Saudi Board Orthopedic Surgery Final Written Exam (SCFHS)

A 25-year-old male presents to the emergency department after a motor vehicle accident with an open tibia fracture. There is a 4 cm wound over the anterior leg with moderate soft-tissue damage, bone coverage, and minimal contamination. Which Gustilo-Anderson grade is this, and what is the recommended antibiotic prophylaxis?

• AGrade I; Cefazolin
• BGrade II; Cefazolin
• CGrade IIIA; Cefazolin and Gentamicin
• DGrade IIIB; Cefazolin, Gentamicin, and Penicillin

A 32-year-old male sustains a closed tibia-fibula fracture. Six hours after splinting, he reports escalating pain out of proportion to the injury. On examination, there is severe pain with passive stretch of the toes, but distal pulses are palpable. What is the most sensitive diagnostic threshold for acute compartment syndrome?

• ADelta pressure (diastolic BP minus compartment pressure) less than 30 mmHg
• BAbsolute compartment pressure greater than 45 mmHg
• CAbsence of distal pulses and capillary refill
• DLoss of sensation in the first webspace

A 45-year-old male presents with a pelvic ring injury after falling from a height. Radiographs show a symphysis pubis diastasis of 4 cm and widening of the left sacroiliac joint. What is the classification of this injury according to the Young-Burgess system, and what is the initial stabilization method?

• AAPC-I; Pelvic binder at the iliac crests
• BAPC-II; Pelvic binder at the greater trochanters
• CAPC-III; Pelvic binder at the greater trochanters
• DLC-II; Anterior external fixator

A 38-year-old male sustains a posterior hip dislocation with an associated acetabular fracture. Post-reduction CT reveals a large fracture fragment of the posterior wall of the acetabulum involving 45% of the articular surface. What is the definitive treatment indication?

• ANonoperative management with skeletal traction
• BClosed reduction and percutaneous screw fixation
• COpen reduction and internal fixation (ORIF) with plate and screws
• DTotal hip arthroplasty (THA)

An 82-year-old active female sustains a displaced femoral neck fracture (Garden Type IV). She has a history of mild controlled hypertension but is otherwise healthy. What is the most appropriate surgical treatment?

• ACannulated screw fixation
• BSliding hip screw fixation
• CUnipolar hemiarthroplasty
• DTotal hip arthroplasty (THA)

A 28-year-old male sustains a displaced femoral neck fracture in a high-energy fall. What is the primary concern that guides the timing and execution of surgical management for this patient?

• AHigh rate of deep vein thrombosis
• BAvascular necrosis (AVN) of the femoral head
• CInability to mobilize early
• DSevere blood loss from the fracture site

A 24-year-old polytrauma patient sustains closed bilateral femoral shaft fractures. Twelve hours after admission, he becomes confused, tachypneic, and hypoxic, with a petechial rash noted on his axilla and conjunctiva. What is the most likely diagnosis?

• APulmonary embolism from DVT
• BAcute respiratory distress syndrome (ARDS)
• CFat embolism syndrome (FES)
• DHypovolemic shock

A 45-year-old male sustains a distal femur fracture. CT scan reveals a coronal plane shear fracture of the posterior aspect of the medial femoral condyle (Hoffa fracture). What is the recommended treatment strategy?

• ANonoperative management in a long leg cast
• BOpen reduction and internal fixation using anterior-to-posterior lag screws
• CRetrograde intramedullary nailing
• DExternal fixation only

A 40-year-old male presents with a Schatzker Type II tibial plateau fracture. Which of the following best describes the anatomical pattern of this injury?

• APure cleavage split of the lateral plateau
• BSplit-depression fracture of the lateral plateau
• CPure central depression of the lateral plateau
• DBicondylar tibial plateau fracture

A 35-year-old male sustains a closed tibial shaft fracture. What are the acceptable alignment parameters for nonoperative management in a long leg cast?

• AUp to 15 degrees varus/valgus, 20 degrees anterior/posterior angulation
• BLess than 5 degrees varus/valgus, 10 degrees anterior/posterior angulation, and <1 cm sho…
• CLess than 10 degrees varus/valgus, 15 degrees anterior/posterior angulation, and <2 cm sh…
• DNo angulation or shortening is acceptable; all adult tibial fractures require surgery

A 42-year-old female presents with an ankle fracture. According to the Lauge-Hansen classification, which mechanism of injury begins with a rupture of the anterior tibiofibular ligament, followed by a spiral fibular fracture, posterior malleolar fracture (or posterior ligament rupture), and finally a medial malleolar fracture (or deltoid ligament rupture)?

