Orthopedic Trauma 2026 MCQs: Board Review Questions

Question 1

A 36-year-old woman sustained a tarsometatarsal joint fracture-dislocation in a motor vehicle accident. The patient is treated with open reduction and internal fixation. What is the most common complication?

Explanation

The most common complication associated with tarsometatarsal joint injury is posttraumatic arthritis. In one series, symptomatic arthritis developed in 25% of the patients and half of those went on to fusion. In another series, 26% had painful arthritis. Initial treatment should consist of shoe modification, inserts, and anti-inflammatory drugs. Fusion is reserved for failure of nonsurgical management. Hardware failure may occur, but it is clinically unimportant. Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618. Arntz CT, Veith RG, Hansen ST Jr: Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am 1988;70:173-181.

Question 2

What is the most appropriate indication for replantation in an otherwise healthy 35-year-old man?

Explanation

Vascular anastamoses are exceedingly difficult with amputations distal to the nail fold as the digital vessels bifurcate or trifurcate at this level, and little functional benefit is gained compared to other means of soft-tissue coverage. Single digit amputations, other than the thumb, are a relative contraindication for replantation. Replantations at the level of the proximal phalanx lead to poor motion of the proximal interphalangeal joint. In a healthy active adult, an amputation through the wrist is an appropriate situation to proceed with a replantation. A transverse forearm amputation is a good indication with a warm ischemia time of less than 6 hours. Urbaniak JR: Replantation, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1085.

Question 3

Figure 1 shows the radiograph of an 11-year-old boy who stubbed his great toe while playing soccer barefoot. He is able to walk home despite a small amount of bleeding at the nail fold. Management should consist of

Explanation

Great toe fractures through the physis should be considered open fractures if there is bleeding at the nail fold. Treatment should include irrigation and debridement and appropriate antibiotics. Immobilization with a cast is usually sufficient for treatment of the fracture. Noonan KJ, Saltzman CL, Dietz FR: Open physeal fractures of the distal phalanx of the great toe: A case report. J Bone Joint Surg Am 1994;76:122-125.

Question 4

Figure 2a shows the radiograph of a 48-year-old man who was involved in a motorcycle accident. A CT scan is shown in Figure 2b. The patient underwent pelvic angiography for persistent hypotension despite resuscitation. What vessel is most likely to be injured?

Explanation

2b The pelvic injury is a severe anterior-posterior compression III or Tile C injury. The vessel most likely injured is the superior gluteal artery, but several arterial bleeding sources are likely. Vertical shear injuries can also injure this vessel, but it is much less common. When arterial injury follows a lateral compression injury, it is usually related to injury of a more anterior vessel like the obturator artery or a branch of the external iliac artery. O'Neill PA, Riina J, Sclafani S, et al: Angiographic findings in pelvic fractures. Clin Orthop 1996;329:60-67.

Question 5

A 46-year-old man fell 20 feet and sustained the injury shown in Figure 3. The injury is closed; however, the soft tissues are swollen and ecchymotic with blisters. The most appropriate initial management should consist of

Explanation

Although this is a fracture of the medial and lateral malleoli, the degree of displacement and comminution of the medial dome indicate that this injury is similar to a pilon fracture. Initial management should consistent of stabilization to allow for soft-tissue healing. The use of temporizing spanning external fixation should be the initial step, followed by limited or more extensive open reduction and internal fixation when the soft-tissue status will allow. Initial placement in either a short or long leg cast does not provide the needed stability and does not allow for care and monitoring of soft tissues. In addition, maintaining reduction of the talus may be very difficult. Immediate open reduction and internal fixation through an injured soft-tissue envelope adds the risk of difficulties with incision healing and a higher risk of deep infection. In the acute setting, a primary ankle fusion through this soft-tissue envelope is not indicated. Marsh JL, Bonar S, Nepola JV, et al: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509. Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am 1996;78:1646-1657.

Question 6

A 13-year-old boy hyperextends his knee while playing basketball and reports a pop that is followed by a rapid effusion. A lateral radiograph is shown in Figure 4. Initial management consists of attempted reduction with extension, with no change in position of the fragment. What is the next most appropriate step in management?

Explanation

Avulsion fractures of the tibial spine are rare injuries that result from rapid deceleration or hyperextension of the knee in skeletally immature individuals. This injury is the equivalent of ruptures of the anterior cruciate ligament in adults. These fractures are classified as types 1 through 3. Type 1 is a minimally displaced fracture, type 2 fractures have an intact posterior hinge, and type 3 fractures have complete separation. The radiograph demonstrates a completely displaced, or type III, tibial spine avulsion. Surgical reduction is indicated in type 2 fractures that fail to reduce with knee extension and in all type 3 fractures. Reduction may be arthroscopic or open, with fixation of the bony fragment using a method that maintains physeal integrity and prevents later growth arrest. Preferred techniques would be with suture or an intra-epiphyseal screw Wiley JJ, Baxter MP: Tibial spine fractures in children. Clin Orthop 1990;255:54-60. Mulhall KJ, Dowdall J, Grannell M, et al: Tibial spine fractures: An analysis of outcome in surgically treated type III injuries. Injury 1999;30:289-292. Owens BD, Crane GK, Plante T, et al: Treatment of type III tibial intercondylar eminence fractures in skeletally immature athletes. Am J Orthop 2003;32:103-105.

Question 7

A collegiate golfer sustains a hook of the hamate fracture. After 12 weeks of splinting and therapy, the hand is still symptomatic. What is the most appropriate management to allow return to competitive activity?

Explanation

Excision of the fracture fragment typically leads to rapid return to function. Fixation techniques are difficult to perform because of the size of the bone; hardware prominence is common. Nerve deficits are not typically noted in this injury. The motor branch of the ulnar nerve in Guyon's canal must be protected during the surgical approach. Kulund DN, McCue FC III, Rockwell DA, et al: Tennis injuries: Prevention and treatment: A review. Am J Sports Med 1979;7:249-253.

Question 8

In an acute closed boutonniere injury, what is the most appropriate splinting technique for the proximal interphalangeal joint?

Explanation

Rupture of the central slip of the extensor mechanism and a varying degree of lateral band volar migration are the pathologic entities in an acute boutonniere injury. Splinting the proximal interphalangeal joint in full extension allows reapproximation of the central slip to the base of the middle phalanx. Distal interphalangeal joint flexion is permitted to allow movement of the lateral bands distally and dorsally, preventing contracture. Newport ML: Extensor tendon injuries in the hand. J Am Acad Orthop Surg 1997;5:59-66.

Question 9

A 20-year-old man sustained a closed tibial fracture and is treated with a reamed intramedullary nail. What is the most common complication associated with this treatment?

Explanation

The most common complication is anterior knee pain (57%). The knee pain is activity related (92%) and exacerbated by kneeling (83%). Although knee pain is the most common complication, most patients rate it as mild to moderate and only 10% are unable to return to previous employment. Some authors report less knee pain with a peritendinous approach when compared to a tendon-splitting approach. In one study, nail removal resolved pain in 27%, improved it in 70%, and made it worse in 3%. The incidence of the other complications was: infection 0% to 3%, nonunion 0% to 6%, and malunion 2% to 13%. Compartment syndrome is rare after nailing. Court-Brown CM: Reamed intramedullary tibial nailing: An overview and analysis of 1106 cases. J Orthop Trauma 2004;18:96-101. McQueen MM, Gaston P, Court-Brown CM: Acute compartment syndrome: Who is at risk? J Bone Joint Surg Br 2000;82:200-203.

Question 10

An 8-year-old boy sustained an isolated distal radial fracture that was reduced and immobilized with 10 degrees of residual dorsal tilt. What is the next step in management?

Explanation

Distal radial fractures in children are common, and a large amount of displacement is acceptable. In general, 20 degrees of dorsal displacement and complete bayonet apposition in girls to age 12 years and in boys to age 14 years can be expected to remodel with an excellent outcome. The potential for increased fracture displacement and subsequent malunion may exist in up to one third of patients with displaced fractures with less than anatomic reduction. Therefore, early follow-up is recommended and remanipulation is indicated should loss in reduction occur. Consideration for percutaneous pinning of isolated distal radial fracture is reasonable in patients with little growth remaining. In these patients, higher rates of redisplacement exist with little chance for remodeling. Gibbons CL, Woods DA, Pailthorpe C, et al: The management of isolated distal radius fractures in children. J Pediatr Orthop 1994;14:207-210. McLauchlan GJ, Cowan B, Annan IH, et al: Management of completely displaced metaphyseal fractures of the distal radius in children. J Bone Joint Surg Br 2002;84:413-417. Proctor MT, Moore DJ, Patterson JH: Redisplacement after manipulation of distal radial fractures in children. J Bone Joint Surg Br 1993;75:453-454.

Question 11

A 46-year-old man has incomplete paraplegia after being involved in a motor vehicle accident. The CT scan shown in Figure 5 reveals marked canal compromise. What is the most appropriate management to improve neurologic status?

Explanation

According to a study by the Scoliosis Research Society, the use of anterior decompression is most predictable for improving neurologic status. This is particularly true of bowel and bladder functional loss. Laminectomy is contraindicated because it further destabilizes the spine. Posterior instrumentation and indirect reduction through distraction and ligamentotaxis only incompletely decompress the compromised canal and are successful only if performed within 48 hours of injury. While some improvement may occur with closed management, the amount of recovery is less than that achieved with surgical decompression. A posterior approach and instrumentation may be added to the anterior decompression based on the characteristics of associated injuries to the posterior element. Gertzbein SD: Scoliosis Research Society multicenter spine fracture study. Spine 1992;17:528-540. Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-215.

