1. From this Xray imaging, there is >30 degrees of Kyphosis and >50% vertebral body collapse.

It
indicates of
A. Posterior ligamentous complex injury and instability
B. Distraction failure of the posterior tension band type B injury
C. Vertebral translation
D. Collapse of vertebral body
E. Isolated fractures of the transverse process

2. What is the advantages of CT Scan examination

A. Most accurately depicts bony injuris
B. Sensitivity and specificity > 95%
C. Cocomitant multi-slice CT of Chest, abdomen and pelvis can be done to detect visceral injuries
D. All of above
E. Non of all above
3. An 11-year-old girl came to hospital to follow up the
abnormal posture of her back noticed by her mom 6
months ago. The radiographs of this visit were as below.
Cobb's angle was increased from 21 to 27 degrees. She is
pre-menarche. What is the most proper treatment for this
patient?
a. Observe and repeat radiographs in 3 months
b. Observe and repeat radiographs in 6 months
c. Thoracic lumbar sacral orthosis (TLSO)
d. Body cast with corrective molding
e. Posterior spinal fusion with instrumentation
4. Which of the following signs is considered evidences of cervical myelopathy?
A. Lhermitte’s Sign (Electric-type tingling running down the spine with neck flexion)
B. Spurling’s Signs (Reproduction of arm symptoms with extension and ipsilateral bending )
C. Tinel’s Signs ( Reproduction of paresthesis with tapping ) over the wrist
D. Increased jaw-jerk
E. Decreased brachioradialis reflex

5. What is the prognosis for ambulation,from best to worst ,for patients with an incomplete spinal
cord injury
A. Central cord syndrome ,anterior cord syndrome ,Brown-sequard syndrome
B. Central cord syndrome ,Brown-sequard syndrome, anterior cord syndrome
C. Brown-sequard syndrome, anterior cord syndrome, central cord syndrome
D. Brown-sequard syndrome, central cord syndrome, anterior cord syndrome
E. Anterior cord syndrome, central cord syndrome, Brown -sequard syndrome

6. Which of the following are considered characteristic features of degeneration of a disk

A. Reduced water and glycoaminoglycans content and increased non
collagen glycoprotein
B. Reduced water and glycoaminoglycans content and reduced non collagen glycoprotein
C. Reduced water , increased glycoaminoglycans content and increased non
collagen glycoprotein
D. Increased water and glycoaminoglycans content and increased non collagen glycoprotein
E. Increased water and glycoaminoglycans content and decreased non
collagen glycoprotein

7. What spinal nerves in the cauda equine are primarily responsible for innervations of the
bladder?
A. L1,L2, and L3
B. L4 and L5
C. L5 and S1
D. S2,S3, and S4
E. Filum terminale
8. It is the 3-dimensional CT scan of a 9-month-old infant who had vertebral abnormalities noted on a
standard chest radiograph. He was asymptomatic, but his parents saw that he was ‘crooked.’ He had no
abnormalities in other organ systems. An MRI scan of the spine revealed the distal cord to be at L-1
with no cord compression, syrinx, or diastematomyelia. Which is the most appropriate treatment?

a. No surgical treatment until age 5

b. Hemifusion and instrumentation from T-11 to L-1
c. Vertebral excision at T-12 with fusion and instrumentation from T-8 to L-3
d. Vertebral excision at T-12 with fusion and instrumentation from T-10 to L-1
e. Vertebral excision at T-12 with anterior and posterior fusion from C-7 to L-2
9. A 76-year-old woman has neck pain after falling down a flight of stairs. Figures 65a and 65b show a
lateral radiograph and sagittal CT scan of her cervical spine. Which factor is an absolute
contraindication for the placement of C1-C2 transarticular screws?

a. Osteoporosis
b. Aberrant vertebral artery
c. Previous C2 laminectomy
d. Concomitant C1 ring fracture
e. Disruption of the transverse ligament

10. The MRI scans of the cervical spine without contrast of a 38-year-old man with neck pain radiating
into the right upper extremity for the past 4 weeks. He denies numbness or weakness. Examination was
significant for reproduction of pain going down the right arm with neck extension and right lateral
rotation. What is the next treatment step?

a. Physical therapy
b. Epidural steroid injection
c. High-dose intravenous steroid
d. Posterior cervical foraminotomy
e. Anterior cervical discectomy and fusion

11. The lumbar spine lateral radiograph of a 33-year-old woman who experienced worsening back pain
4 months after undergoing lumbar surgery. What is the most appropriate treatment option?

a. Laminectomy
 b. Facet injection
c. Posterior fusion
d. Revision arthroplasty
e. Immobilization in a rigid orthosis

12. The lateral radiograph of a 77-year-old man who had neck pain after a low-speed motor vehicle
collision. He had diffuse tenderness to palpation over his posterior cervical spine but the remainder of
the examination was unremarkable. Plain radiographs including. The figure were negative for any
evidence of fracture. What is the best next step in management?

a. Pulmonary function testing

b. An MRI scan of the cervical spine
c. Physical therapy and oral steroids
d. Immobilization in a rigid cervical collar for 6 weeks
e. Referral to a rheumatologist

13. It is the MRI scan of a 43-year-old man with an acute onset of neck pain, bilateral upper-extremity
weakness, and burning pain in his arms after hitting his head on a bookshelf. Examination initially
revealed 3/5 strength in both upper extremities, with normal motor strength in the lower extremities.
What is the best description of his spinal cord injury?

a. Central cord syndrome

b. Anterior cord syndrome
 c. Posterior cord syndrome
d. Brown-Séquard syndrome
e. Complete spinal cord injury

14. Figures 19a and 19b are the CT scans of an 18-year-old man who was a restrained driver in a rollover
motor vehicle collision. What was the primary mechanism of injury?

a. Axial Load
b. Rotation
c. Extension
d. Distraction

15. Below here shows the T2-weighted MR image through the L4-5 level of a 60- year-old man who has
new-onset acute right lower-extremity pain and numbness and weakness in his right quadriceps muscle.
The arrow in Figure 32 is pointing to which structure?

a. Lumbar synovial cyst

b. Dorsal root ganglion
c. Herniated nucleus pulposus
d. Ligamentum flavum
16. Figure 7 shows the radiograph of a 64-year-old man who has neck pain and weakness of the upper
and lower extremities following a motor vehicle accident. Examination reveals 3/5 quadriceps and
4/5 hip flexors but no ankle dorsiflexion or plantar flexion. His intrinsics are 1/5, with finger flexors
of 3/5. He is awake, alert, and cooperative. Management should consist of

a. Halo vest immobilization.

b. MRI.
c. Gardner-Wells tongs and closed reduction.
d. posterior open reduction and fusion.
e. observation until the patient’s general medical status improves, followed by closed
reduction via Gardner- Wells tongs.

17. Of the following, what is the most reliable method of assessing spinal fusion?
a. Radiographs
b. MRI
c. Flexion/extension radiographs
d. CT
e. CTmyelography
 18. A 75-year-old woman reports persistent severe low back pain after lifting a bag of groceries 8
weeks ago. She denies the presence of any lower extremity pain, weakness, or other symptoms. AP
and lateral lumbarspine radiographs are shown in Figures 47a and 47b. For further evaluation, what
imaging study should be obtained next?

a. Lumbar spine flexion and extension radiographs

b. Lumbar spine CT
c. Lumbar spine MRI
d. Whole body bone scan
e. Tagged white blood cell scan

19. When evaluating a patient with a lumbar burst fracture, the integrity of the posterior ligamentous
complexmust be evaluated. Which of the following is a complete and accurate list of the components
of the posterior ligamentous complex?

a. Supraspinous ligament, interspinous ligament, ligamentum flavum, and the facet

joint capsules
b. Supraspinous ligament, interspinous ligament, ligamentum flavum, facet joint capsules,
and disks
c. Supraspinous ligament, interspinous ligament, and ligamentum flavum
d. Supraspinous ligament, interspinous ligament, ligamentum flavum, and the facet joints
e. Supraspinous ligament, interspinous ligament, ligamentum flavum, facet joint capsules,
facet joints, and the posterior longitudinal ligament

20. Which of the following is the most common site for compression and burst fractures?
a. L2 level
b. L3 level
c. L4 level
d. L5 level
e. S1 level

21. The findings in Brown-Séquard syndrome include loss of which of the following?

a. Greater loss of upper extremity motor function than lower extremity function
b. Ipsilateral motor function and ipsilateral pain and temperature sensation
c. Ipsilateral motor function and contralateral pain and temperature sensation
d. Contralateral motor function and ipsilateral pain and temperature sensation
e. Lower of extremity proprioception and balance
22. Figure 1 is the CT scan of a 36-year-old man who fell from a roof. Eight hours later at the
emergency department he describes low-back pain with numbness and weakness in his bilateral lower
extremity. A neurologic examination reveals 2/5 strength in his quadriceps and iliopsoas bilaterally, 2/5
strength in his right anterior tibialis and gastrocsoleus, and 1/5 strength in his left anterior tibialis and
gastrocsoleus. Two hours later, strength in his lower extremities has diminished markedly. What is the
best next step?

