Orthopedic Surgery Prometric exam questions

The Orthopedic Surgery exam in every GCC country

From each regulator's own exam pages; anything a regulator does not publish says so. Assessment mode also depends on your licence title, so confirm your route on your eligibility notice.

12 worked Orthopedic Surgery practice questions

Original exam-style questions from the bank, spread across the blueprint domains. They are not real or recalled exam questions. Try each one, then open the answer for the rationale and reference. None of them appear in the free mock exam, so reading them will not spoil it.

1. Question 1 · Basic Science & Principles of Orthopedics

   During a posterior (Thompson) exposure of the proximal third of the radius for plating, which structure is at greatest risk and must be identified and protected?

   1. AMedian nerve as it passes between the two heads of pronator teres
   2. BSuperficial branch of the radial nerve beneath brachioradialis
   3. CPosterior interosseous nerve within the substance of supinator
   4. DUlnar nerve as it passes deep to flexor carpi ulnaris
   Show answer and explanation

   Correct answer: C. Posterior interosseous nerve within the substance of supinator

   The posterior interosseous nerve pierces and runs within the supinator muscle wrapping the proximal radius, so it is directly in the field during a Thompson approach and should be formally identified and protected before the supinator is elevated. The superficial radial nerve is the nerve at risk in the distal part of Henry's anterior approach, while the median and ulnar nerves lie in the anterior and ulnar compartments respectively and are not encountered in this posterior dissection.

   Reference: Hoppenfeld, deBoer and Buckley, Surgical Exposures in Orthopaedics: The Anatomic Approach, 5th edition (2017)

2. Question 2 · Perioperative Care, Rehabilitation & Complications

   A 66-year-old man had a drug-eluting coronary stent inserted 6 weeks ago and takes aspirin plus ticagrelor. He now requires fixation of a displaced femoral neck fracture. What is the most appropriate perioperative antiplatelet strategy?

   1. AStop both agents for 7 days and operate electively thereafter
   2. BSubstitute both agents with therapeutic low-molecular-weight heparin until surgery
   3. CStop aspirin only and continue ticagrelor throughout
   4. DProceed with surgery without delay, continuing aspirin and stopping ticagrelor for the shortest feasible interval, after cardiology discussion
   Show answer and explanation

   Correct answer: D. Proceed with surgery without delay, continuing aspirin and stopping ticagrelor for the shortest feasible interval, after cardiology discussion

   Hip fracture surgery is time-critical and delay increases mortality, so surgery should not be postponed for a full washout; aspirin is generally continued and the P2Y12 inhibitor is withheld for the minimum interval, with cardiology input given the very high stent-thrombosis risk in the first months. Stopping both agents for a week in a fresh drug-eluting stent risks catastrophic stent thrombosis and delays a fracture that should be fixed within 24-48 hours. Continuing ticagrelor while stopping aspirin is the reverse of accepted practice. Heparin does not prevent stent thrombosis, which is a platelet-driven event.

   Reference: 2022 ESC Guidelines on non-cardiac surgery; NICE NG157 Hip fracture management (2023 update)

3. Question 3 · Orthopedic Sports Medicine & Arthroscopy

   A 27-year-old rugby player sustained a varus hyperextension injury. On the dial test, external rotation of the tibia is increased by 15 degrees compared with the contralateral side at 30 degrees of knee flexion, but the difference disappears at 90 degrees. What is the most likely injury?

   1. AIsolated posterior cruciate ligament tear
   2. BCombined posterior cruciate ligament and posterolateral corner injury
   3. CIsolated posterolateral corner injury
   4. DIsolated superficial medial collateral ligament tear
   Show answer and explanation

   Correct answer: C. Isolated posterolateral corner injury

   Increased external rotation at 30 degrees only is the classic pattern for an isolated posterolateral corner injury, because the popliteus complex and lateral collateral ligament are the primary restraints to tibial external rotation near extension. When the difference persists or increases at 90 degrees, a combined PCL and PLC injury is implied. An isolated PCL tear produces a posterior drawer/sag rather than rotational asymmetry on the dial test, and superficial MCL injury produces valgus laxity, not increased external rotation.