Question 12

What is the most likely complication following treatment of the humeral shaft fracture shown in Figure 6?

Explanation

The humerus was treated with an intramedullary nail. Findings from two prospective randomized studies of intramedullary nailing or compression plating of acute humeral fractures have shown approximately a 30% incidence of shoulder pain with antegrade humeral nailing. This is the most common complication in both of these series. Nonunions are present in approximately 5% to 10% of humeral fractures treated with an intramedullary nail. Infection has an incidence of approximately 1%. Elbow injury is unlikely unless the nail is excessively long. Rarely, injury to the radial nerve is possible if it is trapped in the intramedullary canal. Chapman JR, Henley MB, Agel J, et al: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166.

Question 13

A 4-year-old girl sustains an isolated spiral femoral fracture after falling from her tricycle. Management should consist of

Explanation

Immediate spica casting is ideal for younger children with uncomplicated femoral fractures that are the result of relatively low-energy injury. Surgical stabilization of pediatric femoral fractures is most commonly performed in children who are older than age 6 years or in children with other factors associated with their femoral fracture, such as concomitant head injury, open fracture, floating knee, severe comminution, or vascular injury. Flynn JM, Skaggs DL, Sponseller PD, et al: The surgical management of pediatric fractures of the lower extremity. Instr Course Lect 2003;52:647-659. Sponseller PD: Surgical management of pediatric femoral fractures. Instr Course Lect 2002;51:361-365. Wright JG: The treatment of femoral shaft fractures in children: A systematic overview and critical appraisal of the literature. Can J Surg 2000;43:180-189.

Question 14

A 16-year-old girl sustained the injury shown in Figure 7a. CT scans are shown in Figures 7b through 7d. The results of treatment of this injury have been shown to most correlate with which of the following factors?

Explanation

7b 7c 7d The patient has a very low T-type acetabular fracture; however, the head is not congruent under the dome so surgical reduction is necessary. The anterior and posterior columns are displaced and will move independent from each other. The extended iliofemoral is the only approach allowing for visualization and reduction of each column. A combined anterior and posterior approach may also be used. The timing of surgery should be within the first 3 weeks of injury to optimize chances of obtaining an accurate reduction because this is an important factor in determining outcome. Letournel E, Judet R (eds): Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer-Verlag, 1991.

Question 15

An 18-month-old child sustains a crush amputation of the tip of the index finger. Bone is exposed, but the nail is intact. Management should consist of

Explanation

Children have a much greater capacity to heal soft-tissue injuries than adults. Most crush or avulsion fingertip amputations in children, particularly those younger than age 2 years, can be treated with serial dressing changes, even with bone exposed. Das SK, Brown HG: Management of lost finger tips in children. Hand 1978;10:16-27.

Question 16

An otherwise healthy 25-year-old man sustained a wound with a 1-cm by 1.5-cm soft-tissue loss over the volar aspect of the middle phalanx of his middle finger. After appropriate debridement and irrigation, the flexor digitorum profundus tendon and neurovascular bundles are visible. The wound should be treated with a

Explanation

The wound described indicates loss of soft tissue directly to the level of the tendon, precluding use of skin grafts if excursion of the tendon is desired. A cross-finger flap is ideal for small wounds on the volar aspect of digits. A thenar flap is suitable for tip injuries. A lateral arm flap will not reach the fingers. A Moberg flap is limited to distal injuries of the thumb. Kappel DA, Burech JG: The cross-finger flap: An established reconstructive procedure. Hand Clin 1985;1:677-683.

Question 17

An active 49-year-old woman who sustained a diaphyseal fracture of the clavicle 8 months ago now reports persistent shoulder pain with daily activities. An AP radiograph is shown in Figure 8. Management should consist of

Explanation

The radiograph reveals an atrophic nonunion of the diaphysis of the clavicle. Electrical or ultrasound stimulation may be an option in diaphyseal nonunions that have shown some healing response with callus formation, but these techniques are not successful in an atrophic nonunion. The preferred technique for achieving union is open reduction and internal fixation with bone graft. Percutaneous fixation has no role in treatment of nonunions of the clavicle. Boyer MI, Axelrod TS: Atrophic nonunion of the clavicle: Treatment by compression plating, lag-screw fixation and bone graft. J Bone Joint Surg Br 1997;79:301-303.

Question 18

Examination of a 25-year-old man who was injured in a motor vehicle accident reveals a fracture-dislocation of C5-6 with a Frankel B spinal cord injury. He also has a closed right femoral shaft fracture and a grade II open ipsilateral midshaft tibial fracture. Assessment of his vital signs reveals a pulse rate of 45/min, a blood pressure of 80/45 mm Hg, and respirations of 25/min. A general surgeon has assessed the abdomen, and a peritoneal lavage is negative. His clinical presentation is most consistent with what type of shock?

Explanation

Assessment of the acutely injured patient follows the Advanced Trauma Life Support protocol. Cervical cord injury is often associated with a disruption in sympathetic outflow. Absent sympathetic input to the lower extremities leads to vasodilatation, decreased venous return to the heart, and subsequent hypotension. With hypotension, the physiologic response of tachycardia is not possible because of the unopposed vagal tone. This results in bradycardia. Patient positioning, fluid support, pressor agents, and atropine are used to treat neurogenic shock.

Question 19

A 32-year-old woman sustained an injury to her left upper extremity in a motor vehicle accident. Examination reveals a 2-cm wound in the mid portion of the dorsal surface of the upper arm and deformities at the elbow and forearm; there are no other injuries. Her vital signs are stable, and she has a base deficit of minus 1 and a lactate level of less than 2. Radiographs are shown in Figures 9a and 9b. In addition to urgent debridement of the humeral shaft fracture, management should include

Explanation

9b With a severe injury to the upper extremity, the best opportunity for achieving a good functional result for a floating elbow is immediate debridement of the open fracture, followed by internal fixation of the fractures. The ability to do this depends on the patient's physiologic status. In this patient, the procedure is acceptable because she has normal vital signs and no chest or abdominal injuries, and normal physiologic parameters (base excess and lactate) show adequate peripheral perfusion. The surgical approaches will be determined by the associated injury patterns and open wounds. In this patient, the humerus was debrided and stabilized through a posterior approach as was the medial condyle fracture. The ulna was fixed through an extension of the posterior incision and the radius through a separate dorsal approach. Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.

Question 20

A patient sustained the injuries shown in the radiographs and clinical photograph seen in Figures 10a through 10c. The neurovascular examination is normal. The first step in emergent management of the extremity injuries should consist of

Explanation

10b 10c The figures show an open tibial fracture, a femoral shaft fracture, and femoral head dislocation. The most urgent treatment is reduction of the femoral head, as timing to reduction has been correlated with preventing osteonecrosis. After reduction of the femoral head, the next priority is wound management, followed by stabilization of the femoral and tibial fractures with either splinting, traction, or external fixation. Sahin V, Karakas ES, Aksu S, et al: Traumatic dislocation and fracture-dislocation of the hip: A long-term follow-up study. J Trauma 2003;54:520-529.

Question 21

Figure 11 shows the radiograph of a 3-year-old girl who sustained a proximal radius injury. Appropriate initial management should include

Explanation

The patient has a displaced radial neck fracture. Displaced radial neck fractures with angulation of more than 30 to 45 degrees require reduction. Methods of attempted closed reduction include wrapping the arm with an Esmarch's bandage and applying direct pressure over the maximum deformity of the radial head. More aggressive methods include a Kirschner wire used as a joystick or intramedullary reduction as described by the Metaizeau technique. Open reduction should be avoided because of complications such as stiffness or osteonecrosis. Indications for open reduction are irreducible displacement of more than 45 degrees with severe restriction of forearm rotation. Leung AG, Peterson HA: Fractures of the proximal radial head and neck in children with emphasis on those that involve the articular cartilage. J Pediatr Orthop 2000;20:7-14. Radomisli TE, Rosen AL: Controversies regarding radial neck fractures in children. Clin Orthop 1998;353:30-39. Skaggs DL, Mirzayan R: The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am 1999;81:1429-1433.

Question 22

Figures 12a and 12b show the radiographs of a 56-year-old man with diabetes mellitus who has had left foot swelling with no pain for the past several weeks. He denies any history of trauma. Examination reveals warmth, moderate swelling, no tenderness, and mild pes planus with standing. Pulses are palpable, and his sensory examination is grossly intact to light touch. Standing radiographs are shown in Figures 12c and 12d. What is the most likely diagnosis?

Explanation

12b 12c 12d The radiographs show tarsometatarsal joint subluxation without fragmentation. The clinical history and delay in presentation with the radiographic findings suggest a neuropathic or Charcot arthropathy involving the midfoot area. Intact sensory examination to light touch is not diagnostic for an intact peripheral neurologic system; monofilament testing is a more accurate office baseline examination for the presence of sensory peripheral neuropathy. With an acute traumatic Lisfranc fracture-dislocation, a history of a traumatic event is necessary, and radiographic abnormalities are expected, although nonstanding radiographs still may be misleading. Acquired pes planus due to posterior tibial tendon rupture may have negative nonstanding radiographs. Standing radiographs may reveal pes planus. However, intermetatarsal disruption is not expected as seen in a Lisfranc abnormality. Localized osteomyelitis of the foot without a penetrating injury or cutaneous ulceration is extremely unlikely and does not fit with the clinical picture described. An isolated metatarsal stress fracture would show osseous irregularity without the instability pattern pictured. Brodsky JW: The diabetic foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 895-969.

