Sample Orthopaedic Questions & Critiques

Sample Orthopaedic Surgery Questions & Critiques

The sample NCCPA items and item critiques are provided to help PAs better understand how exam
questions are developed and should be answered for NCCPA’s Orthopaedic Surgery CAQexam.

Question #1

A 25-year-old man comes to the orthopedic clinic because he has had pain in the ankle since he
sustained an inversion injury 10 days ago. The patient is otherwise healthy. On physical examination,
the skin is intact and mild edema is noted. Tenderness to palpation is noted over thedistal fibula and
anteromedial ankle. Neurovascular examination shows no abnormalities. X-ray study is shown. Which
of the following is the most appropriate management?

(A) Application of a long leg cast

(B) Application of a short leg cast

(C) Closed reduction and external fixation

(D) Open reduction and internal fixation

(E) Percutaneous pinning

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 Sample Orthopaedic Questions & Critiques

Content Area: Fractures/Dislocations (25%)

Critique

This question assesses the examinee’s ability to correctly interpret an x-ray study to determine the
diagnosis and then select the most appropriate management. The correct answer is Option (D), open
reduction and internal fixation. The x-ray study shows oblique fracture of the lateral malleolus,widening
of the medial clear space, and lateral displacement of the talus. On the basis of these findings, the
diagnosis is supination external rotation, type IV (Weber B2), which is an unstable injury to the ankle that
requires operative intervention.

Option (A), application of a long leg cast, is plausible but incorrect because closed reduction must be
performed first. Additionally, even with adequate closed reduction and cast immobilization, outcomes
with surgery are superior. Option (B), application of a short leg cast, is incorrect becausethis method of
immobilization allows internal and external rotation of the leg and is, therefore, not suitable management
of this patient’s injury. Option (C), closed reduction and external fixation, is incorrect because although
this intervention is useful for fractures of the tibial plafond or for ankle arthrodesis, it is not appropriate
for the injury described. Option (E), percutaneous pinning, is incorrect because this intervention is not as
appropriate as fixation with a plate and screws.

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 Sample Orthopaedic Questions & Critiques

Question #2

A 19-year-old woman is brought to the emergency department by ambulance after she sustained an
injury to the right knee while rollerblading. The patient says she felt sudden, severe pain in the knee
when she turned a corner quickly. She fell to the ground and was unable to bear weight on the right leg.
Physical examination shows swelling and deformity of the right knee as well as inability to fully extend
and straighten the right lower extremity. X-ray studies show dislocation of the patella.In addition to
administration of analgesics, which of the following is the most appropriate management?

(A) Arthroscopic lateral release

(B) Arthroscopic medial plication

(C) Closed reduction of the patella

(D) Open reduction of the patella

(E) Tibial tubercle medialization

Content Area: Fractures/Dislocations (25%)

Critique

This question tests the examinee’s ability to select the most appropriate management of a patient with
a known diagnosis. The correct answer is Option (C), closed reduction of the patella. The patient’s age,
gender, and athletic activity are all predisposing factors of this injury, and the x-ray study confirms the
diagnosis. Prompt reduction of a dislocated patella is the most appropriate management because the
longer the patella remains dislocated, the more damage is done to the medial retinaculum and the
medial ligamentous structure. In addition, risks of closed reduction areminimal compared with other
surgical options.

Option (A), arthroscopic lateral release, is incorrect because this procedure is not indicated for
management of acute patellofemoral instability. It is a more suitable intervention for patients with
retinacular tightness and pain. Option (B), arthroscopic medial plication, is incorrect because this
procedure is used to manage chronic patellofemoral instability. Option (D), open reduction of the patella,
is incorrect because surgery is rarely required for management of dislocation of the patella.Open reduction
may be needed, but this is only in circumstances in which closed reduction is repeatedly unsuccessful or
when a clear mechanical obstruction to reduction is evident. Option (E),tibial tubercle medialization, is
incorrect because this procedure is used to correct patellofemoral alignment in patients with
patellofemoral instability due to factors such as increased Q angle.

