Orthopedic Surgery Basics Practice Questions

Q: A 50-year-old manual laborer sustained a comminuted distal radius fracture treated with ORIF 3 months ago. Despite supervised hand therapy, he has persistent stiffness with 30-degree wrist extension (normal 70), weak grip strength at 40% of contralateral side, and visible muscle atrophy. He reports burning pain with light touch and keeps his hand wrapped in a sock. Skin appears mottled with decreased hair growth. He is applying for disability and has a pending lawsuit. Evaluate the clinical picture and appropriate next step.

Triple-phase bone scan and referral to pain management. ***Triple-phase bone scan and referral to pain management*** - The presence of **allodynia** (pain with light touch), **autonomic dysfunction** (mottled skin, hair changes), and **atrophy** following trauma is classic for **Complex Regional Pain Syndrome (CRPS)**. - A **triple-phase bone scan** typically shows increased periarticular uptake in the delayed phase, and multidisciplinary **pain management** is the gold standard for treatment. *EMG/NCS to evaluate for nerve injury* - While nerve injury can cause pain, it does not explain the **vasomotor changes** and skin/hair trophic changes seen in this patient. - This patient likely has **CRPS Type I** (reflex sympathetic dystrophy), which occurs in the absence of a defined nerve injury. *Psychiatric evaluation for malingering assessment* - Despite the **secondary gain** considerations (lawsuit/disability), the physical findings of **mottled skin** and decreased hair growth are objective clinical signs that cannot be faked. - Labeling the patient as malingering before ruling out organic conditions like **CRPS** is inappropriate and delays necessary care. *Repeat surgery for hardware removal and capsular release* - Additional surgery is often **contraindicated** in the acute/active phase of CRPS as it can significantly worsen the pain and inflammatory response. - Stiffness in CRPS is due to **neurogenic inflammation** and sympathetic overactivity rather than simple mechanical obstruction by hardware. *Independent functional capacity evaluation* - While useful for measuring work readiness, this is a **diagnostic tool** for disability status rather than a clinical management step for an active pathology. - The priority is to confirm the diagnosis of **CRPS** and initiate treatment to prevent permanent **joint contracture** and functional loss.

Q: A 42-year-old woman presents with progressive hip pain over 18 months. She has a history of chronic steroid use for SLE. X-ray shows femoral head flattening with subchondral lucency but preserved joint space. MRI shows serpentine low-signal band on T1 in femoral head with surrounding edema. She has significant functional limitation and failed conservative management. Analyze the pathophysiology and most appropriate intervention.

Core decompression with possible bone grafting. ***Core decompression with possible bone grafting*** - This patient has **Avascular Necrosis (AVN)** of the femoral head, likely secondary to **chronic steroid use** for SLE, presenting with the characteristic **crescent sign** (subchondral lucency). - **Core decompression** is the surgical treatment of choice for early-stage AVN (Ficat Stage I-II/III) before joint space narrowing occurs, as it reduces **intraosseous pressure** and promotes revascularization. *Hip arthroscopy for debridement* - This procedure is typically used for **labral tears** or **femoroacetabular impingement**, not for treating the subchondral bone death seen in AVN. - It does not address the underlying **vascular compromise** or structural failure of the femoral head. *Hip resurfacing arthroplasty* - While an alternative to total hip replacement in young patients, it is generally **avoided in SLE patients** or those on steroids due to poor bone quality and high failure rates. - This procedure is for **end-stage arthritis**, whereas this patient still has a **preserved joint space**. *Total hip arthroplasty given advanced changes* - Total hip arthroplasty (THA) is the definitive treatment for **Ficat Stage IV** AVN, characterized by **secondary osteoarthritis** and joint space loss. - Because the **joint space is preserved** in this patient, joint-preserving operations like core decompression are preferred to delay the need for THA in a relatively young patient. *Continue conservative management with protected weight bearing* - Non-operative management has a **high failure rate** (over 80%) in symptomatic AVN and typically leads to rapid progression to femoral head collapse. - The patient has already **failed conservative management** and has significant functional limitations, necessitating surgical intervention.