Question 23

A 25-year-old student sustains the injury shown in Figures 13a through 13c after falling off a curb. Initial management should consist of

Explanation

13b 13c The radiographs reveal a fracture entering the 4-5 intermetatarsal articulation, consistent with a zone 2 injury. This classically is also referred to as a Jones fracture. The history and radiographic findings indicate this is an acute fracture, which guides management. A zone 1 fracture enters the fifth tarsometatarsal joint, and a zone 3 fracture is a proximal diaphyseal fracture distal to the 4-5 articulation. Initial management is usually nonsurgical and consists of non-weight-bearing in a short leg cast. This method has been shown to result in a better healing rate compared to weight bearing as tolerated. Rosenberg GA, Sterra JJ: Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg 2000;8:332-338.

Question 24

What structure is most often injured in a volar proximal interphalangeal joint dislocation?

Explanation

Closed ruptures of the central slip of the extensor tendon may occur with volar proximal interphalangeal joint dislocation, forced flexion of the proximal interphalangeal joint, or blunt trauma to the dorsum of the proximal interphalangeal joint. The other structures are not typically injured in proximal interphalangeal joint dislocations. Treatment typically requires static splinting of the proximal interphalangeal joint. In the more common dorsal proximal interphalangeal joint dislocation, the volar plate is injured, and early range of motion may be started after reduction. Doyle JR: Extensor tendons: Acute injuries, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1925.

Question 25

What patient factor is predictive of better outcomes for surgical management of a displaced calcaneal fracture compared to nonsurgical management?

Explanation

A recent randomized trial of surgical versus nonsurgical management of calcaneal fractures showed that patients who were on workers' compensation did poorly with surgical care. These patients had less favorable outcomes regardless of their initial management. Factors such as age, smoking, and vasculopathies compromise skin healing, leading to greater surgical risks. The best results were obtained in patients who are younger than age 40 years, have unilateral injuries and are injured during noncompensable activities. Women tend to do better with surgery than men. Howard JL, Buckley R, McCormack R, et al: Complications following management of displaced intra-articular calcaneal fractures: A prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17:241-249.

Question 26

A 25-year-old male sustains a high-energy trauma resulting in a vertically oriented femoral neck fracture (Pauwels Type III). What biomechanical construct provides the most superior fixation to resist the high shear forces in this fracture pattern?

Explanation

Pauwels Type III femoral neck fractures are highly vertical and inherently unstable, subjected to high shear forces. Biomechanical studies have demonstrated that a fixed-angle construct, such as a sliding hip screw (with an anti-rotation screw to control rotational forces), provides superior stability and higher load-to-failure compared to three parallel cancellous screws in these vertical fracture patterns.

Question 27

A 45-year-old male undergoes open reduction and internal fixation of a transverse posterior wall acetabular fracture via a Kocher-Langenbeck approach. Postoperatively, the patient demonstrates a foot drop and inability to extend his toes. Which of the following intraoperative positioning or retraction errors most likely contributed to this complication?

Explanation

The sciatic nerve, specifically its peroneal division, is at significant risk during the Kocher-Langenbeck approach to the acetabulum. Tension on the sciatic nerve is increased when the hip is flexed and the knee is extended. To protect the nerve during this approach, the patient's knee should be kept flexed (at least 60-90 degrees) and the hip extended while retractors are in place.

Question 28

A 30-year-old female sustains a Hawkins Type II talar neck fracture in a motor vehicle collision and undergoes timely open reduction and internal fixation. At the 8-week postoperative follow-up, an anteroposterior mortise radiograph reveals a subchondral radiolucent band in the dome of the talus. What is the clinical significance of this radiographic finding?

Explanation

The presence of a subchondral radiolucent band in the dome of the talus at 6 to 8 weeks post-injury is known as the Hawkins sign. It represents subchondral osteopenia secondary to disuse. Because bone resorption requires an active blood supply, the presence of the Hawkins sign is a highly reliable indicator that the vascularity to the talar body is intact, making osteonecrosis highly unlikely.

Question 29

A 28-year-old male falls and sustains a closed middle-third humeral shaft fracture. In the emergency department, he is noted to have a complete inability to extend his wrist and fingers, with intact triceps function. A closed reduction is performed and a coaptation splint is applied. Post-reduction examination reveals the neurologic deficit is completely unchanged. What is the most appropriate next step in management?

Explanation

Primary radial nerve palsy associated with a closed humeral shaft fracture is typically a neurapraxia that spontaneously resolves in 70% to 90% of cases. The standard of care is observation and supportive management (e.g., a dynamic splint to prevent contractures). Immediate surgical exploration is generally not indicated for primary palsy unless it is an open fracture, there is a vascular injury, or if the palsy occurs secondary to (after) closed reduction (though even this is debated, observation remains standard for unchanged primary palsies). EMG is not useful until 3 to 6 weeks post-injury.

Question 30

A 40-year-old farmer sustains an open tibial shaft fracture (Gustilo-Anderson IIIA) after his leg is pinned under a tractor in a muddy field. In addition to thorough surgical debridement, which of the following intravenous antibiotic regimens is most appropriate for initial management?

Explanation

Open fractures occurring in heavily contaminated environments, such as farms or muddy fields, carry a significant risk for anaerobic infections, particularly Clostridium species. The standard antibiotic prophylaxis for Gustilo-Anderson Type III open fractures includes a first-generation cephalosporin (for Gram-positive coverage) and an aminoglycoside (for Gram-negative coverage). High-dose penicillin must be added specifically for anaerobic coverage in the setting of farm or soil contamination.

Question 31

A 22-year-old male sustains a low-velocity gunshot wound to the thigh resulting in a comminuted midshaft femur fracture. The bullet is lodged in the vastus lateralis. There is no expanding hematoma, and distal pulses are palpable and symmetric. Which of the following is the standard orthopedic management of the retained bullet in this scenario?

Explanation

For low-velocity gunshot wounds resulting in extra-articular long bone fractures, the heat generated by the bullet does not sterilize it, but routine bullet extraction and formal tract debridement are not required unless the bullet is intra-articular, within the spinal canal causing neurologic deficit, or causing mechanical block/vascular impingement. Standard treatment is local wound care, appropriate antibiotics, and standard internal fixation (such as intramedullary nailing for a femur fracture). Lead toxicity is exceedingly rare with extra-articular bullets in soft tissue.

Question 32

A 45-year-old construction worker falls from a height, sustaining a high-energy closed Pilon fracture. He has tense swelling and hemorrhagic fracture blisters over the ankle. A spanning external fixator is applied on the day of injury. What is the most reliable clinical indicator that the soft tissues have recovered sufficiently to proceed with definitive open reduction and internal fixation?

Explanation

The timing of definitive fixation for high-energy Pilon fractures is dictated by the condition of the soft tissues to minimize the high risk of wound breakdown and deep infection. The most reliable clinical indicator that interstitial edema has resolved sufficiently to safely make surgical incisions is the return of skin creases or the 'wrinkle sign'. This typically occurs between 10 to 21 days post-injury.

Question 33

A 30-year-old male is brought to the trauma bay after a severe motorcycle collision. His blood pressure is 70/40 mmHg and heart rate is 135 bpm. A pelvic radiograph shows an Anteroposterior Compression (APC-III) pelvic ring injury. A pelvic binder is appropriately applied, and he receives 2 units of uncrossmatched packed red blood cells, but remains hemodynamically unstable. A FAST (Focused Assessment with Sonography for Trauma) exam is negative. What is the most appropriate next step in management?

Explanation

In a hemodynamically unstable patient with a pelvic fracture, the initial step is closing the pelvic volume (e.g., pelvic binder), which has already been done. If the patient remains unstable and the FAST exam is negative (ruling out massive intraperitoneal hemorrhage), the source of bleeding is presumed to be the retroperitoneal venous plexus or pelvic arterial injury. The next mandatory step is preperitoneal pelvic packing and/or pelvic angiography. CT is contraindicated in hemodynamically unstable patients.

Question 34

A 35-year-old skier sustains a high-energy Schatzker VI tibial plateau fracture. Twelve hours post-injury, he complains of severe leg pain out of proportion to the injury. Examination reveals intense pain with passive stretch of the hallux and diminished sensation in the first web space. His diastolic blood pressure is 65 mmHg. Compartment pressures are measured: Anterior 45 mmHg, Lateral 30 mmHg, Deep Posterior 25 mmHg, Superficial Posterior 20 mmHg. What is the most appropriate next step in management?

Explanation

This patient has classic clinical signs of acute compartment syndrome (pain out of proportion, pain with passive stretch, and paresthesias in the deep peroneal nerve distribution). The diagnosis is confirmed objectively using the Delta P (Diastolic BP - Compartment Pressure). A Delta P of less than 30 mmHg is the accepted threshold for fasciotomy. Here, Delta P = 65 - 45 = 20 mmHg in the anterior compartment. Immediate four-compartment fasciotomy is required. Elevation above the heart is contraindicated as it further decreases arterial perfusion pressure to the compartment.

Question 35

A 55-year-old man falls from a ladder and sustains a displaced, intra-articular calcaneus fracture (Sanders Type III). He has a medical history significant for smoking one pack of cigarettes per day and poorly controlled type 2 diabetes mellitus (HbA1c 9.5%). Which of the following surgical approaches minimizes the high risk of wound complications in this specific patient while still allowing for articular reduction?

Explanation

Patients with a history of smoking and poorly controlled diabetes are at an exceptionally high risk for wound necrosis and deep infection following the classic extensile lateral approach for calcaneus fractures. The sinus tarsi approach is a minimally invasive lateral approach that significantly reduces the incidence of soft-tissue complications while still providing adequate visualization for the reduction and fixation of the posterior facet.

