Orthopedic Trauma 2026 MCQs: Fracture Management

Question 1

A 26-year-old woman sustained a nondisplaced femoral neck fracture and treatment consisted of use of percutaneous cannulated screws. At her 3-month follow-up visit, she reports hip pain and is unable to ambulate. A radiograph is shown in Figure 1. What is the next most appropriate treatment?

Explanation

Femoral neck fracture nonunion is a challenging problem for orthopaedic surgeons. Vertical fractures are more prone to nonunion due to shear stress rather than compressive forces across the fracture site. Several authors have suggested these fractures are more common in young adults due to injury type and bone composition. It is widely regarded that an effort should be made to salvage the femoral head if vascularity remains. The most common method to treat this complication is valgus intertrochanteric osteotomy of the femur. This functionally makes a vertical fracture more horizontal, converting shear into compressive forces. It also helps correct the varus position of the fracture nonunion. Hartford JM, Patel A, Powell J: Intertrochanteric osteotomy using a dynamic hip screw for femoral neck nonunion. J Orthop Trauma 2005;19:329-333.

Question 2

Which of the following choices best describes the fracture pattern shown in Figures 2a through 2c?

Explanation

2b 2c The fracture pattern shown in the radiographs is a fracture of the posterior column. The only line interrupted on the AP pelvis is the ilioischial line. The obturator oblique view shows that the iliopectineal line is intact as is the outline of the posterior wall. The iliac oblique view shows an interruption of the ilioischial line and an intact anterior wall. Therefore, this fracture is a fracture of the posterior column. Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.

Question 3

The correct starting point for an external fixation half pin placed into the anterior inferior iliac spine (AIIS) is labeled by what letter in Figure 3?

Explanation

Half pins placed in the AIIS are an alternative to pins placed in the iliac crest. A strong pillar of bone runs from the AIIS to the posterior iliac crest and less soft tissue is typically present in this area. The starting point is best seen on an obturator outlet view. The obturator outlet view is a combination of the pelvic outlet view and the obturator view of Judet and Letournel. The beam is rotated "over the top" of the patient since the iliac wing is externally rotated as well as cephalad to best visualize this column of bone running from the AIIS to the posterior iliac spine. This corridor of bone will appear as a teardrop. Once the correct view is obtained, the pin should be started at least 2 cm proximal to the hip joint to avoid placing a pin within the hip capsule. Blunt dissection and a guide sleeve should be used to prevent damage to the lateral femoral cutaneous nerve. An iliac oblique view is used after the pin has been partially inserted to make sure the pin is passing superior to the superior gluteal notch, and an obturator inlet view can be used at the completion of the procedure to make sure the pin is contained within the bone for its entire length. Gardner MJ, Nork SE: Stabilization of unstable pelvic fractures with supra-acetabular compression external fixation. J Orthop Trauma 2007;21:269-273. Haidukewych GJ, Kumar S, Prpa B: Placement of half-pins for supra-acetabular external fixation: An anatomic study. Clin Orthop Relat Res 2003;411:269-273.

Question 4

Figures 4a and 4b show the radiographs of a 53-year-old woman who was injured in a fall. After initial closed reduction, what is the preferred treatment for this fracture?

Explanation

4b This elbow fracture-dislocation involves a radial head fracture, coronoid fracture, and ulnohumeral dislocation (terrible triad). Several algorithms exist for treatment; surgical treatment is indicated. The treatment should address the radial head. Studies have shown replacement to be superior to repair in comminuted fractures. The coronoid may be addressed in unstable cases at the time of radial head excision and replacement. Lateral ligamentous repair is carried out during closure of the lateral elbow capsule. Medial ligamentous repair also may be undertaken but usually in concert with bony repair. Hinged external fixation remains an option when instability exists following bony and soft-tissue repair. Acute ulnar nerve transposition is rarely indicated. Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551.

Question 5

A 25-year-old semiprofessional football player sustains a hyperextension injury to the left foot. He is unable to bear weight. Examination reveals tenderness along the midfoot with swelling and plantar ecchymosis. Radiographs are negative. What is the next step in evaluation of this patient?

Explanation

The patient has a suspected Lisfranc sprain based on the plantar ecchymosis. The first step in diagnosis is a dynamic radiographic study. This should include a physician-assisted midfoot stress examination or standing weight-bearing radiographs to evaluate for displacement. There is no evidence of compartment syndrome, and a bone scan, CT, and MRI are expensive tests that are not warranted. Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green's Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.

Question 6

A 52-year-old woman slips in her bathroom and strikes her right hand on a cabinet. She notes swelling, ecchymosis, and pain with attempted motion. There are no open wounds. Radiographs are shown in Figures 5a through 5c. What is the most appropriate treatment?

Explanation

5b 5c Nondisplaced transverse fractures of the phalanges are stable. Immobilization in the intrinsic plus position will prevent MCP joint stiffness. Displaced oblique fractures are more at risk for instability. Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green's Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.

Question 7

A 19-year-old college student reports a 1-week history of wrist pain following an intramural rugby match. A PA radiograph is shown in Figure 6. He denies any prior wrist injury. What is the best course of action?

Explanation

The patient has a scaphoid fracture involving the proximal pole. Surgical treatment is recommended for such fractures because of the prolonged period of cast immobilization necessary and the increased risk of delayed union, nonunion, and/or osteonecrosis with nonsurgical management. A cannulated compression screw, inserted in the central scaphoid via a dorsal approach, is biomechanically advantageous and provides greater stability for fracture healing than Kirschner wires. Recently, good outcomes have been reported with arthroscopic-assisted percutaneous fixation of nondisplaced or minimally displaced scaphoid fractures. Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210. Chan KW, McAdams TR: Central screw placement in percutaneous screw scaphoid fixation: A cadaveric comparison of proximal and distal techniques. J Hand Surg Am 2004;29:74-79. Bedi A, Jebson PJ, Hayden RJ, et al: Internal fixation of acute non-displaced scaphoid waist fractures via a limited dorsal approach: An assessment or radiographic and functional outcomes. J Hand Surg Am 2007;32:326-333.

Question 8

A 29-year-old woman was injured in a high-speed motor vehicle accident 3 hours ago. Radiographs are shown in Figures 7a through 7e. Her right foot injury is open and contaminated. Her associated injuries include a closed head injury and a ruptured spleen requiring resection. She has had 6 units of packed red blood cells and the trauma surgeon has turned her care over to you. Her current base deficit is 10 and her urinary output has averaged 0.4 mL/kg for the last 2 hours. What is the best treatment at this time?