• ASupination-Adduction (SAD)
• BPronation-Abduction (PAB)
• CSupination-External Rotation (SER)
• DPronation-External Rotation (PER)

A 29-year-old male sustains an ankle fracture. Radiographs demonstrate a fibula fracture that is proximal to the distal tibiofibular syndesmosis, with associated widening of the medial joint clear space. What is the Danis-Weber classification of this fracture, and what does it imply about the syndesmosis?

• AWeber A; The syndesmosis is completely intact
• BWeber B; The syndesmosis is partially disrupted but stable
• CWeber C; The syndesmosis is disrupted and likely requires stabilization
• DWeber B; The syndesmosis is completely torn and requires a tightrope

A 50-year-old male falls from a ladder and sustains a closed, highly comminuted distal tibia metadiaphyseal fracture with articular involvement (Pilon fracture). Severe soft-tissue swelling and early fracture blisters are present. What is the appropriate initial management strategy?

• AImmediate open reduction and internal fixation (ORIF) with dual plates
• BPrimary ankle arthrodesis
• CApplication of a bridging ankle spanning external fixator, followed by delayed ORIF when…
• DImmediate circular frame application with percutaneous wires

A 33-year-old male sustains a displaced intra-articular calcaneus fracture. A CT scan of the calcaneus is obtained to evaluate the injury. According to the Sanders classification, what criteria are used to categorize these fractures?

• AThe number of primary fracture lines in the coronal plane
• BThe number of articular fragments of the posterior facet seen on the coronal CT image
• CThe degree of shortening and varus collapse of the tuberosity
• DThe displacement of the sustentaculum tali relative to the cuboid

A 26-year-old male sustains a talus fracture-dislocation. Radiographs and CT show a fracture of the talar neck with subluxation of the subtalar joint and dislocation of the talar body from the tibiotalar joint. What is the Hawkins classification of this injury, and what is the risk of avascular necrosis (AVN)?

• AHawkins Type II; 10-25% risk of AVN
• BHawkins Type II; 50-100% risk of AVN
• CHawkins Type III; 50-100% risk of AVN
• DHawkins Type IV; 100% risk of AVN

A 30-year-old female presents with a closed distal-third humeral shaft fracture (Holstein-Lewis variant). On examination, she has a complete radial nerve palsy (inability to dorsiflex the wrist and extend the fingers). What is the most appropriate initial management?

• AEmergent open reduction and internal fixation (ORIF) with radial nerve exploration
• BClosed reduction and application of a coaptation splint followed by functional bracing
• CPercutaneous pinning of the humerus and radial nerve decompression
• DImmediate tendon transfers to restore wrist extension

According to the Neer classification of proximal humerus fractures, what criteria must be met for a fracture segment to be considered a displaced 'part'?

• AAny visible fracture line on radiographs
• BDisplacement greater than 0.5 cm or angulation greater than 30 degrees
• CDisplacement greater than 1.0 cm or angulation greater than 45 degrees
• DArticular surface involvement of more than 20%

A 22-year-old male sustains displaced midshaft fractures of both the radius and ulna. What is the primary surgical goal of open reduction and internal fixation (ORIF) of this injury?

• ARestoration of the radial bow to preserve forearm rotation
• BShortening of the ulna to prevent distal radioulnar joint (DRUJ) impingement
• CRigid bridging fixation using an intramedullary nail
• DAvoidance of plates to prevent radioulnar synostosis

A 31-year-old male presents with a Bado Type I Monteggia fracture-dislocation. What anatomical deformity is characterized by this specific injury subtype?

• AFracture of the proximal ulna with posterior dislocation of the radial head
• BFracture of the proximal ulna with anterior dislocation of the radial head
• CFracture of the distal radius with distal radioulnar joint (DRUJ) dislocation
• DFracture of the proximal ulna with lateral dislocation of the radial head

A 25-year-old female sustains a Galeazzi fracture-dislocation. What is the definitive treatment, and what is the primary surgical target that ensures stability of the distal radioulnar joint (DRUJ)?

