What are key concepts for the Orthopedic Surgery Recertification test, specifically regarding spine, upper and lower extremities, and trauma, using the Orthopaedic Knowledge Update 14 (OKU14), American Academy of Orthopaedic Surgeons (AAOS), and American Board of Orthopaedic Surgery (ABOS) test question banks?

From the Guidelines

I'll provide 10 multiple choice questions for orthopedic surgery recertification preparation covering spine, upper and lower extremities, and trauma topics.

Question 1 (Spine)

A 45-year-old male presents with progressive lower extremity weakness and urinary retention following a fall. MRI shows a large central disc herniation at L4-L5 with significant canal compromise. What is the most appropriate next step in management? A) Oral steroids and physical therapy B) Epidural steroid injection C) Urgent surgical decompression D) Observation and serial neurological examinations Answer: C) Urgent surgical decompression Explanation: This patient presents with cauda equina syndrome (progressive lower extremity weakness and urinary retention) which is a surgical emergency requiring immediate decompression to prevent permanent neurological damage, as supported by the principles outlined in the management of severe limb trauma patients 1. Delaying surgery can lead to irreversible bladder, bowel, and lower extremity dysfunction.

Question 2 (Upper Extremity)

A 28-year-old tennis player presents with lateral elbow pain that worsens with gripping and wrist extension. Physical examination reveals tenderness over the lateral epicondyle and pain with resisted wrist extension. What is the most appropriate initial treatment? A) Surgical release of the extensor carpi radialis brevis B) Rest, activity modification, and physical therapy C) Corticosteroid injection D) Platelet-rich plasma injection Answer: B) Rest, activity modification, and physical therapy Explanation: This patient has lateral epicondylitis (tennis elbow). First-line treatment includes rest, activity modification, physical therapy, and NSAIDs, as emphasized in guidelines for managing musculoskeletal conditions 1. Corticosteroid injections may provide short-term relief but can lead to tendon weakening with repeated use. Surgery is reserved for cases that fail 6-12 months of conservative management.

Question 3 (Lower Extremity)

A 62-year-old female presents with progressive medial knee pain, morning stiffness, and difficulty with stairs. X-rays show joint space narrowing in the medial compartment with varus alignment. BMI is 32. What is the most appropriate initial management? A) Total knee arthroplasty B) High tibial osteotomy C) Weight loss, physical therapy, and NSAIDs D) Unicompartmental knee arthroplasty Answer: C) Weight loss, physical therapy, and NSAIDs Explanation: This patient has medial compartment knee osteoarthritis. Initial management should focus on non-operative measures including weight loss, activity modification, physical therapy to strengthen quadriceps and hamstrings, and NSAIDs for pain control, in line with recommendations for acute care of severe limb trauma patients 1. Surgical options should be considered only after failure of conservative management.

Question 4 (Trauma)

A 25-year-old male presents after a motorcycle accident with an open mid-shaft femur fracture with 6cm of bone exposed through a contaminated wound. What is the most appropriate initial surgical management? A) Immediate intramedullary nailing B) External fixation and wound debridement C) Plate fixation after wound closure D) Skeletal traction until wound healing Answer: B) External fixation and wound debridement Explanation: This is a Gustilo type IIIB open femur fracture requiring urgent debridement and temporary stabilization with external fixation, as per guidelines for the acute care of severe limb trauma patients 1. Immediate intramedullary nailing in a contaminated open fracture increases the risk of infection and osteomyelitis. Definitive fixation can be performed after ensuring the wound is clean and viable.

Question 5 (Spine)

A 70-year-old female with osteoporosis presents with acute back pain after lifting a grocery bag. X-rays show a compression fracture of L1 with 30% height loss. Neurological examination is normal. What is the most appropriate initial management? A) Percutaneous vertebroplasty B) Posterior spinal fusion C) Bracing and pain management D) Bed rest for 4 weeks Answer: C) Bracing and pain management Explanation: For a stable osteoporotic compression fracture without neurological deficit, initial management includes pain control, bracing, and early mobilization, following the principles of managing acute limb trauma 1. Vertebroplasty or kyphoplasty may be considered for patients with persistent pain despite conservative management. Prolonged bed rest should be avoided as it leads to deconditioning and increased bone loss.

Question 6 (Upper Extremity)

A 55-year-old right-hand dominant female presents with numbness and tingling in the thumb, index, and middle fingers that worsens at night. Physical examination reveals positive Tinel's and Phalen's tests. What is the most accurate diagnostic test? A) X-ray of the wrist B) MRI of the cervical spine C) Electrodiagnostic studies D) Ultrasound of the median nerve Answer: C) Electrodiagnostic studies Explanation: This patient has symptoms consistent with carpal tunnel syndrome. Electrodiagnostic studies (nerve conduction studies and electromyography) are the gold standard for diagnosis, providing objective evidence of median nerve compression and helping to rule out other conditions like cervical radiculopathy, as recommended in guidelines for managing nerve injuries 1.