A. Intravenous (IV) methylprednisolone with a 30-mg/kg loading dose followed bycontinuous

infusion of 5.4 mg/kg/hour for 24 hours
B. Immediate awake traction reduction
C. Emergent open reduction/decompression
D. Admission to the intensive care unit for fluid resuscitation followed by reduction/decompression
when stable

23. In the MRI scan shown in Figure 1, what is it about this fracture pattern that increasesits risk of
nonunion?

A. Early treatment
B. Younger age
C. Posterior displacement >5 mm
D. Angulation <10°
E. Angulation >10o

24. A 57-year-old man is involved in a rear-ended motor vehicle collision. He is able to leave his
pickup and assist others involved in the collision. The next day he is seen in the emergency department
with low back pain. The patient's radiograph and MRI scans of the lumbosacral spine are shown in
Figures 1 through 3. What is the most likely diagnosis of his pain?

A. Spinal fluid leakage

B. Lumbosacral degloving
C. Lipomatosis
D. Flexion-distraction injury of the spine
25. Figures 1 and 2 are the radiographs of a 75-year-old patient who has a 1-year historyof progressive
low back pain. He reports difficulty ambulating, inability to sit for extended periods, and pain when
arising from a seated position. His medical historyis positive for coronary artery disease, type II
diabetes, depression, and mild obesity(BMI 32). His surgical history is positive for a lumbar fusion 3
years previously. Laboratory studies show normal CBC and metabolic profile. HgbA1C is 6.3. What
factor is most predictive of his perceived clinical outcome after revision surgery?
A. Intraoperative cervical spine fluid leak
B. Postoperative infection
C. Depression status
D. Intraoperative blood loss requiring transfusion
Question Number 1-5

The following radiograph is a figure of a 17-year-old male involved in a high-speed motor vehicle
accident. Upon initial evaluation in the emergency department, he is coherent and interactive
appropriately, currently has severe pain coming from his stomach, has no perineal wounds, is
neurologically intact to his bilateral lower extremities, and his blood pressure is 90/60 mmHg, HR
102bpm, RR 32 x/min.

1. What is the best next step in his initial management?

A. Application of circumferential sheet or binder about the greater trochanters

B. Oxygenation with face mask 10 lpm, 2-large-bores IV lines with RL, and inserting a urinary
catheter
C. Immobilization with a traction splint
D. Anterior pelvic external fixation
E. Blood Transfusion

2. What are the beneficial laboratory studies that are important in this case?

A. sCRP, Blood Gas Analysis, Electrolyte (Na, K, Cl, Ca, P)

B. ESR, CRP, Leukocyte differential count
C. Complete blood count, Blood Gas Analysis, Lactate
D. Haemoglobin, Urinalysis, Cerebrospinalfluid
E. ESR, CRP, Haemoglobin
3. What is the best operative option in this emergency setting for treating the pelvic issue in this case?

A. External fixation using anterior frame

B. Pelvic C-clamp
C. Angiographic embolization
D. Skeletal traction
E. Skin Traction

4. What are the points that have to be achieved to make the patient is stable condition?

A. Stable Hemodynamics, Stable Oxygen Saturation, lactate <2 mmol/l, Normal temperature,
Urine Outpus <1ml /Kg/H
B. Stable Oxygen Saturation, lactate <2 mmol/l, Normal temperature, Urine Output <0,5ml/Kg/H,
No Coagulation disturbances
C. Stable Hemodynamics, Stable Oxygen Saturation, lactate > 2mmol/l, Normal temperature,
<0,5ml/Kg/H
D. Lactate <2 mmol/l, Normal temperature, Urine Output >1ml/Kg/H, Use inotropic support
E. Lactate <2 mmol/l, Normal temperature, Urine Output > 1ml/Kg/H, Stable Hemodynamics

5. When is the right time to perform defenitive treatment ?

A. 7 days after trauma

B. 14 days after trauma
C. 10 days after trauma
D. 21 days after trauma
E. 3-5 days after trauma

Question Number 6-10

A 30-year-old man is involved in a high-speed motorcycle accident. She has

tension pneumothorax and sustains a grade IIIB open tibia fracture. Examination
reveals a large soft-tissue defect and an insensate foot. Her blood pressure is
84/62 mmHg, HR 110 bpm, RR 34 x/min, Serum lactate 4 mmol/l.

6. What is the most appropriate initial treatment at emergency departmen?

A. Chest Needle emergency
B. Blood transfusion
C. Applying External Fixator
D. Perform Skeletal traction
E. Bloos Transfution

7. What would be the best management of her orthopaedic injury?

A. Perform Debridement and Skin Graft
B. Perform Debridement and External fixation
C. Perform Open Reduction and Internal Fixation
D. Perform Debridement and Posterior slab
E. Perform Debridement, Open Reduction and Internal Fixation

8. What is the most ideal for soft tissue coverage?

A. Full-thickness skin graft (FTSG)

B. Split-thickness skin graft (STSG)

C. Free Flap

D. Primary suture
E. Secondary Wound Healing

9. What is the borderline criteria in cases of polytrauma?

 A. Blood preassure > 100mmhg, lactate Levels 2-2,5 mmol/l,Temperature 33-35
degree, Platelet Count 90.00-110.000

B. Blood preassure 80-100mmhg, lactate Levels 2-2,5 mmol/l,Temperature

33-35 degree, Platelet Count 90.00-110.000

C. Blood preassure 80-100mmhg, lactate Levels >5 mmol/l,Temperature 33-35

degree, Platelet Count 90.00-110.000

D. Blood preassure 80-100mmhg, lactate Levels 2-2,5 mmol/l,Temperature 33-35

degree, Platelet Count < 70.000

E. Blood preassure > 100 mmhg, lactate Levels >5 mmol/l,Temperature 33-35
degree, Platelet Count 90.00-110.000

10. What is the parameter that most accurately to determine patient stability?

A. Serum lactate <2,5 mmol/l.

B. Base excess ≥ -5.5 mmol/L

C. PO2/FIO2 < 200

D. Arterial Blood Gases (ABGs) is normal

E. Haemoglobin > 12 gr/l

 1. With electric shock and seizures, why are posterior shoulder dislocations more common than
anterior dislocations?

A. The glenoid is retroverted.

B. The humeral head is retroverted.
C. The internal rotators of the shoulder are stronger than the external rotators.
D. The external rotators of the shoulder are stronger than the internal rotators.
E. The internal rotators of the shoulder are weaker than the external rotators.

ANSWER 3: C. The shoulder internal rotators (pectoralis major, latissimus dorsi, and
subscapularis) are stronger than the external rotators (teres minor and infraspinatus), which
is why posterior shoulder dislocations are more common than anterior dislocations after
electrical shock and seizures.

2. Which portion of the acromioclavicular capsule should be preserved during an arthroscopic

distal clavicle resection to prevent late instability?

A. Anterosuperior

B. Posterosuperior

C. Anteroinferior

D. Posteroinferior

E. Anterior

ANSWER: B. Several studies have stressed the importance of the acromioclavicular ligaments to
preventing displacement and instability. Fakuda and associates (1986) found that with minimal
displacements, the acromioclavicular ligaments were the primary restraint to superior (68%) and
posterior (89%) translation. Klimkiewicz and colleagues (1999) showed that the superior and
posterior acromioclavicular ligaments were the main restraints to preventing posterior instability
of the clavicle.

3. Which portion of the ulnar collateral ligament is most important in preventing valgus instability
in overhead throwers?

A. Anterior band

B. Posterior band

C. Transverse band

D. A and B

E. All of the above

ANSWER: A. The anterior band of the ulnar or medial collateral ligament is the primary restraint
to valgus stress at the elbow. Additional restraint is provided by the flexor pronator mass,
radiocapitellar articulation and the elbow joint capsule. With the elbow in full extension, the
ulnohumeral articulation and anterior joint capsule provide significant stability against valgus
stress.

4. A patient with a known brachial plexus injury is being examined in your office. Posterior
examination of the right shoulder reveals medial scapular winging with muscle wasting or atrophy
in the supraspinatus and infraspinatus fossa, indicative of chronic dysfunction of the suprascapular
nerve. Which type of plexus injury pattern does this represent?

a. Supraclavicular
b. Infraclavicular
c. Preclavicular
d. Infraclavicular
e. Both a and c

ANSWER : E. Muscle atrophy in the infraspinatus and supraspinatus scapula fossae indicate
injury to the preclavicular (or supraclavicular) suprascapular nerve. Medial scapular winging
results from long thoracic nerve injury that causes serratus anterior dysfunction. Remember that
chronic muscle denervation produces MRI changes of fatty infiltration, volume loss, and high
signal intensity on T1-weighted sequences and fibrillations and sharp waves on electromyographic
(EMG) testing.

5. The relocation test is most reliable for diagnosing anterior subluxation of the glenohumeral joint
when :

A. external rotation with the arm in 90 degrees of abduction produces pain that is relieved by
posterior pressure on the humeral head.
B. posterior pressure placed on the humeral head results in increased pain.
C. external rotation with the arm in 90 degrees of abduction produces no symptoms, but posterior
pressure on the humeral head produces apprehension.
D. external rotation with the arm in 90 degrees of abduction produces no symptoms, but
posterior pressure on the humeral head produces pain and apprehension.
E. external rotation with the arm in 90 degrees of abduction produces apprehension that is
relieved by posterior pressure on the humeral head.

