USMLE Step 2 Quiz
Practice Orthopedic And Soft Tissue Injuries in USMLE Step 2 with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.
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A 52-year-old woman with a history of chronic low back pain presents to the emergency department with a 12-hour history of new-onset bilateral leg weakness, numbness in her perineal area, and urinary retention. She required catheterization for 600 mL of urine. On examination, she has 3/5 strength in her lower extremities bilaterally, decreased sensation in a 'saddle' distribution, and diminished anal sphincter tone.
Which of the following is the most appropriate next step in management?
This quiz focuses on Orthopedic And Soft Tissue Injuries, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.
Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.
A 52-year-old woman with a history of chronic low back pain presents to the emergency department with a 12-hour history of new-onset bilateral leg weakness, numbness in her perineal area, and urinary retention. She required catheterization for 600 mL of urine. On examination, she has 3/5 strength in her lower extremities bilaterally, decreased sensation in a 'saddle' distribution, and diminished anal sphincter tone.
Which of the following is the most appropriate next step in management?
Explanation: This patient's presentation of saddle anesthesia, bilateral lower extremity weakness, and bowel/bladder dysfunction is classic for cauda equina syndrome, a neurosurgical emergency. The most critical next step is to obtain an emergent MRI of the lumbosacral spine to confirm the diagnosis and identify the level of compression, which will guide immediate surgical decompression. Delay in diagnosis and treatment can lead to permanent neurologic deficits.
A 45-year-old man is rescued from a collapsed building 4 hours after an earthquake. His lower extremities were crushed by debris. In the emergency department, he is found to have extensive bruising and swelling of both legs. His blood pressure is 90/60 mm Hg and heart rate is 120/min. A urine sample is dark brown and tests strongly positive for heme, but microscopy shows no red blood cells. His serum creatine kinase is markedly elevated.
Which of the following is the most important initial intervention to prevent acute kidney injury in this patient?
Explanation: This patient has rhabdomyolysis secondary to a crush injury. The breakdown of skeletal muscle releases myoglobin, which is nephrotoxic and can cause acute tubular necrosis, leading to acute kidney injury. The cornerstone of management is early and aggressive intravenous fluid resuscitation to maintain renal perfusion and flush out the myoglobin casts from the renal tubules. While therapies like sodium bicarbonate are sometimes used, fluid resuscitation is the most critical first step.
An 82-year-old woman with a history of severe osteoporosis presents with the sudden onset of intense, localized mid-back pain after she sneezed forcefully. The pain is sharp and worse with movement. There is no history of trauma, fever, or weight loss. On examination, there is exquisite point tenderness over the T10 spinous process. Her neurologic examination, including strength, sensation, and reflexes, is completely normal.
Which of the following is the most likely diagnosis?
Explanation: The acute onset of severe, localized back pain after a minimal trauma event (like sneezing or coughing) in an elderly patient with osteoporosis is the classic presentation of a vertebral compression fracture. The localized point tenderness over the affected vertebra is a key physical finding. The absence of neurologic deficits makes other causes like a large disc herniation or severe stenosis less likely.
A 60-year-old woman with peripheral vascular disease and diabetes mellitus presents with a rapidly progressing infection of her left lower leg. The area is erythematous, warm, and swollen, with several dark, violaceous bullae. She complains of pain that she rates as '12 out of 10,' which seems disproportionate to the physical findings. She is tachycardic, hypotensive, and febrile. Palpation of the area reveals crepitus.
Which of the following is the most important next step in management?
Explanation: This patient's presentation, with pain out of proportion, rapidly progressing cellulitis, bullae, systemic signs of toxicity (sepsis), and crepitus (suggesting gas-producing organisms), is highly suggestive of necrotizing fasciitis. This is a life-threatening surgical emergency. While broad-spectrum antibiotics are crucial and should be started immediately, the definitive and most critical step is emergent surgical debridement of all necrotic tissue. Delaying surgery for imaging or culture results significantly increases mortality.
A 35-year-old construction worker is brought to the emergency department 6 hours after a severe crush injury to his right lower leg. A cast was placed for a closed tibial fracture. He now complains of severe, escalating pain that is not relieved by intravenous morphine. On examination, the leg is extremely tense and swollen. He reports numbness in his foot, and pain is elicited with passive dorsiflexion of his toes. His dorsalis pedis pulse is palpable via Doppler.