Explanation

7b 7c 7d 7e The patient appears to be a borderline or unstable surgical patient following her initial trauma and spleenectomy (high base excess and low urine output). She needs continued resuscitation and minimal additional blood loss. This is best accomplished with irrigation and debridement of the ankle, external fixation of the ankle, foot, and femur, and splinting of the forearm. A traction pin for the femoral fracture will not control bleeding as well as an external fixator. Intramedullary nailing of the femur and open reduction and internal fixation of the forearm would be appropriate in patients that are euvolemic and stable. Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461. Taeger G, Ruchholtz S, Waydhas C, et al: Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. J Trauma 2005;59:409-416. Harwood PJ, Giannoudis PV, van Griensven M, et al: Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma 2005;58:446-452.

Question 9

A 45-year-old man who is a smoker has a significant hemothorax and bilateral closed femoral fractures. On insertion of a chest tube, 1,100 mL of blood was returned. He has had 75 mL of chest tube output over the last 2 hours while being resuscitated in the ICU. His base deficit is now 2 and his urine output has been 3 mL/kg over the last hour. What is the next most appropriate step in management?

Explanation

Although this patient had a hemothorax, the bleeding has stopped and he has been resuscitated to a euvolemic status with a small base deficit and good urine output. External fixation of both femurs is an option but an unnecessary step in the treatment algorithm. Nork SE, Agel J, Russell GV, et al: Mortality after reamed intramedullary nailing of bilateral femur fractures. Clin Orthop Relat Res 2003;415:272-278.

Question 10

A 47-year-old woman falls and sustains a direct blow to her middle finger. She notes pain and swelling and is unable to move the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints. Radiographs are shown in Figures 8a through 8c. Proper management should consist of

Explanation

8b 8c The oblique nature of the fracture and extension of the fracture to the condyles implies an unstable fracture. Lag screw fixation provides an excellent chance of union, and the ability to start early range of motion. Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green's Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.

Question 11

Figures 9a and 9b show the radiographs of a 4-year-old child who sustained an elbow injury. What is the most likely complication resulting from this fracture if treated in a cast?

Explanation

9b The radiographs show a lateral condyle fracture with 2 mm of displacement. As opposed to other pediatric elbow fractures, lateral condyle fractures have a higher incidence of nonunion. This may be due to minimal metaphyseal bone on the distal fragment, the intra-articular nature of the fracture, or from further displacement when treated nonsurgically. These fractures with 2 mm and greater of displacement should be treated with reduction and stabilization. Osteonecrosis and fishtail deformity may be seen in very rare cases of lateral condyle fractures. The incidence is certainly less than the rates of nonunion seen in nonsurgically treated fractures with 2 mm and greater of displacement. Varus malunion from overgrowth and elbow stiffness are more likely seen in fractures treated surgically. Pirker ME, Weinberg AM, Hollwarth ME, et al: Subsequent displacement of initially nondisplaced and minimally displaced fractures of the lateral humeral condyle in children. J Trauma 2005;58:1202-1207. Finnbogason T, Karlsson G, Lindberg L, et al: Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: A prospective radiographic investigation of fracture stability. J Pediatr Orthop 1995;15:422-425.

Question 12

Which of the following is most commonly associated with an open clavicular fracture?

Explanation

Open clavicular fractures are rare and result from high-energy trauma. In a series of 20 patients with open clavicular fractures, 13 (65%) sustained a closed head injury. Fifteen (75%) had associated pulmonary injuries and 35% had a cervical or thoracic spine fracture. Only one demonstrated scapulothoracic dissociation. Screening for pulmonary and closed head injuries should be considered in the setting of traumatic open clavicular fractures.

Question 13

A 22-year-old woman injures her neck in a motor vehicle accident. Examination reveals no sensory or motor function below T8. Radiographs and an MRI scan show a burst fracture at T7. Forty-eight hours later, the bulbocavernosus reflex is present but there is no evidence of motor or sensory recovery in the lower extremities. What is the most likely diagnosis?

Explanation

Spinal shock typically ends after 48 hours with the return of reflexes, including the bulbocavernosus reflex. Lack of motor or sensory recovery in the lower extremities with the return of reflexes generally indicates a complete cord syndrome. Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 179-187.

Question 14

A 26-year-old man falls off a motorcycle and injures his left wrist. There are no open wounds and the neurovascular examination is normal. Radiographs are shown in Figures 10a and 10b. Definitive management should consist of

Explanation

10b The patient has a high-energy injury with resultant comminution of the distal radius metaphysis. Cast immobilization is likely to lead to radial shortening and angulation due to the comminution. Similarly, while external fixation and pinning has been successful in the past, some loss of radial length and volar angulation is typically noted. Present plate fixation devices for the distal radius employing locking screw technology have a superior ability to resist radial shortening and dorsal angulation. Fixation of the ulnar styloid is warranted when there is distal radioulnar joint instability or significant displacement of the styloid. This is more likely to occur with a fracture at the base of the styloid. In this instance, the distal radioulnar joint does not appear to be disrupted. May MM, Lawton JN, Blazar PE: Ulnar styloid fractures associated with distal radius fractures: Incidence and implications for distal radioulnar joint instability. J Hand Surg Am 2002;27:965-971.

Question 15

Which of the following studies best increases the ability to diagnose femoral neck fractures in patients with femoral shaft fractures?

Explanation

Tornetta and associates and Yang and associates found that nearly half of all femoral neck fractures associated with femoral shaft fractures were being missed at their institution. On the basis of the delayed diagnosis of these injuries, a best-practice protocol was developed by the attending trauma surgeons for the evaluation of the femoral neck in patients with a femoral shaft fracture. This protocol includes a preoperative AP internal rotation radiograph of the hip, a fine-cut (2-mm) CT scan through the femoral neck (as a part of the initial trauma scan), and an intraoperative fluoroscopic lateral evaluation of the hip just prior to fixation of the femoral shaft. In addition, postoperative AP and lateral radiographs of the hip are made in the operating room to specifically evaluate the femoral neck before the patient is awakened. They found that fine-cut CT (2 mm was the best screening tool in this group of patients) identified 12 of the 13 fractures, whereas 8 of the 13 fractures were visible on the dedicated preoperative AP internal rotation hip radiographs. Tornetta P III, Kain MS, Creevy WR: Diagnosis of femoral neck fractures in patients with a femoral shaft fracture: Improvement with a standard protocol. J Bone Joint Surg Am 2007;89:39-43.

Question 16

The axis of forearm rotation occurs between what two anatomic points?

Explanation

Forearm rotation results from a complex interaction of osseous articulations and soft tissues including the radiocapitellar articulation, proximal and distal radioulnar joints, the interosseous membrane, and the adjacent forearm muscles. The rotation occurs around a longitudinal forearm axis extending from the center of the radial head proximally through the foveal region of the ulnar head distally. Werner FW, An KN: Biomechanics of the elbow and forearm. Hand Clin 1994;10:357-373.

Question 17

Figure 11 shows the radiograph of a 26-year-old man with type I diabetes mellitus who was struck by a motor vehicle. What is the most common complication associated with this pelvic fracture?