Question 1

A 50-year-old manual laborer sustained a comminuted distal radius fracture treated with ORIF 3 months ago. Despite supervised hand therapy, he has persistent stiffness with 30-degree wrist extension (normal 70), weak grip strength at 40% of contralateral side, and visible muscle atrophy. He reports burning pain with light touch and keeps his hand wrapped in a sock. Skin appears mottled with decreased hair growth. He is applying for disability and has a pending lawsuit. Evaluate the clinical picture and appropriate next step.

Accepted Answer

Triple-phase bone scan and referral to pain management

Answer

EMG/NCS to evaluate for nerve injury

Answer

Psychiatric evaluation for malingering assessment

Answer

Repeat surgery for hardware removal and capsular release

Answer

Independent functional capacity evaluation

Question 2

A 16-year-old basketball player presents with chronic anterior knee pain worse with jumping and kneeling. Examination shows tenderness at the inferior pole of the patella and pain with resisted knee extension. X-ray shows elongation and fragmentation of the inferior patellar pole. He has failed 6 months of physical therapy, activity modification, and NSAIDs. His AAU season starts in 6 weeks and a college scout will be attending. His parents want definitive treatment. Evaluate the management approach balancing medical and contextual factors.

Accepted Answer

Recommend season withdrawal, continued conservative management for 6 more months

Answer

Corticosteroid injection to allow play through season with surgery after

Answer

Arthroscopic excision of inferior pole fragments allowing return to play in 4 weeks

Answer

Open excision of ossicle with patellar tendon repair, 4-6 month recovery

Answer

PRP injection series with continued play and close monitoring

Question 3

A 68-year-old woman falls and sustains a displaced femoral neck fracture. She was ambulatory with a walker pre-injury, has moderate dementia, osteoporosis, and multiple comorbidities including CHF and CKD stage 3. Her family wants her to return to her assisted living facility. The orthopedic team debates between hemiarthroplasty and total hip arthroplasty. Evaluate the optimal surgical approach considering her overall status.

Accepted Answer

Hemiarthroplasty given age and comorbidities

Answer

ORIF with cannulated screws to preserve native anatomy

Answer

Delay surgery until medical optimization for 2-3 weeks

Answer

Total hip arthroplasty for better long-term function

Answer

Non-operative management with palliative care focus

Question 4

A 42-year-old woman presents with progressive hip pain over 18 months. She has a history of chronic steroid use for SLE. X-ray shows femoral head flattening with subchondral lucency but preserved joint space. MRI shows serpentine low-signal band on T1 in femoral head with surrounding edema. She has significant functional limitation and failed conservative management. Analyze the pathophysiology and most appropriate intervention.

Accepted Answer

Core decompression with possible bone grafting

Answer

Hip arthroscopy for debridement

Answer

Hip resurfacing arthroplasty

Answer

Total hip arthroplasty given advanced changes

Answer

Continue conservative management with protected weight bearing

Question 5

A 35-year-old motorcyclist presents after a high-speed collision with a closed femoral shaft fracture, ipsilateral tibial fracture, and pulmonary contusions. He is hemodynamically stable after resuscitation. Oxygen saturation is 92% on 4L nasal cannula. Chest X-ray shows bilateral infiltrates. Analyze the optimal timing and method of fracture fixation.

Accepted Answer

External fixation of both fractures with delayed conversion to IM nailing

Answer

Skeletal traction for 2 weeks followed by definitive fixation

Answer

Delay all surgical intervention until pulmonary status improves

Answer

Immediate intramedullary nailing of both femur and tibia within 24 hours

Answer

Immediate femoral IM nailing and tibial external fixation

Orthopedic Surgery Basics — MCQs

Orthopedic Surgery Basics — MCQs

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