   Reference: LaPrade RF, Posterolateral Knee Injuries: Anatomy, Evaluation and Treatment; DeLee & Drez's Orthopaedic Sports Medicine, 5th ed. (2020)

4. Question 4 · Foot & Ankle

   A 24-year-old man has deep ankle pain and intermittent swelling 9 months after an inversion injury, despite bracing and physiotherapy. MRI shows a shallow 8 mm (approximately 0.8 cm squared) anterolateral osteochondral lesion of the talar dome with no subchondral cyst and an intact ligamentous complex. Which is the most appropriate surgical treatment?

   1. AAutologous chondrocyte implantation
   2. BOsteochondral autograft transfer from the ipsilateral knee
   3. CTibiotalar arthrodesis
   4. DArthroscopic debridement with bone marrow stimulation (microfracture)
   Show answer and explanation

   Correct answer: D. Arthroscopic debridement with bone marrow stimulation (microfracture)

   For a symptomatic talar osteochondral lesion smaller than roughly 1-1.5 cm squared without a large subchondral cyst, arthroscopic debridement and bone marrow stimulation gives good to excellent results in the majority and is the accepted first-line surgical option. Osteochondral autograft transfer and cell-based techniques such as ACI/MACI are reserved for larger, cystic or failed primary lesions because of donor-site morbidity, cost and the need for a second procedure. Arthrodesis is inappropriate in a young ankle with a focal lesion and preserved joint space.

   Reference: Mann's Surgery of the Foot and Ankle, 10th ed. (2023), osteochondral lesions of the talus; AAOS Orthopaedic Knowledge Update: Foot and Ankle 6 (2020)

5. Question 5 · Musculoskeletal Oncology

   A 58-year-old woman treated 12 years ago with breast conservation and adjuvant radiotherapy now has a painful, enlarging mass over the chest wall within the previous radiation field. Biopsy shows a high-grade spindle cell sarcoma. Which set of criteria BEST supports a diagnosis of radiation-induced sarcoma?

   1. AAny sarcoma occurring in a patient with a previous malignancy, regardless of site
   2. BA sarcoma arising within 6 months of radiotherapy at any anatomical site
   3. CA sarcoma of the same histological type as the original tumour arising outside the treated field
   4. DA sarcoma arising within the irradiated field after a latency of several years, histologically distinct from the original tumour, in a previously normal irradiated region
   Show answer and explanation

   Correct answer: D. A sarcoma arising within the irradiated field after a latency of several years, histologically distinct from the original tumour, in a previously normal irradiated region

   The Cahan criteria require that the second tumour arise within the previously irradiated field, after a long latent period (conventionally at least 3 to 4 years), and be histologically distinct from the primary malignancy that was treated. Osteosarcoma and undifferentiated pleomorphic sarcoma are the commonest histologies. A short latency, a lesion outside the field, or identical histology point instead to recurrence or coincidental disease.

   Reference: Cahan WG et al., Cancer 1948 (criteria for radiation-induced sarcoma, reprinted Cancer 1998); WHO Classification of Tumours of Soft Tissue and Bone, 5th edition (2020)

6. Question 6 · Adult Reconstruction - Arthritis & Arthroplasty

   A 72-year-old woman on apixaban 5 mg twice daily for non-valvular atrial fibrillation (CHA2DS2-VASc 3, creatinine clearance 80 mL/min) is scheduled for elective total hip arthroplasty under spinal anaesthesia. What is the most appropriate perioperative anticoagulation plan?

   1. AContinue apixaban up to and including the morning of surgery
   2. BStop apixaban 48 hours before surgery without heparin bridging
   3. CStop apixaban 5 days before surgery and bridge with therapeutic low-molecular-weight heparin
   4. DConvert to warfarin 2 weeks preoperatively and operate at an INR of 2.0
   Show answer and explanation

   Correct answer: B. Stop apixaban 48 hours before surgery without heparin bridging

   For a direct oral anticoagulant before high-bleeding-risk surgery in a patient with normal renal function, stopping about 48 hours preoperatively allows adequate clearance and safe neuraxial blockade, and bridging is not required because DOACs have a rapid on-off effect and bridging increases bleeding without reducing stroke. Continuing apixaban risks spinal haematoma, and converting to warfarin needlessly exposes the patient to a longer window of unpredictable anticoagulation.

   Reference: ASRA Pain Medicine Guidelines on Regional Anesthesia in the Patient Receiving Antithrombotic Therapy, 4th ed (2018); Douketis JD et al. PAUSE study, JAMA Intern Med 2019

7. Question 7 · Upper Limb - Shoulder, Elbow, Hand & Wrist

   A 25-year-old motorcyclist has a flail, insensate left arm after a high-speed crash. Examination reveals ptosis and miosis on the left, and the chest radiograph shows an elevated left hemidiaphragm. Nerve conduction studies show preserved sensory nerve action potentials in an anaesthetic hand. What do these findings indicate?