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 Sample Orthopaedic Questions & Critiques

Question #3

A 40-year-old woman comes to the emergency department because she has pain in the right armtwo
hours after she fell in her home. Physical examination shows swelling and deformity of the right arm.
The patient is unable to dorsiflex the wrist. X-ray studies show a spiral midshaft fractureof the humerus.
Which of the following nerves is most likely affected by this fracture?

(A)Axillary

(B) Median

(C) Musculocutaneous

(D) Radial

(E) Ulnar

Content Area: Fractures/Dislocations (25%)

Critique

This question tests the examinee’s knowledge of anatomy and the ability to correlate this knowledge
with findings on physical examination and x-ray studies. The correct answer is Option (D), radial. The
radial nerve courses posterior to the middle third of the humeral shaft and is proneto injury with
fractures of the midshaft of the humerus. Sensory distribution of the radial nerve includes the first
dorsal web space of the hand, and motor innervation includes the dorsal forearmextensor muscles,
including those of the wrist.

Option (A), axillary, is incorrect because this nerve is located posterior to the humeral neck. It provides
sensation over the deltoid region and innervates the deltoid muscle. Option (B), median, isincorrect
because this nerve courses through the medial aspect of the arm between the biceps brachii and
brachialis muscles. It provides sensation to the radial aspect of the palm and fingers aswell as the distal
dorsal surfaces of the thumb, index finger, long finger, and the radial aspect of thering finger. Motor
innervation within the hand includes the muscles of the thenar eminence. Option (C), musculocutaneous,
is incorrect because this nerve does not innervate any muscles involved in motor function of the wrist or
hand. Option (E), ulnar, is incorrect because this nerve courses through the arm relatively parallel to the
median nerve and is not in proximity to the humerus at the level of the fracture. It provides sensation to
the ulnar aspect of the dorsal and palmar surfaces of the hand and innervates the flexor carpi ulnaris,
which provides wrist flexion and ulnar deviation. The patient described is unable to dorsiflex the wrist,
which is not related to the ulnar nerve.

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 Sample Orthopaedic Questions & Critiques

Question #4

A 16-year-old girl who plays tennis on her high school team is brought to the emergency department by
her parents because she has had pain and worsening swelling of her right knee since she sustained an
injury during a match four hours ago. The patient says she was playing on ahard court and fell directly
onto her knee. She was able to complete the match. The pain is localized to the anterior aspect of the
knee and is dull in nature. The patient rates the pain as 6 on a10-point scale. Physical examination of the
right knee shows a fluctuant mass (5×3 cm) over the patella. Full range of motion is noted, and muscle
strength is 5/5. Result of apprehension test is negative. Which of the following is the most likely
diagnosis?

(A) Dislocation of the patella

(B) Fracture of the patella

(C) Patellar tendinitis

(D) Prepatellar bursitis

(E) Sprain of the patellar ligament

Content Area: Soft-Tissue Injuries and Disorders (25%)

Critique

This question tests the examinee’s ability to discriminate among various types of injury involving the
patella to determine the most likely diagnosis. The correct answer is Option (D), prepatellar bursitis. The
history and physical examination findings of a direct blow to the anterior aspect of theknee followed by
localized pain, swelling, a fluctuant mass, normal to near-normal range of motion (depending on size of
the mass), and normal muscle strength are characteristic of prepatellar bursitis.

Option (A), dislocation of the patella, is incorrect because the patient does not exhibit characteristics of
this condition, such as the knee acutely giving way, intense pain, rapid swelling, and deformity.
Additionally, findings on range of motion and muscle strength testing would not beexpected to be
normal if dislocation of the patella were present. Also, negative result of apprehension test effectively
excludes dislocation of the patella as a possible diagnosis. Option (B), fracture of the patella, is
plausible but incorrect in the patient described for several reasons. Pain from fracture is typically intense
and would most likely preclude the patient from completing her tennis match. Additionally, in a patient
with fracture of the patella, physical examination is unlikely to show full range of motion and muscle
strength is likely to be diminished because of pain. Option (C), patellar tendinitis, is incorrect because
this condition typically is the result of an overuse injury from repetitive overloading of the extensor
mechanism of the knee. The physical examination findings in the patient described are not consistent

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 Sample Orthopaedic Questions & Critiques

with patellar tendinitis. Option (E),sprain of the patellar ligament, is incorrect because this injury would
cause pain and swelling localized to the patellar tendon and decreased muscle strength because of pain.
Complete ruptureof the patellar ligament would manifest as inability to extend the knee.