Explanation

The most common complication following acetabular or pelvic ring injury is deep venous thrombosis (DVT). Without prophylaxis, rates of DVT are as high as 70% to 80%. With prophylaxis, the rates are around 10%. Infection rates in surgical repair of acetabular fractures are relatively low but a history of diabetes mellitus and a significant Morel-Lavalle lesion certainly increase the risk. However, even with these two complicating factors, the rates of infection are still lower than 10%. Sciatic nerve palsy rates from the injury alone approach 20% and iatrogenic injury is usually less than 2%. Degenerative changes to the hip following this injury approach 20% to 25%, even with an anatomic reduction. Geerts WH, Code KI, Jay RM, et al: A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994;331:1601-1606.

Question 18

Which of the following factors is a significant predictor of reoperation following open reduction and internal fixation of intertrochanteric fractures with a sliding-compression hip-screw device?

Explanation

As shown by Palm and associates from the Hip Fracture Study group, the integrity of the lateral femoral cortex in intertrochanteric hip fractures is a significant predictor of reoperation. Baumgartner and associates have shown that a tip-apex distance of greater than 25 mm is associated with a high risk of femoral head cut-out. Lastly, intertrochanteric hip fractures can be described as standard obliquity or reverse obliquity when describing the fracture pattern. Mechanistically, a reverse obliquity pattern is important to recognize because it reflects the presence or absence of a lateral buttress to which the proximal fracture fragment may compress. Palm H, Jacobsen S, Sonne-Holm S, et al: Integrity of the lateral femoral wall in intertrochanteric hip fractures: An important predictor of a reoperation. J Bone Joint Surg Am 2007;89:470-475. Sadowski C, Lübbeke A, Saudan M, et al: Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: A prospective, randomized study. J Bone Joint Surg Am 2002;84:372-381.

Question 19

Following fixation of a displaced intra-articular fracture of the distal humerus through a posterior approach, what is the expected outcome?

Explanation

Following repair of a displaced intra-articular distal humerus fracture, the ability to regain full elbow range of motion is rare. Recent reports of olecranon osteotomy have yielded healing rates of between 95% to 100%. According to McKee and associates, patients can be expected to have residual loss of elbow flexion strength of 25%. McKee MD, Wilson TL, Winston L, et al: Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82:1701-1707.

Question 20

A 15-year-old boy falls from his bicycle and sustains an injury to his elbow. Prereduction radiographs are shown in Figure 12a. Closed reduction is performed without difficulty and postreduction radiographs are shown in Figure 12b. What is the next most appropriate step in treatment?

Explanation

12b Elbow dislocations in children are rare injuries and usually result from a fall on an outstretched arm. The incidence of these injuries increases as patients age and concurrently the incidence of supracondylar humerus fractures decreases. In adolescent patients, simple elbow dislocations are treated with splint immobilization and the initiation of physical therapy once comfortable. The practitioner must be aware of structures that may get caught in the joint on reduction. These include the median nerve as well as the medial epicondyle. In this patient, the radiographs reveal a medial epicondyle fracture. Postreduction radiographs show the joint to be incongruous secondary to intra-articular displacement. At this point, the most appropriate treatment is to perform an open reduction and repair of the medial epicondyle fragment. Rasool MN: Dislocations of the elbow in children. J Bone Joint Surg Br 2004;86:1050-1058.

Question 21

A 7-year-old boy is seen in the emergency department with an isolated and displaced supracondylar humerus fracture and absent radial and ulnar pulses. Despite a moderately painful attempt at realignment, examination reveals that his hand remains pulseless. What is the next most appropriate step in management?

Explanation

Displaced supracondylar humerus fractures in children may have associated vascular compromise. Decreased blood flow may be due to vessel injury, entrapment within the fracture site, kinking from fracture displacement, or from vessel spasm. Optimal initial treatment in the emergency department includes gentle realignment of the limb and vascular assessment. Angiography is not required in isolated injuries as the level of the vessel compromise is always at the site of the fracture. When blood flow is not restored, the next best step in treatment is to proceed urgently to the operating room. A formal closed reduction and pinning is performed, and then the vascular status is reassessed. Exploration and vascular repair is required if the hand is cool, white, and without pulses. Ay S, Akinci M, Kamiloglu S, et al: Open reduction of displaced pediatric supracondylar humeral fractures through the anterior cubital approach. J Pediatr Orthop 2005;25:149-153. Sabharwal S, Tredwell SJ, Beauchamp RD, et al: Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop 1997;17:303-310.

Question 22

A 28-year-old cowgirl was injured while herding cattle 1 week ago. A radiograph and CT scans are shown in Figures 13a through 13c. What is the most appropriate management for this injury?

Explanation

13b 13c The patient has an AP I pelvic ring disruption with minimal symphyseal widening. The best treatment is nonsurgical management and weight bearing as tolerated. This will help close the anterior pelvic ring during the healing process. Pelvic binders are excellent for acute treatment of widely displaced pelvic fractures but are not recommended for long-term use. Open reduction and internal fixation is not indicated for this injury and furthermore, the posterior ring is not injured. Matta JM: Indications for anterior fixation of pelvic fractures. Clin Orthop Relat Res 1996;329:88-96. Templeman DC, Schmidt AH, Sems SA, et al: Diastasis of the symphysis pubis: Open reduction internal fixation, in Wiss D (ed): Masters Techniques in Orthopaedic Surgery-Fractures, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 639-648.

Question 23

As reflected by the SF-36 scores, patients with which of the following conditions demonstrate the most disability in physical function?

Explanation

Pollak and associates found that the average SF-36 score for patients who sustained a pilon fracture was significantly lower than patients with diabetes mellitus, AIDS, hypertension, asthma, migraines, pelvic fracture, polytrauma, and AMI. Moreover, patients having undergone pilon fixation scored lower on all but three of the SF-36 scales (vitality, mental health, and emotional health).

Question 24

A 25-year-old man is involved in a motor vehicle accident and brought to the emergency department at 4 am on Sunday morning. He has a closed distal third femoral shaft fracture. His leg is initially pulseless but after applying inline traction, a distal pulse can be palpated and the limb appears to be viable. The pulse in the injured limb "feels" different than the pulse in the uninjured limb. What is the next step in assessing the vascular status of this limb?

