of the graft is in the posterior 1/3rd
of Bluemensaat’s line
E Femoral tunnel placement should be in the 11 o’clock position in the right knee and
1 o’clock position in the left knee.

158/189 84%

176/188 94%