Which of the following is the most appropriate next step in management?
Explanation: This patient has classic signs and symptoms of acute compartment syndrome: pain out of proportion to the injury, pain with passive stretch, paresthesias, and a tense compartment. The presence of a pulse does not rule out this diagnosis. The immediate first step is to relieve all external pressure, which includes bivalving (cutting) the cast and any underlying padding down to the skin. The definitive diagnosis is then confirmed by measuring intracompartmental pressures. If pressures are elevated (typically >30 mmHg or a delta pressure <30 mmHg), an emergent fasciotomy is required.
A 70-year-old man with a known history of metastatic lung cancer presents to the emergency department with a 2-week history of worsening thoracic back pain. The pain is constant, dull, and is not relieved by rest; in fact, it is often worse at night. Over the last 24 hours, he has developed difficulty walking due to leg weakness and has had one episode of urinary incontinence. An emergent MRI is ordered.
While awaiting the MRI results, which of the following interventions should be administered immediately?
Explanation: This patient's presentation is highly concerning for metastatic spinal cord compression, a neurologic emergency. The combination of cancer history, worsening back pain (especially at night), and new neurologic deficits (weakness, incontinence) warrants immediate action. High-dose intravenous corticosteroids (e.g., dexamethasone) should be administered immediately, even before definitive imaging is completed, to reduce vasogenic edema around the spinal cord and potentially alleviate cord compression, preserving neurologic function.
A 24-year-old woman presents after twisting her ankle while hiking. She reports immediate pain and swelling over the lateral aspect of her ankle. She was able to walk off the trail with assistance. In the clinic, she is able to bear weight and take six steps, albeit with a limp. There is no bony tenderness to palpation over the distal 6 cm of the posterior edge of the fibula or tibia, the base of the fifth metatarsal, or the navicular bone.
Based on this presentation, which of the following is the most appropriate next step?
Explanation: This patient's presentation meets the criteria for low risk according to the Ottawa ankle rules, which are used to determine the need for radiography in acute ankle injuries. The rules state that imaging is not required if there is no bony tenderness in the specified malleolar or midfoot zones AND the patient is able to bear weight (take 4 steps) both immediately after the injury and in the emergency department/clinic. Since she meets these criteria, radiographs are unnecessary, and conservative management for a likely ankle sprain is appropriate.
A 68-year-old woman with a 50-pack-year smoking history presents with a 3-month history of worsening low back pain. She reports a 15-lb unintentional weight loss over the same period. The pain is dull, constant, and frequently awakens her at night. It is not relieved by rest. On examination, there is tenderness to percussion over the L4 vertebra. Her neurologic examination is normal.
Given the 'red flag' symptoms in this patient, which of the following is the most appropriate initial step in her evaluation?
Explanation: This patient presents with multiple 'red flags' for a serious underlying cause of back pain, such as malignancy or infection. These flags include age >50, significant smoking history (risk factor for lung cancer with potential spinal metastases), unintentional weight loss, and night pain not relieved by rest. In a patient with red flags but no neurologic deficits, the appropriate initial workup includes plain radiographs to look for obvious bony lesions and inflammatory markers (ESR, CRP) to screen for an inflammatory or infectious process. While plain films may be normal early in metastatic disease, they are the appropriate initial imaging. An emergent MRI is reserved for patients with suspected cauda equina syndrome, spinal cord compression, or when initial workup suggests malignancy.
A 40-year-old mechanic was cleaning a grease gun when it accidentally discharged into the tip of his left index finger. He presents to the emergency department 30 minutes later. There is a small, 2-mm puncture wound on the volar pad of the finger. He has minimal pain and the finger has a normal appearance with only slight swelling. He has full range of motion.
Despite the benign initial appearance, which of the following is the most appropriate management for this injury?
Explanation: High-pressure injection injuries are surgical emergencies. The injected material can travel far along fascial planes and tendon sheaths, causing extensive tissue damage, ischemia, and inflammation, which may not be apparent on initial examination. The seemingly benign entry wound belies the severe internal injury. Urgent surgical exploration, debridement of foreign material and necrotic tissue, and broad-spectrum antibiotics are required to prevent devastating complications such as compartment syndrome, infection, and amputation.