Explanation

The patient initially has a distal third femoral fracture and a pulseless limb. The first step is to reduce the fracture and reassess the vascular status. Although the pulse returns, it feels different than the quality of the pulse in the contralateral uninjured extremity. There is a risk of a vascular injury with this fracture pattern due to tethering of the femoral vessels at the adductor hiatus; therefore, the vascular status needs further assessment since the pulses are not symmetrical. A physical examination is not very accurate in assessing whether a vascular injury is present; therefore, serial examinations are not appropriate. Angiography is very sensitive and specific but is time consuming and can cause complications secondary to the dye and the arterial puncture required to perform it. Duplex ultrasound is effective but is very operator-dependent and may not be available 24 hours a day. The ABI is easily performed and has been shown to be sensitive and specific. If the value is greater than 0.9, the negative predictive value is 99% and when the value is less than 0.9, it is 95% sensitive and 97% specific for a major arterial injury. It has been shown to be useful for blunt lower extremity injuries as well as knee dislocations. Levy BA, Zlowodzki MP, Graves M, et al: Screening for extremity arterial injury with the arterial pressure index. Am J Emerg Med 2005;23:689-695. Abou-Sayed H, Berger DL: Blunt lower-extremity trauma and politeal artery injuries: Revisiting the case for selective arteriography. Arch Surg 2002;137:585-589.

Question 25

What is the most appropriate treatment for a 50-year-old woman who sustains the injury shown in Figures 14a and 14b?

Explanation

14b This intra-articular distal humerus fracture with displacement at the joint surface is best treated with surgical fixation. The most biomechanically sound construct is two plates applied to either column 180 degrees from one another. Elbow arthroplasty is most appropriate for low demand elderly patients. Schemitsch EH, Tencer AF, Henley MB: Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 1994;8:468-475. McCarty LP, Ring D, Jupiter JB: Management of distal humerus fractures. Am J Orthop 2005;34:430-438.

Question 26

A 28-year-old man sustains a closed right tibial shaft fracture. Two hours after admission, he complains of severe leg pain exacerbated by passive toe stretch. His blood pressure is 110/70 mm Hg. The anterior compartment pressure is measured at 45 mm Hg. Which of the following is the most appropriate next step in management?

Explanation

The patient has a delta P (diastolic BP minus compartment pressure) of 25 mm Hg, which is highly diagnostic for acute compartment syndrome (threshold < 30 mm Hg). Urgent four-compartment fasciotomy is required to prevent irreversible muscle and nerve necrosis.

Question 27

Six months after undergoing volar locked plating for a distal radius fracture, a 55-year-old woman reports sudden inability to actively flex the interphalangeal joint of her thumb. Radiographs reveal the plate was placed distal to the watershed line. What is the most likely cause of her current symptoms?

Explanation

Placement of a volar plate distal to the watershed line of the radius increases the risk of flexor tendon attrition and subsequent rupture. The flexor pollicis longus (FPL) is the most commonly affected tendon in this scenario.

Question 28

Which of the following fracture characteristics is the most reliable predictor of humeral head ischemia following a proximal humerus fracture?

Explanation

Hertel's criteria for predicting humeral head ischemia include an anatomical neck fracture, a disrupted medial hinge, and a metaphyseal head extension (calcar length) of less than 8 mm. These factors compromise the blood supply from the anterior and posterior humeral circumflex arteries.

Question 29

A 35-year-old man is brought to the trauma bay with an APC-III pelvic ring injury and hemodynamic instability. The trauma team decides to place a circumferential pelvic binder. To be most effective, the binder should be centered over which of the following anatomic landmarks?

Explanation

Circumferential pelvic binders are most effective at reducing pelvic volume and stabilizing the pelvis when centered over the greater trochanters. Placement over the iliac crests is incorrect and can exacerbate certain fracture patterns.

Question 30

A 30-year-old man sustains a displaced, vertically oriented (Pauwels Type III) femoral neck fracture. What is the most appropriate surgical management to minimize the risk of nonunion and avascular necrosis?

Explanation

Young patients with displaced femoral neck fractures require urgent anatomic reduction and stable internal fixation. A sliding hip screw (with or without a derotational screw) or length-stable construct is biomechanically superior to parallel screws for vertically oriented (Pauwels III) fractures.

Question 31

A 40-year-old patient presents with a severe knee injury following a motor vehicle collision. Lateral knee radiographs reveal a coronal shear fracture of the lateral femoral condyle. Which of the following best describes this fracture pattern and its optimal fixation?

Explanation

A coronal shear fracture of the femoral condyle is known as a Hoffa fracture. It is inherently unstable and typically requires open reduction and internal fixation using AP or PA lag screws to compress the articular surface.

Question 32

A 45-year-old man sustains a Gustilo-Anderson Type IIIB open tibial shaft fracture. According to recent literature, which of the following interventions has the greatest impact on reducing his risk of deep infection?

Explanation

The most critical factor in reducing the risk of infection in open fractures is the early administration of systemic antibiotics, ideally within 1 hour of injury. The '6-hour rule' for surgical debridement is less supported by current evidence compared to prompt antibiotic delivery.

Question 33

When stabilizing an intertrochanteric femur fracture with a cephalomedullary nail, the concept of the tip-apex distance (TAD) is critical to prevent hardware failure. A TAD greater than which of the following thresholds is associated with a significantly increased risk of lag screw cut-out?

Explanation

A tip-apex distance (TAD) greater than 25 mm is a strong predictor of lag screw cut-out in the treatment of intertrochanteric hip fractures. The measurement is the sum of the distance from the tip of the screw to the apex of the femoral head on both AP and lateral radiographs.

Question 34

A 35-year-old male sustains a severely comminuted open tibial shaft fracture with a 12 cm soft tissue laceration and stripped periosteum. A segmental bone defect is noted, but pedal pulses are palpable and symmetrical. According to the Gustilo-Anderson classification, what is the appropriate classification and definitive soft tissue coverage strategy?

Explanation

This is a Gustilo-Anderson Type IIIB fracture due to extensive soft tissue injury, periosteal stripping, and adequate vascularity. Standard management requires skeletal stabilization and local (e.g., gastrocnemius) or free flap coverage.

Question 35

A 28-year-old man presents with a closed midshaft tibia fracture. He complains of pain out of proportion to his injury that is exacerbated by passive stretch of his great toe. Compartment pressure monitoring reveals a diastolic blood pressure of 70 mmHg and a tissue pressure of 45 mmHg in the anterior compartment. What is the most appropriate next step?

Explanation

A delta pressure (diastolic BP minus compartment pressure) of less than 30 mmHg is highly indicative of acute compartment syndrome. The definitive and emergent treatment for tibial compartment syndrome is a four-compartment fasciotomy.

Question 36

A 45-year-old hypotensive male presents after a motorcycle crash. Pelvic radiographs demonstrate a symphyseal diastasis of 4 cm and widening of both sacroiliac joints. A pelvic binder was applied in the field. He remains hemodynamically unstable despite 2 units of uncrossmatched blood. FAST exam is negative. What is the most appropriate next intervention?

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST, the source of bleeding is primarily the presacral venous plexus or internal iliac arterial branches. Pre-peritoneal pelvic packing and/or angiography with embolization are the required emergent interventions.