Question 36

A 25-year-old man sustains a displaced basicervical femoral neck fracture following a motorcycle collision. He is otherwise healthy and is scheduled for surgical intervention. Which of the following biomechanical constructs provides the most stable fixation and is the preferred implant choice for this specific fracture pattern?

Explanation

Basicervical femoral neck fractures are biomechanically distinct from subcapital fractures, behaving more like intertrochanteric fractures due to high shear forces. Fixation with cancellous screws alone has an unacceptably high rate of failure. A sliding hip screw (with or without a derotation screw) or a cephalomedullary nail provides superior biomechanical stability and is the standard of care.

Question 37

A 55-year-old woman undergoes volar locked plating for a displaced intra-articular distal radius fracture. Postoperative radiographs show the plate positioned distal to the watershed line of the distal radius. Six months later, she presents to the clinic with an inability to actively flex the interphalangeal joint of her thumb. Which of the following is the most likely cause?

Explanation

Plate placement distal to the watershed line of the distal radius increases the risk of flexor tendon irritation and subsequent attrition rupture. The flexor pollicis longus (FPL) tendon is most commonly affected due to its anatomical proximity to the prominent distal edge of the volar plate.

Question 38

A 30-year-old man sustains a closed spiral fracture of the distal third of his humerus (Holstein-Lewis fracture) during an arm-wrestling match. On presentation in the emergency department, he is unable to extend his wrist or fingers, and has numbness in the first dorsal web space. What is the most appropriate initial management of this nerve palsy?

Explanation

The initial management for a closed humeral shaft fracture with a primary radial nerve palsy is conservative. The vast majority of these injuries represent neuropraxia (usually due to nerve tethering at the lateral intermuscular septum) and resolve spontaneously within 3 to 4 months. Surgical exploration is indicated for open fractures, secondary nerve palsies (developing after closed reduction), or failure to recover clinically or electrodiagnostically after 3 to 4 months.

Question 39

A 40-year-old construction worker sustains a severe crush injury resulting in an open tibia fracture with a 12 cm wound, extensive periosteal stripping, and massive soft tissue loss requiring a free tissue transfer (Gustilo-Anderson IIIB). According to current evidence-based guidelines, what is the single most critical factor in reducing his risk of deep surgical site infection?

Explanation

In the management of open fractures, the most critical factor for reducing the infection rate is the early administration of appropriate systemic antibiotics, ideally within 1 hour of injury. While prompt surgical debridement is essential, modern literature does not support a rigid '6-hour rule' as an independent predictor of infection, provided antibiotics are administered promptly.

Question 40

A 28-year-old man is struck by a car and sustains an anteroposterior compression type II (APC-II) pelvic ring injury. He is hemodynamically stable. Fluoroscopic examination under anesthesia demonstrates 3 cm of symphyseal diastasis and widening of the anterior sacroiliac joints. Which of the following ligaments must be disrupted to produce this specific injury pattern?

Explanation

An APC-II pelvic ring injury ('open book' pelvis) involves disruption of the symphysis pubis (or anterior rami) along with the anterior sacroiliac ligaments, sacrotuberous ligaments, and sacrospinous ligaments. The posterior sacroiliac ligaments remain intact, which preserves vertical stability while allowing rotational instability.

Question 41

A 32-year-old snowboarder sustains a high-energy forced dorsiflexion injury to his right ankle. Radiographs and CT imaging reveal a Hawkins type III fracture of the talar neck. Based on the Hawkins classification, what does a type III fracture specifically indicate?

Explanation

The Hawkins classification for talar neck fractures is: Type I (nondisplaced), Type II (displaced with subtalar joint subluxation/dislocation), Type III (displaced with both subtalar and tibiotalar joint dislocations), and Type IV (Type III plus talonavicular joint dislocation). Type III injuries carry a very high risk of avascular necrosis (AVN) of the talar body.

Question 42

A 45-year-old man presents after a high-speed motor vehicle collision with a right-sided posterior hip dislocation and a posterior wall acetabular fracture. Following closed reduction of the hip, a computed tomography (CT) scan shows a posterior wall fragment comprising 45% of the posterior articular surface and a 5 mm intra-articular step-off due to marginal impaction. What is the most appropriate definitive management?

Explanation

Posterior wall fractures involving more than 20-40% of the articular surface are highly unstable and require ORIF. Marginal impaction occurs when articular cartilage is driven into the underlying cancellous bone. It is crucial to elevate the impacted segment to restore joint congruity and fill the resulting metaphyseal void with bone graft prior to fixing the posterior wall fragment. Failure to do so leads to rapid post-traumatic osteoarthritis.

Question 43

A 50-year-old roofer falls 15 feet, landing squarely on his heels. He sustains a closed, displaced intra-articular calcaneus fracture (Sanders type III). If the surgeon elects to proceed with open reduction and internal fixation via an extensile lateral approach, which of the following is the most frequent and significant complication associated with this specific surgical approach?

Explanation

The extensile lateral approach for calcaneus fractures relies on a full-thickness fasciocutaneous flap. It is notorious for a high rate of wound complications (up to 25%), including edge necrosis, dehiscence, and deep infection. The risk is significantly increased by smoking, diabetes, and performing surgery before soft tissue swelling has adequately subsided (positive wrinkle test).

Question 44

A 22-year-old collegiate football player sustains a closed midshaft tibia fracture. Eight hours later, he develops excruciating leg pain out of proportion to the injury that is completely unresponsive to intravenous opioids. On examination, the leg is visibly tense, and passive stretch of the great toe elicits severe pain. Distal pulses are palpable. Compartment pressure monitoring reveals an absolute anterior compartment pressure of 45 mmHg with a concurrent diastolic blood pressure of 70 mmHg. What is the most appropriate next step in management?

Explanation

The patient is presenting with classic clinical signs of acute compartment syndrome. The delta pressure (diastolic blood pressure minus absolute compartment pressure) is 70 - 45 = 25 mmHg. A delta pressure of less than 30 mmHg is diagnostic for acute compartment syndrome and is an absolute indication for an emergent four-compartment fasciotomy to prevent irreversible muscle and nerve necrosis.

Question 45

A 5-year-old boy falls from the monkey bars and sustains a widely displaced Gartland type III supracondylar humerus fracture. On evaluation in the emergency department, his hand is warm and well-perfused (pink), but he has an absent radial pulse. What is the most appropriate initial management?

Explanation

In a pediatric patient with a displaced supracondylar humerus fracture and a 'pink, pulseless' hand, collateral circulation is maintaining limb viability. The initial management is emergent closed reduction and percutaneous pinning. The brachial artery is frequently tethered, kinked, or entrapped over the fracture fragments, and anatomical reduction usually restores the pulse. Angiography delays treatment, and open vascular exploration is reserved for a 'white, pulseless' hand that does not improve after reduction.

Question 46

A 42-year-old male sustains an anteroposterior compression type III (APC-III) pelvic ring injury following a high-speed motorcycle crash. On arrival, his systolic blood pressure is 75 mm Hg, and his heart rate is 125 bpm. A pelvic binder is applied, and he receives 2 units of uncrossmatched packed red blood cells. His blood pressure remains 78 mm Hg. Extended focused assessment with sonography for trauma (eFAST) is negative. What is the most appropriate next step in his management?

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST exam, the primary source of bleeding is presumed to be the pelvis (retroperitoneal venous plexus or arterial branches). According to the ATLS and orthopedic trauma algorithms, once a pelvic binder is applied to reduce pelvic volume and fluid resuscitation is underway, persistent instability warrants emergent preperitoneal pelvic packing (PPP) and/or pelvic angiography to address the hemorrhage. External fixation provides volume reduction similar to a binder but does not address ongoing major bleeding better than packing/angio in this emergent phase.

Question 47

A 65-year-old woman with severe rheumatoid arthritis on chronic corticosteroids sustains a highly comminuted, intra-articular distal femur fracture (AO/OTA 33-C3). Radiographs demonstrate profound osteopenia. She is treated with open reduction and internal fixation. Which of the following surgical strategies provides the most mechanically robust construct to minimize the risk of varus collapse?

Explanation

Highly comminuted distal femur fractures in severely osteopenic bone have a high failure rate, most commonly presenting as varus collapse and hardware pullout when treated with isolated lateral locked plating. Biomechanical studies demonstrate that dual plating (adding a medial structural plate) significantly increases the construct stiffness, torque to failure, and overall axial load to failure compared to isolated lateral locked plating or the addition of an endosteal fibular strut.

Question 48

A 30-year-old man sustains a Gustilo-Anderson IIIB open midshaft tibia fracture following a motorcycle accident. He undergoes emergent irrigation and debridement, and placement of a spanning external fixator. According to the Lower Extremity Assessment Project (LEAP) study, which of the following factors is the most significant predictor of poor long-term functional outcome for this limb?

Explanation

The LEAP study profoundly impacted the understanding of severe lower extremity trauma by showing that patient characteristics (such as lower socioeconomic status, lack of insurance, smoking, poor psychosocial support) are the strongest predictors of poor long-term functional outcomes, regardless of whether the limb was salvaged or amputated. An insensate foot on presentation does not necessarily correlate with poor long-term functional salvage and is not an absolute indication for primary amputation.

Question 49

A 28-year-old man sustains a vertical, high-shear femoral neck fracture (Pauwels type III) after a fall from height. He undergoes closed reduction and internal fixation with three cannulated screws. Which of the following best describes the mechanical environment and the most likely mode of failure for this specific fracture pattern?