A 38-year-old man presents with a painful and swollen left middle finger. He notes that he sustained a small cut on the finger while washing dishes two days ago. On examination, the finger is held in a slightly flexed position. There is uniform, fusiform swelling of the entire finger, tenderness along the course of the flexor tendon sheath, and severe pain with passive extension of the finger.
Which of the following is the most appropriate management for this patient?
Explanation: This patient's presentation demonstrates Kanavel's cardinal signs of infectious flexor tenosynovitis: 1) fusiform swelling, 2) finger held in slight flexion, 3) tenderness along the flexor tendon sheath, and 4) pain with passive extension. This condition is an orthopedic emergency because the infection is in a closed space and can rapidly lead to tendon necrosis and loss of function. Management requires emergent surgical incision and drainage along with broad-spectrum intravenous antibiotics.
A 22-year-old man presents to the emergency department after falling onto his outstretched right hand during a skateboarding accident. He complains of pain at the base of his thumb. On examination, there is tenderness to palpation in the anatomic snuffbox. There is no visible deformity or swelling. A radiograph of the wrist is performed and shows no evidence of a fracture.
Which of the following is the most appropriate next step in management?
Explanation: The patient's presentation with a fall on an outstretched hand and tenderness in the anatomic snuffbox is highly suspicious for a scaphoid fracture, even with negative initial radiographs. Scaphoid fractures are often occult on initial imaging. The standard of care is to treat empirically by immobilizing the wrist with a thumb spica splint to prevent nonunion or avascular necrosis, a significant complication due to the scaphoid's tenuous retrograde blood supply. Follow-up with repeat imaging in 10-14 days is necessary.
A 19-year-old collegiate soccer player planted her foot and twisted her knee during a game. She felt a distinct 'pop' and was unable to continue playing due to pain and instability. Within an hour, her knee became significantly swollen. In the clinic, examination of the knee reveals a large effusion. When the knee is flexed to 30 degrees and the tibia is gently pulled forward, there is significant anterior translation without a firm endpoint.
This physical examination finding is most consistent with an injury to which of the following structures?
Explanation: The clinical scenario describes a classic mechanism for an anterior cruciate ligament (ACL) tear: a non-contact, pivoting injury associated with a 'pop,' rapid hemarthrosis (swelling), and instability. The described physical examination finding is a positive Lachman test, which is the most sensitive test for an ACL tear. It assesses for anterior translation of the tibia relative to the femur.
A 44-year-old man is playing a game of pickup basketball when he pushes off for a rebound and feels a sudden, sharp pain in the back of his left ankle. He states it felt as if someone had kicked him, but no one was nearby. He is now unable to push off with his left foot. On examination, there is a palpable defect in the posterior ankle above the calcaneus. When the patient's calf muscle is squeezed, there is no plantarflexion of the foot.
This physical examination finding is pathognomonic for which of the following injuries?
Explanation: The clinical presentation and physical examination findings are classic for an Achilles tendon rupture. The described maneuver, squeezing the calf muscle to elicit plantarflexion, is the Thompson test. An absence of plantarflexion during this test indicates a complete rupture of the Achilles tendon.
A 21-year-old rugby player sustained a blow to his shoulder and is brought to the sideline for evaluation. He is holding his right arm in slight abduction and external rotation and is unable to move it. The shoulder appears 'squared off' with a prominent acromion. After reduction of the shoulder dislocation is performed, the patient is unable to abduct his arm and has decreased sensation over the lateral deltoid area.
The patient's post-reduction findings are most likely due to an injury to which of the following nerves?
Explanation: The most common type of shoulder dislocation is anterior, which can stretch or damage the axillary nerve as it wraps around the surgical neck of the humerus. Axillary nerve injury results in paralysis of the deltoid muscle (inability to abduct the arm) and teres minor, as well as loss of sensation over the lateral shoulder, an area known as the 'regimental badge' area.
A 62-year-old man with a history of intravenous drug use and type 2 diabetes presents with a 3-day history of fever, chills, and severe, focal mid-thoracic back pain. Today, he developed progressive bilateral leg weakness and is now unable to stand. On examination, he has a temperature of 39.0°C (102.2°F), tenderness to percussion over the T6-T8 spinous processes, and 2/5 strength in his lower extremities with decreased sensation below the umbilicus.