• ACast immobilization in full supination
• BRigid plate fixation of the radial shaft to restore anatomical length, followed by DRUJ s…
• CPrimary repair of the TFCC through an arthroscopic approach
• DK-wire fixation of the DRUJ without fixing the radius

A 67-year-old male presents with severe groin pain and difficulty walking. Radiographs of the pelvis demonstrate advanced osteoarthritis of the right hip. What are the four classic radiographic features of osteoarthritis seen on plain film?

• AOsteopenia, subchondral sclerosis, marginal osteophytes, and symmetric joint space narrow…
• BAsymmetric joint space narrowing, subchondral sclerosis, osteophytes, and subchondral cys…
• CSymmetric joint space narrowing, periarticular osteopenia, marginal erosions, and soft ti…
• DSubchondral osteopenia, punch-out erosions, joint subluxation, and geode formation

A surgeon plans a direct anterior approach for a total hip arthroplasty (THA). What is the internervous plane utilized in this approach, and what nerve is at risk if the lateral retractors are placed too aggressively?

• ASartorius and tensor fasciae latae (TFL); Lateral femoral cutaneous nerve (LFCN)
• BRectus femoris and gluteus medius; Femoral nerve
• CSartorius and rectus femoris; Femoral nerve
• DTFL and gluteus medius; Superior gluteal nerve

A 70-year-old female presents to the emergency department after falling from her chair. She had a right total hip arthroplasty (via posterior approach) 4 weeks ago. Her right lower extremity is held in flexion, adduction, and internal rotation. What is the most likely diagnosis?

• AAnterior dislocation of the THA
• BPosterior dislocation of the THA
• CFemoral neck prosthetic fracture
• DProsthetic joint infection

What is the primary cellular mechanism responsible for aseptic osteolysis and late loosening of components in total hip arthroplasty?

• ABacterial colonization and biofilm formation
• BMacrophage phagocytosis of polyethylene wear debris triggering TNF-alpha and RANKL activa…
• CDirect osteoclast toxicity from metal ions (cobalt-chromium)
• DAutoimmune rejection of the titanium alloy

During a total hip arthroplasty, the surgeon decides to increase the femoral offset. What is the biomechanical effect of increasing femoral offset?

• ADecreases the lever arm of the abductor muscles, increasing joint reaction forces
• BIncreases the lever arm of the abductor muscles, decreasing joint reaction forces and imp…
• CLengthens the limb, increasing the risk of sciatic nerve palsy
• DIncreases the risk of impingement and anterior dislocation

When placing screws in the acetabular cup during a total hip arthroplasty, which quadrants of the acetabulum are considered 'safe zones' to avoid major vascular and nerve injuries?

• AAnterosuperior and Anteroinferior
• BAnterosuperior and Posterosuperior
• CPosterosuperior and Posteroinferior
• DPosteroinferior and Anteroinferior

A 58-year-old male with medial compartment knee osteoarthritis is evaluated for a unicompartmental knee arthroplasty (UKA). Which of the following findings is an absolute contraindication to UKA?

• AAge younger than 60 years
• BInflammatory arthritis (e.g., Rheumatoid Arthritis)
• CPatellofemoral chondromalacia without bone-on-bone pain
• DObesity (BMI of 32 kg/m2)

During a total knee arthroplasty (TKA), the surgeon performs trial reduction and finds that the knee is balanced and stable in flexion but is tight in extension (cannot reach full extension). What is the most appropriate next step to balance the gaps?

• AResect more distal femur
• BResect more proximal tibia
• CDecrease the polyethylene insert thickness
• DRecut the posterior femoral condyles

A 66-year-old female presents with persistent anterior knee pain and a limp 1 year after undergoing a total knee arthroplasty. Radiographs demonstrate lateral subluxation of the patella. What component malposition is the most common cause of patellar maltracking in TKA?

• AExternal rotation of the femoral component
• BInternal rotation of either the femoral or tibial component
• CLateralization of the patellar button on the patella
• DPlacement of a patellar component that is too small

A 72-year-old female undergoes a total knee arthroplasty for severe valgus osteoarthritis. In the recovery room, she is noted to have a foot drop. What nerve was injured, and what preoperative deformity is a risk factor for this complication?