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 Sample Orthopaedic Questions & Critiques

Question #5

A 20-year-old man who plays baseball on his college team comes to the clinic because he has hadpain
in the right elbow for the past three weeks. The pain began approximately one week after the beginning
of the baseball season. Physical examination of the elbow shows full range of motion in flexion,
extension, supination, and pronation. No pain is elicited on varus or valgus stress of the elbow.
Dorsiflexion of the right hand against resistance immediately elicits pain that is localized to the lateral
aspect of the elbow. Which of the following is the most likely diagnosis?

(A) Biceps tendinitis

(B) Fracture of the radial head

(C) Lateral epicondylitis

(D) Olecranon bursitis

(E) Sprain of the lateral collateral ligament

Content Area: Soft-Tissue Injuries and Disorders (25%)

Critique

This question tests the examinee’s ability to recognize signs and symptoms of a musculoskeletal
disorder to determine the most likely diagnosis. The correct answer is Option (C), lateral epicondylitis.
Overuse or repetitive motion activities involving wrist extension and/or supination are common causes
of lateral epicondylitis. Clinical manifestations usually include pain in thelateral aspect of the elbow and
the dorsal aspect of the forearm that is exacerbated by use. Physical examination usually shows
maximal point tenderness over the lateral epicondyle and/orthe area overlying the extensor carpi
radialis brevis muscle. Extension or supination of the wrist against resistance typically elicits pain.

Option (A), biceps tendinitis, is incorrect because this condition involves inflammation of the long head
of the biceps tendon, which causes pain in the anterior aspect of the shoulder. Option (B), fracture of the
radial head, is incorrect because the patient has no history of substantive trauma. Inaddition, the physical
examination findings of full range of motion in all planes and provocation of pain on dorsiflexion of the
wrist against resistance point away from this diagnosis as a possibility. Option (D), olecranon bursitis, is
incorrect because this condition involves inflammation of the bursa overlying the olecranon process and
none of the physical examination findings in the patientdescribed are suggestive of this condition.
Option (E), sprain of the lateral collateral ligament, is incorrect because the physical examination finding
of no pain elicited on varus or valgus stress of the elbow excludes this condition as the most likely
diagnosis. Additionally, activities that involve overhead throwing, such as baseball in the patient
described, are more likely to involve the medial collateral ligament rather than the lateral collateral
ligament.

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 Sample Orthopaedic Questions & Critiques

Question #6

A 54-year-old man with a history of metastatic lung cancer comes to the office because he had sudden
onset of pain in the lower back 24 hours ago. Which of the following findings in this patient differentiates
lumbar disk herniation from cauda equina syndrome as the cause of his pain?

(A) Anesthesia of the saddle region

(B) Bilateral weakness of the legs

(C) Impotence

(D) Pain radiating to one buttock

(E) Urinary incontinence

Content Area: Spine (7%)

Critique

This question tests the examinee’s ability to discriminate between clinical characteristics of lumbardisk
herniation and cauda equina syndrome. The correct answer is Option (D), pain radiating to onebuttock.
Most lumbar disk herniations are posterolateral, and 90% to 95% of compressive radiculopathies occur at
the level of L4-L5 and L5-S1. Pain associated with disk disease is usually localized to the lower back and
gluteal region and commonly radiates down the leg, particularly below the knee. Therefore, pain radiating
to one buttock differentiates lumbar disk herniation from cauda equina syndrome. Cauda equina
syndrome is typically associated with significant neurologic disability and is causedby an intraspinal lesion
caudal to the conus medullaris that impacts two or more of the 18 nerve roots comprising the cauda
equina. Clinical manifestations most often include bilateral leg weakness in multiple root distributions (L3-
S1); bowel, bladder, and sexual dysfunction; and/or perineal sensory loss (S2-S4). Causes of cauda equina
syndrome include neural tube defects, infection or inflammation, trauma, spinal stenosis, or mass lesions
(e.g., tumor, ruptured disk).