Which of the following is the most likely diagnosis?
Explanation: The classic triad for spinal epidural abscess is fever, focal back pain, and progressive neurologic deficits. This patient has all three, along with significant risk factors (IV drug use, diabetes). The rapid progression to severe weakness indicates compression of the spinal cord, making this a neurosurgical emergency. While vertebral osteomyelitis is often a precursor, the acute neurologic compromise points specifically to an epidural abscess.
A 68-year-old woman presents to the urgent care center after falling onto her outstretched left hand. She has significant pain and swelling at the wrist. On examination, there is a visible dorsal displacement of the distal radius, creating a 'dinner fork' deformity. She is neurovascularly intact distally. Radiographs confirm a dorsally displaced, extra-articular fracture of the distal radius.
Which of the following is the most appropriate initial management in the urgent care setting?
Explanation: This patient has a Colles' fracture, a common injury in older adults. For a displaced fracture, the initial management involves closed reduction to restore alignment, followed by immobilization in a splint. A sugar-tong splint is preferred initially over a circumferential cast to accommodate for swelling. Definitive management may involve casting or surgery, but immediate reduction and splinting is the correct first step.
A 28-year-old motorcyclist presents after a collision. Radiographs reveal a displaced fracture of the mid-shaft of the clavicle. The distal fragment is displaced inferiorly and medially. There is 3 cm of shortening at the fracture site. The patient is neurovascularly intact and there is no tenting of the skin.
Which of the following is the most appropriate management for this patient's fracture?
Explanation: While most mid-shaft clavicle fractures can be managed nonoperatively with a sling, there are specific indications for surgical intervention (open reduction and internal fixation). These include significant displacement, shortening greater than 2 cm, an open fracture, or associated neurovascular injury. This patient's 3 cm of shortening is a clear indication for surgery to restore length, improve functional outcomes, and reduce the risk of nonunion.
A 25-year-old man was the unrestrained driver in a high-speed motor vehicle collision where his knee impacted the dashboard. He presents with severe left hip pain and is unable to move his leg. On examination, his left leg is shortened, adducted, and internally rotated. Radiographs confirm a posterior dislocation of the hip.
Prompt reduction of the hip is critical to reduce the risk of which of the following long-term complications?
Explanation: Posterior hip dislocation is an orthopedic emergency. The dislocation can disrupt the blood supply to the femoral head, primarily from the medial femoral circumflex artery. The risk of avascular necrosis (osteonecrosis) increases significantly if the hip is not reduced within 6 hours of the injury. While post-traumatic osteoarthritis is also a long-term risk, avascular necrosis is the complication most directly related to the duration of dislocation.
A 30-year-old man sustains a closed, displaced fracture of both the tibia and fibula in a soccer match. He is hemodynamically stable, the skin is intact, and there are no signs of compartment syndrome or neurovascular compromise.
Which of the following is considered the standard of care for definitive management of this patient's tibial fracture?
Explanation: For displaced tibial shaft fractures in adults, intramedullary nailing is the treatment of choice. This technique provides stable internal fixation, allowing for early mobilization and weight-bearing, which promotes fracture healing and reduces the risk of complications like nonunion, malunion, and joint stiffness. Long leg casting is typically reserved for non-displaced or minimally displaced fractures. External fixation is generally used for severe open fractures or as a temporary measure.
A 45-year-old man presents with a 2-month history of right knee pain that began after he twisted it while stepping out of his car. He describes a 'catching' and 'locking' sensation in the knee, particularly when he tries to fully extend it. He also reports intermittent swelling. On examination, there is tenderness over the medial joint line. A test involving flexion, internal and external rotation of the tibia on the femur elicits a painful click.
Which of the following diagnostic studies is most appropriate to confirm the suspected diagnosis?
Explanation: The patient's history of a twisting injury followed by mechanical symptoms like locking and catching, along with joint line tenderness and a positive McMurray test (as described), is highly suggestive of a meniscal tear. MRI is the non-invasive imaging modality of choice for diagnosing meniscal and other soft-tissue injuries of the knee. Plain radiographs are typically normal but may be done to rule out fracture or arthritis. Arthrocentesis would be indicated for a large, acute effusion to rule out infection or gout.