2. Trauma MCQs

A 48-year-old male presents with an AO/OTA 41-A3 fracture of the proximal tibia. The fracture is extra-articular, comminuted in the metaphysis, but the articular surface is intact. Soft tissues are amenable to surgery. Which of the following is the most appropriate primary surgical fixation method for this fracture pattern?

During intramedullary nailing of a proximal tibia fracture, the most common and challenging malalignment to prevent is procurvatum (apex anterior angulation). Which of the following biomechanical factors is the primary contributor to this specific deformity?

A surgeon is preparing for intramedullary nailing of a proximal tibia fracture. The image shows an intraoperative fluoroscopic view during guidewire placement. To minimize the risk of procurvatum and anterior knee pain, which entry point and approach is generally preferred for proximal tibia fractures?

During IMN for a proximal tibia fracture, the surgeon notes persistent procurvatum (apex anterior angulation) on the lateral fluoroscopic view, similar to the malalignment seen in the provided image (lateral view). The guidewire is already in place. Which of the following is the most effective intraoperative maneuver to correct this procurvatum before reaming?

A 62-year-old patient undergoes IMN for a proximal tibia fracture. Intraoperatively, despite traction and manual reduction, the AP fluoroscopic view reveals persistent valgus malalignment of the proximal fragment, similar to the malalignment seen in the provided image (AP view). The guidewire is centrally placed in the distal fragment. Which of the following is the most appropriate next step to correct this valgus deformity?

A 55-year-old male sustains a comminuted extra-articular proximal tibia fracture (AO/OTA 41-A3) with a significant medial metaphyseal wall defect. After achieving provisional reduction and inserting an intramedullary nail, the surgeon is concerned about potential valgus collapse and instability. Which adjunctive fixation technique would be most appropriate to enhance stability in this scenario?

A 30-year-old patient undergoes IMN for a proximal tibia fracture. Eighteen months post-surgery, the fracture is fully united, but the patient complains of persistent, debilitating anterior knee pain, especially with kneeling and squatting. Clinical examination reveals tenderness over the superior pole of the patella. Which of the following is the most common reason for secondary surgical intervention in this patient's situation?

A 70-year-old female presents for follow-up 6 months after intramedullary nailing of a proximal tibia fracture. She complains of persistent knee pain and an altered gait. The provided radiographs show the post-operative result. Based on these images, what is the most significant malunion present?

A 40-year-old male undergoes IMN for a stable, extra-articular proximal tibia fracture (AO/OTA 41-A1) with rigid fixation. The soft tissues are healthy, and there are no signs of compartment syndrome. What is the most appropriate initial post-operative weight-bearing protocol for this patient?

A 78-year-old female with a history of osteoporosis (T-score -3.1 at the femoral neck) presents to the emergency department after a mechanical fall from standing height, sustaining a displaced intertrochanteric hip fracture. She has multiple comorbidities including well-controlled hypertension and type 2 diabetes. Pre-operative imaging confirms a comminuted intertrochanteric fracture. The orthopedic surgeon plans for cephalomedullary nailing. During the procedure, after guide wire placement and reaming, the lag screw is inserted. Intraoperative fluoroscopy reveals the following image:

Based on the principles of osteoporotic fracture fixation and the provided image, what is the most critical technical parameter to assess to prevent lag screw cut-out in this patient?

A 65-year-old postmenopausal female with severe osteoporosis (T-score -3.5) sustains a highly comminuted, displaced 4-part proximal humerus fracture after a low-energy fall. She is physiologically active and desires to return to her previous level of function. Pre-operative CT scan reveals significant metaphyseal comminution and a deficient medial calcar. The orthopedic surgeon plans for open reduction and internal fixation (ORIF) with a locking plate. During the procedure, after reduction and plate application, the surgeon notes persistent concern for varus collapse. Which of the following intraoperative strategies is most critical to address this specific concern in osteoporotic bone?

A 70-year-old female undergoes open reduction and internal fixation (ORIF) of a comminuted intertrochanteric hip fracture with a cephalomedullary nail. Post-operatively, she is allowed immediate weight-bearing as tolerated (WBAT). Six months later, she presents with new onset thigh pain and is diagnosed with a periprosthetic fracture distal to the tip of the intramedullary nail. The case describes this as a common complication in osteoporotic bone. What is the most likely mechanism for this complication, and what is the general salvage strategy?

A 60-year-old female with a history of chronic steroid use for rheumatoid arthritis (a risk factor for secondary osteoporosis) presents with a displaced femoral neck fracture. She is otherwise healthy and active. After thorough medical optimization, the orthopedic surgeon is considering surgical options. Based on the principles outlined in the case for osteoporotic fractures, which surgical approach is generally considered the gold standard for this patient?

A 70-year-old female with severe osteoporosis undergoes open reduction and internal fixation (ORIF) of a comminuted proximal humerus fracture with a locking plate. Post-operatively, she is allowed immediate weight-bearing as tolerated (WBAT). The orthopedic surgeon emphasizes the importance of a Fracture Liaison Service (FLS) and secondary fracture prevention. Which of the following statements best describes the rationale for this emphasis?

A 76-year-old male with a history of multiple medical comorbidities, including severe cardiac disease and chronic kidney disease, sustains a displaced intertrochanteric hip fracture. He is deemed an ASA IV patient. The orthopedic team is discussing the timing of surgery. Based on the AAOS Clinical Practice Guidelines mentioned in the case, what is the recommended timeframe for surgical intervention for this patient?

A 42-year-old male sustains a proximal third diaphyseal tibia fracture. During intramedullary nailing, the surgeon plans to use blocking (Poller) screws to prevent the most common postoperative malalignments (procurvatum and valgus). In the proximal fragment, where should the blocking screws be placed relative to the intramedullary nail?

When optimizing screw purchase in an osteoporotic tibia fracture, which of the following screw design modifications provides the greatest increase in pullout strength?

A 55-year-old male sustains a severe bicondylar tibial plateau fracture (Schatzker VI) with a large displaced posteromedial fragment. Biomechanically, which of the following is the most appropriate fixation strategy for the posteromedial fragment to prevent coronal plane instability?

During the intramedullary nailing of a proximal tibia fracture, the surgeon elects to use a suprapatellar approach in a semi-extended position. Compared to an infrapatellar approach in hyper-flexion, what is the primary mechanical advantage of the semi-extended position?