Case 1 (for question number 1 – 4)

A 30-year -old, right-hand-dominant man presents to clinic complaining of anterior right

shoulder pain. There is pain mostly with overhead movement that radiates to the biceps
muscle belly. He takes no medications, is otherwise healthy, and works as a car mechanic.
He is an avid volleyball player. His examination includes a positive Hawkins test, positive
Yerguson’s test, tenderness to palpation over the intertubercular sulcus, and a negative
Speed’s test. The rest of the examination is normal. Plain radiographs are normal.

1. Which of the following is not a physical examination finding in biceps tendon

pathology?
A. Positive Speed’s test
B. Positive Yerguson’s test
C. Tenderness to palpation over the intertubercular sulcus
D. Positive apprehension test
E. Popeye deformity

2. If the above patient is clinically diagnosed with biceps tendonitis, what is the
preferred initial management ?
A. Biceps tenotomy
B. Biceps tenodesis
C. Reconstruction of the transverse humeral ligament
D. Physical therapy, rest, NSAIDs, cryotherapy, and corticosteroid injections
E. Biceps repair

3. Which of the following is not an indication for surgical intervention with long
head of the biceps tendon pathology?
A. “Hourglass” biceps tendon on arthroscopy
B. 20% thickness tear
C. Subscapularis tear with biceps tendon subluxation
D. Isolated medial biceps tendon subluxation
E. Inflamed “lipstick” biceps tendon on arthroscopy

4. If the patient were elderly, what would be the preferred surgical intervention?
A. Biceps tenotomy
B. Biceps tenodesis
C. Reconstruction of the transverse humeral ligament
D. Physical therapy, rest, NSAIDs, cryotherapy, and corticosteroid injections
E. Biceps repair
Case 2 (for question number 5 – 8)
An active, 19-year-old gymnast complains of ulnar-sided wrist pain. She has already
obtained an MRI scan which reveals ECU tendinitis.

5. Where does this tendon principally insert ?

A. Base of 4th metacarpal
B. Hamate
C. Dorsal ridge of triquetrum
D. Blends with the 4th dorsal interosseous aponeurosis
E. Base of 5th metacarpal

6. What is the anatomical peculiarity of the ECU?

A. It receives dual nerve supply
B. It is the only extensor which also provides attachment to a lumbrical muscle
C. It contains a sesamoid bone
D. It is enclosed by a separate subsheath
E. It is the only extensor not contained within a compartment

7. Which extensor compartment does the ECU pass through?

A. 4th
B. 5th
C. 6th
D. 7th
E. None of the above

8. In addition to acting as a wrist extensor, what other role has been attributed to the
ECU?
A. It stabilizes the ulnar head preventing dorsal subluxation
B. It enables opposition of the 5th metacarpal
C. It is responsible for rotator y movements at the capitate-hamate joint
D. It augments the dorsal radio-triquetral bundle
E. It provides attachment to the TFCC

Case 3 (for question number 9 – 12)

A patient present s after a fall on an outstretched hand. X-rays reveal a distal radius and
ulnar styloid fracture. You decide to perform open reduction and internal fixation with a
volar plate and screws.
9. Which segment of the distal radius is considered to be the keystone in fixing these
fractures?
A. Radial styloid
B. Lister ’s tubercle
C. The volar ulnar part of the lunate fossa
D. The dorsal half of the sigmoid notch
E. Scaphoid fossa
10. While placing the plate, you remember hearing that the plate needs to be placed
proximal to a certain landmark line. What is this line called?
A. Watershed line
B. Cardinal line
C. Translational line
D. Tectonic line
E. Finish line

11. What complication are you likely to avoid by placing the plate proximal to the
landmark?
A. Dorsal penetration of screws
B. Attritional rupture of flexor pollicis longus
C. Rotational malalignment of fracture fragments
D. Screw penetration through the sigmoid notch
E. Damage to the short radiolunate ligament

12. Which of the following features of an ulnar styloid fracture has been shown to
definitively predispose to instability of the distal radioulnar joint ?
A. Fractures involving gr eater than 50% of the size of the styloid
B. Fractures displaced more than 2 mm
C. Fractures with gr eater than 90-degree rotation of the fragment
D. All of the above
E. None of the above

Case 4 (for question number 13 – 16)

A 56-year -old homemaker fell down the steps of her basement injuring her left ring finger. She
was seen at an outside facility with significant deformity of the ring finger. There were
no open wounds. There was severe pain and limited motion. Radiographs are shown in
Figures 4A and B.

