INI-CET 2026 Practice Questions

Q: A 60-year-old man with treated TB 1 year ago presents with low back pain. MRI spine shows a lesion. What is the most appropriate next investigation?

Mantoux test. ***Mantoux test*** - In a patient with a history of treated tuberculosis presenting with a new spinal lesion, reactivation or reinfection must be considered, and the **Mantoux test** (or Tuberculin Skin Test) helps assess the patient's immune response to Mycobacterium tuberculosis. - While the Mantoux test helps guide the clinical suspicion, a **positive test** in a previously treated patient requires careful clinical correlation to distinguish between old immunity and active disease. *CECT spine* - A **CECT spine** generally provides less soft-tissue resolution compared to an MRI, which has already been performed in this case. - Further imaging with contrast is usually focused on the extent of the disease or planning for intervention rather than the primary next diagnostic step in this context. *CT chest* - While **CT chest** may show old healed TB foci or reactivation, it is not the next most appropriate step to characterize the specific spinal lesion presenting as back pain. - It is a secondary investigation to rule out pulmonary involvement but does not directly diagnose the spinal pathology. *Biopsy* - Although **histopathology** via biopsy is the gold standard for a definitive diagnosis of Pott's spine or suspected malignancy, it is an invasive procedure generally reserved for cases where prior non-invasive testing or clinical suspicion remains unresolved. - In the initial diagnostic workup for a suspected tuberculous spinal lesion, less invasive investigations are prioritized before proceeding to surgical intervention.

Q: A 30-year-old female post-RTA has persistent pain uncontrolled by analgesics. Compartment pressure is 90 mmHg with absent pulse. What is the treatment?

Emergency fasciotomy. ***Emergency fasciotomy*** - This patient presents with hallmark signs of **acute compartment syndrome**, specifically a pressure of 90 mmHg (normal is <10-15 mmHg) and absent pulses indicating **vascular compromise**. - **Emergency fasciotomy** is the definitive and limb-saving treatment to release the internal pressure and restore **tissue perfusion**. *Observation* - Observation is dangerous and inappropriate given the clinical evidence of **ischemia** and elevated compartment pressures. - Delaying surgical intervention significantly increases the risk of permanent **neuromuscular damage** and **rhabdomyolysis**. *Increase IV analgesics* - Increasing analgesia masks the symptoms without addressing the underlying **pathophysiology** of the increased **intra-compartmental pressure**. - Pain out of proportion to the injury is a classic sign of compartment syndrome that mandates surgical decompression, not sedation. *External fixation* - While external fixation is used to stabilize fractures, it does not relieve the **intramuscular pressure** causing the compartment syndrome. - Relying on stabilization rather than decompression leads to irreversible ischemic contractures such as **Volkmann's contracture**.

Q: In femoral neck fracture management using Garden classification, which treatment is indicated for an elderly patient?

Hemiarthroplasty. ***Hemiarthroplasty*** - In elderly patients with displaced femoral neck fractures, Hemiarthroplasty is the preferred treatment as it lowers the risk of non-union and avascular necrosis compared to internal fixation. - This procedure provides immediate stability and early mobilization, reducing the complications associated with prolonged bed rest in geriatric populations. *Cannulated screws* - These are typically reserved for **nondisplaced** femoral neck fractures (Garden I and II) or in younger patient populations where preserving the femoral head is a priority. - Using screws in elderly patients with displaced fractures carries a high risk of **fixation failure** and the need for reoperation. *Total hip replacement (THR)* - While THR can be used for displaced femoral neck fractures, it is generally reserved for active, physiologically younger, or high-functioning elderly individuals with intact acetabular cartilage. - It is a more extensive surgery than hemiarthroplasty and carries a slightly higher risk of **dislocation**, though it offers better long-term functional outcomes. *Conservative management* - This approach is almost exclusively reserved for patients who are medically unfit for surgery due to severe comorbidities or extremely limited baseline mobility. - It generally leads to poor outcomes, including significant pain, loss of independence, and high rates of **complications related to immobility** like pneumonia and deep vein thrombosis.

Q: A proximal humerus fracture is classified using Neer's classification. Which surgical option is most appropriate for a 4-part fracture in a young patient?

Humerus plating. ***Humerus plating*** - In **young patients** with a **4-part proximal humerus fracture**, the goal is **joint preservation** and anatomical restoration of the humeral head. - **Open Reduction Internal Fixation (ORIF)** using a **locking plate** provides stable fixation, allowing for early rehabilitation while avoiding the long-term complications of arthroplasty. *Humerus nailing* - **Intramedullary nailing** is generally reserved for **2-part surgical neck fractures** or certain proximal shaft fractures. - It is often unsuitable for **4-part fractures** because it provides poor purchase in the fragmented humeral head and complicates reduction of the tuberosities. *Hanging cast/K-wires* - A **hanging cast** is a conservative management technique typically used for **diaphyseal humeral shaft fractures**, not intra-articular proximal fractures. - **K-wire fixation** generally lacks the **mechanical stability** required to maintain a complex 4-part fracture pattern during the healing process. *Shoulder hemiarthroplasty* - This is typically reserved for **elderly patients** with low functional demand or where the **vascularity of the humeral head** is severely compromised resulting in a high risk of avascular necrosis. - In a **young patient**, hemiarthroplasty is considered a salvage procedure due to limited longevity and the potential for **glenoid erosion** over time.