ANSWER E : The relocation test is most accurate when true apprehension is produced with the
arm in combined abduction and external rotation and then relieved when posterior pressure is
placed on the humeral head. Pain with this test is a less specific response and may occur with
other shoulder disorders such as impingement.

6. A 17-year-old baseball player presents after he slid awkwardly into second base and has
continued shoulder pain. MRI shows evidence of what type of lesion?
A. HAGL lesion

B. PASTA lesion

C. ALPSA lesion

D. Kim lesion

E. SLAP tear

ANSWER: C. This magnetic resonance image shows evidence of a detached medial anteroinferior
labral tear with migration medially by an intact periosteal sleeve, which is consistent with an
anterior labroligamentous periosteal sleeve avulsion (ALPSA). This injury differs from a classic
Bankart lesion, in which the scapular periosteum is also disrupted with the anteroinferior
labral/anterior band of inferior glenohumeral ligamentous tear. The other options are explained as
follows:

• A PASTA lesion is a partial articular supraspinatus tendon avulsion.

• A HAGL lesion is a humeral avulsion of the glenohumeral ligament.

• A SLAP tear is a superior labral tear in an anterior-to-posterior direction.

• A Kim lesion is an incomplete and concealed avulsion of the posteroinferior labrum in posterior
or multidirectional posteroinferior instability of the shoulder.

7. An elderly patient undergoes reverse total shoulder arthroplasty (TSA). Which arm position
would risk dislocation during the early postsurgical period?

A. Extension, adduction, internal rotation

B. Extension, adduction, external rotation
C. Extension, abduction, internal rotation
D. Extension, abduction, external rotation
E. Flexion, adduction, external rotation

ANSWER : A Instability is the most common complication associated with reverse TSA. All
reported dislocations are anterior. Studies have shown that in reverse TSA designs with a
medialized center of rotation, insufficiency of the subscapularis is an important risk factor, and
subscapularis repair decreases the rate of dislocation. The most common position of dislocation is
extension, adduction, and internal rotation. This most commonly occurs as patients push
themselves out of a chair. Surgeons and staff must emphasize that this position is to be avoided
during the initial postsurgical recovery phase.

8. Posterolateral rotatory elbow instability is caused by deficiency of which of the following

ligaments?
A. Radial portion of the lateral collateral ligament
B. Ulnar portion of the lateral collateral ligament

C. Annular ligament

D. Anterior band of the ulnar collateral ligament

E. Posterior band of the ulnar collateral ligament

ANSWER: B. Posterolateral rotatory elbow instability is caused by a deficiency in the ulnar

portion of the lateral collateral ligament of the elbow. This can be tested by supinating the forearm
and applying a valgus moment along with axial compression while the elbow is brought from
extension to flexion. Flexion of more than 40 degrees reduces the radiocapitellar joint.

10. What three structures are considered the primary constraints necessary for elbow stability?
A. Capsule, anterior band of the medial collateral ligament, radial head
B. Coronoid, ulnar part of the lateral collateral ligament, capsule
C. Ulnar part of the lateral collateral ligament, anterior band of the medial collateral
ligament, coronoid
D. Anterior band of the medial collateral ligament, coronoid, radial head
E. Radial head, ulnar part of the lateral collateral ligament, capsule medial collateral ligament,
coronoid

ANSWER C : The three primary constraints necessary for elbow stability in all directions are
the ulnar part of the lateral collateral ligament (also called the lateral ulnar collateral ligament),
the anterior band of the medial collateral ligament, and the coronoid. The radial head and capsule
are secondary constraints to elbow instability.

With electric shock and seizures, why are posterior shoulder dislocations more common than
anterior dislocations?

F. The glenoid is retroverted.

 G. The humeral head is retroverted.
H. The internal rotators of the shoulder are stronger than the external rotators.
I. The external rotators of the shoulder are stronger than the internal rotators.
J. The internal rotators of the shoulder are weaker than the external rotators.

ANSWER 3: C. The shoulder internal rotators (pectoralis major, latissimus dorsi, and
subscapularis) are stronger than the external rotators (teres minor and infraspinatus), which
is why posterior shoulder dislocations are more common than anterior dislocations after
electrical shock and seizures.

10. What is the role of the long head of the biceps brachii tendon in providing stability to the
humeral head?

A. It provides no stability to the humeral head

B. Its stabilizing function is greatest with the shoulder forward elevated 120 degrees

C. It decreases superior translation of the humeral head only

D. It decreases anterior, inferior, and superior translation of the humeral head

E. It ecreases superior translation of the humeral head only

ANSWER: D. It decreases anterior, inferior, and superior translation of the humeral head
Cadaveric studies have been performed to evaluate the biomechanical role of the long head of the
biceps brachii tendon in providing shoulder stability. A study performed by Pagnani and associates
assessed the impact of contraction of the long head of the biceps brachii on glenohumeral
translation. Sequential 50-N anterior, posterior, superior, and inferior forces and a 22-N joint
compressive load were applied to the shoulders. A constant force to the tendon of the long head of
the biceps brachii was applied. The shoulders were tested in 7 positions of glenohumeral elevation
and rotation. Application of a force to the long head of the biceps brachii resulted in statistically
significant decreases in humeral head translation. The influence of the long head of the biceps was
more pronounced at middle and lower elevation angles. When the shoulder was placed in 45
degrees of elevation and neutral rotation, application of a 55-N force to the biceps tendon reduced
anterior translation by 10.4 mm, inferior translation by 5.3 mm, and superior translation by 1.2
mm.

A cadaveric study by Kumar and associates assessed the role of the tendon of the long head of the
biceps in the stabilization of the head of the humerus. Upward migration of the humeral head was
measured by noting any reduction in the acromiohumeral distance in radiographs of the shoulder.
There was a statistically significant decrease in the acromiohumeral interval on tensing the short
head of biceps, but there was no significant change in the interval on tensing either the long head
or both heads of the biceps brachii. Complete transection of the tendon of the long head while both
heads were tensed caused a significant upward migration of the head of the humerus. This study
concluded that 1 of the important functions of the long head of the biceps is to stabilize the humeral
head in the glenoid during powerful elbow flexion and forearm supination. Additionally,
transection of the intra-articular segment of this tendon in surgical procedures of the shoulder may
produce instability and dysfunction.
 KEMENTERIAN PENDIDIKAN , KEBUDAYAAN , RISET DAN TEKNOLOGI
UNIVERSITAS SEBELAS MARET
FAKULTAS KEDOKTERAN
PROGRAM STUDI ORTHOPAEDI & TRAUMATOLOGI
Jl.Kol Soetarto 132 Solo 57126 Telp & Fax : ( 0271) 663166,634634 Ext : 192
E-mail : ppdsorthopaedi11maret@gmail.com

1. What structure that cervical vertebrae have, which the thoracic and lumbar vertebrae do not have?
a. spinous process
b. transverse foramen
c. transverse processes
d. mamillary processes
e. accecorius processes

2. To which vertebrae do ribs attach to?

a. Thoracic
b. Cervical
c. Lumbar
d. Sacral
e. Throcolumbar

3. Which of the following are involved in making the vertebral arch that forms the boundary of the
vertebral foramen?
a. pedicle and lamina
b. vertebral body and spinous process
c. spinous process and transverse process
d. facet joint
e. foramen vertebrae

4. The lateral view of the vertebral column shows four curved regions in adults. How many anteriorly‐
concave curves are produced by the natural curvature of the vertebral column?
a. 0
b. 2
c. 4
d. 6
e. 8

1
 KEMENTERIAN PENDIDIKAN , KEBUDAYAAN , RISET DAN TEKNOLOGI
UNIVERSITAS SEBELAS MARET
FAKULTAS KEDOKTERAN
PROGRAM STUDI ORTHOPAEDI & TRAUMATOLOGI
Jl.Kol Soetarto 132 Solo 57126 Telp & Fax : ( 0271) 663166,634634 Ext : 192
E-mail : ppdsorthopaedi11maret@gmail.com
5. One cervical vertebra has a structure that none of the other vertebrae have. This single structure
is designed to permit rotation of the head. What is the structure?
a. dens; C 2
b. vertebra prominens; C 2
c. facet; C 2
d. lamina; C 2
e. transverse processes, C 2

6. Which structure generally is found overlying the anterior surface of the L4 vertebra?
a. Aorta
b. Right common iliac artery
c. Left common iliac vein
d. Right ureter
e. Left common iliac artery

7. Which of the following is not a gross movement of the vertebral column/trunk?

a. Extension
b. Flexion
c. Dorisflexion
d. Lateral flexion
e. Rotation

8. Kyphosis can be described by all of the following EXCEPT:

a. An excessive posterior curvature
b. Occurs in thoracic spine
c. Can occur due to compression fractures
d. Excessive anterior curvature
e. Straight vertebra

