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2. Trauma MCQs

Practice Set 84 of 640

This practice set contains high-yield board review questions covering key concepts in 2. Trauma. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1661

Topic: 2. Trauma

Following the decision to proceed with flexible intramedullary nailing for the 7-year-old girl's femur fracture, you measure the preoperative x-ray at the isthmus, finding it to be 7.5 mm. The goal for flexible intramedullary nail fixation is to achieve approximately 80% canal fill. Given this information, which combination of nails would be most appropriate?

. Two 2.5-mm nails, 67% canal fill
. Two 3-mm nails, 80% canal fill
. One 3.0-mm nail and one 3.5-mm nail, 87% canal fill
. Two 3.5-mm nails, 93% canal fill
. One 2.5-mm nail and one 3.0-mm nail, 73% canal fill

Correct Answer & Explanation

. Two 3-mm nails, 80% canal fill

Explanation

Correct Answer: Two 3-mm nails, 80% canal fillThe goal for flexible intramedullary nail fixation of a pediatric femur fracture is to achieve approximately 80% canal fill at the narrowest point (isthmus) to provide adequate stability without overstuffing the canal. The patient's isthmus measures 7.5 mm.Two 2.5-mm nails:The combined diameter would be 5.0 mm. (5.0 / 7.5) * 100% = 66.7% canal fill. This is less than the ideal 80% and could lead to inadequate fixation and risk of failure.Two 3-mm nails:The combined diameter would be 6.0 mm. (6.0 / 7.5) * 100% = 80% canal fill. This perfectly meets the target canal fill and provides optimal stability.One 3.0-mm nail and one 3.5-mm nail:The combined diameter would be 6.5 mm. (6.5 / 7.5) * 100% = 86.7% canal fill. While close to 80%, using two nails of different sizes can contribute to loss of reduction and malalignment. Additionally, exceeding 80% fill can increase the risk of complications.Two 3.5-mm nails:The combined diameter would be 7.0 mm. (7.0 / 7.5) * 100% = 93.3% canal fill. This significantly exceeds the 80% target, increasing the risk of iatrogenic fracture, malalignment, and other complications due to overstuffing the canal.One 2.5-mm nail and one 3.0-mm nail:The combined diameter would be 5.5 mm. (5.5 / 7.5) * 100% = 73.3% canal fill. This is below the ideal 80% and also involves nails of different sizes, which is generally less desirable.

Question 1662

Topic: 2. Trauma

When discussing the potential complications of flexible intramedullary nailing for a pediatric femur fracture with the parents, which of the following is the most common complication you should inform them about?

. Infection
. Bleeding
. Pain at the knee (insertion sites)
. Loss of reduction
. Nonunion

Correct Answer & Explanation

. Pain at the knee (insertion sites)

Explanation

Correct Answer: Pain at the knee (insertion sites)Flexible intramedullary nailing is a generally safe and effective procedure for pediatric femur fractures. While all surgical procedures carry risks, studies have shown relatively low rates of serious complications such as infection, significant bleeding, and loss of reduction (especially with length-stable fractures). The most common complication associated with flexible intramedullary nails is irritation of the soft tissues at the nail insertion sites, typically around the knee. This irritation can cause pain and discomfort, often necessitating hardware removal once the fracture has healed. To mitigate this, it is suggested that the nail ends be left no more than 25 mm out of the bone.Infection:While a risk with any surgery, infection rates for flexible nailing are low.Bleeding:Significant bleeding requiring transfusion is uncommon with this procedure.Loss of reduction:With proper nail sizing and technique for length-stable fractures, loss of reduction is infrequent.Nonunion:Nonunion is a rare complication in pediatric femur fractures, especially with appropriate fixation.

Question 1663

Topic: 2. Trauma

When discussing the general complications of femur fractures in children with the family preoperatively, what information should you provide regarding the amount of overgrowth that may occur in a 7-year-old?