Explanation

Pauwels type III fractures are highly vertical fractures (angle > 50 degrees). Because the fracture line is nearly parallel to the vector of joint reactive forces, shear forces predominate at the fracture site rather than compressive forces. This high shear environment makes standard parallel cannulated screw fixation biomechanically inferior, leading to a high rate of failure via varus collapse, shortening, and nonunion. A fixed-angle device (like a sliding hip screw or cephalomedullary nail) is generally preferred to counteract these shear forces.

Question 50

A 6-year-old boy falls from monkey bars and sustains a widely displaced posterolateral extension-type supracondylar humerus fracture. On examination, the hand is pink and warm, but the radial pulse is absent by palpation and Doppler. After closed reduction and percutaneous pinning, the hand remains pink and warm, but the radial pulse is still absent. What is the most appropriate next step in management?

Explanation

A 'pink, pulseless' hand after reduction and pinning of a pediatric supracondylar humerus fracture indicates that collateral circulation is adequate to perfuse the hand, despite possible spasm, kinking, or intimal injury to the brachial artery. The standard of care for a well-perfused (pink and warm) hand is observation, as the pulse typically returns within several days. Exploration is indicated for a 'white, pulseless' (ischemic) hand.

Question 51

A 34-year-old snowboarder sustains a Hawkins type III fracture of the talar neck. He undergoes prompt open reduction and internal fixation. At the 8-week postoperative visit, plain radiographs reveal a subchondral radiolucent band in the dome of the talus (Hawkins sign). What does this radiographic finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucent band seen in the talar dome on the AP or mortise radiograph, typically appearing 6 to 8 weeks after injury. It represents subchondral osteopenia secondary to regional hyperemia. The presence of this hyperemia confirms that the vascular supply to the talar body is intact, thereby serving as a positive prognostic indicator that avascular necrosis (AVN) will not develop.

Question 52

A 24-year-old male is involved in a high-speed motor vehicle collision resulting in a closed, comminuted midshaft tibia fracture. He is admitted and treated with a reamed intramedullary nail. Twelve hours postoperatively, he complains of severe leg pain requiring increasing doses of IV opioids. Passive stretch of his toes elicits excruciating pain. The physician decides to measure compartment pressures. Which of the following is the most accepted threshold for diagnosing acute compartment syndrome and proceeding with fasciotomy?

Explanation

The diagnosis of acute compartment syndrome is primarily clinical, but objective measurement is crucial in equivocal cases or in obtunded patients. The delta pressure (ΔP) is the most reliable parameter, calculated as Diastolic Blood Pressure minus Compartment Pressure. A delta pressure of less than 30 mm Hg suggests inadequate tissue perfusion and is the universally accepted threshold for emergent fasciotomy.

Question 53

A 45-year-old male sustains a transverse posterior wall acetabular fracture after being struck by a car as a pedestrian. On examination, there is a large, fluctuant swelling over the greater trochanter with overlying skin ecchymosis and decreased sensation. Which of the following statements regarding this soft tissue lesion is true?

Explanation

This clinical description represents a Morel-Lavallée lesion, which is a closed degloving injury where the skin and subcutaneous tissue are violently separated from the underlying fascia. This creates a potential space filled with blood, lymph, and necrotic fat. It is associated with a significantly increased risk of infection if an incision is made through it for internal fixation. Management often involves early percutaneous drainage, debridement, or delaying internal fixation until the soft tissue envelope recovers.

Question 54

A 72-year-old woman sustains a 3-part proximal humerus fracture after a ground-level fall. Nonoperative management is initiated. During her first follow-up visit, she is found to have weakness with shoulder abduction and decreased sensation over the lateral aspect of her shoulder. Which of the following muscles shares its innervation with the muscle primarily affected by this neurological injury?

Explanation

The patient exhibits classic signs of an axillary nerve palsy (deltoid weakness limiting abduction, and numbness over the lateral shoulder or 'regimental badge' area). The axillary nerve, a branch of the posterior cord of the brachial plexus, innervates both the deltoid and the teres minor. The teres major is innervated by the lower subscapular nerve, while supraspinatus and infraspinatus are innervated by the suprascapular nerve.

Question 55

A 25-year-old equestrian falls from a horse and sustains a Denis Zone 3 sacral fracture (longitudinal fracture medial to the neural foramina). She complains of perineal numbness and difficulty voiding. Which of the following statements best describes the risk of neurologic injury in this specific sacral fracture zone?

Explanation

The Denis classification of sacral fractures predicts neurologic deficit based on location. Zone 1 (alar) has the lowest risk (~6%, often L5). Zone 2 (foraminal) has a higher risk (~28%, often S1/S2 causing radiculopathy). Zone 3 involves the central sacral canal and carries the highest risk of neurologic injury (>50%). Because the fracture involves the central canal, it frequently damages the sacral roots responsible for sphincter tone, leading to cauda equina syndrome with bowel, bladder, and sexual dysfunction.

Question 56

A 35-year-old male is brought to the trauma bay in hemorrhagic shock after a heavy crush injury. Pelvic radiographs reveal an anterior posterior compression (APC-III) pelvic ring injury. Despite the application of a pelvic binder and initiation of a massive transfusion protocol, he remains persistently hypotensive. FAST exam is negative. He is taken emergently to the operating room for preperitoneal pelvic packing. Through which anatomic space are the laparotomy sponges primarily placed to tamponade the most common source of bleeding?

Explanation

Preperitoneal pelvic packing is an effective method for controlling venous and small arterial hemorrhage in hemodynamically unstable pelvic ring injuries. The packing is performed via a midline incision, entering the preperitoneal retropubic space (Space of Retzius), and bluntly dissecting along the pelvic brim toward the sacroiliac joints. Three laparotomy sponges are typically packed sequentially on each side to tamponade the presacral and paravesical venous plexuses, which are the most common sources of bleeding in pelvic fractures.

Question 57

A 32-year-old male sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III, angle > 50 degrees). Open reduction and internal fixation is planned. Which of the following fixation constructs provides the greatest biomechanical stability for this specific fracture pattern in a young adult?

Explanation

Pauwels III fractures are vertically oriented and subjected to high vertical shear forces during weight-bearing, which leads to a high rate of varus collapse, nonunion, and failure if fixed with standard cancellous screws alone. Biomechanical studies have consistently shown that a fixed-angle construct, such as a sliding hip screw (SHS), provides superior resistance to vertical shear. A supplemental derotation screw is typically added to prevent rotation of the femoral head during insertion of the lag screw and to provide additional rotational stability.

Question 58

A 45-year-old male presents with a closed, highly comminuted tibial pilon fracture. There is severe soft tissue swelling, pitting edema, and hemorrhagic fracture blisters over the medial ankle. A standard staged protocol using a spanning external fixator is initiated. What is the most appropriate clinical indicator that the soft tissue envelope is ready for definitive open reduction and internal fixation?

Explanation

The timing of definitive fixation for tibial pilon fractures is dictated by the condition of the soft tissues rather than a specific time frame. The appearance of the 'wrinkle sign' indicates a significant reduction in interstitial edema and suggests that the soft tissue envelope can tolerate surgical incisions with a minimized risk of wound dehiscence and deep infection. Capillary refill evaluates perfusion but not edema, and while 10-14 days is a typical timeframe, the clinical wrinkle sign is the definitive metric.

Question 59

A 25-year-old male sustains a low-velocity gunshot wound to the right thigh, resulting in a comminuted midshaft femur fracture. He is hemodynamically stable. There is no expanding hematoma, distal pulses are normal, and he has an intact neurologic examination. What is the most appropriate initial management of the wound and fracture?

Explanation

Low-velocity gunshot wounds resulting in long bone fractures without evidence of neurovascular compromise or massive contamination are generally treated similarly to closed fractures. Aggressive operative debridement of the bullet track is unnecessary and increases morbidity. The standard of care involves superficial local wound care, tetanus prophylaxis, short-course intravenous antibiotics, and stabilization with reamed intramedullary nailing.

Question 60

A 6-year-old boy falls from a playground structure and sustains a widely displaced, posteromedial type III supracondylar humerus fracture. On initial presentation, his hand is pink and warm, but the radial pulse is absent. Capillary refill is 2 seconds. After prompt closed reduction and percutaneous pinning in the operating room, the hand remains pink and warm with brisk capillary refill, but the radial pulse remains non-palpable. What is the next best step in management?

Explanation

The 'pulseless, pink hand' is a well-recognized presentation in pediatric supracondylar humerus fractures. It indicates that while the radial pulse is not palpable (often due to brachial artery spasm, kinking, or minor intimal injury), there is adequate collateral circulation to perfuse the hand. If the hand remains well-perfused (pink, warm, brisk capillary refill) after adequate anatomic reduction and pinning, surgical exploration is not indicated. The patient should be observed closely with serial neurovascular checks. Exploration is indicated for a 'pulseless, white (ischemic) hand' that does not improve with reduction.

Question 61

A 28-year-old man sustains a closed tibial shaft fracture and undergoes uncomplicated reamed intramedullary nailing. In the recovery room, he complains of severe, unrelenting leg pain that is out of proportion to the injury and not relieved by intravenous opioids. Passive stretch of his toes elicits excruciating pain. The leg feels tense to palpation, but dorsalis pedis and posterior tibial pulses are full and symmetric to the contralateral side. What is the most appropriate next step?

Explanation

The patient is presenting with classic signs of acute compartment syndrome (ACS): pain out of proportion to the injury, intense pain with passive stretch of the involved muscles, and a tense compartment. Distal pulses are typically maintained in ACS until very late in the clinical course, so their presence does not rule out the condition. In a conscious, alert patient with unequivocal clinical signs of ACS, the diagnosis is clinical, and time should not be wasted measuring compartment pressures. The definitive treatment is immediate surgical release via a four-compartment fasciotomy.