9. Which of the following collectively provides a passageway for the spinal cord?
a. Intervertebral foramen

2
 KEMENTERIAN PENDIDIKAN , KEBUDAYAAN , RISET DAN TEKNOLOGI
UNIVERSITAS SEBELAS MARET
FAKULTAS KEDOKTERAN
PROGRAM STUDI ORTHOPAEDI & TRAUMATOLOGI
Jl.Kol Soetarto 132 Solo 57126 Telp & Fax : ( 0271) 663166,634634 Ext : 192
E-mail : ppdsorthopaedi11maret@gmail.com
b. Vertebral foramen
c. Vertebral canal
d. Transverse foramen
e. Sacralis foramen

10. Which cervical vertebrae has a spinous process that is a common landmark for palpation?
a. C1
b. C3
c. C2
d. C7
e. T2

3
1. Male 80-year-old come to the polyclinic with a chief complaint of pain in the right hip for
the last one year. The orthopedic surgeon decided to do total hip arthroplasty. What should
you do in the setting of pre-operative period, except?
a. Control the blood test required (blood count, hepatogram, ionogram, renal function,
coagulogram, others)
b. Presurgical cardiology studies (electrocardiography, others)
c. Imaging studies (radiography, ultrasound, tomography, resonances, others)
d. Material applied prosthetic (prosthetic mashes, mechanical sutures, other devices)
e. Maintain the operation technique asepsis

Davrieux CF, Palermo M, Serra E, Houghton EJ, Acquafresca PA, Finger C, Giménez ME. Stages and
factors of the “perioperative process”: points in common with the aeronautical industry. ABCD Arq
Bras Cir Dig. 2019;32(1):e1423. DOI: /10.1590/0102-672020180001e1423

2. Peri-operative care includes the following steps, which is not correct?

a. Control of preoperative studies
b. Anesthetic induction
c. Surgery
d. Control during hospitalization
e. Rehabilitation control

Davrieux CF, Palermo M, Serra E, Houghton EJ, Acquafresca PA, Finger C, Giménez ME. Stages and
factors of the “perioperative process”: points in common with the aeronautical industry. ABCD Arq
Bras Cir Dig. 2019;32(1):e1423. DOI: /10.1590/0102-672020180001e1423

3. During isolated lower extremity fractures, which of the following location will cause the
most prevalent proximal DVT cases (examined by DUS)?
a. Hip
b. Femoral shaft
c. Tibial plateau
d. Tibial shaft
e. Patellar

Wang, H., Kandemir, U., Liu, P., Zhang, H., Wang, P. F., Zhang, B. F., Shang, K., Fu, Y. H., Ke, C.,
Zhuang, Y., Wei, X., Li, Z., & Zhang, K. (2018). Perioperative incidence and locations of deep vein
thrombosis following specific isolated lower extremity fractures. Injury, 49(7), 1353–1357.
https://doi.org/10.1016/j.injury.2018.05.018

4. While the perioperative incidence of overall DVT examined by DUS following isolated
lower extremity fractures, which one the most complication to:
a. Distal DVT
b. Proximal DVT
c. Pulmonary embolism
d. All above true
e. None is true
 Wang, H., Kandemir, U., Liu, P., Zhang, H., Wang, P. F., Zhang, B. F., Shang, K., Fu, Y. H., Ke, C.,
Zhuang, Y., Wei, X., Li, Z., & Zhang, K. (2018). Perioperative incidence and locations of deep vein
thrombosis following specific isolated lower extremity fractures. Injury, 49(7), 1353–1357.
https://doi.org/10.1016/j.injury.2018.05.018

5. The mortality of post-operative after total hip replacement is pulmonary embolism and
cerebral vascular complications. Which of the following risk factors presents in a patient
causing that mortality?
a. Revision of total hip arthroplasty
b. Advanced age
c. Cerebral disease
d. Dementia
e. All above true

Memtsoudis, S. G., Della Valle, A. G., Besculides, M. C., Esposito, M., Koulouvaris, P., & Salvati, E.
A. (2010). Risk factors for perioperative mortality after lower extremity arthroplasty: a population-based
study of 6,901,324 patient discharges. The Journal of arthroplasty, 25(1), 19–26.
https://doi.org/10.1016/j.arth.2008.11.010

6. In the perioperative pain management for arthroscopic and open knee procedure, which
technique provides the most improvement in early postoperative pain control, early
mobilization, and patient satisfaction?
a. Opioid
b. NSAID
c. Paracetamol infusion
d. Peripheral nerve block
e. All above true

Stein, B. E., Srikumaran, U., Tan, E. W., Freehill, M. T., & Wilckens, J. H. (2012). Lower-extremity
peripheral nerve blocks in the perioperative pain management of orthopaedic patients: AAOS exhibit
selection. The Journal of bone and joint surgery. American volume, 94(22), e167.
https://doi.org/10.2106/JBJS.K.01706

7. Deep vein thrombosis is a common complication of lower extremity fractures. The tibial fractures often
occur in both low and high energy trauma, or repetitive impact activities. Which of the following
fracture line cause the most common DVT?
a. Proximal tibial fracture
b. Shaft tibial fracture
c. Distal tibial fracture
d. Ankle fractures
e. Foot fractures

8. Male, 50 year old with severe right hip osteoarthritis was planned to have total arthroplasty surgery.
During operation the surgeon found the femoral canal was narrow and decided to used a short femoral
stem in place. Which of the following statement is true regarding post operative outcomes?
 a. Equivalence in preference during gait
b. Differences in lower limb loading
c. Differences in lower limb length
d. A and B are true
e. All above true
Wiik, A. V., Aqil, A., Al-Obaidi, B., Brevadt, M., & Cobb, J. P. (2021). The impact of reducing the
femoral stem length in total hip arthroplasty during gait. Archives of orthopaedic and trauma surgery,
141(11), 1993–2000. https://doi.org/10.1007/s00402-021-03852-w
9. If we want to do total hip arthroplasty or total knee arthroplasty, we must remember mortality rate
especially in age group. Which of the procedure have highest mortality rate?
a. THR revision
b. Primary THR
c. TKR revision
d. Primary TKR
e. A, B, C, D equal mortality rate
Memtsoudis, S. G., Della Valle, A. G., Besculides, M. C., Esposito, M., Koulouvaris, P., & Salvati, E.
A. (2010). Risk factors for perioperative mortality after lower extremity arthroplasty: a population-based
study of 6,901,324 patient discharges. The Journal of arthroplasty, 25(1), 19–26.
https://doi.org/10.1016/j.arth.2008.11.010

10. Which of the following is related to the risk of complication in femoral nerve block except?
a. Intravascular injury
b. Neural injury
c. Quadriceps weakness
d. Prolonged neuropathy
e. Hamstring muscle weakness
Stein, B. E., Srikumaran, U., Tan, E. W., Freehill, M. T., & Wilckens, J. H. (2012). Lower-extremity
peripheral nerve blocks in the perioperative pain management of orthopaedic patients: AAOS exhibit
selection. The Journal of bone and joint surgery. American volume, 94(22), e167.
https://doi.org/10.2106/JBJS.K.01706
 Vignette Questions
A 51-year-old woman has shoulder pain after a minor fall. A radiograph, MRI scan, and bone
scan are seen in Figure 17, A through C. Biopsy specimens are seen in Figure 17, D and E.

1. What is the most likely diagnosis?

A. Osteosarcoma
B. Enchondroma
C. Fibrous dysplasia
D. Chondrosarcoma
E. Chondromyxoid fibroma

2. What is the next best step in treatment?

A. Adjuvant Chemotherapy
B. Wide Resection
C. Watchful Waiting
D. Serial Radiotherapy
E. Investigating distant metastase site

A 56-year-old woman has a 5-month history of a rapidly growing mass in the posteromedial
aspect of the right leg. A clinical photograph, MRI scan, and biopsy specimen are shown in
figures below.
 3. What is the most appropriate treatment for this patient?
A. Observation
B. Wide resection alone
C. Radiation therapy alone
D. Wide resection and radiation therapy
E. Débridement and antibiotics

4. All of the following are known steps in the development of a malignant tumor with the
ability to metastasize EXCEPT?
A. Increased apoptosis
B. Tumor cell intravasation
C. Sustained angiogenesis
D. Genomic instability
E. Avoidance of immune surveillance

A 58-year-old healthy woman had hip arthroplasty 3 years ago with a recalled modular stem
and metal-on-metal articulation. She continued to have hip pain following her surgery. Her
cobalt and chromium ion levels are elevated, but her C-reactive protein level and erythrocyte
sedimentation rate are within defined limits. A small fluid collection is seen around the hip on
metal artifact reduction sequence MRI. At the time of revision, there was a large amount of
cloudy fluid around the hip joint. Her cell count is 1,000/mm3 with 45% nucleated cells (by
manual count). The femoral and acetabular components are in good position and are well
fixed to the bone. There is evidence of taper corrosion.

5. What is the most appropriate next step?

A. Remove all components and place the cement spacer
B. Remove all components and revise the femur and acetabulum
C. Retain the components and place a new femoral head and acetabular liner
D. Revise the femoral component and acetabular liner
E. Close the wound and await culture results before proceeding with the revision

6. What test would best evaluate for the most concerning complication from this implant?
A. CT including the pelvis, hip, and femur
B. Whole body triple phase bone scan
C. MRI with metal artifact reduction sequences
D. Serum cobalt and chromium levels
E. Serum cobalt, chromium, molybdenum, and nickel levels.
These pictures below are the radiographs of a 26-year-old woman who has anterior and
lateral hip pain with all activities. Nonsurgical therapy has been exhausted.