Question 37

A 30-year-old female sustains a vertically oriented (Pauwels Type III) displaced femoral neck fracture. She is taken to the OR for closed reduction and percutaneous pinning. Which of the following biomechanical constructs provides the most stable fixation for this specific fracture pattern?

Explanation

Pauwels Type III fractures have a high shear angle, leading to increased failure rates with standard parallel cannulated screws. A sliding hip screw (fixed-angle device) with a derotational screw provides superior biomechanical stability against vertical shear forces.

Question 38

An 82-year-old female with a history of atrial fibrillation presents with a displaced left femoral neck fracture. She takes apixaban 5 mg twice daily, with her last dose 12 hours ago. Renal function is normal. What is the recommended timing for surgical intervention?

Explanation

For patients on direct oral anticoagulants like apixaban with normal renal function, a delay of 24 to 48 hours is recommended to allow clearance and reduce bleeding risks. Reversal agents are typically reserved for life-threatening hemorrhage.

Question 39

A 25-year-old snowboarder sustains a displaced talar neck fracture treated with open reduction and internal fixation. At 8 weeks postoperatively, AP ankle radiographs demonstrate a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

Explanation

The subchondral radiolucent band is known as Hawkins sign. It represents subchondral osteopenia, which requires an intact vascular supply to occur, effectively indicating viability and ruling out avascular necrosis.

Question 40

An 85-year-old community-ambulating female with severe pre-existing knee osteoarthritis sustains a comminuted distal femur fracture (AO/OTA 33-C2). She has severely osteopenic bone. What is the most reliable surgical option to allow immediate weight-bearing?

Explanation

In elderly patients with osteoporotic bone, comminuted distal femur fractures, and severe osteoarthritis, distal femoral replacement offers immediate stability. It allows early weight-bearing and addresses the arthritic joint, avoiding the high failure rates of internal fixation.

Question 41

A 40-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. Which of the following best describes the typical sequence of surgical repair to restore stability?

Explanation

Surgical management of terrible triad elbow injuries traditionally proceeds from deep to superficial, or 'inside-out'. The standard sequence is fixation of the coronoid fracture, followed by radial head repair or replacement, and finally repair of the lateral collateral ligament (LCL).

Question 42

A 22-year-old cyclist sustains a completely displaced midshaft clavicle fracture with 2.5 cm of shortening and no cortical contact. What is the most significant advantage of operative fixation compared to non-operative management for this specific injury?

Explanation

Displaced midshaft clavicle fractures with greater than 2 cm of shortening or no cortical contact have a significantly higher nonunion rate when treated non-operatively. Operative fixation reduces the rate of symptomatic nonunion and improves early functional outcomes.

Question 43

A 38-year-old man sustains a pelvic injury. CT imaging demonstrates a fracture line involving both columns of the acetabulum, with a 'spur sign' seen on the obturator oblique radiograph. No part of the articular surface remains attached to the intact ilium. What is the diagnosis?

Explanation

A both-column acetabular fracture detaches all articular segments from the intact axial skeleton. The 'spur sign' represents the intact strut of the ilium protruding above the medially displaced articular segments, pathognomonic for a both-column fracture.

Question 44

When evaluating a severely injured lower extremity using the Mangled Extremity Severity Score (MESS), which of the following variables contributes most heavily to a higher score predicting amputation?

Explanation

In the MESS criteria, prolonged limb ischemia (especially greater than 6 hours) receives the highest point allocation. Severe ischemia strongly correlates with a higher likelihood of eventual amputation.

Question 45

A 29-year-old rugby player sustains an external rotation ankle injury with a high fibula fracture. Intraoperatively, the syndesmosis remains unstable after fibula length is restored. Which of the following is true regarding syndesmotic screw fixation?

Explanation

Syndesmotic screws should be placed 2-3 cm above the ankle joint, parallel to the joint line, and angled roughly 20-30 degrees anteriorly to match the anatomic axis. Routine removal is no longer considered mandatory.

Question 46

A 24-year-old male presents with a closed middle-third spiral humeral shaft fracture. He develops an inability to extend his wrist or fingers immediately following a closed reduction attempt in the ED. What is the most appropriate management?

Explanation

A secondary radial nerve palsy that develops after a closed reduction attempt of a humeral shaft fracture is an absolute indication for surgical exploration. The nerve is highly likely to be entrapped in the fracture site.

Question 47

Following volar locked plating of a comminuted distal radius fracture, the patient develops attrition rupture of a tendon due to prominent screws penetrating the dorsal cortex. Which tendon is at greatest risk?

Explanation

The Extensor Pollicis Longus (EPL) tendon is highly susceptible to attrition rupture from dorsal screw prominence. It resides in the 3rd extensor compartment and courses around Lister's tubercle, where overpenetrating screws often protrude.

Question 48

A 20-year-old male sustains a low-velocity gunshot wound to the mid-thigh, resulting in a comminuted midshaft femur fracture. He is neurovascularly intact with no exit wound. What is the most appropriate initial management?

Explanation

Low-velocity gunshot wounds causing femur fractures without neurovascular compromise do not require formal tract debridement or bullet retrieval. Local wound care, IV antibiotics, and standard intramedullary nailing demonstrate excellent outcomes.

Question 49

A 24-year-old male presents with persistent wrist pain 8 months after a fall. Imaging reveals a scaphoid waist fracture nonunion with a 'humpback' deformity and proximal pole avascular necrosis. Which surgical intervention is most appropriate?

Explanation

A scaphoid nonunion with humpback deformity and proximal pole AVN requires restoration of length and robust blood supply. A vascularized bone graft (e.g., 1,2 ICSRA) combined with rigid fixation provides the best chance of union.

Question 50

A 32-year-old male presents with a comminuted tibial shaft fracture following a crush injury. He complains of severe pain out of proportion to the injury. Clinical examination is highly concerning for acute compartment syndrome. Which of the following pressure measurements is the most reliable threshold for indicating a fasciotomy?

Explanation

The delta P (diastolic blood pressure minus compartment pressure) is the most reliable indicator for acute compartment syndrome. A threshold of < 30 mm Hg strongly indicates the need for emergent fasciotomy, as absolute pressures can be misleading in hypotensive patients.

Question 51

A 25-year-old man sustains a low-velocity gunshot wound to the thigh resulting in a comminuted femoral shaft fracture. The bullet passed cleanly through without expanding. Distal pulses are normal, and there is no expanding hematoma. What is the most appropriate initial management?

Explanation

Low-velocity gunshot wounds causing femur fractures without vascular injury or massive contamination do not require formal operative debridement of the bullet tract. They are appropriately treated with local wound care, short-course antibiotics, and standard intramedullary nailing.

Question 52

A 45-year-old male is brought to the trauma bay after a motorcycle crash. He is hypotensive and tachycardic. A pelvic radiograph reveals an APC-III (open-book) pelvic ring injury. What is the correct anatomical landmark for the application of a circumferential pelvic sheet or binder?