Therefore, Option (A), anesthesia of the saddle region, Option (B), bilateral weakness of the legs,Option
(C), impotence, and Option (E), urinary incontinence, are incorrect because they are characteristic of
cauda equina syndrome and do not support the diagnosis of lumbar disk herniation.

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 Sample Orthopaedic Questions & Critiques

Question #7

A 32-year-old man comes to the clinic because he has had pain in the back for the past 24 hours.The
patient says he first noticed the pain when he awoke in the morning and had difficulty getting out of bed.
He had been playing flag football the day before the pain began but did not sustain any injuries during
the game. Acetaminophen has provided only minimal relief of the patient's pain. On physical
examination, pain is elicited on palpation of the back on the left, lateral to the region of L2-L5. Full range
of motion is noted in vertebral flexion, extension, lateral rotation, and lateral bending, with some
hesitancy because of pain on the left side. Which of thefollowing is the most appropriate initial step?

(A) Anti-inflammatory and muscle relaxant therapy

(B) CT scan of the lumbar spine

(C) Epidural injection of a corticosteroid

(D) MRI of the lumbar spine

(E) Strict bed rest and application of moist heat to the lower back

Content Area: Spine (7%)

Critique

This question tests the examinee’s ability to recognize signs and symptoms of a common
musculoskeletal disorder and then determine the most appropriate initial step. The correct answeris
Option (A), anti-inflammatory and muscle relaxant therapy. In high-performing or “weekend”
athletes, the most common causes of pain in the lower back are musculoligamentoussprains and
strains. Typicalsigns and symptoms include pain and muscle spasm localized over the posterior
paraspinous muscles. Range of motion may be decreased because of pain. Pain in the midback as
well as neurologic symptoms, which are suggestive of structural deformities, should be absent. During
the acute phase, the most appropriate management is therapy with anti- inflammatory drugs and
muscle relaxants.

Option (B), CT scan of the lumbar spine, is incorrect because there is no clinical evidence of structural
deformity (e.g., fracture)or neurologic symptoms. Option(C), epidural injection of a corticosteroid, is
incorrect because although this therapy has been shown to be effective in reducing radicular pain in
patients with disk herniation, it is not indicated in the treatment of acute strain or sprain of the back.
Option (D), MRI of the lumbar spine, is incorrect because there is no clinical evidence of structural
deformity or neurologic complaint (e.g., radiculopathy). Option(E), strict bed rest and application of
moist heat to the lower back, is plausible but incorrect because most studies show that patients have a
more rapid functional recovery if they maintain some levelof activity, even during the acute phase.

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 Sample Orthopaedic Questions & Critiques

Question #8

A 63-year-old man is referred to the office by his primary care provider because he has pain in the right
knee that has been worsening over the past two years. He usually plays tennis several timesper week,
but recently the pain has made it difficult for him to continue this routine. Conservative treatment
measures such as courses of nonsteroidal anti-inflammatory drugs and injections of cortisone have
failed to relieve the patient's pain. Current physical examination of the right knee shows moderate
effusion and tenderness along the medial joint line. Result of the McMurray test is positive. MRI of the
knee shows a 3-cm defect of the articular cartilage of the medial femoral condyle. Weight-bearing x-ray
studies of the right knee show no narrowing of the joint spaces. Which of the following is the most
appropriate management?

(A) Application of a medial unloader knee brace

(B) Arthroscopy with microfracture of the articular cartilage defect

(C) Osteochondral grafting of the articular cartilage defect

(D) Total arthroplasty of the knee

(E) Unicompartmental joint replacement

Content Area: Joint Disorders (20%)

Critique

This question tests the examinee’s ability to recognize signs and symptoms of a common
musculoskeletal disorder and interpret imaging studies to determine the appropriate management.The
correct answer is Option (B), arthroscopy with microfracture of the articular cartilage defect. Recent
studies have shown that microfracture of a defect that is 3 cm or smaller restores pain-freeactivity in
80% to 90% of patients. Therefore, arthroscopy with microfracture is the most appropriate treatment of
the patient described.