7. Based on these radiographic findings, what is the preferred treatment at this time?
A. Hip resurfacing
B. Hip arthroscopy
C. Total hip arthroplasty (THA)
D. Periacetabular osteotomy
E. Proximal femoral osteotomy

8. Which factor associated with fractures of the acetabulum indicates the need for early
conversion to a total hip arthroplasty (THA)?
A. Age younger than 40 years
B. Initial displacement less than 20 mm
C. Use of the extended iliofemoral approach
D. Anatomic reduction with congruence of the acetabular roof
E. None of the above

A 36-year-old man who is a rock climber sustains an L1 burst fracture from a 30-foot fall while
climbing. He sustained no other fractures or serious injuries. He is neurologically intact and
has minimal posterior tenderness without increased spinous process separation on examination.
Radiographs reveal kyphosis of 20° between T12 and L2 with 30% vertebral height loss. A CT
scan shows 55% canal compromise.

9. What is the most appropriate management?

A. Bed rest for 6 weeks, followed by a thoracolumbosacral orthosis (TLSO) until the
fracture is healed
B. TLSO and or body cast for 3 to 6 months with mobilization when comfortable
C. Posterior spinal fusion and instrumentation
D. Anterior decompression with spinal fusion and instrumentation
E. Anterior decompression and anterior-posterior spinal fusion and instrumentation
 10. All of the following are variables used to calculate the Thoracolumbar Injury
Classification and Severity (TLICS) score EXCEPT:
A. Percent spinal canal compromise
B. Fracture morphology (compression vs. burst)
C. Nerve root symptoms
D. Cauda equina syndrome symptoms
E. Posterior ligamentous complex integrity

An 83-year-old man has had an L1 osteoporotic burst fracture with progressive lower extremity
weakness for 4 days. He can no longer walk because of back and leg pain and leg weakness.
Examination reveals bilateral weakness in his hip flexors and quadriceps. MRI reveals severe
canal stenosis and compression on the conus medullaris and cauda equina.

11. What is the best treatment option?

A. Kyphoplasty
B. Vertebroplasty
C. Laminectomy
D. Laminectomy and fusion
E. Thoracolumbosacral orthosis
12. According to AAOS Clinical Practice Guideline for treatment of symptomatic
osteoporotic spinal compression fractures, a strong recommendation is made:
A. For the use of calcitonin 4 weeks after a fracture is sustained
B. Against the use of vertebroplasty to treat fractures
C. For the use ibandronate to prevent additional fractures
D. Against the use of kyphoplasty to treat fractures
E. For the use of kyphoplasty to treat the fracture
Below are the anteroposterior and lateral radiographs of the hand of a 16-year-old boy. A
player stepped on his right small finger during a football game and he experienced immediate
pain and swelling. Closed reduction was performed with restoration of a stable congruent
joint.
 13. Without appropriate postreduction treatment, which deformity is most likely to develop?
A. Swan neck
B. Boutonniere
C. Bouchard nodes
D. Abduction of the small finger
E. Mallet finger

14. Chronic injury to what anatomic structure can lead to a that deformity of the finger?
A. terminal extensor tendon
B. sagittal band
C. volar plate
D. flexor digitorum profundis tendon insertion
E. central slip of the extensor tendon

These pictures below are the current radiographs of a 52-year-old man who sustained an
injury to his dominant wrist 8 weeks ago. He is an alcoholic and does not remember the
details of how he injured it. Paperwork showing what treatment he received at an urgent care
facility indicates that he was given a splint for his “sprained wrist.” Examination reveals the
pain is getting better, but there is persistent swelling and range of motion is very limited.

15. Recommended treatment at this time should consist of?

A. discontinuation of the splint and commencement of a regimen of hand therapy
B. casting for an additional 2 weeks and reassessment of the fracture healing at that
time
C. open reduction and internal fixation of the injury
D. proximal row carpectomy
E. wrist arthrodesis

16. You choose to perform a scaphoid excision with four-corner fusion. Which four bones
are fused in this procedure?
A. Capitate, hamate, triquetrum, and pisiform
B. Pisiform, triquetrum, trapezium, and trapezoid
C. Lunate, capitate, trapezium, and trapezoid
D. Lunate, triquetrum, capitate, and hamate
E. Trapezium, trapezoid, capitate, and hamate
A 3-year-old child has the deformity seen in Figure 7, A and B.

17. In discussing the condition with the family, it is important to inform them that this
problem is associated with?
A. osteogenesis imperfecta
B. neurofibromatosis
C. limb length discrepancy
D. congenital pseudarthrosis
E. renal anomalies

18. What is the strongest predictor of prognosis

A. Age
B. Lateral pillar by Herring
C. Range of motion
D. Extent of femoral head involvement by Caterall
E. The appearance of crescent sign

Figure below is a standing lower extremity anteroposterior radiograph of a 2½-year-old boy

who has bowed legs. An examination reveals a 6-cm distance between the medial condyles of
his knees when his feet are touching and his legs are extended. A gait evaluation reveals a
moderate varus thrust while walking. He is slightly overweight.
 19. What is the best next step?
A. Observation
B. Bilateral knee-ankle-foot orthoses
C. Bilateral medial tibial hemiepiphysiodesis using two-hole plate and screws
D. Bilateral medial femoral and tibial hemiepiphysiodesis using two-hole plate and
screws
E. Bilateral valgus-producing tibial osteotomies

20. When was evaluated for a progressive increase in tibia vara and complains that his
feet are turning in. What is the most appropriate course of action?
A. Bilateral tibia and fibular osteotomies
B. Observation
C. Valgus positioning knee-ankle-foot orthosis (KAFO)
D. Use of a Denis-Browne bar
E. Schedule a return visit in 4 months

A 28-year-old woman with a history of systemic lupus erythematosus was involved in a

motor vehicle crash. She sustained a closed left tibia fracture and underwent surgery. During
surgery, the tourniquet was left inflated while the surgeon reamed the tibial canal to place the
largest diameter nail that could be fit. At 6 weeks’ follow-up, there is evidence of massive
bone necrosis.

21. What event most likely led to the necrosis?

A. History of steroid use
B. History of systemic lupus erythematosus
C. Overreaming of the tibial canal
D. Reaming of the tibia with the tourniquet inflated
E. Reaming of the tibia with the knee in hyperflexion

22. What is the advantage of reaming?

A. Higher rate of secondary interventions
B. Patello-femoral complications
C. Smaller diameter nails with decreased stability
D. Shorter union time with fewer nonunions
E. Shorter operating time
These pictures below are radiographs of an open fracture in a 46-year-old man who injured
his elbow of his nondominant arm in a motorcycle crash. On the day of injury, he underwent
irrigation and débridement of the fracture. He was also treated with antibiotics.

23. What definitive treatment method will most likely lead to the best functional outcome?
A. Cast immobilization
B. Intramedullary screw fixation
C. Open reduction and plate fixation
D. Open reduction and internal fixation with tension band wiring
E. Fragment excision and triceps advancement

24. What is the indication of primary closure of the wound of this patient?
A. Injury to debridement interval less than 24 hours
B. Stable fixation achieved by internal fixation.
C. Absent of bleeding wound margins which can be apposed without tension.
D. Wounds without primary skin loss or secondary skin loss after debridement
E. Type III A and B injuries of limbs without vascular deficit.
OSCE Questions
1. A 53 years old female have mild pain on his right hip since 2 months. She was
diagnosed with breast carcinoma 1 year ago and underwent surgery and
chemotheraphy

A. Please describe the xray finding

 Lytic lesion at metadiaphyseal area of left proximal femur Wide transitional
zone, ill defined margin (permeative)
 Cortical thinning
 No matrix
 No periosteal reaction no cortical break
 No soft tissue involment
B. Please mention the mirels score for this case:
Total= 10 (mild pain: 1, pertochanter: 3, lytic: 3, >2/3: 3)
C. What is the possible diagnosis?
Secondary bone tumour at left proximal femur suspect Metastasis bone disease
due to breast carcinoma DD multiple myeloma

2. A 75-year-old male sustains a ground-level fall while ambulating at home. The patient
has been optimized for surgical intervention. Both prosthetic components are deemed
to be stable. How would you classify this fracture and what is the appropriate treatment
plan?
A. What is working diagnosis?
Vancouver C periprosthetic fracture about stable total hip and knee arthroplasties
B. What Risk of factor which cause this fracture?
Impaction bone grafting, female gender, technical errors, cementless implants,
osteoporosis, revision, minimally invasive techniques (controversial)
C. What the best treatment for this case?
ORIF with lateral locking plate

3. A 57-year-old woman with rheumatoid arthritis and a history of chronic low back pain
is seen in the emergency department reporting a 2-month history of increasing low back
pain. She denies any extremity pain. Examination reveals full lower extremity strength
and normal sensation. She has a history of intermittent, low-grade fevers over the past
few weeks. Vital signs reveal a temperature of 100.2°F, blood pressure of 135/70 mm
Hg, a heart rate of 95/min, and respirations of 18/min. lumbar spine MRI scan is shown
below

.
A. What is the most likely diagnosis?
Infectious diskitis in the lumbar spine
B. What is the most appropriate course of action at this time?
Tissue biopsy followed by intravenous antibiotics and close patient monitoring

4. A 40-year-old scaffolder presents with persistent pain in his wrist following a fall on
his outstretched hand about six days ago. This is the radiographs (Fig. 2).