   1. AA postganglionic rupture amenable to direct nerve grafting
   2. BAn isolated axillary nerve injury
   3. CA neuropraxic lesion likely to recover fully within 6 weeks
   4. DA preganglionic root avulsion
   Show answer and explanation

   Correct answer: D. A preganglionic root avulsion

   Horner syndrome (from T1 sympathetic outflow), phrenic nerve palsy raising the hemidiaphragm (C3-C5) and preserved sensory nerve action potentials in an anaesthetic limb all localise the lesion proximal to the dorsal root ganglion, indicating preganglionic root avulsion, which is not graftable and is managed with nerve transfers or free functioning muscle transfer. Postganglionic ruptures abolish sensory nerve action potentials because the axon is separated from its ganglion cell body. An isolated axillary nerve lesion could not produce a flail insensate arm, and a neuropraxic lesion would not be accompanied by Horner syndrome and phrenic palsy.

   Reference: Green's Operative Hand Surgery, 8th ed. (Elsevier, 2022); Miller's Review of Orthopaedics, 8th ed. (Elsevier, 2020)

8. Question 8 · Pediatric Orthopedics

   A 5-year-old boy with GMFCS level IV spastic quadriplegic cerebral palsy is enrolled in a hip surveillance programme. His latest pelvic radiograph shows a right hip Reimers migration percentage of 38%, up from 25% one year ago. He has tight adductors and hip flexors, the acetabulum is well formed and there is no femoral head deformity. What is the most appropriate management?

   1. AContinue radiographic surveillance annually with no intervention
   2. BAdductor and psoas lengthening with post-operative abduction management
   3. CVarus derotation femoral osteotomy with pelvic osteotomy
   4. DProximal femoral resection (McHale procedure)
   Show answer and explanation

   Correct answer: B. Adductor and psoas lengthening with post-operative abduction management

   A migration percentage of 30 to 40% that is progressing in a young child with soft-tissue contracture but a preserved acetabulum and femoral head is the classic indication for preventive soft-tissue surgery, namely adductor longus and gracilis lengthening with psoas release at the pelvic brim. Simply continuing to observe a progressing hip allows subluxation to become dislocation, bony reconstruction with femoral and pelvic osteotomy is reserved for migration beyond roughly 40 to 50% or established acetabular dysplasia, and proximal femoral resection is a salvage operation for a painful chronically dislocated hip.

   Reference: Australian Hip Surveillance Guidelines for Children with Cerebral Palsy (2020); Reimers J, Acta Orthop Scand Suppl 1980

9. Question 9 · Spine

   A 34-year-old man from an endemic region presents with three months of thoracic back pain, weight loss and night sweats. Which MRI pattern would most strongly favour tuberculous spondylitis over pyogenic spondylodiscitis?

   1. ARelative preservation of the disc with multilevel anterior vertebral body involvement, subligamentous spread and a large, well-defined rim-enhancing paraspinal abscess
   2. BEarly and severe disc destruction at a single level with marked disc space narrowing
   3. CDiffuse marrow oedema confined to a single vertebral body with no paraspinal component
   4. DFacet joint effusion and enhancement with sparing of the vertebral bodies
   Show answer and explanation

   Correct answer: A. Relative preservation of the disc with multilevel anterior vertebral body involvement, subligamentous spread and a large, well-defined rim-enhancing paraspinal abscess

   Mycobacterium tuberculosis lacks proteolytic enzymes, so the intervertebral disc is relatively spared until late; the infection spreads beneath the anterior longitudinal ligament to involve multiple contiguous or skip vertebral bodies and characteristically produces large, well-defined, thin rim-enhancing cold abscesses. Early aggressive disc destruction at a single level is typical of pyogenic infection. Isolated single-vertebra marrow oedema and isolated facet involvement are non-specific and do not distinguish the two.

   Reference: World Health Organization Consolidated Guidelines on Tuberculosis (2022); Tuli SM, Tuberculosis of the Skeletal System, 5th edition (2016)

10. Question 10 · Patient Safety, Professionalism, Ethics & Evidence-Based Practice

    An arthroplasty surgeon receives design royalties on a hip stem and is publishing a single-centre cohort study reporting excellent results with that stem. Which course of action best manages the conflict of interest?