Q: A child presents with a Gower sign. What does this finding indicate?

Proximal muscle weakness. ***Proximal muscle weakness*** - The **Gowers sign** is a classic clinical finding where a child must use their hands and arms to 'walk' up their own body to transition from a seated or squatting position to a standing one. - It indicates significant weakness of the **proximal hip and thigh muscles**, typically associated with conditions like **Duchenne muscular dystrophy**. *Sensory neuropathy* - While sensory neuropathies can cause gait disturbances or balance issues, they do not cause the structural weakness of proximal muscles required for the **Gowers maneuver**. - Symptoms typically include **numbness**, **tingling**, or **sensory loss** in a stocking-glove distribution rather than motor weakness. *Joint laxity* - Joint laxity often relates to connective tissue disorders like **Ehlers-Danlos syndrome** and typically results in joint instability or hypermobility. - Patients with laxity do not exhibit the specific compensatory motor pattern seen in **Gowers sign** unless there is a concurrent myopathy. *Distal muscle weakness* - Distal muscle weakness often manifests as **foot drop** or difficulty with fine motor tasks, rather than core and thigh strength deficits. - Conditions affecting distal muscles, such as **Charcot-Marie-Tooth disease**, typically present with atrophy of the lower legs rather than the proximal compensatory movements seen here.

Q: A 2-year-old child with a history of old knee injury now has varus deformity of the left knee. Deformity persists on flexion; blood report is normal. X-ray shows unilateral genu varum and angulated tibia. What is the diagnosis?

Malunion of tibial fracture. ### ***Malunion of tibial fracture*** - The history of an **old knee injury** combined with a fixed **varus deformity** that persists on flexion is classic for malunion following a previous tibial fracture in a young child. - The X-ray finding of an **angulated tibia** in a unilateral distribution supports the diagnosis of a sequela from trauma rather than a developmental or metabolic bone disorder. *Osteofibrous dysplasia* - This typically presents as a **lytic lesion** located specifically in the **diaphysis** of the tibia rather than being a post-traumatic angular deformity. - It is a benign fibro-osseous lesion that generally evolves slowly and is not caused by a history of acute trauma. *Rickets* - This condition is consistently associated with **abnormal blood biochemistry**, specifically hypocalcemia, hypophosphatemia, or elevated alkaline phosphatase levels, which are absent here. - Rickets typically presents with **bilateral** genu varum and symmetric bowing, rather than a unilateral deformity following injury. *Focal fibrocartilaginous dysplasia* - This is a rare, self-limiting cause of unilateral infantile tibia vara that typically presents with a **characteristic metaphyseal lucency**. - It is a developmental condition rather than a post-traumatic one, and the history here strongly emphasizes a prior injury as the etiology.

Q: A young patient presents with recurrent fever and constitutional symptoms. Evaluation reveals a mediastinal mass and biopsy confirms lymphoma. In the staging system, 'X' is mentioned. What does 'X' denote?

Bulky or large tumor mass. ***Bulky or large tumor mass*** - In the Ann Arbor staging system for lymphoma, the suffix **'X'** is utilized to denote a **bulky disease**. - This is defined as a mass greater than **10 cm** in maximum dimension or a mass that occupies more than one-third of the **transthoracic diameter** on a chest radiograph. *Extranodal spread of disease* - The suffix **'E'** is used to designate **extranodal involvement**, indicating localized extralymphatic tissue disease adjacent to a known lymph node site. - This does not refer to the size of the tumor mass, but rather the anatomical location of the disease process. *Presence of systemic symptoms* - The suffixes **'A'** (absence) and **'B'** (presence) are used to indicate the status of **systemic symptoms** like fever, night sweats, and significant weight loss. - These are known as **'B' symptoms** and are crucial for prognosis, but they do not relate to the anatomical size of the tumor. *Tumor present on both sides of the diaphragm* - This finding is represented by the stage **Stage III** designation in the Ann Arbor classification. - It describes the **anatomic extent** of the disease geographically rather than the specific tumor burden or bulk.

Q: In which type of constipation are stimulant laxatives contraindicated or should be avoided?

Spastic constipation. ***Spastic constipation*** - In this condition, the bowel hyperactivates causing **painful spasms** and cramping; therefore, **stimulant laxatives** are contraindicated as they increase peristalsis and worsen the spasm. - Management typically involves **antispasmodics** and dietary adjustments rather than motility-enhancing agents. *Habitual constipation* - This type results from poor dietary habits and ignoring the urge to defecate, often requiring **lifestyle modifications** such as increased fiber and fluid intake. - Mild stimulant laxatives may sometimes be used as a last resort, but they are not the primary treatment of choice. *Atonic constipation* - This presents with a **hypotonic colon** characterized by sluggish motility, where stimulant laxatives can be beneficial to promote movement. - It is often associated with aging, chronic laxative abuse, or neurological disorders where the bowel lacks the tone to propel contents. *Post-operative constipation* - Often caused by **anesthesia** or **post-surgical ileus**, which requires careful management of intestinal motility. - While caution is advised to prevent bowel perforation, stimulant laxatives are sometimes cautiously used if there is no evidence of obstruction.