Option (A), application of a medial unloader knee brace, Option (D), total arthroplasty of the knee, and
Option (E), unicompartmental joint replacement, are incorrect because the x-ray studies do notshow joint
space narrowing. Option (C), osteochondral grafting of the articular cartilage defect, is incorrect
because this intervention has not been proven to be effective in the knee joint of patientsin this age
group.

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 Sample Orthopaedic Questions & Critiques

Question #9

A 35-year-old man comes to the primary care office because he has had pain and swelling of the right
knee for the past three days. Also, for the past two days, he has felt feverish. The patient is able to
ambulate, but walking exacerbates the pain in his knee. Temperature is 39.3°C (102.7°F). On physical
examination, the right knee is red, warm to touch, and tender. A large effusion is noted.Which of the
following diagnostic studies of the knee is the most appropriate initial step?

(A) Arthrocentesis

(B) Arthroscopy

(C) Bone scan

(D) CT scan

(E) MRI

Content Area: Soft-Tissue Injuries and Disorders (25%)

Critique

This question tests the examinee’s ability to select the most appropriate study to determine the
diagnosis. The correct answer is Option (A), arthrocentesis. The clinical presentation described is
characteristic of septic joint. Arthrocentesis for aspiration and analysis of joint fluid is the only
diagnostic study that will specify the diagnosis of septic joint.

Option (B), arthroscopy, is incorrect because this study is not the initial step in diagnosis. Option(C),
bone scan, is incorrect because this study is appropriate to nonspecifically localize areas of
inflammation but cannot be used to distinguish infectious from sterile processes. Option (D), CTscan,
and Option (E), MRI, are incorrect because these studies are more sensitive for diagnosing
osteomyelitis and periarticular abscesses.

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 Sample Orthopaedic Questions & Critiques

Question 10

A 49-year-old man comes to the sports medicine office because he has pain in the right hip andthigh
that has been worsening since he fell while working in his yard two weeks ago. Physical
examination shows a healing puncture wound over the proximal aspect of the thigh. Erythemaand
warmth are noted over the lateral aspect of the right hip and the proximal aspect of the right thigh.
Full range of motion of the hip is noted, and distal sensation and pulses are intact. On laboratory
studies, erythrocyte sedimentation rate is 30 mm/hr. Results of complete blood cell count are
within normal limits. X-ray studies of the hip show a slightly raised periosteum in the proximal
femoral shaft. Which of the following additional diagnostic studies is most appropriate?

(A) CT scan

(B) Indium 111 bone scan

(C) MRI

(D) Technetium 99m bone scan

(E) Ultrasonography

Content Area: Infectious Diseases and Connective Tissue Disorders (5%)

Critique

This question tests the examinee’s ability to review a detailed clinical scenario, including historyand
physical examination findings, interpret laboratory values, evaluate x-ray study findings, andthen
determine the most appropriate additional study to establish the diagnosis. The correct answer is
Option (C), MRI. The clinical presentation is characteristic of osteomyelitis, and MRI isthe most
appropriate study to confirm this diagnosis because it shows marrow edema and periosteal
elevation.

Option (A), CT scan, is incorrect because this study is not sensitive for acute osteomyelitis. Option(B),
indium 111 bone scan, and Option (D), technetium 99m bone scan, are incorrect because although these
studies might show increased metabolic activity in patients with osteomyelitis, thisfinding is not
distinguishable from post-traumatic injury, cancer, or postoperative findings. Option (E),
ultrasonography, is incorrect because this study can only show fluid collection next to bone, which is not
distinguishable from a traumatic response.

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 Sample Orthopaedic Questions & Critiques

Question 11

A male neonate who was delivered vaginally at term one hour ago has a deformity of the right foot.On
physical examination, plantar flexion of the ankle, inversion of the subtalar joint, and medial subluxation
of the talocalcaneal and calcaneocuboid joints are noted. The position of thefoot cannot be passively
corrected. Which of the following disorders is the most likely diagnosis?