. There is no risk of overgrowth at this age; overgrowth only happens in children under 2.
. Ipsilateral overgrowth does occur, with an average of less than 5 mm.
. Ipsilateral overgrowth does occur, usually around 9 mm in 2 to 10-year-olds.
. Ipsilateral overgrowth does occur, usually between 15 and 20 mm in 2 to 10-year-olds.
. Overgrowth is a risk in children over 10, not in those younger than 10.

Correct Answer & Explanation

. Ipsilateral overgrowth does occur, usually around 9 mm in 2 to 10-year-olds.

Explanation

Correct Answer: Ipsilateral overgrowth does occur, usually around 9 mm in 2 to 10-year-olds.Femur fractures in children, particularly in the 2 to 10-year age range, are known to stimulate growth, leading to ipsilateral limb overgrowth. This phenomenon is thought to be related to hyperemia following the injury. While the range of overgrowth can vary (approximately 4 to 25 mm), the average amount of overgrowth observed in this age group is around 9 mm.There is no risk of overgrowth at this age; overgrowth only happens in children under 2:This is incorrect. Children under 2 years and those over 10 years are less likely to experience significant overgrowth compared to the 2-10 year age group.Ipsilateral overgrowth does occur, with an average of less than 5 mm:This underestimates the typical average overgrowth in this age group.Ipsilateral overgrowth does occur, usually between 15 and 20 mm in 2 to 10-year-olds:This overestimates the typical average overgrowth, although overgrowth within this range can occur in some cases.Overgrowth is a risk in children over 10, not in those younger than 10:This is incorrect. Children over 10 are less prone to significant overgrowth, while the 2-10 year age group is most susceptible.

Question 1664

Topic: 2. Trauma

A 14-year-old boy presents to the ER with acute right knee pain after a basketball injury. Radiographs and a CT scan are performed, with the CT scan shown below.

What condition is thought to be a significant risk factor for this type of fracture?

. Patellofemoral syndrome
. Osgood–Schlatter disease
. Sinding-Larsen–Johansson syndrome
. Patellar tendonitis
. Chondromalacia patellae

Correct Answer & Explanation

. Osgood–Schlatter disease

Explanation

Correct Answer: Osgood–Schlatter diseaseTibial tubercle fractures, as depicted in the image, occur more commonly in adolescents who have a history of Osgood–Schlatter disease. Osgood–Schlatter disease is an overuse injury characterized by repetitive strain across the tibial tubercle apophysis, leading to inflammation and microtrauma. While a direct causal relationship is not always demonstrated, the weakened apophysis in Osgood–Schlatter patients makes them more susceptible to avulsion fractures of the tibial tubercle.Patellofemoral syndrome:This condition involves anterior knee pain associated with overuse but is not specifically linked to an increased risk of tibial tubercle fractures.Sinding-Larsen–Johansson syndrome:Similar to Osgood–Schlatter, this is an overuse injury, but it affects the inferior pole of the patella, not the tibial tubercle, and therefore is not associated with tibial tubercle fractures.Patellar tendonitis:This is inflammation of the patellar tendon, which can cause pain but is not a known risk factor for avulsion fractures of the tibial tubercle itself.Chondromalacia patellae:This refers to softening and breakdown of the cartilage on the underside of the patella and is not a risk factor for tibial tubercle fractures.

Question 1665

Topic: 2. Trauma

A 14-year-old boy sustains a tibial tubercle fracture. You are concerned about the risk of compartment syndrome. Which compartment and associated vessel are most commonly at risk with this injury?