Figure 4 A-B
13. The most appropriate treatment at this time would be which of the following?
A. Emergent open reduction and internal fixation of the ring finger
B. Emergent closed reduction and splinting
C. Emergent closed reduction and percutaneous pin fixation
D. Application of an external fixator to restore length

14. The causation of the deformity includes which of the following?

A. Deforming force from the fall
B. Attachment of the central extensor mechanism to the base of the middle phalanx
C. Flexion of the base of the proximal phalanx by the attachment of the intrinsics
D. All of the above

15. The most appropriate treatment at this time would be which of the following?
A. Closed reduction and percutaneous pin fixation
B. Open reduction and plate fixation
C. Application of an external fixator
D. Continued management with closed treatment with buddy taping and hand-based
ulnar gutter splint

16. The most likely complication after this fracture is likely to be which of the
following?
A. Stiffness of the PIP and DIP joints
B. Difficulty with excursion of the FDS and the FDP
C. Reflex sympathetic dystrophy affecting the ring finger
D. Complex regional pain syndrome affecting the ring finger
E. Complex regional pain syndrome

Case 5 (for question number 17 – 19)

A 42-year -old, right-hand-dominant, male, government contractor sustains blunt trauma to
his right arm while using a jackhammer. He has immediate pain and deformity to his right
upper extremity and presents immediately to the emergency department with this isolated
injury. Physical examination shows skin to be intact, and patient has wrist extensor
weakness. Plain radiographs reveal a spiral fracture of the right humerus mid-diaphysis
with 30 degrees of anterior and 30 degrees of varus angulation.

17. Which of the following is NOT a contraindication to nonoperative treatment with

a coaptation splint?
A. 20 degrees of varus angulation
B. Vascular injury
C. Radial nerve injury
D. Brachial plexus injury

18. Which of the following about the radial nerve is true?

A. It courses across the posterior humerus from lateral to medial.
 B. It can be found 5 cm proximal to the lateral epicondyle of the humerus.
C. It can be found 10 cm proximal to the medial epicondyle.
D. It has an increased incidence of injury with a distal one-third humeral shaft
fracture.

The above patient is treated with an intramedullary nail and is later lost to follow-up. He presents
to clinic 9 months later with a complaint of persistent right arm pain. Radiographs and advanced
imaging reveal that he has a hypertrophic nonunion

19. What is the most appropriate definitive treatment?

A. Nail removal and open reduction with internal fixation
B. Revision intramedullary nailing
C. Nail removal and functional bracing
D. Continued observation

Case 6 (for question number 20 – 23)

A 43-year -old man was struck by a car while walking along the road. Neurologic
examination demonstrates 5/5 strength in all muscle groups in his upper extremities but 0/5
strength throughout the lower extremities. Though sensation throughout the lower
extremities is absent, he has diminished yet present perianal sensation to light touch and
pinprick. His imaging studies are shown in Figure 6 A–C.

Figure 6 A - C
20. The patient’s neurologic injury can be best described by which of the following
American Spinal Injury Association (ASIA) impairment scale grades?
A. ASIA A
B. ASIA B
C. ASIA C
 D. ASIA D

21. In the trauma bay, the patient ’s blood pressure suddenly drops to 80/50 mm Hg while
his pulse increases to 120 bpm. A 1-L fluid bolus of lactated Ringers is infused
which normalizes his blood pressure and pulse. This clinical phenomenon is best
characterized as which of the following?
A. Hypovolemic shock
B. Spinal shock
C. Neurogenic shock
D. Autonomic dysreflexia

22. During early management and resuscitation of this patient, which of the
following is currently recommended in order to maximize neurological recovery?
A. Systemic hypothermia using an intravenous cooling system
B. High-dose methylprednisolone infusion
C. Maintaining mean arterial pressure of 85 mm Hg
D. Injection of olfactory ensheathing cells into the injury site

23. Definitive management of this patient’s spinal injury should be:

A. Anterior corpectomy, strut graft, and instrumentation
B. Custom-molded thoracolumbar orthosis
C. Laminectomy and short-segment fusion
D. Long-segment instrumented fusion