(A) Calcaneovalgus

(B) Congenital clubfoot

(C) Metatarsus adductus

(D) Pes planus

(E) Tarsal coalition

Content Area: Pediatric (4%)

Critique

This question tests the examinee’s knowledge of anatomy and the ability to correlate this knowledge
with physical examination findings to determine the diagnosis. The correct answer is Option (B),
congenital clubfoot. The physical examination findings described are characteristic ofcongenital
clubfoot.

Option (A), calcaneovalgus, is incorrect because this condition involves the foot in dorsiflexion, not
plantar flexion. Option (C), metatarsus adductus, is incorrect because this condition is characterized by
deformity that can be passively corrected. Option (D), pes planus, is incorrect because in patients with
this condition, the foot is flexible. Option (E), tarsal coalition, is incorrect because this condition typically
presents during the second decade of life but can present as earlyas 3 years of age, when the tarsal
bones begin to ossify.

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 Sample Orthopaedic Questions & Critiques

Question 12

A 6-year-old boy is brought to the office by his parents because he has had pain in the right hip with
weight-bearing as well as obvious limping for the past week. The patient's parents say they have
noticed the child favoring his right leg during the past few weeks. He has not had any recent illness or
injury to the leg. Medical history includes no chronic disease conditions. Physical examination shows
tenderness on passive internal rotation of the hip joint and mild diffuse atrophy of the rightthigh
musculature. X-ray studies of the hip and femur show no abnormalities. Which of the following studies
is the most appropriate next step?

(A) Aspiration of the hip

(B) Bone scan

(C) CT scan

(D) MRI

(E) Ultrasonography

Content Area: Pediatric (4%)

Critique

This question tests the examinee’s ability to review a detailed clinical scenario, including history and
physical examination findings, evaluate x-ray study findings, and then determine the most appropriate
additional study to establish the diagnosis. The correct answer is Option D, MRI. The clinical
presentation is characteristic of Legg-Calvé-Perthes disease, and MRI is the most sensitivestudy for
staging of this condition.

Option (A), aspiration of the hip, is incorrect because the patient has no history of current or recent
illness and, therefore, septic joint is very low on the differential diagnosis list. Option (B), bone scan,is
incorrect because it can only confirm the presence of avascular necrosis and not the extent of
involvement of the femoral head. Option (C), CT scan, is incorrect because although this study is used to
diagnosis Legg-Calvé-Perthes disease, it is not as sensitive as MRI. Option (E), ultrasonography, is
incorrect because this study can only confirm the presence of a joint effusion, which is a nonspecific
finding when confirming a suspected diagnosis of Legg-Calvé-Perthes disease.

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 Sample Orthopaedic Questions & Critiques

Question 13

A 12-year-old boy is brought to the office by his mother because he has had intermittent pain in theright
hip during the past two weeks. The patient ambulates with difficulty. He has not had fever, chills,
malaise, recent illness, or trauma to the hip. The patient is obese but otherwise healthy. On physical
examination, vague pain in the groin is elicited on range of motion of the right hip. The most appropriate
next step is x-ray studies to rule out which of the following conditions?

(A) Femoral acetabular impingement syndrome

(B) Legg-Calvé-Perthes disease

(C) Septic arthritis

(D) Slipped capital femoral epiphysis

(E) Tear of the labrum

Content Area: Pediatric (4%)

Critique

This question tests the examinee’s ability to discriminate between various types of conditions involving
the hip joint in a pediatric patient and determine which condition is most likely to be ruled out by x-ray
studies. The correct answer is Option (D), slipped capital femoral epiphysis. The historyand physical
examination findings are characteristic of slipped capital femoral epiphysis, including obesity, limp, and
pain with range of motion of the joint.