. Anterior compartment—medial inferior geniculate artery
. Anterior compartment—recurrent anterior tibial artery
. Anterior compartment—anterior tibial artery
. Lateral compartment—recurrent anterior tibial artery
. Lateral compartment—fibular artery

Correct Answer & Explanation

. Anterior compartment—recurrent anterior tibial artery

Explanation

Correct Answer: Anterior compartment—recurrent anterior tibial arteryTibial tubercle fractures, particularly displaced ones, carry a significant risk of developing compartment syndrome. Anatomical studies and clinical experience have shown that the anterior compartment is most commonly affected. The recurrent anterior tibial artery, which courses near the tibial tubercle, is particularly vulnerable to injury or compression in the setting of this fracture, contributing to the risk of anterior compartment syndrome. Therefore, close monitoring of the neurovascular status of the anterior compartment is crucial in the perioperative period, and many surgeons will perform a prophylactic anterior compartment fasciotomy during surgery.Anterior compartment—medial inferior geniculate artery:The medial inferior geniculate artery supplies the knee joint and surrounding structures but is not the primary vessel at risk for compartment syndrome in the anterior compartment with this specific fracture.Anterior compartment—anterior tibial artery:While the anterior tibial artery is the main artery of the anterior compartment, the recurrent anterior tibial artery is more directly implicated in the immediate vicinity of the tibial tubercle fracture.Lateral compartment—recurrent anterior tibial artery:The recurrent anterior tibial artery is associated with the anterior compartment, not the lateral compartment.Lateral compartment—fibular artery:The fibular artery (also known as the peroneal artery) supplies the lateral and posterior compartments but is not typically at risk with an isolated tibial tubercle fracture.

Question 1666

Topic: 2. Trauma

After attempting a closed reduction for a triplane ankle fracture in a 13-year-old male, you recognize the importance of re-evaluating the fracture alignment. Which of the following is the most appropriate next step in evaluating the reduction quality, especially concerning the articular surface?

. Magnetic resonance imaging (MRI) without contrast of the left ankle
. Magnetic resonance imaging (MRI) with contrast of the left ankle
. Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) of the left ankle
. Computed tomography scan (CT) without contrast of the left ankle
. Computed tomography scan (CT) with contrast of the left ankle

Correct Answer & Explanation

. Computed tomography scan (CT) without contrast of the left ankle

Explanation

Correct Answer: Computed tomography scan (CT) without contrast of the left ankleThe primary goal after reducing a triplane ankle fracture is to assess the anatomical alignment of the articular surface and the physeal gap. While MRI is excellent for soft tissue evaluation (ligaments, tendons, cartilage), CT scanning is considered the gold standard for evaluating bony injury, fracture alignment, and articular congruity, especially in complex fractures like triplane fractures where displacement can be subtle on plain radiographs. A non-contrast CT scan provides sufficient detail for this purpose, and contrast enhancement would not add significant useful information for assessing bony alignment.Magnetic resonance imaging (MRI) without contrast:While it can show bony detail, CT is superior for precise assessment of fracture fragments and articular step-off. MRI is more for soft tissue.Magnetic resonance imaging (MRI) with contrast:Contrast is typically used for evaluating vascularity, tumors, or infection, not primarily for post-reduction bony alignment.Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC):This specialized MRI technique is used to evaluate articular cartilage health and injury, but it is not the immediate post-reduction imaging of choice for assessing fracture alignment.Computed tomography scan (CT) with contrast:Contrast is not necessary for evaluating bony alignment and articular congruity in this setting.

Question 1667

Topic: 2. Trauma

A 12-year-old gymnast falls and sustains an acute posterior elbow dislocation. After closed reduction, a post-reduction radiograph shows the medial epicondyle is missing from its anatomic location and is incarcerated within the joint space. What is the absolute indication for operative intervention in this scenario?

. Displacement greater than 5 mm
. Displacement greater than 2 mm
. Incarceration of the fragment within the joint
. Presence of a concomitant olecranon fracture
. Mild ulnar nerve neuropraxia

Correct Answer & Explanation

. Incarceration of the fragment within the joint

Explanation

Absolute indications for operative fixation of a medial epicondyle fracture include an open fracture or incarceration of the fragment within the joint, which blocks reduction and motion. Millimetric displacement criteria (e.g., >5mm) remain controversial and are considered relative indications.