    1. ANo disclosure is needed, since royalties relate to design work rather than to the research
    2. BDisclosure to the journal is sufficient, and the institution need not be informed
    3. CDeclare the financial relationship to the journal and readers, to the institution and its conflict-of-interest committee, and to patients where the implant is being recommended, and ensure implant choice for individual patients is driven by evidence and patient factors rather than by the financial interest
    4. DThe conflict is eliminated simply by having a co-author who has no financial relationship analyse the data
    Show answer and explanation

    Correct answer: C. Declare the financial relationship to the journal and readers, to the institution and its conflict-of-interest committee, and to patients where the implant is being recommended, and ensure implant choice for individual patients is driven by evidence and patient factors rather than by the financial interest

    Conflicts of interest are managed by full transparency at every level at which the interest could bias a decision, which means journal and reader disclosure, institutional declaration, and disclosure to patients when recommending the device, together with a decision process anchored in evidence and patient-specific factors. Royalties are precisely the kind of financial interest that disclosure requirements target, whether or not they fund the study. Delegating analysis to a co-author may reduce analytic bias but does not discharge the duty to disclose, nor does it address bias in patient-level implant selection.

    Reference: ICMJE Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals (2024); AAOS Standards of Professionalism on Orthopaedist-Industry Conflicts of Interest

11. Question 11 · Musculoskeletal Infection

    A 52-year-old diabetic rice farmer who recently returned from South-East Asia presents with multifocal osteomyelitis, a septic knee and a splenic abscess. Blood cultures grow a bipolar-staining Gram-negative bacillus identified as Burkholderia pseudomallei. What is the correct antibiotic strategy?

    1. AOral co-trimoxazole alone for 12 weeks
    2. BTwo weeks of ciprofloxacin only
    3. CIntravenous ceftazidime or a carbapenem for an intensive phase, followed by prolonged oral eradication therapy with co-trimoxazole
    4. DVancomycin plus rifampicin for six weeks
    Show answer and explanation

    Correct answer: C. Intravenous ceftazidime or a carbapenem for an intensive phase, followed by prolonged oral eradication therapy with co-trimoxazole

    Melioidosis requires a two-phase regimen: an intensive intravenous phase with ceftazidime or a carbapenem (extended to four or more weeks for osteomyelitis or septic arthritis), followed by an eradication phase of oral co-trimoxazole for three to six months to prevent relapse. Burkholderia pseudomallei is intrinsically resistant to many agents including aminoglycosides and standard anti-staphylococcal drugs, so vancomycin-based therapy is ineffective, and neither short fluoroquinolone courses nor oral monotherapy from the outset achieves cure.

    Reference: Wiersinga WJ et al., 'Melioidosis', N Engl J Med (2012); Darwin Melioidosis Treatment Guideline (2020)

12. Question 12 · Musculoskeletal Oncology

    A 14-year-old with a high-grade distal femoral osteosarcoma completes neoadjuvant chemotherapy and undergoes limb-salvage resection. Which histological finding in the resected specimen is the STRONGEST predictor of favourable survival?

    1. ATumour necrosis of 90 per cent or more in the resected specimen
    2. BPredominantly chondroblastic rather than osteoblastic differentiation
    3. CAbsence of mitotic figures at the periphery of the specimen
    4. DA marginal rather than a wide resection margin
    Show answer and explanation

    Correct answer: A. Tumour necrosis of 90 per cent or more in the resected specimen

    Histological response to neoadjuvant chemotherapy, defined as 90 per cent or more tumour necrosis (Huvos grade III/IV), is the most powerful pathological prognostic factor in osteosarcoma and correlates strongly with event-free and overall survival. Histological subtype has far less prognostic weight, mitotic count at the periphery is not a validated osteosarcoma prognostic index, and a marginal margin is a risk factor for local recurrence rather than a favourable finding.

    Reference: Huvos AG et al., Archives of Pathology and Laboratory Medicine 1977; Bielack SS et al., Journal of Clinical Oncology 2002 (Cooperative Osteosarcoma Study Group)

Orthopedic Surgery reference books and guidelines

Every question in this bank names the textbook or guideline its answer rests on. These are the sources our Orthopedic Surgery questions cite most often - the reading list to revise from alongside the bank.

Where your regulator publishes a reading list, use the editions it names. Exam questions are not taken from any one book.