Question 62

A 31-year-old snowboarder sustains a Hawkins Type III fracture of the talar neck. Despite prompt open reduction and internal fixation, the patient is counseled regarding a high risk of developing avascular necrosis (AVN) of the talar body. Which of the following blood vessels provides the predominant blood supply to the body of the talus, which is typically disrupted in this injury?

Explanation

The talar body receives its blood supply from a rich extraosseous anastomotic ring. The artery of the tarsal canal, which is a branch of the posterior tibial artery, provides the predominant blood supply to the body of the talus. A Hawkins Type III fracture involves a talar neck fracture with dislocation of both the subtalar and tibiotalar joints, disrupting the extraosseous blood supply (including the artery of the tarsal canal, artery of the tarsal sinus, and deltoid branches) and leading to a very high rate of avascular necrosis.

Question 63

A 44-year-old woman falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. Operative intervention is planned. To restore concentric stability of the elbow joint, which of the following represents the most appropriate and widely accepted sequence of surgical reconstruction?

Explanation

A terrible triad injury of the elbow consists of an elbow dislocation, a radial head fracture, and a coronoid fracture. The standard surgical treatment algorithm dictates a 'deep to superficial' or 'inside-out' approach, typically beginning anteriorly and laterally. The recommended sequence is: 1) Fixation of the coronoid fracture to restore the anterior buttress; 2) Fixation or replacement of the radial head to restore the lateral column; and 3) Repair of the lateral ulnar collateral ligament (LUCL/LCL complex) to restore posterolateral rotatory stability. The medial collateral ligament (MCL) is typically only repaired if the elbow remains grossly unstable after these steps.

Question 64

A 22-year-old male motorcyclist is struck by a car and presents with massive swelling over his left shoulder girdle and a completely flail, pulseless left upper extremity. A chest radiograph demonstrates a laterally displaced scapula, a widened acromioclavicular joint, and an intact clavicle. What is the most critical immediate priority in the management of this specific injury?

Explanation

The clinical and radiographic presentation describes a scapulothoracic dissociation, a severe, high-energy injury characterized by complete disruption of the scapulothoracic articulation. It is often likened to a 'closed forequarter amputation'. It is highly associated with massive, potentially life-threatening hemorrhage from subclavian or axillary artery disruption, as well as severe brachial plexus avulsions. Because of the immediate threat to life and limb from vascular injury, CT angiography and vascular surgery evaluation are the most critical immediate priorities.

Question 65

A 72-year-old woman with a 10-year history of alendronate use presents with several weeks of vague, aching right thigh pain that worsens with weight-bearing. Radiographs reveal focal lateral cortical thickening ('cortical beaking') and a transverse radiolucent line extending partially through the lateral cortex in the subtrochanteric region of the right femur. What is the most appropriate management?

Explanation

This patient presents with a symptomatic, incomplete atypical femur fracture (AFF) associated with long-term bisphosphonate use. The presence of a radiolucent line (incomplete fracture) in the setting of thigh pain indicates an impending complete fracture. The standard of care for a symptomatic incomplete AFF with a visible radiolucent fracture line is prophylactic intramedullary nailing. This prevents completion and displacement of the fracture, which is associated with high morbidity and high rates of nonunion. Medical optimization (stopping bisphosphonates, considering teriparatide) is also important but secondary to surgical stabilization of the impending fracture.

Question 66

A 45-year-old male presents in hemorrhagic shock following a high-speed motor vehicle collision. Primary survey reveals an unstable pelvis. Anteroposterior pelvic radiograph demonstrates an anteroposterior compression type III (APC III) injury. A pelvic binder is to be applied. What is the anatomically correct landmark for the placement of the pelvic binder to optimally reduce pelvic volume?

Explanation

The optimal placement for a pelvic binder is centered over the greater trochanters. This allows the forces to be transmitted directly through the femurs to the pubic symphysis, effectively closing the pelvic ring and reducing pelvic volume in "open book" (APC) injuries. Placement over the iliac crests is a common error; it is less effective and can paradoxically open the true pelvis further or cause skin necrosis over bony prominences.

Question 67

A 28-year-old construction worker sustains an isolated, severe open midshaft tibia fracture. The wound is 12 cm long with significant periosteal stripping, but there is adequate soft tissue for coverage. The patient arrives at the emergency department 45 minutes after the injury. What single intervention has been shown in the literature to be the most critical for reducing the patient's risk of deep infection?

Explanation

Early administration of systemic intravenous antibiotics (ideally within 1 hour of injury) is the most heavily supported, single most critical factor in reducing infection rates in open fractures. While prompt surgical debridement is standard of care, the rigid "6-hour rule" has not been definitively supported by recent literature. High-pressure pulsatile lavage has been shown to potentially drive debris deeper into tissues and damage bone, making low-pressure gravity lavage preferable.

Question 68

A 40-year-old female presents with a severely comminuted intra-articular distal femur fracture (OTA/AO 33C3). Computed tomography reveals a coronal plane fracture of the lateral femoral condyle. During open reduction and internal fixation, what is the most appropriate biomechanical fixation strategy for this specific coronal plane fragment before applying a lateral locking plate?

Explanation

A coronal plane fracture of the femoral condyle is known as a Hoffa fracture, which most commonly affects the lateral condyle. The standard and biomechanically most practical approach to fixing a Hoffa fragment is using anterior-to-posterior (A-P) lag screws, placed perpendicular to the fracture line to achieve compression. While P-A screws are biomechanically stronger, they are technically difficult to place due to the posterior neurovascular structures and required exposure. A lateral locking plate alone cannot provide the necessary interfragmentary compression for this articular shear injury.

Question 69

A 24-year-old man sustains a displaced, highly vertical femoral neck fracture (Pauwels type III) after falling from a height. Which of the following surgical constructs provides the greatest biomechanical stability to counteract the significant shear forces associated with this fracture pattern?

Explanation

Pauwels type III fractures have a fracture angle greater than 50 degrees from the horizontal, leading to high shear forces and a propensity for varus collapse and nonunion. Biomechanical studies have demonstrated that a fixed-angle device, such as a sliding hip screw (SHS) augmented with an anti-rotation screw, provides superior biomechanical stability against shear forces compared to multiple cancellous screws in young adults with vertical femoral neck fractures.

Question 70

A 32-year-old male is admitted with a closed midshaft tibia fracture. Ten hours later, he complains of extreme leg pain unrelieved by intravenous opioids. On examination, his leg is tight, and he has severe pain with passive extension of his toes. Dorsalis pedis pulses are 2+. Intracompartmental pressure testing reveals an anterior compartment pressure of 35 mmHg. His systemic blood pressure is 110/65 mmHg. What is the most appropriate next step in management?

Explanation

The patient has clinical acute compartment syndrome (ACS) supported by pressure measurements. The "delta pressure" (diastolic blood pressure minus compartment pressure) is 65 - 35 = 30 mmHg. A delta pressure of 30 mmHg or less, combined with classical clinical signs (pain out of proportion, pain on passive stretch), is a definitive indication for urgent surgical decompression via four-compartment fasciotomy. Palpable pulses do not rule out ACS, as arterial flow is maintained until late in the process. Elevation above the heart decreases arterial inflow, exacerbating ischemia, and is contraindicated.

Question 71

A 25-year-old snowboarder sustains a forced dorsiflexion injury to his right ankle. Radiographs reveal a displaced fracture of the talar neck with subluxation of the subtalar joint, while the tibiotalar joint remains concentrically reduced. According to the Hawkins classification, what is the approximate historical risk of developing avascular necrosis (AVN) of the talar body in this patient?

Explanation

This injury represents a Hawkins Type II talar neck fracture, defined as a talar neck fracture with subluxation or dislocation of the subtalar joint but a reduced ankle joint. The historical risk of avascular necrosis (AVN) of the talar body for a Type II fracture is between 20% and 50%. Type I (non-displaced) fractures have a 0-10% risk, Type III (subtalar and tibiotalar dislocation) have a >50% (often up to 90%) risk, and Type IV (Type III plus talonavicular dislocation) approaches a 100% risk.

Question 72

A 68-year-old active female presents with an anterior shoulder dislocation and an associated displaced greater tuberosity fracture after a fall. Closed reduction of the shoulder is successful. Post-reduction radiographs confirm a concentrically located glenohumeral joint, but the greater tuberosity fragment remains displaced 12 mm superiorly. What is the most common nerve injury associated with this dislocation, and what is the appropriate management of the greater tuberosity?

Explanation

The axillary nerve is the most commonly injured nerve in anterior shoulder dislocations (typically a neurapraxia). Regarding the greater tuberosity fracture, if the fragment remains displaced by more than 5 mm (and some argue >3 mm in young, active patients) after glenohumeral reduction, surgical fixation is indicated. Superior displacement of 12 mm will almost certainly lead to severe subacromial impingement and rotator cuff dysfunction if left unreduced.

Question 73

A 50-year-old male is involved in a high-speed MVC. Anteroposterior pelvic radiograph demonstrates disruption of both the iliopectineal and ilioischial lines on the right side. The radiographic teardrop is displaced medially, but the obturator ring is completely intact without any fracture lines. Based on the Letournel and Judet classification, what type of acetabular fracture does this patient have?

Explanation

A transverse fracture of the acetabulum uniquely disrupts both the anterior column (iliopectineal line) and posterior column (ilioischial line) while leaving the obturator ring intact. A both-column fracture typically involves the obturator ring and demonstrates a "spur sign." A T-type fracture is essentially a transverse fracture with an inferior vertical split that breaks the obturator ring. Thus, disruption of both lines with an intact obturator ring is pathognomonic for a transverse fracture.