Question 1668

Topic: 2. Trauma

An 8-year-old boy sustains a midshaft both-bone forearm fracture. Non-operative management with cast immobilization is planned. What is the maximum acceptable angulation for this fracture in this age group to still allow for adequate spontaneous remodeling?

. 5 degrees
. 15 degrees
. 25 degrees
. 35 degrees
. 45 degrees

Correct Answer & Explanation

. 15 degrees

Explanation

In children under 9 years of age with a midshaft both-bone forearm fracture, up to 15-20 degrees of angulation and 45 degrees of malrotation are generally acceptable due to their substantial remodeling potential.

Question 1669

Topic: 2. Trauma

A 10-year-old boy presents with a Seymour fracture of his right middle finger. Which of the following is the most appropriate definitive management?

. Closed reduction and splinting without nail removal
. Nail bed repair, fracture reduction, and oral antibiotics without K-wire fixation
. Nail plate removal, irrigation, nail bed repair, fracture reduction, and potential K-wire fixation
. Immediate terminal sympathoadrenal block and casting
. Amputation of the distal phalanx

Correct Answer & Explanation

. Nail plate removal, irrigation, nail bed repair, fracture reduction, and potential K-wire fixation

Explanation

A Seymour fracture is an open Salter-Harris I or II fracture of the distal phalanx with an associated nail bed laceration and proximal nail plate avulsion. Appropriate management includes nail plate removal, thorough irrigation, nail bed repair, reduction of the fracture, and K-wire stabilization if unstable, along with antibiotics.

Question 1670

Topic: 2. Trauma
A 32-year-old male sustains a high-pressure injection injury to his palm. He presents to the ED 2 hours post-injury. Which of the following interventions is contraindicated in the emergency department?
. Administration of broad-spectrum intravenous antibiotics
. Updating tetanus prophylaxis
. Digital or regional block for pain control
. Obtaining plain radiographs of the hand
. Keeping the patient NPO for immediate surgery

Correct Answer & Explanation

. Digital or regional block for pain control

Explanation

Digital blocks are contraindicated in high-pressure injection injuries because the injected volume and ensuing edema already severely compromise digital perfusion. Adding more fluid into the confined space heavily exacerbates the risk of compartment syndrome and irreversible ischemia.

Question 1671

Topic: 2. Trauma

A 5-year-old sustains a displaced phalangeal neck fracture of the proximal phalanx. Which complication is most frequently associated with failure to anatomically reduce this fracture pattern?

. Extension contracture of the MCP joint
. Loss of PIP joint flexion
. Avascular necrosis of the phalangeal head
. Premature physeal closure
. Symptomatic nonunion

Correct Answer & Explanation

. Loss of PIP joint flexion

Explanation

Displaced phalangeal neck fractures feature a dorsally extended distal condylar fragment. Failure to reduce this obliterates the subcondylar fossa, creating a mechanical block that severely limits PIP joint flexion.

Question 1672

Topic: 2. Trauma

A 34-year-old basketball player sustains a dorsal fracture-dislocation of the PIP joint of his middle finger. Radiographs reveal a volar lip fragment involving 45% of the articular surface. Which surgical treatment is most appropriate?

. Closed reduction and buddy taping
. Extension block pinning alone
. Volar plate arthroplasty or hemi-hamate autograft
. Primary PIP joint arthrodesis
. Dynamic external fixation alone

Correct Answer & Explanation

. Volar plate arthroplasty or hemi-hamate autograft

Explanation

Dorsal fracture-dislocations of the PIP joint with greater than 40-50% articular involvement are inherently unstable. Volar plate arthroplasty or an osteochondral graft (like a hemi-hamate autograft) is required to restore joint stability and congruity.

Question 1673

Topic: 2. Trauma

Which ankle fracture classification system is based on the mechanism of injury and describes predictable patterns of ligamentous and osseous injury?