Figure 2.
 A. What is the diagnosis.
non-displaced fracture of the scaphoid
B. What are the indications for internal fixation of this injury?
the displacement is more than 1 mm
Or the scapholunate angle > 60 °
Lunocapitate angle > 15 °
Intrascaphoid angle > 20 ° (dorsal humpback)
Proximal pole fractures, fractures associated with a peri-lunate dislocation
Delayed union
C. What are the complications of this injury?
avascular necrosis (AVN)of the proximal pole and non-union

5. Figures 1 through 4 are the radiographs and clinical photograph of a 6-month-old girl
whose parents are seeking a second opinion of her feet. Since birth, her parents noted
bilateral foot deformities, with some improvement in flexibility and alignment achieved
with a stretching program recommended by her pediatrician.

A. What is the diagnosis ?

congenital vertical talus (CVT)
B. What is the most appropriate course of action?
Reverse Ponseti serial casting with stabilization of the talonavicular joint and
Achilles tenotomy
OTD

BASIC IMAGING UPPER EXTREMITY

1. Rule of two in Xray, except?

a. Two views
b. Two joints
c. Two sides
d. Two hospital

Rules of two in X-ray

Two views: One view is too few; 2- Two joints: Above and below the injured bone; 3- Two sides:
Compare with the other normal side; 4- Two abnormalities: Find a second abnormality; 5- Two
occasions: Compare the current x-ray with a previous one (especially in CXR); 6- Two visits:
Repeat after an interval or a procedure; 7- Two opinions: Ask for a second opinion or use the red
dot system; 8- Two records: Write down the radiographic and clinical finings; 9- Two specialists:
Get a radiology report; 10- Two examinations: Ask for CT, MRI, US, NM, etc.

References: Miller Review Orthopaedics section upper extremity

2. The earliest radiological change seen in a case of acute osteomyelitis is?

a. Bony sclerosis
b. Loose of plane between soft tissue and muscle
c. Periosteal reaction
d. Sequestrum Formation

The earliest changes are seen in adjacent soft tissues +/- muscle outlines with swelling and loss or
blurring of normal fat planes. An effusion may be seen in an adjacent joint. In general,
osteomyelitis must extend at least 1 cm and compromise 30 to 50% of bone mineral content to
produce noticeable changes on plain radiographs. Early findings may be subtle, and changes may
not be obvious until 5 to 7 days from the onset in children and 10 to 14 days in adults. On
radiographs taken after this time period, a number of changes may be noted: regional osteopenia,
pperiosteal reaction/thickening (periostitis): variable; may appear aggressive, including the
formation of a Codman's triangle, focal bony lysis or cortical loss, endosteal scalloping, loss
of trabecular bone architecture, new bone apposition, eventual peripheral sclerosis. In chronic or
untreated cases, the eventual formation of a sequestrum, involucrum, and/or cloaca may be seen.

References: Miller Review Orthopaedics section upper extremity

3. The goal standart for the diagnosis of osteoporosis is?
a. Dual energy X-ray absorptiometry
b. Singel energy X-ray absorptiometry
c. Ultrasonography
d. Quantitative Computed Tomography

Dual-energy x-ray absorptiometry (DEXA or DXA) is a technique used to aid in the diagnosis
of osteopenia and osteoporosis. Bone mineral density (BMD) is calculated in g/cm2, and then
compared against two reference population giving two scores 1-3:

 T-score: comparison by standard deviation (SD) to a young adult population, matched for
sex and ethnicity (used for postmenopausal women and men >50 years) and classified by
WHO criteria 4
o ≥-1.0: normal
o <-1.0 to >-2.5: osteopenia
o ≤-2.5: osteoporosis
o ≤-2.5 plus fragility fracture: severe osteoporosis
 Z-score: compared by SD to an age, sex, and ethnicity population (used for premenopausal
women, men <50 years, and children instead of T-score WHO criteria 4)
o <-2.0: below expected range/low bone density for age, and a cause should be sought

References: Miller Review Orthopaedics section upper extremity

4. On an x-ray, onion peel appearance is seen in?

a. Osteoclastoma
b. Osteosarcoma
c. Ewing’s sarcoma
d. Osteochondroma

Ewing sarcoma appears radiographically as a destructive lesion in the diaphysis of a long bone
with an “onion skin” periosteal reaction.

References: Miller Review Orthopaedics section upper extremity

5. On an x-ray, appearance of sunray/sunburst?
a. Osteoclastoma
b. Ewing’s sarcoma
c. Osteomyelitis
d. Osteosarcoma

The sunburst appearance occurs when the lesion grows too fast and the periosteum does not
have enough time to lay down a new layer and instead the Sharpey's fibers stretch out
perpendicular to the bone. It is frequently associated with osteosarcoma but can also occur with
other aggressive bony lesions

References: Miller Review Orthopaedics section upper extremity

 BASIC IMAGING LOWER EXTREMITY

1. A 28-year-old male presents to the emergency department via ambulance after a motorcycle
collision. He was helmeted however has considerable upper extremity road rash and a type 1
open tibial shaft fracture with radiographs shown in Figure A. CT scan shows no intra-articular
involvement. The attending on-call plans to perform a suprapatellar approach for tibial
intramedullary nailing. When compared to infrapatellar nailing, suprapatellar nailing has been
shown to have which of the following effects?

A. Increased risk for developing a nonunion

B. Decreased risk of procurvatum deformity
C. Lower implant cost
D. Shorter operative time
E. Worse post-operative anterior knee pain

Suprapatellar nailing has been shown to have less post-operative anterior knee pain and decreased
risk for malunion when compared to infrapatellar nailing techniques. Tibial shaft fractures are most
commonly treated with intramedullary nailing. Proximal 1/3 tibial shaft fractures are notorious for
being difficult to treat without developing the classic valgus and procurvatum deformity. The
ligamentotaxis of the patellar tendon induces a procurvatum deformity while the ligamentotaxis of
the pes anserine musculature induces a valgus deformity. Infrapatellar techniques require terminal
flexion at the knee in order to place the final nail implant without abutting against the femoral
condyles. This often places excessive tension on the patellar tendon, promoting the procurvatum
deformity. When a knee is placed in the semi-extended position to facilitate the suprapatellar
approach, there is considerably less tension placed through the patellar tendon, minimizing the risk
for procurvatum deformity. Metcalf and colleagues performed a retrospective case-control
evaluation to compare the clinical, radiographic, and functional outcomes between suprapatellar
and infrapatellar intramedullary nail fixation of tibia fractures. After multivariable analysis, they
found that suprapatellar nailing was associated with decreased risk of malunion and a decreased
risk of postoperative knee pain compared to infrapatellar nailing. They conclude that suprapatellar
nailing provides superior fracture alignment and decreased risk of post-operative knee pain.
Ponugoti and colleagues performed a systematic review comparing suprapatellar and infrapatellar
nailing techniques for tibial fractures. Utilizing a total of 12 included studies, they found that
postoperative pain scores and improved functional outcomes were shown in the suprapatellar
nailing group while there was no difference in operative time, deep infection, non-union, or
secondary operation rates. The authors concluded that further studies are required to confirm their
findings and assess long-term results, however, suprapatellar nailing has notable aforementioned
advantages compared to infrapatellar nailing.

Figure A shows AP and lateral radiographic imaging of a proximal 1/3 tibial shaft fracture.
Incorrect Answers:
Answer 1: While there is a decreased risk for malunion, there is no Increased risk of developing a
nonunion with suprapatellar nailing. Decreased risk of procurvatum deformity
Answer 3: There is no difference in implant costs as the same nail is utilized for suprapatellar and
infrapatellar nailing.
Answer 4: Multiple studies have shown equivalent operative and fluoroscopy times between
suprapatellar and infrapatellar nailing techniques.
Answer 5: Some authors have hypothesized that the increased knee pain from infrapatellar nailing
is due to patellar tendon splitting, proximal nail protrusion, chondral injury, or involvement of the
infrapatellar nerve. In any case, suprapatellar nailing has consistently been shown to impart less
post-operative knee pain when compared to infrapatellar nailing.

References: ABOS comprehensive 2022 Section Lower Extremity

2. A 41-year-old male underwent intramedullary nailing for a low-energy left femoral shaft
fracture. At his follow-up appointment, he complains that his feet are pointing in opposite
directions when walking. Using the imaging study shown in Figure A, which of the following
represents this patient's left femur malalignment?