• ATibial nerve; Varus deformity
• BCommon peroneal nerve; Valgus deformity
• CFemoral nerve; Flexion contracture
• DObturator nerve; Valgus deformity

A 68-year-old male presents 6 months after a right total hip arthroplasty with persistent dull pain. There is no erythema or drainage. Synovial fluid aspiration is performed. According to the Musculoskeletal Infection Society (MSIS) criteria, what synovial fluid analysis thresholds are diagnostic for chronic periprosthetic joint infection (PJI)?

• AWBC > 50,000 cells/uL and polymorphonuclear (PMN) cells > 90%
• BWBC > 3,000 cells/uL and PMN cells > 80%
• CWBC > 1,500 cells/uL and PMN cells > 70%
• DWBC > 500 cells/uL and PMN cells > 50%

A 71-year-old male is diagnosed with a chronic periprosthetic joint infection (PJI) of the knee, 14 months after the index total knee arthroplasty. The pathogen is identified as methicillin-resistant Staphylococcus aureus (MRSA). What is the gold-standard surgical treatment for chronic PJI in this patient?

• ADebridement, antibiotics, and implant retention (DAIR) with polyethylene exchange
• BOne-stage exchange arthroplasty
• CTwo-stage revision arthroplasty (removal of components, antibiotic spacer placement, intr…
• DLong-term suppressive oral antibiotic therapy without surgery

An 80-year-old female presents with groin pain after a low-energy fall. She has a right total hip arthroplasty that was placed 10 years ago. Radiographs demonstrate a fracture around the mid-portion of the femoral stem. The stem is noted to be loose and subsided compared to prior films. How is this periprosthetic fracture classified under the Vancouver system, and what is the appropriate treatment?

• AVancouver Type B1; Open reduction and internal fixation (ORIF) with a cable-plate constru…
• BVancouver Type B2; Revision of the femoral component to a long-stem prosthesis, with or w…
• CVancouver Type B3; Revision of the femoral component with proximal femoral replacement
• DVancouver Type C; ORIF of the fracture, leaving the hip prosthesis alone

A 75-year-old female sustains a displaced distal femoral fracture above a stable total knee arthroplasty (Su Type II periprosthetic fracture). The femoral component is well-fixed. What is the most appropriate management?

• ARevision of the femoral component to a distal femoral replacement
• BOpen reduction and internal fixation with a distal femoral locking plate or retrograde in…
• CCylinder cast immobilization for 12 weeks
• DExternal fixation as definitive treatment

A 69-year-old male presents with chronic shoulder pain, weakness, and inability to actively elevate his arm above 60 degrees. Radiographs demonstrate glenohumeral osteoarthritis, superior migration of the humeral head, and acetabularization of the acromion. What is the most appropriate surgical intervention?

• AAnatomic Total Shoulder Arthroplasty (TSA)
• BHemiarthroplasty of the shoulder
• CReverse Total Shoulder Arthroplasty (RTSA)
• DArthroscopic rotator cuff repair and debridement

What is the primary biomechanical principle by which a Reverse Total Shoulder Arthroplasty (RTSA) restores active elevation in a patient with a non-functioning rotator cuff?

• AIt anatomical reconstructs the rotator cuff using synthetic graft options
• BIt medializes and distalizes the center of rotation, increasing the deltoid moment arm an…
• CIt lateralizes the humerus to recruit the pectoralis major muscle for abduction
• DIt fuses the glenohumeral joint to allow scapulothoracic motion to substitute for shoulde…

A 35-year-old male presents with groin pain. He has a history of high-dose corticosteroid use for asthma. Bilateral hip radiographs are normal, but an MRI demonstrates a circumscribed band-like lesion in the anterosuperior femoral head of the right hip, with no collapse of the articular surface (Ficat Stage II). What is the most appropriate management?

• AProtected weight-bearing and observation
• BCore decompression of the femoral head
• CVascularized fibular grafting
• DTotal hip arthroplasty (THA)

A 74-year-old male with Parkinson's disease and severe lumbar spine stenosis (status post lumbar spinal fusion from L2 to S1) is scheduled for a total hip arthroplasty. What type of acetabular component construct should be considered to minimize his high risk of postoperative dislocation?