. Danis-Weber classification
. Gustilo-Anderson classification
. AO classification
. Lauge-Hansen classification
. Salter-Harris classification

Correct Answer & Explanation

. Lauge-Hansen classification

Explanation

Correct Answer: DThe Lauge-Hansen classification system categorizes ankle fractures based on the position of the foot at the time of injury and the deforming force applied. It describes a sequential pattern of injury to ligaments and bones, which can help predict the extent of damage and guide reduction. The Danis-Weber classification is based on the level of the fibular fracture relative to the syndesmosis. The Gustilo-Anderson classification is for open fractures. The AO classification is a comprehensive alphanumeric system for all fractures. The Salter-Harris classification is for physeal injuries in children.

Question 1674

Topic: 2. Trauma

Following the initial diagnosis of a Lisfranc injury in the 49-year-old female, the emergency physician is considering the next steps in management. Beyond immediate analgesia and splinting, which of the following is the MOST critical assessment to perform in the acute setting for this patient?

. A. Detailed assessment of ankle range of motion.
. B. Evaluation for signs of deep vein thrombosis (DVT).
. C. Exclusion of compartment syndrome.
. D. Assessment of hip and knee joint stability.
. E. Measurement of foot arch height.

Correct Answer & Explanation

. C. Exclusion of compartment syndrome.

Explanation

Correct Answer: CThe case specifically highlights the importance of excluding compartment syndrome in the initial management of a Lisfranc injury. The candidate states, 'Compartment syndrome must be excluded.' and 'On admission to hospital I would arrange for regular clinical examinations and monitoring in order not to miss an early developing compartment syndrome.' Lisfranc injuries, especially high-energy mechanisms, are associated with significant soft tissue swelling and can lead to acute compartment syndrome of the foot, which requires emergent surgical decompression to prevent permanent tissue damage.Option A (Detailed assessment of ankle range of motion)is incorrect. While a general examination is important, the immediate priority in a midfoot trauma with significant swelling is to rule out limb-threatening conditions like compartment syndrome.Option B (Evaluation for signs of deep vein thrombosis (DVT))is incorrect. DVT is a potential complication of lower limb immobilization but is not an acute, limb-threatening emergency in the immediate post-injury period like compartment syndrome.Option D (Assessment of hip and knee joint stability)is incorrect. While a thorough trauma assessment includes joints proximal and distal, the most critical acute assessment directly related to the foot injury itself is compartment syndrome.Option E (Measurement of foot arch height)is incorrect. This is a biomechanical assessment that is not acutely critical in the emergency management of a Lisfranc fracture-dislocation.

Question 1675

Topic: 2. Trauma

A 55-year-old active patient presents with a Lisfranc injury. Initial radiographs, including AP, oblique, and lateral views, show a 1.5 mm diastasis between the first and second metatarsal bases, with no obvious fracture or subluxation on static views. Stress radiographs, however, demonstrate a 3 mm increase in this diastasis. The patient is otherwise healthy. Based on the case discussion, what is the MOST appropriate management strategy for this patient?

. A. Non-weightbearing cast for 6 weeks with regular clinical and radiological review.
. B. Immediate open reduction and internal fixation (ORIF) with screws.
. C. Primary arthrodesis of the tarsometatarsal joints.
. D. Non-weightbearing cast for 2 weeks, then progressive weight-bearing.
. E. Physical therapy with early range of motion exercises.

Correct Answer & Explanation

. B. Immediate open reduction and internal fixation (ORIF) with screws.