Explanation

Circumferential pelvic binders should be centered directly over the greater trochanters to effectively reduce pelvic volume in open-book pelvic ring injuries. Placement higher over the iliac crests is biomechanically less effective and restricts abdominal access.

Question 53

A 30-year-old male falls from a height and sustains a Hawkins type III fracture of the talar neck. Which of the following best describes the expected rate of avascular necrosis (AVN) of the talar body in this injury pattern?

Explanation

Hawkins type III fractures involve dislocation of the talar body from both the subtalar and tibiotalar joints, disrupting all three main blood supplies. This results in an AVN rate approaching 70% to 100%.

Question 54

A 28-year-old female sustains a closed midshaft humerus fracture with an immediate, complete radial nerve palsy. She is managed nonoperatively in a functional brace. At 12 weeks, there is no clinical or electromyographic (EMG) evidence of radial nerve recovery. What is the next most appropriate step in management?

Explanation

For a closed humerus fracture with initial radial nerve palsy treated nonoperatively, failure to show clinical or EMG recovery by 3 to 4 months is an absolute indication for surgical exploration of the nerve.

Question 55

Which of the following is considered the most important blood supply to the articular segment of the humeral head, making it a critical structure to preserve during proximal humerus fracture fixation?

Explanation

Modern anatomical studies demonstrate that the posterior humeral circumflex artery (PHCA) provides the predominant blood supply (up to 64%) to the humeral head. This contradicts older literature that heavily emphasized the arcuate branch of the AHCA.

Question 56

A 40-year-old man sustains a Grade IIIB open tibia fracture following an industrial crush injury. According to current evidence-based guidelines, what is the most critical factor in reducing his risk of deep infection?

Explanation

Early administration of intravenous antibiotics (ideally within 1 hour of injury) is the single most critical factor in reducing infection rates in open fractures. The traditional '6-hour rule' for surgical debridement has not been consistently supported by modern literature.

Question 57

A 70-year-old woman taking alendronate for 8 years presents with severe right thigh pain after a minor trip. Radiographs show a transverse fracture in the subtrochanteric region with lateral cortical thickening and a medial spike. What is the most appropriate management?

Explanation

This is a classic bisphosphonate-associated atypical femur fracture. Management requires stopping the drug, utilizing a full-length intramedullary nail to protect the entire bowed femur, and evaluating the contralateral side for impending lesions.

Question 58

A 24-year-old polytrauma patient with a severe head injury (GCS 7) and bilateral femoral shaft fractures presents to the trauma bay. His initial lactate is 5.5 mmol/L and base excess is -8. What is the most appropriate initial management of his bilateral femur fractures?

Explanation

In a hemodynamically unstable or 'borderline' polytrauma patient with elevated lactate and severe traumatic brain injury, Damage Control Orthopedics (DCO) with rapid external fixation is indicated. This minimizes the 'second hit' inflammatory response from a lengthy IM nailing procedure.

Question 59

A 45-year-old female falls onto an outstretched hand and sustains a 'terrible triad' injury of the elbow. Which of the following represents the most accepted surgical sequence for reconstructing this injury?

Explanation

The standard surgical sequence for a terrible triad injury works deep to superficial from lateral to medial. It involves fixing the coronoid first, addressing the radial head (repair or replacement), and finally repairing the lateral ulnar collateral ligament (LUCL).

Question 60

A 40-year-old male sustains a posteromedial shear fracture of the tibial plateau. Which of the following surgical approaches is most appropriate for direct visualization and buttress plating of this specific fracture fragment?

Explanation

The posteromedial approach utilizes the interval between the medial head of the gastrocnemius and the pes anserinus tendons. It allows direct access for anti-glide or buttress plating of posteromedial shear fragments in complex tibial plateau fractures.

Question 61

A 35-year-old male is brought to the trauma bay after a high-speed motorcycle collision. He is hemodynamically unstable with a suspected anteroposterior compression (APC) pelvic ring injury. A pelvic binder is ordered. To be most biomechanically effective at reducing pelvic volume, at what anatomical level should the binder be centered?

Explanation

Pelvic binders should be centered over the greater trochanters to effectively close an open-book pelvic injury. Placement over the iliac crests or ASIS is less effective and may paradoxically widen the pelvis in some fracture patterns.

Question 62

A 28-year-old intubated male with a closed tibial shaft fracture develops a tense, swollen leg. His blood pressure is 110/70 mmHg. Direct compartment pressure measurement of the anterior compartment yields an absolute pressure of 45 mmHg. Which of the following defines the accepted pressure threshold indicating the need for a four-compartment fasciotomy in this scenario?

Explanation

A delta pressure (diastolic blood pressure minus absolute compartment pressure) of less than 30 mmHg is the most reliable indicator for surgical fasciotomy. In this patient, the delta pressure is 25 mmHg (70 - 45), indicating inadequate perfusion.

Question 63

A 45-year-old female sustains a severe crush injury to her lower extremity, resulting in a Grade IIIA open tibial diaphyseal fracture. According to current evidence-based literature, which of the following variables is most significantly associated with a decreased risk of deep infection?

Explanation

Early administration of systemic antibiotics is the single most critical factor in reducing infection rates in open fractures. Delaying antibiotics significantly increases the risk of deep infection.

Question 64

A 22-year-old male sustains bilateral closed femoral shaft fractures and a severe bilateral pulmonary contusion following a motor vehicle collision. Initial resuscitation reveals a serum lactate of 5.5 mmol/L and a pH of 7.21. After initial fluid resuscitation, his lactate remains 4.0 mmol/L. What is the most appropriate initial orthopedic management of his femur fractures?

Explanation

This patient meets the criteria for a borderline/unstable polytrauma patient with evidence of persistent hypoperfusion (elevated lactate). Damage control orthopedics (DCO) utilizing bilateral external fixation is indicated to minimize the second hit associated with reamed intramedullary nailing.

Question 65

A 32-year-old male is 8 weeks status post open reduction and internal fixation of a displaced talar neck fracture. Routine follow-up radiographs demonstrate a distinct band of subchondral radiolucency in the talar dome. What is the most likely clinical significance of this radiographic finding?

Explanation

This subchondral radiolucency is known as the Hawkins sign. It indicates intact vascularity to the talar body, as it represents subchondral osteopenia secondary to normal hyperemic revascularization.

Question 66

A 78-year-old female falls from a standing height and sustains an anterior column/posterior hemitransverse acetabular fracture. Radiographs and CT imaging show severe osteopenia, marginal impaction of the superior dome, and full-thickness cartilage damage to the femoral head (gull sign). What is the most appropriate definitive management?