• AA standard polyethylene liner with a 28 mm femoral head
• BA dual-mobility cup construct
• CA constrained acetabular liner
• DA high-walled posterior elevated liner

A 45-year-old active male underwent a metal-on-metal hip resurfacing arthroplasty 6 years ago. He presents with progressive groin discomfort and a soft-tissue mass in the lateral hip. Serum cobalt and chromium levels are elevated. What is the histopathologic term for this tissue reaction?

• AAcute purulent synovitis
• BAseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL)
• CGiant-cell tumor-like reaction
• DPolyethylene granulomatous foreign-body reaction

What is the relationship between pelvic tilt and femoral head coverage during the transition from standing to sitting, and how does this affect THA planning in spine-hip syndrome?

• ASitting causes the pelvis to tilt anteriorly, increasing acetabular anteversion
• BSitting causes the pelvis to tilt posteriorly (retroversion), which increases functional…
• CStanding causes the pelvis to tilt posteriorly, increasing anterior coverage
• DSpinal fusion increases pelvic mobility, reducing dislocation risk

A 3-week-old female is evaluated for a positive Ortolani sign on the left hip. What is the most appropriate initial diagnostic modality to confirm developmental dysplasia of the hip (DDH), and what is the first-line treatment?

• AAnteroposterior pelvic radiograph; Closed reduction and spica casting
• BHip ultrasonography; Pavlik harness
• CHip MRI; Abduction splint
• DCT scan of the pelvis; Pavlik harness

A 6-year-old boy presents with an antalgic limp and mild groin pain. Pelvic radiographs demonstrate fragmentation of the right femoral head. According to the Herring Lateral Pillar classification, how would you categorize a hip where more than 50% of the height of the lateral pillar of the femoral head is maintained?

• AHerring Class A
• BHerring Class B
• CHerring Class C
• DHerring Class B/C Borderline

An obese 13-year-old male presents with right knee pain of 3 weeks' duration and an externally rotated gait. He is able to bear weight on the right lower extremity. Radiographs of the hip demonstrate posterior and medial displacement of the femoral epiphysis relative to the neck. What is the diagnosis, and what is the recommended immediate treatment?

• ALegg-Calve-Perthes disease; Non-weight bearing and observation
• BStable Slipped Capital Femoral Epiphysis (SCFE); In situ single cannulated screw fixation
• CUnstable SCFE; Open reduction and dual screw fixation
• DOsteoid osteoma of the femoral neck; Radiofrequency ablation

A 4-year-old female presents with acute onset of left hip pain, fever of 38.8 C, and refusal to bear weight. On examination, the hip is held in flexion, abduction, and external rotation. According to the Kocher criteria, which combination of findings would yield a 99% probability of septic arthritis over transient synovitis?

• AInability to bear weight, ESR > 20 mm/hr, Fever > 38.0 C, Synovial fluid WBC > 10,000 cel…
• BInability to bear weight, ESR > 40 mm/hr, Fever > 38.5 C, Serum WBC > 12,000 cells/uL
• CGroin pain, CRP > 10 mg/L, Fever > 37.5 C, Serum WBC > 10,000 cells/uL
• DInability to bear weight, CRP > 2.0 mg/L, ESR > 20 mm/hr, positive blood culture

A newborn is diagnosed with bilateral congenital talipes equinovarus (clubfoot). What is the classic sequence of deformity correction using the Ponseti casting technique?

• AEquinus, Varus, Adduction, Cavus
• BCavus, Adduction, Varus, Equinus
• CAdduction, Cavus, Equinus, Varus
• DVarus, Adduction, Cavus, Equinus

A 5-year-old child presents after falling from playground equipment. Radiographs demonstrate a displaced supracondylar humerus fracture. On the lateral view, what is the normal relationship of the anterior humeral line relative to the capitellum?

• AIt should pass anterior to the capitellum
• BIt should pass posterior to the capitellum
• CIt should pass through the middle third of the capitellum
• DIt should intersect the radial head ossification center

A 6-year-old boy has a Gartland Type III supracondylar humerus fracture with posterolateral displacement of the distal fragment. On examination, he is unable to flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger ('unable to make an OK sign'). Which nerve is injured?

• ARadial nerve
• BMedian nerve (main branch)
• CAnterior interosseous nerve (AIN)
• DUlnar nerve