Q: A 40-year-old female with progressive left flank pain, no mass or fever. What is the next best step?

Ultrasound followed by non-contrast CT. ***Ultrasound followed by non-contrast CT*** - In a non-pregnant patient with classic symptoms of suspected **urolithiasis** (flank pain without systemic signs of infection), initial imaging often involves low-dose **non-contrast CT (NCCT)** of the abdomen and pelvis as the study of choice, - However, to minimize radiation exposure in appropriate clinical settings, an initial **ultrasound** can identify hydronephrosis; if the diagnosis remains uncertain or if complications are suspected, a **non-contrast CT** remains the gold standard to pinpoint stone size and location. *CECT followed by MRI* - **Contrast-enhanced CT (CECT)** is not typically indicated as the first step for suspected kidney stones because intravenous contrast can obscure small stones on the scan. - **MRI** is generally reserved for special populations like pregnant patients or those where radiation must be strictly avoided, and it is not the primary diagnostic tool for stone detection. *Contrast-enhanced CT abdomen* - **Intravenous contrast** is not required to diagnose nephrolithiasis and may actually make stones harder to visualize, as iodine density can mimic stone high-density appearance. - This study is more appropriate if one is ruling out vascular abnormalities, complex masses, or bowel pathology, rather than evaluating for uncomplicated flank pain. *Non-contrast CT followed by contrast CT* - An initial **non-contrast CT** is sufficient to diagnose most cases of nephrolithiasis; performing a follow-up **contrast CT** exposes the patient to unnecessary, excessive radiation and contrast-related risks. - **Contrast enhancement** should only be added if there is a suspicion of alternative pathologies (like complex cysts, tumors, or renal infarction) after the initial NCCT results are reviewed.

Question 1

A 60-year-old man with treated TB 1 year ago presents with low back
pain. MRI spine shows a lesion. What is the most appropriate next
investigation?

Accepted Answer

Mantoux test

Answer

CECT spine

Answer

CT chest

Answer

Biopsy

Question 2

A 30-year-old female post-RTA has persistent pain uncontrolled by analgesics. Compartment
pressure is 90 mmHg with absent pulse. What is the treatment?

Accepted Answer

Emergency fasciotomy

Answer

Observation

Answer

Increase IV analgesics

Answer

External fixation

Question 3

In femoral neck fracture management using Garden classification, which treatment is indicated
for an elderly patient?

Accepted Answer

Hemiarthroplasty

Answer

Cannulated screws

Answer

Total hip replacement (THR)

Answer

Conservative management

Question 4

A proximal humerus fracture is classified using Neer's classification. Which surgical option is
most appropriate for a 4-part fracture in a young patient?

Accepted Answer

Humerus plating

Answer

Humerus nailing

Answer

Hanging cast/K-wires

Answer

Shoulder hemiarthroplasty

Question 5

A child presents with a Gower sign. What does this finding indicate?

Accepted Answer

Proximal muscle weakness

Answer

Sensory neuropathy

Answer

Joint laxity

Answer

Distal muscle weakness

Question 6

A 2-year-old child with a history of old knee injury now has varus deformity of the left knee.
Deformity persists on flexion; blood report is normal. X-ray shows unilateral genu varum and
angulated tibia. What is the diagnosis?

Accepted Answer

Malunion of tibial fracture

Answer

Osteofibrous dysplasia

Answer

Rickets

Answer

Focal fibrocartilaginous dysplasia

Question 7

A young patient presents with recurrent fever and constitutional symptoms. Evaluation reveals a
mediastinal mass and biopsy confirms lymphoma. In the staging system, 'X' is mentioned. What
does 'X' denote?

Accepted Answer

Bulky or large tumor mass

Answer

Extranodal spread of disease

Answer

Presence of systemic symptoms

Answer

Tumor present on both sides of the diaphragm

Question 8

In which type of constipation are stimulant laxatives contraindicated or should be avoided?

Accepted Answer

Spastic constipation

Answer

Habitual constipation

Answer

Atonic constipation

Answer

Post-operative constipation

Question 9

A 40-year-old female with progressive left flank pain, no mass or fever. What is the next best
step?

Accepted Answer

Ultrasound followed by non-contrast CT

Answer

CECT followed by MRI

Answer

Contrast-enhanced CT abdomen

Answer

Non-contrast CT followed by contrast CT

Question 10

Assertion (A): In a patient with scrotal swelling, examination of the superficial inguinal lymph
nodes should always be performed. Reason (R): Most lymphatic drainage from scrotal skin goes to
the superficial inguinal lymph nodes. Choose the correct option:

Accepted Answer

Both A and R are true, and R is the correct explanation of A

Answer

Both A and R are true, but R is not the correct explanation of A

Answer

A is true, but R is false

Answer

A is false, but R is true

INI-CET 2026

Orthopaedics

Surgery