Explanation

In elderly patients with specific acetabular fractures complicated by severe impaction (gull sign), severe osteopenia, or femoral head damage, combining limited ORIF (to stabilize the columns) with acute THA yields superior functional outcomes compared to ORIF alone.

Question 67

A 62-year-old female presents with a distal radius fracture following a fall. Closed reduction and splinting are performed in the emergency department. Which of the following radiographic parameters present on the initial injury films is most predictive of instability and secondary loss of reduction?

Explanation

According to Lafontaine's criteria, initial dorsal tilt > 20 degrees, dorsal comminution, intra-articular involvement, age > 60, and associated ulnar fractures are predictors of instability. Volar comminution typically requires a distinct surgical approach but initial dorsal tilt > 20 degrees is a classic predictor of collapse.

Question 68

A 40-year-old male sustains a high-energy complex bicondylar tibial plateau fracture (Schatzker VI). CT imaging reveals a large, medially displaced, and coronally oriented posteromedial fragment. What is the optimal surgical approach to safely and directly reduce and stabilize this posteromedial fragment?

Explanation

A coronally oriented posteromedial fragment in a bicondylar plateau fracture cannot be adequately reduced or buttressed from a purely anterolateral approach. A dual incision technique (anterolateral and posteromedial) is standard for direct visualization and buttress plating.

Question 69

A 55-year-old male is treated with a lateral locked plating construct for a supracondylar femur fracture (AO 33-A3). Six months later, he presents with pain and radiographic evidence of a nonunion. Retrospective review of his surgical construct reveals high screw density near the fracture site and the use of all locking screws. What mechanical factor most likely contributed to this nonunion?

Explanation

Comminuted extra-articular distal femur fractures heal primarily via secondary bone healing (callus formation), which requires controlled interfragmentary motion. A construct that is too rigid (e.g., high screw density, all locking screws) prevents this micro-motion, increasing the risk of nonunion.

Question 70

A 35-year-old male sustained a highly comminuted, displaced intra-articular calcaneus fracture (Sanders Type III) after a fall from a roof. The surgeon plans an open reduction internal fixation via an extensile lateral approach. Which of the following is the most reliable clinical indicator that the soft tissue envelope is ready for surgery?

Explanation

The extensile lateral approach to the calcaneus carries a high risk of wound healing complications. Surgery must be delayed until soft tissue swelling has subsided, reliably indicated by the presence of a positive wrinkle sign on the lateral hindfoot.

Question 71

A 19-year-old male presents with a midshaft diaphyseal femur fracture caused by a low-velocity handgun bullet. There is no active bleeding, normal distal pulses, and intact neurological function. What is the most appropriate management strategy for the fracture?

Explanation

Low-velocity gunshot wounds to the diaphyseal femur without neurovascular compromise or massive contamination do not require formal operative debridement of the bullet tract. They are safely and effectively managed with standard reamed intramedullary nailing.

Question 72

A 25-year-old male is involved in a severe rollover motor vehicle crash. Examination reveals massive swelling over the left shoulder girdle. An AP chest radiograph demonstrates lateral displacement of the left scapula with a widened sternoclavicular joint and an intact clavicle. Which of the following associated injuries is most critical to evaluate in this patient?

Explanation

Lateral displacement of the scapula suggests scapulothoracic dissociation, a severe, high-energy injury. It is highly associated with devastating neurological (complete brachial plexus avulsion) and vascular (subclavian or axillary artery) injuries that can be life- or limb-threatening.

Question 73

A 70-year-old male with a history of a cemented total hip arthroplasty (THA) sustains a spiral fracture of the femoral diaphysis after a minor fall. The fracture occurs entirely distal to the tip of the well-fixed femoral stem (Vancouver C). What is the recommended surgical management?

Explanation

Vancouver C periprosthetic fractures occur well below the tip of the prosthesis. They are managed similarly to standard diaphyseal femur fractures but require internal fixation with a plate that safely overlaps the distal tip of the existing stem to prevent a stress riser.

Question 74

A 40-year-old male presents to the emergency department after falling on his outstretched arm. Radiographs reveal an anterior shoulder dislocation and an associated greater tuberosity fracture. Following a successful closed reduction of the glenohumeral joint, repeat radiographs show the greater tuberosity fragment displaced 8 mm superiorly. What is the most appropriate next step in management?

Explanation

In the setting of an anterior shoulder dislocation, a greater tuberosity fracture that remains displaced >5 mm (or >3 mm in an active patient) after closed reduction requires surgical fixation to prevent significant subacromial impingement and loss of rotator cuff function.

Question 75

A 30-year-old male is evaluated after striking his chin on the steering wheel during a frontal motor vehicle collision. Cervical spine imaging demonstrates bilateral fractures of the pars interarticularis of C2 with anterior displacement of C2 on C3. What is the classic mechanism of this specific injury?

Explanation

This injury describes a traumatic spondylolisthesis of the axis, commonly known as a Hangman's fracture. The classic mechanism in a motor vehicle collision (e.g., striking the chin) is severe hyperextension combined with axial loading.

Question 76

A 30-year-old man presents with a high-energy grade IIIA open tibia shaft fracture. Which of the following factors is the most critical and reliable predictor for preventing a deep surgical site infection in this patient?

Explanation

The most critical factor in decreasing infection rates in open fractures is the early administration of systemic antibiotics. Delaying antibiotic administration significantly increases the risk of deep infection.

Question 77

A 25-year-old intubated polytrauma patient with a comminuted tibial shaft fracture is suspected of having acute compartment syndrome. Which of the following criteria is the most reliable threshold for diagnosing acute compartment syndrome and indicating fasciotomy?

Explanation

The Delta P (diastolic blood pressure minus compartment pressure) is the most reliable metric for diagnosing acute compartment syndrome. A Delta P of <= 30 mmHg signifies critical local ischemia and is a strict indication for fasciotomy.

Question 78

A hemodynamically unstable patient arrives with an anterior-posterior compression (APC-III) pelvic ring injury. A pelvic binder is ordered to reduce pelvic volume. Over which anatomic landmark must the binder be centered to effectively achieve mechanical stabilization?

Explanation

To effectively reduce pelvic volume and stabilize the pelvic ring, a pelvic binder must be centered over the greater trochanters. Placement over the iliac crests is incorrect and can worsen the rotational displacement of an open-book fracture.

Question 79

A polytrauma patient with a severe chest injury and a closed femoral shaft fracture is admitted to the ICU. Which of the following laboratory parameters is the best indicator that the patient is adequately resuscitated and cleared for Early Total Care (ETC) of the femur?

Explanation

Normalization of serum lactate (< 2.0 mmol/L) and correction of base deficit are reliable indicators of adequate physiological resuscitation. This stability permits a safe transition from damage control to Early Total Care.

Question 80

An 18-year-old man sustains a gunshot wound to the distal medial thigh. He presents with an expanding, pulsatile hematoma and absent distal dorsalis pedis and posterior tibial pulses. What is the most appropriate next step in management?