Option (A), femoral acetabular impingement syndrome, is incorrect because the most appropriate study
to rule out this condition is MRI, not x-ray studies. Option (B), Legg-Calvé-Perthes disease, is plausible but
incorrect in this patient considering his age because the mean age of onset of Legg- Calvé-Perthes
disease is 7 years and x-ray studies do not rule this condition out. Option (C), septic arthritis, is plausible
but incorrect because the patient has no history of acute illness and x-ray studies do not rule this
condition out. Option (E), tear of the labrum, is incorrect because the patient has no history of injury and
because MRI is the best diagnostic study to evaluate tear of the labrum.

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 Sample Orthopaedic Questions & Critiques

Question 14

A 19-year-old man who is a long-distance runner is referred to the office by his primary care provider
because he has had dull, aching pain in his right thigh after running during the past nine months. Six
months ago, the patient's primary care provider prescribed ibuprofen, which relieves the pain only
temporarily. The patient has no history of specific injury. Physical examination showsno abnormalities
of the right lower extremity. X-ray studies of the right femur show cortical thickening of the distal one-
third of the shaft with a central nidus measuring approximately 8 mm in diameter. Which of the
following is the most likely diagnosis?

(A) Aneurysmal bone cyst

(B) Enchondroma

(C) Osteoblastoma

(D) Osteochondroma

(E) Osteoid osteoma

Content Area: Benign and Malignant Bone Tumors (5%)

Critique

This question tests the examinee’s ability to review a detailed clinical scenario, including historyand
physical examination findings, evaluate x-ray study findings, and then determine the most likely
diagnosis. The correct answer is Option (E), osteoid osteoma. The x-ray finding of corticalthickening
with a central nidus is characteristic of osteoid osteoma.

Option (A), aneurysmal bone cyst, is incorrect because although the femur is the most common site of
involvement of aneurysmal bone cyst, it usually presents as a large lytic lesion. Option (B),
enchondroma, is incorrect because although the distal femur is a potential location for this lesion, it is
characterized as a lytic area filled with a calcified matrix. Option (C), osteoblastoma, is plausible but
incorrect because although it is closely related to osteoid osteoma, the two are distinguished by the
size of the nidus: larger than 2 cm represents osteoblastoma, and 1 cm or less represents osteoid
osteoma. In addition, the pain of osteoblastoma is less likely to be relievedby nonsteroidal anti-
inflammatory drug therapy. Option (D), osteochondroma, is incorrect because this lesion arises from the
growth plate on the metaphyseal side and results in an exostosis that points away from the joint of
origin.

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 Sample Orthopaedic Questions & Critiques

Question 15

A 72-year-old man comes to the office for follow-up examination eight weeks after he underwenttotal
arthroplasty of the right hip. The patient's rehabilitation had been progressing fairly well until
approximately five days ago, when worsening pain developed in the hip. The patient says the pain is
aggravated by walking and persists during sleeping hours even after he takes acetaminophen.
Infection of the prosthetic joint is suspected. Which of the following is themost likely causative
organism?

(A) Coagulase-negative staphylococcus

(B) Escherichia coli

(C) Group A beta-hemolytic streptococcus

(D) Haemophilus influenzae

(E) Pseudomonas aeruginosa

Content Area: Joint Disorders (20%)

Critique

This question tests the examinee’s ability to apply scientific concepts to a clinical scenario by
discriminating between multiple possible bacterial species to determine the most likely causative
organism of an orthopedic infection. The correct answer is Option (A), coagulase-negative
staphylococcus. The most commonly cultured microorganism (30% to 43%) from prosthetic joint
infections is coagulase-negative staphylococcus. The likelihood of infection with other organisms
depends on perioperative or contiguous factors, hematogenous seeding from distant infections, and/or
other comorbid diseases. The scenario described does not include any of these factors.

Option (B), Escherichia coli, and Option (E), Pseudomonas aeruginosa, are incorrect because they are
gram-negative bacilli, which are uncommon causes of prosthetic joint infection. Gram-negativebacilli
account for 3% to 6% of prosthetic joint infections. Option (C), group A beta-hemolytic streptococcus, is
incorrect because streptococci account for only 9% to 10% of prosthetic joint infections. Option (D),
Haemophilus influenzae, is incorrect because it is a very uncommon cause of prosthetic joint infection.
Its absolute burden is unknown.

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