Question 74

A 21-year-old male cyclist falls directly onto his left shoulder. Radiographs show a displaced, comminuted midshaft clavicle fracture. Which of the following scenarios represents an absolute indication for immediate open reduction and internal fixation of this fracture?

Explanation

Absolute indications for surgical fixation of clavicle fractures are open fractures, skin tenting leading to impending skin necrosis, and associated neurovascular injuries (e.g., subclavian artery disruption). While >2cm shortening, 100% displacement, and floating shoulders are highly regarded relative indications that often lead to surgery (especially in active patients to minimize nonunion and malunion), an open fracture necessitates urgent surgical irrigation, debridement, and internal fixation.

Question 75

A 45-year-old roofer falls 15 feet, landing squarely on both heels. He has severe bilateral heel pain, swelling, and ecchymosis extending into the plantar arch (Mondor's sign). Lateral radiographs of the right foot demonstrate an intra-articular calcaneus fracture. What specific radiographic finding is classically diagnostic of depression of the posterior facet in this injury?

Explanation

Bohler's angle is formed by a line drawn from the highest point of the anterior process to the highest point of the posterior facet, and a line drawn from the highest point of the posterior facet to the superior edge of the calcaneal tuberosity. The normal angle is 20 to 40 degrees. In a depressed intra-articular calcaneus fracture, the posterior facet is driven inferiorly, resulting in a flattening or decrease of Bohler's angle to less than 20 degrees. The critical angle of Gissane typically increases (not decreases) when the posterior facet is depressed.

Question 76

A 42-year-old male presents hypotensive (BP 75/40 mmHg) after a severe crush injury. AP pelvis radiograph demonstrates a 4-cm pubic symphysis diastasis and disruption of the bilateral sacroiliac joints. A pelvic binder is applied in the trauma bay, but his blood pressure remains 80/40 mmHg despite balanced crystalloid and blood product resuscitation. A FAST exam is negative. What is the most appropriate next step in management?

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST exam, retroperitoneal hemorrhage is the most likely source of bleeding. When mechanical stabilization (e.g., pelvic binder) fails to restore hemodynamics, pelvic angiography is indicated to identify and embolize arterial bleeders. The most commonly injured arteries are branches of the internal iliac artery, such as the superior gluteal or internal pudendal arteries.

Question 77

A 28-year-old healthy male sustains a completely displaced, vertically oriented (Pauwels type III) femoral neck fracture in a motor vehicle collision. Which of the following fixation constructs offers the highest biomechanical stability for this specific fracture pattern?

Explanation

Pauwels type III femoral neck fractures in young adults are characterized by a steep, vertical fracture line (angle > 50 degrees) subjected to extremely high shear forces. Biomechanical studies demonstrate that fixed-angle devices, such as a sliding hip screw (often supplemented with an anti-rotation screw), provide superior biomechanical stability and increased resistance to shear forces compared to multiple cancellous screws.

Question 78

A 40-year-old male sustains an isolated, displaced coronal plane fracture of the lateral femoral condyle following a direct blow to the flexed knee. What is the most appropriate surgical management for this specific fracture pattern?

Explanation

A coronal plane fracture of the femoral condyle is known as a Hoffa fracture. It is intrinsically unstable due to the pull of the gastrocnemius and popliteus muscles (for the lateral condyle). Fixation requires lag screws, ideally placed from posterior to anterior to sit perfectly perpendicular to the fracture plane. This is often supplemented with a posterior anti-glide plate to resist the shear forces generated during knee flexion.

Question 79

A 30-year-old male sustains a Type II open fracture of the tibial shaft. Based on recent evidence and consensus guidelines regarding open fracture management, which of the following statements concerning antibiotic administration is true?

Explanation

The most critical factor in preventing infection in open fractures is the early administration of systemic antibiotics, ideally within 1 hour of injury. Current guidelines recommend 24-48 hours of systemic antibiotics; prolonged courses do not decrease infection rates and increase the risk of resistance. The standard prophylactic agent for Type I and II open fractures is a first-generation cephalosporin.

Question 80

A 27-year-old male undergoes intramedullary nailing for a closed tibial shaft fracture. Twelve hours postoperatively, he complains of severe leg pain out of proportion to the injury, unrelieved by opioids. On examination, he has pain with passive stretch of the hallux and diminished two-point discrimination in the first web space. Intracompartmental pressure monitoring is performed. A fasciotomy is strictly indicated when the difference between the diastolic blood pressure and the compartment pressure (Delta P) is less than:

Explanation

Compartment syndrome is primarily a clinical diagnosis, but when continuous or intermittent pressure monitoring is utilized, a Delta P (diastolic blood pressure minus compartment pressure) of less than 30 mmHg is an absolute indication for emergency fasciotomy to prevent irreversible ischemic necrosis of muscles and nerves.

Question 81

A 6-year-old boy falls from the monkey bars and presents with a widely displaced extension-type supracondylar humerus fracture. On examination, the hand is pink but the radial pulse is absent. Capillary refill is brisk. The child is unable to make an 'OK' sign. What is the most appropriate initial management step?

Explanation

In a 'pink, pulseless' hand associated with a pediatric supracondylar humerus fracture, the initial step is urgent closed reduction and percutaneous pinning (CRPP). Often, the brachial artery is kinked or in spasm over the proximal fracture fragment, and anatomical reduction will restore the pulse. Immediate vascular imaging or exploration delays necessary fracture reduction and is not the first step. The inability to make an 'OK' sign indicates an anterior interosseous nerve (AIN) palsy, the most common nerve injury in extension-type fractures.

Question 82

A 45-year-old male construction worker falls from a roof and sustains a displaced intra-articular calcaneus fracture (Sanders Type III). He is scheduled for open reduction and internal fixation via an extensile lateral approach. To minimize the risk of wound sloughing and necrosis, the surgeon should ensure that the full-thickness soft tissue flap protects the vascular supply from which of the following arteries?

Explanation

The extensile lateral approach to the calcaneus carries a notorious risk of wound-healing complications. The large L-shaped soft tissue flap relies entirely on the lateral calcaneal artery, a terminal branch of the peroneal artery. To preserve this precarious blood supply, the flap must be raised as a single, full-thickness ('no touch') subperiosteal layer.

Question 83

A 68-year-old female with a 10-year history of alendronate use presents with right thigh pain for the past 3 months. Radiographs demonstrate focal lateral cortical thickening and a transverse radiolucent line in the subtrochanteric region of the right femur. The patient is ambulating with a limp. What is the recommended orthopedic management?

Explanation

Atypical femur fractures (AFFs) are a recognized complication of long-term bisphosphonate therapy. They typically present with prodromal thigh pain and distinct radiographic features (lateral cortical thickening, transverse 'beaking'). Given the presence of a radiolucent line (incomplete fracture) and mechanical pain (limp), prophylactic intramedullary nailing is highly recommended to prevent catastrophic completion of the fracture, which is associated with a high rate of nonunion.

Question 84

A 32-year-old snowboarder sustains a high-energy hyperdorsiflexion injury to the ankle, resulting in a Hawkins Type III fracture of the talar neck. The fracture is managed with emergent open reduction and internal fixation. At 8 weeks postoperatively, a radiograph is taken. The presence of subchondral radiolucency in the talar dome (Hawkins sign) on the AP view indicates:

Explanation

The Hawkins sign is a subchondral radiolucent band visible on the AP or mortise radiograph of the ankle, typically appearing 6 to 8 weeks after a talar neck fracture. It represents subchondral osteopenia secondary to disuse and active bone resorption. Because bone resorption requires an intact blood supply to deliver osteoclasts, a positive Hawkins sign is a highly reliable indicator of intact vascularity to the talar body, suggesting that avascular necrosis is unlikely.

Question 85

A 22-year-old male is admitted following a motor vehicle collision. He has a severe traumatic brain injury (GCS 6), bilateral pulmonary contusions, and a closed comminuted midshaft femur fracture. His initial lactate is 5.5 mmol/L and base deficit is -8. Based on the principles of Damage Control Orthopedics (DCO), what is the most appropriate management of his femur fracture at this time?

Explanation

Damage Control Orthopedics (DCO) is indicated in 'borderline' or 'unstable' polytrauma patients, particularly those with severe head or chest trauma and profound physiologic derangement (e.g., high lactate, base deficit). Early total care (reamed IM nailing) can exacerbate the systemic inflammatory response ('second hit') and worsen pulmonary or cerebral edema. DCO involves rapid, temporary stabilization with an external fixator to control pain and hemorrhage, followed by definitive fixation once the patient is physiologically optimized.

Question 86

A 35-year-old male is brought to the trauma bay after a motorcycle crash. His blood pressure is 75/40 mmHg, and his heart rate is 135 bpm. A FAST scan is negative. Pelvic radiograph shows a widened pubic symphysis of 4 cm and bilateral sacroiliac joint disruptions. A pelvic binder is placed, and he receives 2 units of uncrossmatched blood, but his blood pressure remains 80/45 mmHg. What is the most appropriate next step in management?

Explanation

Hemodynamically unstable patients with pelvic ring injuries and a negative FAST scan require immediate intervention for pelvic hemorrhage. Preperitoneal pelvic packing or angioembolization are the treatments of choice for ongoing hemorrhage from the presacral venous plexus or internal iliac arterial branches. Binder or sheet placement is the initial step to reduce pelvic volume. CT scan is contraindicated in a hemodynamically unstable patient.

Question 87

A 28-year-old man sustains a completely displaced, vertically oriented (Pauwels type III) femoral neck fracture after falling from a height. He is taken to the operating room for closed reduction and internal fixation. Which of the following fixation constructs offers the highest biomechanical stability for this specific fracture pattern?