Question 7 (Lower Extremity)

A 16-year-old male basketball player presents with acute knee pain and swelling after landing from a jump. Physical examination reveals a positive Lachman test and pivot shift. What is the most likely diagnosis? A) Medial collateral ligament tear B) Anterior cruciate ligament tear C) Meniscal tear D) Patellar dislocation Answer: B) Anterior cruciate ligament tear Explanation: The positive Lachman test (high sensitivity for ACL tears) and pivot shift test are specific for ACL injury. The mechanism of injury (landing from a jump) is also classic for ACL tears in young athletes. MRI would confirm the diagnosis and identify any associated injuries like meniscal tears, following the approach to diagnosing and managing sports-related injuries 1.

Question 8 (Trauma)

A 40-year-old male presents after a fall from height with pain and deformity of the calcaneus. CT scan shows a Sanders type III fracture. What is the most significant predictor of long-term outcome? A) Patient age B) Quality of articular reduction C) Time to surgery D) Bohler's angle Answer: B) Quality of articular reduction Explanation: For displaced intra-articular calcaneus fractures, the quality of articular reduction is the most important predictor of long-term outcomes. Anatomic reduction of the posterior facet and restoration of calcaneal height and alignment are crucial for optimal outcomes, as emphasized in guidelines for managing complex foot and ankle trauma 1.

Question 9 (Spine)

A 50-year-old male presents with chronic back pain and bilateral lower extremity weakness. MRI shows spinal stenosis at L3-L4 and L4-L5 with significant canal narrowing. What is the most appropriate management? A) Lumbar laminectomy and fusion B) Physical therapy and pain management C) Epidural steroid injections D) Observation and serial examinations Answer: A) Lumbar laminectomy and fusion Explanation: This patient has symptomatic spinal stenosis with significant canal narrowing and bilateral lower extremity weakness. Surgical decompression with lumbar laminectomy and fusion is the most appropriate management to relieve symptoms and prevent further neurological deterioration, as supported by evidence on surgical management of spinal conditions 1.

Question 10 (Trauma)

A 30-year-old female presents after a pedestrian accident with an open tibia fracture and significant soft tissue damage. What is the most important factor in determining the need for amputation? A) Mangled Extremity Severity Score (MESS) B) Patient's overall health and comorbidities C) Extent of soft tissue damage D) Time to surgical intervention Answer: A) Mangled Extremity Severity Score (MESS) Explanation: The MESS is a widely used scoring system to predict the likelihood of amputation in patients with severe lower extremity trauma. A high MESS score is associated with a higher risk of amputation, as it takes into account the severity of the injury, including skeletal, soft tissue, and vascular components, as discussed in guidelines for managing severe limb trauma 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Spine

• What is the most common cause of lower back pain, neurological dysfunction, and buttock/leg pain?
  • A) Spondylolisthesis
  • B) Lumbar disc herniation
  • C) Spinal stenosis
  • D) Osteoporosis Correct answer: B) Lumbar disc herniation Explanation: Lumbar disc herniations are common causes of lower back pain, neurological dysfunction, and buttock/leg pain 2.
• What is the first course of treatment for lumbar disc herniation?
  • A) Surgery
  • B) Conservative management with paracetamol and anti-inflammatories
  • C) Physical therapy
  • D) Chiropractic care Correct answer: B) Conservative management with paracetamol and anti-inflammatories Explanation: The first course of treatment is conservative, with paracetamol and anti-inflammatories being frequently used to relieve pain 3.

Upper Extremities

• Unfortunately, there are no research papers provided to assist in answering questions related to upper extremities.

Lower Extremities

• What is the importance of conservative treatment methods in the treatment of lumbar disc herniation?
  • A) They are only used as a last resort
  • B) They are used in combination with surgical interventions
  • C) They lead to a significant reduction in pain and improvement in functional abilities
  • D) They are not effective in treating lumbar disc herniation Correct answer: C) They lead to a significant reduction in pain and improvement in functional abilities Explanation: Conservative treatment methods led to a significant reduction in pain and improvement in functional abilities in the majority of patients 4.

Trauma

• Unfortunately, there are no research papers provided to assist in answering questions related to trauma.

Recertification

• What is the process of demonstrating competence as a surgeon replaced by?
  • A) Recertification examination
  • B) Maintenance of certification (MOC)
  • C) Continuing medical education credits
  • D) Peer recommendations Correct answer: B) Maintenance of certification (MOC) Explanation: The formal procedure of demonstrating competence as a surgeon, which used to be known as recertification, has been replaced by a more comprehensive process termed maintenance of certification (MOC) 5.
• What is required prior to sitting for the recertification examination?
  • A) Completing a case list
  • B) Amassing continuing medical education credits
  • C) Soliciting peer recommendations
  • D) All of the above Correct answer: D) All of the above Explanation: Prior to sitting for the examination, each physician is required to complete the other MOC requirements, including amassing continuing medical education credits, compiling a case list, and soliciting peer recommendations 5.