A. Internal rotation malalignment of 44 degrees

B. External rotation malalignment of 44 degrees
C. Internal rotation malalignment of 21 degrees
D. External rotation malalignment of 21 degrees
E. Internal rotation malalignment of 63 degrees

Figure A shows axial CT scan slices of the pelvis and knee. On the operative left side, there is an
internal rotation malalignment of 21° compared to the contralateral side (44°-23°=21°).
Radiographic rotational malalignment after fixation of femoral shaft fractures may be measured
by comparing the femoral anteversion of both femurs. This can be determined by measuring the
angle between a line tangential to the dorsal bony contours of the femoral condyles and a line
drawn through the axis of the femoral neck. Rotational differences of less than 10° are considered
variations of normal. Jaarsma et al. reviewed rotational malalignment after intramedullary nailing
of femoral fractures. They report that rotational measurements by CT are superior to clinical
assessment. They note a high incidence of malrotation after IM nailing of fractures. This has shown
to be in the range 15% to 30%.
Figure A shows left femoral malrotation using CT-torsion measurements with axial cuts of the
femoral neck and distal femoral condyles. Note the normal anteversion of the right femur (23
degrees; normal range 10-25).

Incorrect Answers:
Answer 1,2,4,5: To measure malrotation using axial CT cuts, the normal side is considered as
neutral = 0 malrotation. For this patient, that correlates with 23 degrees of anteversion. If the
femoral anteversion is increased to 44 degrees, this will mean a 21 degree increase in femoral
anteversion from neutral (0 + [44-23] = +21). The opposite would occur if the femoral anteversion
decreased = external rotation.

References: ABOS comprehensive 2022 Section Lower Extremity

3. A 33-year-old man sustains a femur fracture in a motorcycle accident. AP and lateral

radiographs are provided in Figure A. Prior to surgery, a CT scan of the knee is ordered for
preoperative planning. Which of the following additional findings is most likely to be
discovered?

A. Tibial eminence fracture

B. Sagittal plane fracture of the medial femoral condyle
C. Schatzker I tibia plateau fracture
D. Coronal plane fracture of the lateral femoral condyle
E. Axial plane fracture through the medial femoral condyle

The "Hoffa fracture" is a coronal plane fracture of the femoral condyle that is often missed on plain
radiographs of supracondylar and intercondylar femur fractures. It involves the lateral condyle
more frequently than the medial. Identification is important as it may impact operative planning
and likely require screw fixation in the anteroposterior plane. Nork et al. reviewed 202
supracondylar-intercondylar distal femoral fractures and found a 38% prevalence of associated
coronal plane fractures. The authors recommend CT scan imaging of all supracondylar and
intercondylar fractures. Ostermann et al reported on 24 unicondylar fractures of the distal femur
treated with open reduction internal fixation with a screw construct. Twenty-three patients
acheived satisfactory results at 5 year follow-up. Illustrations A and B are another example of a
supracondylar femur fracture with an associated Hoffa fracture identified on CT scan.

References: ABOS comprehensive 2022 Section Lower Extremity

4. Figures A-D are consecutive sagittal MRI cuts of a 23-year-old male who injured his knee
while playing soccer two days ago. Which of the following structures is most likely also
affected in this acute injury?

A. Posterior cruciate ligament (PCL)

B. Lateral meniscus
C. Medial meniscus
D. Medial collateral ligament
E. Lateral collateral ligament

This patient has a complete tear of his anterior cruciate ligament (ACL) and is most likely to also
have a lateral meniscus tear. The incidence of lateral meniscus tear in the setting of actue ACL
rupture is 54%. The anterior cruciate ligament (ACL) prevents anterior translation of the tibia
relative to the femur and is most commonly injured during non-contact pivoting injuries. MRI is
the imaging modality of choice. On imaging you will see discontinuity of the ACL fibers, most
easily visualized on sagittal cuts. Bone bruising may also be seen in a predictable pattern on the
middle 1/3 of the lateral femoral condyle and the posterior 1/3 of the lateral tibial plateau. In the
setting of acute ACL rupture, lateral meniscus pathology is identified in 54% of patients. This
association is important and should be treated concomitantly. Weiss et al review sagittal MRI
findings in conjunction with arthroscopy to evaluate the association of medial meniscal injuries in
patients with ACL tears. They specifically report on a low-intensity band that is seen parallel to
the PCL in 7 patients. They conclude that the presence of this band, which they describe as low-
signal intensity, above the tibial cortex and in parallel to the PCL is the finding of a bucket-handle
medial meniscus tear. Munk et al review the MRIs and arthroscopic findings in knees to in a
comparative study evaluating ACL injuries, meniscal injuries and cartilage lesions. They report a
similar sensitivity, specificity and negative predictive value of MRI compared to physical exam
for ACL injuries. However, they state that the positive predict value of MRI was found to be nearly
double that of physical exam for meniscal pathology. They conclude that MRI is a valuable
diagnostic tool for planning surgical treatment of knee injuries.

References: ABOS comprehensive 2022 Section Lower Extremity

5. A 36-year-old male presents to the emergency department following a high-speed motor vehicle
collision. Imaging obtained in the trauma bay shows a comminuted femoral shaft fracture.
Which additional imaging should be obtained to rule out a concomitant fracture that occurs in
approximately 6% of cases?

A. CT imaging of the knee

B. Radiograph of the contralateral femur
C. Radiograph of the ipsilateral hip
D. Radiograph of the ipsilateral tibia
E. Radiograph of the lumbar spine

This patient sustained a high-energy femoral shaft fracture. Imaging of the ipsilateral hip should
be obtained to rule out a concomitant femoral neck fracture. Ipsilateral femoral neck fractures
should be considered in all high-energy femoral shaft fractures, as they have a reported incidence
of 0-15%. These associated injuries are often basicervical, vertical, and nondisplaced in nature.
The lack of displacement is due to the majority of energy being dissipated through femoral shaft.
These injuries are missed approximately 19-31% of the time. Imaging of the ipsilateral hip should
be obtained. Cannada et al. retrospectively reviewed the incidence of femoral neck fractures with
high-energy shaft fractures to determine whether there was a correlation of neck fractures with
antegrade or retrograde intramedullary nailing. They reported a rate of neck-shaft combinations of
3.2%, and that ipsilateral femoral neck fractures were missed in 26% of cases. They concluded
that patients with femoral shaft fractures should have good quality radiographs after femoral
nailing to minimize the risk of missed femoral neck fractures. Alho et al. performed a meta-
analysis of ipsilateral fractures of the hip and femoral shaft. They reported that that ipsilateral hip
fractures were divided into 5 subtypes with the following distributions: subcapital-2%,
midcervical-21%, basicervical-39%, pertrochanteric-14% and intertrochanteric-24%.
Furthermore, they noted that the diagnosis of the hip fracture was delayed in 30% of the cases.
They concluded that early diagnosis of all injuries and operative treatment of all fracture
components are the key factors in reducing complications and improving the outcome in ipsilateral
hip and shaft fractures. Rogers et al. reviewed whether the preoperative diagnosis of ipsilateral
femoral neck fractures in patients with high-energy femoral shaft fractures can be improved with
magnetic resonance imaging (MRI) compared with radiographic and CT imaging. They reported
that rapid limited-sequence MRI of the pelvis for patients with femoral shaft fractures identified
femoral neck fractures that were not diagnosed on thin-cut high-resolution CT in 12% of patients.
They concluded that the frequency of femoral neck fractures may be underrepresented on CT
imaging in polytraumatized patients.

References: ABOS comprehensive 2022 Section Lower Extremity

6. A 33-year-old male is involved in a motor vehicle accident and suffers a right pilon fracture.
Which of the bone fragments labeled on the distal tibia in the axial CT scan shown in Figure A
is attached to the posterior inferior tibiofibular ligament?

A. A
B. B
C. C and B
D. D
E. A and D

Figure A is an axial CT scan slice of an intra-articular distal tibia fracture. The bands of the
posterior tibiofibular ligament pass obliquely from the fibula to the posterolateral aspect of the
distal tibia. The ligaments of the ankle often remain intact after a pilon fracture producing the
major fracture segments consisting of posterolateral or Volkmann's fragment (labeled D), the
anterolateral or Chaput fragment (labeled B), and the medial fragment (labeled C). The fibula is
labeled A. Any surgical approach taken to treat this injuries should respect these attachments.
Michelson reviews the important role of ankle ligamentous anatomy in his study on rotational
ankle fractures. Hermans et al review the anatomy of the ankle syndesmosis and state that stress
on the posterior inferior tibiofibular ligament results more often in a posterior malleolus avulsion
fracture than in a rupture of the ligament. They go on to state that with direct reduction of the
posterior malleolus avulsion fracture, the syndesmosis can often be stabilized. Illustration A shows
the posterior inferior tibiofibular ligament highlighted in red on MRI imaging in a LEFT ankle (the
CT image in the question is of a RIGHT ankle).