Explanation

Hard signs of vascular injury, such as a pulsatile or expanding hematoma, absent distal pulses, or active arterial hemorrhage, mandate immediate surgical exploration. Delaying for advanced imaging in the presence of hard signs increases the risk of limb loss.

Question 81

The primary blood supply to the talar body, which is frequently disrupted in Hawkins type III talar neck fractures leading to high rates of avascular necrosis, is provided by which of the following vessels?

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, is the dominant blood supply to the talar body. Its disruption, along with other capsular vessels, drives the high avascular necrosis rate seen in severe talar neck fractures.

Question 82

The Sanders classification is widely used for preoperative planning of intra-articular calcaneus fractures. This classification system is fundamentally based on the number and location of primary fracture lines extending through which specific anatomic structure?

Explanation

The Sanders classification for intra-articular calcaneus fractures is based on the number and location of primary fracture lines running through the posterior facet. This is evaluated using a coronal view on a computed tomography (CT) scan.

Question 83

A 70-year-old woman who has been taking alendronate for 10 years presents with atraumatic thigh pain. Radiographs reveal lateral cortical thickening and a transverse radiolucent line in the subtrochanteric region. What is the primary pathophysiologic mechanism of this fracture?

Explanation

Long-term bisphosphonate use heavily suppresses osteoclast activity, leading to adynamic bone that cannot remodel or repair physiologic microdamage. This directly results in the characteristic transverse atypical femur fractures at the subtrochanteric or diaphyseal lateral cortex.

Question 84

A 45-year-old man involved in a fall from a roof sustains a posterior hip dislocation. Post-reduction, he is noted to have a complete sciatic nerve palsy. Based on the typical pattern of sciatic nerve injury in posterior hip dislocations, which focal neurologic deficit is most likely to be permanent or severe?

Explanation

The peroneal division of the sciatic nerve is structurally tethered and located more laterally, making it disproportionately vulnerable to traction or direct injury during a posterior hip dislocation. Injury predominantly results in foot drop and weak ankle eversion.

Question 85

A 6-year-old child presents with a severe, displaced extension-type supracondylar humerus fracture. On examination, the ipsilateral hand is pulseless but remains pink, warm, and well-perfused. What is the most appropriate initial management?

Explanation

For a pulseless but well-perfused (pink and warm) hand following a supracondylar humerus fracture, the initial step is prompt closed reduction and percutaneous pinning. Open vascular exploration is generally indicated only if the hand remains pulseless and poorly perfused (white/cold) after reduction.

Question 86

A 28-year-old woman is brought to the trauma bay after a high-speed motorcycle crash. Chest radiographs reveal severe lateral displacement of the scapula relative to the chest wall, complete acromioclavicular separation, and a displaced clavicle fracture. The high acute mortality associated with this specific injury complex is primarily driven by:

Explanation

This patient has a scapulothoracic dissociation, a massive closed traction injury to the shoulder girdle. The extremely high acute mortality rate is predominantly driven by massive, often uncontainable hemorrhage from subclavian vascular disruptions.

Question 87

When evaluating a severely traumatized limb for potential amputation versus limb salvage, the Mangled Extremity Severity Score (MESS) is often referenced. Which of the following is NOT a scoring component of the MESS?

Explanation

The MESS score components consist of Skeletal/soft tissue injury severity, Limb ischemia, Systemic shock, and Patient age. Patient sex is not a factor utilized in the calculation of this score.

Question 88

A 34-year-old man suffers a crush injury to his foot. Weight-bearing radiographs demonstrate a 3mm widening between the medial cuneiform and the base of the second metatarsal. Which crucial ligamentous structure is primarily injured?

Explanation

The Lisfranc ligament is an interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the primary stabilizer of the tarsometatarsal joint complex and its disruption results in diastasis.

Question 89

A 42-year-old male is brought in after a severe crush injury. He has an open book pelvic fracture with a perineal laceration exposing the fracture. He remains hemodynamically unstable despite a pelvic binder and initial massive transfusion protocol. FAST exam is negative. What is the most appropriate next step in his acute management?

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and negative FAST, mechanical stabilization and preperitoneal pelvic packing are urgently indicated. This is especially critical in open pelvic fractures where the tamponade effect is lost, making angiography less effective as a first-line intervention.

Question 90

A 30-year-old male presents after an MVA with bilateral closed femoral shaft fractures, a severe pulmonary contusion, and a Glasgow Coma Scale of 7. His initial serum lactate is 4.8 mmol/L and pH is 7.15. What is the most appropriate initial orthopedic management of his femoral fractures?

Explanation

This patient is in extremis with a head injury, pulmonary contusion, and profound acidosis. Damage control orthopedics with rapid provisional bilateral external fixation is indicated to minimize the second hit phenomenon associated with reaming and intramedullary nailing.

Question 91

A 45-year-old obtunded male is admitted after a motorcycle collision with a closed, comminuted midshaft tibia fracture. Intracompartmental pressure monitoring shows an absolute pressure of 45 mmHg. The patient's blood pressure is 110/65 mmHg. What is the most appropriate next step in management?

Explanation

The diagnosis of acute compartment syndrome in an obtunded patient relies on objective pressure measurements. A delta P (diastolic blood pressure minus compartment pressure) of less than 30 mmHg (65 - 45 = 20 mmHg) is an absolute indication for an emergent four-compartment fasciotomy.

Question 92

An 82-year-old female with severe osteoporosis presents with a closed, displaced, comminuted intra-articular distal femur fracture (OTA/AO 33-C2). She has a known history of severe symptomatic knee osteoarthritis. Which surgical option provides the most reliable earliest return to full weight-bearing for this patient?

Explanation

Distal femoral replacement (megaprosthesis) in elderly patients with comminuted intra-articular distal femur fractures and pre-existing osteoarthritis allows for immediate full weight-bearing. Osteosynthesis in the presence of severe osteoporosis carries a high risk of hardware failure and typically requires prolonged restricted weight-bearing.

Question 93

A 32-year-old male sustained a displaced talar neck fracture and underwent open reduction and internal fixation. At his 8-week follow-up visit, mortise radiographs of the ankle reveal a distinct subchondral radiolucent band in the dome of the talus. What does this radiographic finding indicate?

Explanation

The presence of a subchondral radiolucent band in the talar dome, known as Hawkins sign, indicates subchondral osteopenia. This bone resorption requires an intact blood supply, signifying that the talar body is viable and avascular necrosis is highly unlikely.

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

Orthopedic Trauma 2026 MCQs (Part 1): Fracture Management & Emergency Orthopedics | Board Review

Key Takeaway

Orthopedic Trauma 2026 MCQs (Part 1): Fracture Management & Emergency Orthopedics | Board Review

Chapter Index