Explanation

Correct Answer: BThe case states: 'There is a role for non-operative management of an undisplaced stable injury or sprain which includes a non-weightbearing cast for 6 weeks and regular clinical and radiological review. However, in the presence of subluxation or dislocation, accurate reduction and stable fixation is essential.' The 3 mm increase in diastasis on stress views indicates instability, which is equivalent to a subluxation or dislocation, even if not apparent on static views. Therefore, open reduction and internal fixation (ORIF) is required to achieve accurate reduction and stable fixation.Option A (Non-weightbearing cast for 6 weeks with regular clinical and radiological review)is incorrect. This is appropriate only for undisplaced, stable injuries or sprains. The positive stress views indicate instability, making non-operative management inadequate.Option C (Primary arthrodesis of the tarsometatarsal joints)is incorrect. Primary arthrodesis is typically reserved for severely comminuted fractures or chronic instability, not for an acute, reducible unstable injury without severe comminution.Option D (Non-weightbearing cast for 2 weeks, then progressive weight-bearing)is incorrect. This duration is too short for a Lisfranc injury, even for stable sprains, and progressive weight-bearing would be contraindicated in an unstable injury.Option E (Physical therapy with early range of motion exercises)is incorrect. Early range of motion would exacerbate the instability and prevent healing, leading to chronic pain and deformity.

Question 1676

Topic: 2. Trauma

A 62-year-old patient with a history of diabetes and peripheral neuropathy sustains a high-energy Lisfranc injury, resulting in significant comminution of the tarsometatarsal joints and irreducible displacement. The patient is otherwise stable. Based on the treatment principles outlined in the case, what is the MOST appropriate surgical intervention for this specific presentation?

. A. Closed reduction and percutaneous pinning.
. B. Open reduction and internal fixation (ORIF) with screws and plating.
. C. Primary arthrodesis of the tarsometatarsal joints.
. D. External fixation with delayed definitive management.
. E. Non-weightbearing cast immobilization for 12 weeks.

Correct Answer & Explanation

. C. Primary arthrodesis of the tarsometatarsal joints.

Explanation

Correct Answer: CThe case states: 'With a severely comminuted fracture, primary arthrodesis of tarsometatarsal joints may be required.' In cases of severe comminution and irreducible displacement, especially in patients with comorbidities that might affect healing (like diabetes and neuropathy), primary arthrodesis offers a more stable and predictable outcome by fusing the damaged joints, reducing the risk of post-traumatic arthritis and chronic pain associated with joint incongruity.Option A (Closed reduction and percutaneous pinning)is incorrect. This technique is generally reserved for less severe, reducible injuries without significant comminution or displacement.Option B (Open reduction and internal fixation (ORIF) with screws and plating)is incorrect. While ORIF is the standard for most displaced Lisfranc injuries, it may not be feasible or durable in the presence of severe comminution where anatomical reduction and stable fixation of fragments are difficult to achieve. In such cases, primary arthrodesis is often preferred.Option D (External fixation with delayed definitive management)is incorrect. External fixation might be used for temporary stabilization in cases of severe soft tissue injury or open fractures, but it is not the definitive treatment for a severely comminuted, irreducible Lisfranc injury in a stable patient.Option E (Non-weightbearing cast immobilization for 12 weeks)is incorrect. Non-operative management is only for undisplaced, stable injuries. A severely comminuted and irreducible injury requires surgical intervention.

Question 1677

Topic: 2. Trauma

A 49-year-old female presents with a Lisfranc injury after falling down stairs. During her initial hospital stay, she complains of increasing pain in her foot, which is disproportionate to the injury. On examination, her foot is tense, swollen, and she experiences severe pain with passive toe extension. Her dorsalis pedis pulse is palpable but weak. Based on these findings and the case discussion, what is the MOST appropriate immediate action?

. A. Administer additional opioid analgesia and re-evaluate in 4 hours.
. B. Elevate the limb further and apply ice packs.
. C. Obtain urgent compartment pressure measurements.
. D. Order an urgent MRI to assess soft tissue damage.
. E. Consult physical therapy for early mobilization.

Correct Answer & Explanation

. C. Obtain urgent compartment pressure measurements.