Explanation

Pauwels type III fractures (highly vertical) experience significant shear forces leading to varus collapse and nonunion. A sliding hip screw (fixed-angle device) combined with an anti-rotation cancellous screw provides superior biomechanical stability against shear forces compared to multiple cancellous screws alone in young adults.

Question 88

A 45-year-old woman presents with a complex bicondylar tibial plateau fracture (Schatzker VI). Preoperative CT scan demonstrates a displaced posteromedial articular fragment. To adequately visualize and reduce this specific fragment, which of the following surgical approaches is most appropriate?

Explanation

A displaced posteromedial fragment in a bicondylar tibial plateau fracture cannot be adequately reduced or stabilized through a standard anterolateral approach alone. A posteromedial approach allows direct visualization, reduction, and application of a buttress plate to counteract the typical apex-posterior and distal displacement of the fragment.

Question 89

A 40-year-old male falls from a ladder and sustains a severely displaced closed distal tibia pilon fracture with significant soft tissue swelling and fracture blisters. He is initially managed with a joint-spanning external fixator. What is the most appropriate timing for definitive open reduction and internal fixation?

Explanation

Standard of care for severe pilon fractures involves a staged protocol. Initial management includes a spanning external fixator to stabilize bone and allow soft tissue rest. Definitive ORIF is delayed until the soft tissues are amenable, typically indicated by the presence of skin wrinkling (the 'wrinkle sign') and resolution of significant edema, usually 10-21 days post-injury.

Question 90

A 30-year-old male sustains a Hawkins Type III fracture of the talar neck. Six weeks after open reduction and internal fixation, an AP radiograph of the ankle shows a subchondral radiolucent band in the talar dome. What is the clinical significance of this radiographic finding?

Explanation

A subchondral radiolucent band in the talar dome on an AP or mortise radiograph 6 to 8 weeks post-injury is known as the Hawkins sign. It represents subchondral osteopenia secondary to hyperemia and disuse, which confirms that the talar body has an intact vascular supply. Its presence is highly predictive that avascular necrosis will not occur.

Question 91

A 65-year-old woman undergoes volar locked plating for a displaced distal radius fracture. Four months postoperatively, she suddenly loses the ability to actively flex the interphalangeal joint of her thumb. She reports no recent acute trauma. What is the most likely cause of this complication?

Explanation

Attritional rupture of the flexor pollicis longus (FPL) tendon is a known complication of volar locked plating of the distal radius. It is usually caused by the plate being placed too far distally (beyond the watershed line), leading to mechanical prominence and frictional wear of the tendon. This presents as an inability to actively flex the thumb IP joint.

Question 92

A 25-year-old man sustains a Gustilo-Anderson Type IIIA open tibia fracture in a farming accident. The wound is heavily contaminated with soil. In addition to prompt surgical debridement, what is the most appropriate initial intravenous antibiotic regimen?

Explanation

For severe open fractures (Type III) occurring in farm environments, there is a high risk of clostridial infection due to soil contamination. The recommended prophylactic antibiotic regimen includes a first-generation cephalosporin (to cover Gram-positives), an aminoglycoside (to cover Gram-negatives), and Penicillin to cover anaerobes, specifically Clostridium species.

Question 93

A 22-year-old football player sustains a high-energy knee dislocation, which is closed reduced in the emergency department. His ankle-brachial index (ABI) is measured at 0.85 on the injured leg. Dorsalis pedis and posterior tibial pulses are palpable but asymmetrical compared to the contralateral limb. What is the next most appropriate step in management?

Explanation

In a patient with a knee dislocation, vascular injury is a major concern. An ABI < 0.9, abnormal pulses, or an asymmetrical pulse exam are absolute indications for further advanced vascular imaging. CT angiography is the standard non-invasive diagnostic modality of choice to definitively assess for popliteal artery injury before surgical intervention.

Question 94

A 45-year-old man falls from a roof and sustains a closed, displaced intra-articular calcaneus fracture (Sanders Type III). He is a current smoker (1 pack/day) and has poorly controlled diabetes mellitus (HbA1c = 9.5%). Which of the following management options minimizes his risk of soft-tissue complications while addressing the fracture?

Explanation

Extensile lateral approaches for calcaneus fractures carry a high risk of wound breakdown, deep infection, and flap necrosis, particularly in patients with significant risk factors such as active smoking and poorly controlled diabetes. In such cases, non-operative management or minimally invasive/percutaneous fixation techniques are strongly preferred to avoid catastrophic soft-tissue complications.

Question 95

A 34-year-old cyclist is struck by a vehicle and sustains a displaced midshaft clavicle fracture and an ipsilateral displaced fracture of the scapular neck. What is the primary indication for operative fixation of this 'floating shoulder' injury?

Explanation

A 'floating shoulder' (ipsilateral clavicle and scapular neck fractures) is not an absolute indication for surgery. Operative intervention (typically fixing the clavicle to restore the superior suspensory shoulder complex) is indicated when there is significant displacement of the glenohumeral joint, coracoclavicular ligament disruption, or medialization/angulation of the glenoid neck that fundamentally alters the biomechanics of the shoulder.

Question 96

A 45-year-old male is brought to the trauma bay following a high-speed motor vehicle collision. His blood pressure is 70/40 mm Hg and heart rate is 130 bpm. A pelvic radiograph demonstrates an anteroposterior compression type III (APC III) pelvic ring injury. A pelvic binder is applied correctly, and 2 units of uncrossmatched whole blood are administered. A FAST exam is negative for intraperitoneal fluid. His hemodynamics do not improve despite resuscitation. What is the most appropriate next step in management?

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and a negative FAST exam, the primary source of bleeding is assumed to be the pelvic retroperitoneum (venous plexus and cancellous bone). Once a pelvic binder is applied to reduce pelvic volume and stabilize the fracture, if the patient remains unstable, immediate preperitoneal pelvic packing (PPP) and/or pelvic angioembolization is indicated. Sending a hemodynamically unstable patient to the CT scanner is contraindicated. Since the binder is already applied, exchanging it for an external fixator will not provide significantly better immediate hemorrhage control in a patient in extremis.

Question 97

A 32-year-old male sustains a vertically oriented, displaced basicervical femoral neck fracture (Pauwels type III). He is treated with open reduction and internal fixation using a sliding hip screw combined with a derotational cancellous screw. Compared to fixation with three parallel cancellous screws, what is the primary biomechanical advantage of this construct?

Explanation

Pauwels type III femoral neck fractures have a high shear angle, predisposing them to varus collapse and nonunion. Biomechanical studies have consistently shown that fixed-angle constructs, such as a sliding hip screw (SHS) with an anti-rotation screw, provide greater construct stiffness, higher ultimate load to failure, and superior resistance to shear stress compared to standard fixation with three parallel cancellous screws. This makes the SHS construct particularly advantageous for high-angle, vertically oriented fractures in young adults.

Question 98

A 65-year-old female with osteoporosis undergoes minimally invasive plate osteosynthesis (MIPO) using a lateral locked plate for an extra-articular distal femur fracture. Six months postoperatively, she presents with persistent thigh pain and radiographs demonstrate an atrophic nonunion with intact hardware. Which of the following technical errors during the initial fixation most likely contributed to this complication?

Explanation

Bridge plating relies on relative stability to promote secondary bone healing via callus formation. This requires interfragmentary micromotion. If locking screws are placed too close to the fracture site, the working length (the distance between the two closest screws on either side of the fracture) is significantly decreased. This renders the construct overly rigid, which suppresses interfragmentary strain and callus formation, ultimately leading to an atrophic or oligotrophic nonunion.

Question 99

A 40-year-old man sustains a severe bicondylar tibial plateau fracture (Schatzker VI) with severe soft tissue swelling. A spanning external fixator is placed. Two weeks later, the soft tissue envelope has recovered (positive wrinkle test), and the patient undergoes definitive open reduction and internal fixation using dual plates. Which of the following surgical strategies historically carries the highest risk of devastating soft tissue complications and deep infection?

Explanation

Historically, utilizing a single, extensive anterior midline incision to plate both the medial and lateral columns of the tibial plateau required massive subcutaneous stripping. This severely compromises the vascular supply to the skin flaps, leading to unacceptably high rates of wound edge necrosis, breakdown, and deep infection. Standard modern management requires either dual incisions (e.g., anterolateral and posteromedial with a wide skin bridge) or minimally invasive techniques to respect the vulnerable soft tissue envelope.

Question 100

A 28-year-old roofing contractor falls 15 feet, sustaining a closed, displaced intra-articular calcaneus fracture (Sanders type III). He undergoes open reduction and internal fixation via an extensile lateral approach. To minimize the risk of wound edge necrosis, surgical dissection relies on preserving the primary vascular supply to the full-thickness lateral flap. Which of the following arteries provides this critical blood supply?

Explanation

The primary blood supply to the tip (apex) of the extensile lateral flap used for calcaneus fracture fixation is the lateral calcaneal artery, a terminal branch of the peroneal artery. To preserve this vascular supply, the vertical limb of the incision must be placed carefully—typically midway between the posterior margin of the fibula and the lateral border of the Achilles tendon—and the entire flap must be elevated as a full-thickness subperiosteal layer.

Orthopedic Surgery Board Prep: Set 403 (100 MCQs on Fractures & Casting)

Orthopedic Trauma 2026 MCQs: Board Review Questions & Answers (Part 1)

Key Takeaway

Orthopedic Trauma 2026 MCQs: Board Review Questions & Answers (Part 1)

Chapter Index