References: ABOS comprehensive 2022 Section Lower Extremity

(5 SOAL)
1. What are the dynamic stabilizers of the shoulder?
a. Glenoid, labrum, glenohumeral articulation
b. Rotator cuff muscles, biceps tendon, periscapular muscles
c. Rotator cuff muscles, glenohumeral ligaments, biceps tendon
d. Glenoid, glenohumeral ligaments, biceps tendon
e. Glenoid, labrum, rotator cuff muscles, biceps tendon
1. What are the dynamic stabilizers of the shoulder?
a. Glenoid, labrum, glenohumeral articulation
b. Rotator cuff muscles, biceps tendon, periscapular muscles
c. Rotator cuff muscles, glenohumeral ligaments, biceps tendon
d. Glenoid, glenohumeral ligaments, biceps tendon
e. Glenoid, labrum, rotator cuff muscles, biceps tendon
2. The distal dorsal part of the forearm contained 6 extensor compartments. What are
the content of the second compartment?
a. Abductor policis brevis, Extensor policis longus
b. The median nerve
c. Extensori digiti minimi
d. Extensor carpi radialis brevis and Extensor carpi radialis longus
e. Extensor indicis
2. The distal dorsal part of the forearm contained 6 extensor compartments. What are
the content of the second compartment?
a. Abductor policis brevis, Extensor policis longus
b. The median nerve
c. Extensori digiti minimi
d. Extensor carpi radialis brevis and Extensor carpi radialis longus
e. Extensor indicis
3. What are the muscles that forms the “mobile wad” compartment?
a. Flexor carpi ulnaris, Flexor carpi radialis, Brachioradialis
b. Extensor carpi ulnaris, Extensor carpi radialis brevis, Extensor carpi radialis longus
c. Extensor carpi ulnaris, Extensor carpi radialis longus, Extensor indicis
d. Extensor carpi radialis brevis, Extensor carpi radialis longus, Brachioradialis
e. Flexor carpi ulnaris, Flexor carpi radialis, Flexor policis longus
3. What are the muscles that forms the “mobile wad”
compartment?
a. Flexor carpi ulnaris, Flexor carpi radialis,
Brachioradialis
b. Extensor carpi ulnaris, Extensor carpi radialis brevis,
Extensor carpi radialis longus
c. Extensor carpi ulnaris, Extensor carpi radialis longus,
Extensor indicis
d. Extensor carpi radialis brevis, Extensor carpi
radialis longus, Brachioradialis
e. Flexor carpi ulnaris, Flexor carpi radialis, Flexor policis
longus
4. A patient sustains a distal biceps brachii tendon rupture. If treated non-operatively,
the greatest loss of strength would be seen with which activity?
a. Forearm supination
b. Forearm pronation
c. Elbow flexion
d. Shoulder forward flexion
e. Shoulder internal rotation
 4. A patient sustains a distal biceps brachii tendon rupture. If treated non-operatively,
the greatest loss of strength would be seen with which activity?
a. Forearm supination
b. Forearm pronation
c. Elbow flexion
d. Shoulder forward flexion
e. Shoulder internal rotation

Discussion:
MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT
Coracobrachialis Coracoid Middle humerus Musculocutaneous Flex and adduct Part of “conjoined”
process arm tendon

Brachialis Distal anterior Ulnar tuberosity Medial: MSC n. Flex forearm Split in anterior
humerus (proximal ulna) Lateral: Radial n. surgical approach

Biceps brachii
Long head Supraglenoid Radial tuberosity Musculocutaneous Supinate and Rupture, results in
tubercle (proximal radius) flex forearm “Popeye arm”
Short head Coracoid Radial tuberosity Supinate and Part of “conjoined”
process (proximal radius) Musculocutaneous flex forearm tendon
5. Injury to the long thoracic nerve can result in which of the following clinical entities?
a. Teres minor atrophy
b. Infraspinatus atrophy
c. Latissimus dorsi atrophy
d. Medial scapular winging
e. Lateral scapular winging
5. Injury to the long thoracic nerve can result in which of the following clinical entities?
a. Teres minor atrophy
b. Infraspinatus atrophy
c. Latissimus dorsi atrophy
d. Medial scapular winging
e. Lateral scapular winging

Discussion:
STRUCTURE CLINICAL APPLICATION
Sternoclavicular (SC) joint Uncommon site of infection or dislocation
Clavicle Subcutaneous bone: most common bone to fracture
Acromioclavicular (AC) joint Common site of “shoulder separation” or degenerative joint disease/pain
Acromion Landmark of shoulder (especially for injections, e.g., subacromial)
Deltoid muscle Can test muscle function for axillary nerve motor function
Trapezius Common site of pain; weakness results in lateral scapular winging
Serratus anterior Weakness/palsy results in medial scapular winging
Pectoralis major Can rupture off humeral insertion, results in a defect in the axillary fold
Cephalic vein Lies in the deltopectoral interval
Spine of scapula More prominent with supra/infraspinatus muscle wasting (suprascapular nerve palsy)
Inferior angle of scapula May “wing” medially or laterally if muscles are weak (nerve palsies)
(5 SOAL)
1. What is the strongest ligamentous structure that stabilizes the pelvis?
a. Anterior sacroiliac ligament
b. Posterior sacroiliac ligament
c. Sacrotuberous ligament
d. Sacrospinous ligament
e. Iliolumbar ligament
1. What is the strongest ligamentous structure that stabilizes the pelvis?
a. Anterior sacroiliac ligament
b. Posterior sacroiliac ligament
c. Sacrotuberous ligament
d. Sacrospinous ligament
e. Iliolumbar ligament

Discussion:
2. What are the dynamic stabilizers of the knee?
a. Semimembranosus, vastus medial, gastrocnemius
b. MCL, ACL, PCL
c. MCL, Gastrocnemius, Vastus medialis
d. LCL, Iliotibial band, ACL
e. Biceps femoris, Gastrocnemius, Iliotibial band
2. What are the dynamic stabilizers of the knee?
a. Semimembranosus, vastus medial, gastrocnemius
b. MCL, ACL, PCL
c. MCL, Gastrocnemius, Vastus medialis
d. LCL, Iliotibial band, ACL
e. Biceps femoris, Gastrocnemius, Iliotibial band

Discussion:
3. What is the strongest component of the medial ligaments of the ankle?
a. Anterior tibiotalar ligament
b. Tibionavicular ligament
c. Anterior talofibular ligament
d. Calcaneofibular ligament
e. Posterior tibiotalar ligament
3. What is the strongest component of the medial ligaments of the ankle?
a. Anterior tibiotalar ligament
b. Tibionavicular ligament
c. Anterior talofibular ligament
d. Calcaneofibular ligament
e. Posterior tibiotalar ligament

Discussion:
4. The sciatic nerve is most frequently identified passing between which of the
following structures?
a. Obturator internus and Superior gemellus
b. Obturator internus and Inferor gemellus
c. Piriformis and Superior gemellus
d. Piriformis and Gluteus minimus
e. Inferior gemellus and Obturator externus
4. During posterolateral approach of the hip, the
sciatic nerve is most frequently identified
passing between which of the following
structures?
a. Obturator internus and Superior gemellus
b. Obturator internus and Inferor gemellus
c. Piriformis and Superior gemellus
d. Piriformis and Gluteus minimus
e. Inferior gemellus and Obturator externus

Discussion:
In most (> 80%) patients, the sciatic nerve lies
anterior to the piriformis as it exits the pelvis
through the greater sciatic notch and then
through the interval between the piriformis and
the superior gemellus to continue its course
posterior to the remainder of the short external
rotators. Other variations include passing superior
to or piercing the piriformis.
5. Gluteus medius is an important hip abductors that maintains normal gait. What
structure is at risk if the muscle is injured?
a. Superior gluteal nerve
b. Inferior gluteal nerve
c. Pudendal nerve
d. Corona mortis
e. Sciatic nerve
5. Gluteus medius is an important hip abductors
that maintains normal gait. What structure is at
risk if the muscle is injured?
a. Superior gluteal nerve
b. Inferior gluteal nerve
c. Pudendal nerve
d. Corona mortis
e. Sciatic nerve

Discussion:
The superior gluteal nerve enters the deep
surface of the gluteus medius approximately 5 cm
proximal to the tip of the greater trochanter. Splitting
the muscle, as in the Hardinge approach, has been
reported to cause injury to this nerve if the split is
carried above 5 cm. A simple tag suture can be
placed at this level to prevent propogation of the
split inadvertently during surgery.
1. which of the following cell type release osteoclastogenis cytokines such as RANKL?

Osteoclast

2. which of the following enzyme I sused to resorb bone by mature osteoclast?

Cathepsin K

3. which of the following cell involves in bone metabolism derivates from a myeloid origin?

Preosteoclast

4. integrin function in which of the following ways?

Attachment of osteoclast to bone surfaces

5. intermittent daily administration of recombinant parathyroid hormone (rhPTH) is an FDA-

approved treatment for osteoporosis. Intermittent rhPTH treatment target which of the
following cells in osteoporotic patient?

Osteoblasts

6. which of the following components of bone is most responsible for compressive strength?

Proteoglycans

7. during endochondral ossification of the growth plate, the process that most contributes to
the longitudinal growth of long bone is

Chondrocyte hypertrophy

8. salter harris type I fracture typically occur through which zone of the physis?

Zone of provisional calcification

9. osteoclastic bone resorption is stimulated primarily by what molecular interaction?

Receptor activator of nuclear factor kappa beta (RANK) – RANK ligand (RANKL)

10. metastatic disease of several cancers create lytic lesions because these cancers?

Directly produce receptor activator of nuclear factor kappa beta ligand (RANKL)