Explanation

Correct Answer: CThe patient's symptoms (increasing pain disproportionate to injury, tense/swollen foot, pain with passive toe extension, weak dorsalis pedis pulse) are classic signs of acute compartment syndrome of the foot. The case emphasizes, 'Compartment syndrome must be excluded' and 'On admission to hospital I would arrange for regular clinical examinations and monitoring in order not to miss an early developing compartment syndrome.' While clinical diagnosis is paramount, urgent compartment pressure measurements can objectively confirm the diagnosis, especially when clinical signs are equivocal or in a patient with altered sensation. Once diagnosed clinically, emergency decompression is required.Option A (Administer additional opioid analgesia and re-evaluate in 4 hours)is incorrect. This would delay critical intervention for compartment syndrome, potentially leading to irreversible tissue damage.Option B (Elevate the limb further and apply ice packs)is incorrect. While elevation is part of initial management, it can worsen compartment syndrome by reducing perfusion pressure. Ice packs are generally contraindicated in suspected compartment syndrome as they can cause vasoconstriction.Option D (Order an urgent MRI to assess soft tissue damage)is incorrect. MRI is not the primary diagnostic tool for acute compartment syndrome and would cause an unacceptable delay in diagnosis and treatment.Option E (Consult physical therapy for early mobilization)is incorrect. Early mobilization is contraindicated in suspected compartment syndrome and would worsen the condition.

Question 1678

Topic: 2. Trauma
According to the Lauge-Hansen classification, which of the following represents the initial (Stage I) structural failure in a supination-external rotation (SER) ankle injury?
. Rupture of the deltoid ligament
. Spiral fracture of the lateral malleolus
. Rupture of the anterior inferior tibiofibular ligament (AITFL)
. Rupture of the posterior inferior tibiofibular ligament (PITFL)
. Transverse fracture of the medial malleolus

Correct Answer & Explanation

. Transverse fracture of the medial malleolus

Explanation

The SER sequence classically begins with rupture of the AITFL (Stage I), followed by a spiral fibular fracture (Stage II), PITFL rupture or posterior malleolus fracture (Stage III), and finally deltoid rupture or medial malleolus fracture (Stage IV).

Question 1679

Topic: 2. Trauma

A 32-year-old male sustains a trimalleolar ankle fracture where the posterior malleolus fracture involves 30% of the articular surface and is displaced. What is the most biomechanically sound rationale for direct anatomic fixation of the posterior malleolus compared to placing trans-syndesmotic screws alone?

. It completely prevents the need for lateral malleolus fixation
. It optimally restores syndesmotic stability by reestablishing the PITFL attachment
. It eliminates the risk of post-traumatic ankle stiffness
. It allows for immediate full unassisted weight-bearing
. It directly prevents the development of medial clear space widening

Correct Answer & Explanation

. It optimally restores syndesmotic stability by reestablishing the PITFL attachment

Explanation

Fixation of a large posterior malleolus fragment directly restores the anatomic attachment of the posterior inferior tibiofibular ligament (PITFL). This provides significantly greater syndesmotic stability and stiffness than isolated trans-syndesmotic screw fixation.

Question 1680

Topic: 2. Trauma

A 65-year-old diabetic female with advanced peripheral neuropathy presents with a displaced bimalleolar ankle fracture. To minimize her exceptionally high risk of postoperative complications, which surgical modification is most strongly recommended?

. Use of bioabsorbable screws to reduce infection risk
. Enhanced fixation utilizing multiple syndesmotic screws or TTC transfixation
. Solely relying on closed reduction and total contact casting
. Delaying surgery until 4 weeks post-injury to allow soft tissue rest
. Routinely utilizing circular external fixation as definitive treatment

Correct Answer & Explanation

. Enhanced fixation utilizing multiple syndesmotic screws or TTC transfixation

Explanation

Diabetic patients with neuropathy are at high risk for Charcot arthropathy, fixation failure, and nonunion. Utilizing augmented, rigid fixation techniques (e.g., extra syndesmotic screws or trans-calcaneal pins) is recommended to prevent construct failure.

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