Orthopedic Trauma 2026 MCQs: Board Review Part 2

Question 1

The use of nasotracheal intubation for airway management is contraindicated in the acute multiply injured patient when the patient has

Explanation

The use of nasotracheal intubation is less desirable in patients with respiratory arrest because placement of the tube is most reliable when the patient is breathing. Nasotracheal intubation is advantageous in patients with suspected cervical spine trauma because it does not require hyperextension of the neck. A nasotracheal tube may be more comfortable than an orally placed tube because it is fixed at several points and moves less freely within the larynx, subglottic area, and trachea. The presence of a hemothorax or pneumothorax does not affect the choice of airway control but does require placement of a chest tube. Colice GL: Prolonged intubation versus tracheostomy in the adult. J Intern Care Med 1987;2:85.

Question 2

A 65-year man has right hip pain after a fall. Radiographs reveal a reverse oblique intertrochanteric femoral fracture. Treatment consists of reduction and internal fixation. Which of the following implants is most commonly associated with nonunion and hardware failure?

Explanation

Reverse oblique intertrochanteric femoral fractures account for 5% of all intertrochanteric or subtrochanteric fractures. They are uncommon but not rare and will be encountered in practice. The sliding hip screw is associated with the most problems because of its design. When reverse oblique fractures are fixed with a sliding hip screw, the action of the construct causes medial displacement of the distal fragment rather than compression of the proximal and distal fragments. All of the other implants prevent medial displacement of the distal segment. It should not be assumed that simply using one of the other implants is reason for success. There is a significant failure rate for each of these implants with reverse oblique fractures. The implant must be ideally placed and the fracture must be reduced. Haidukewych GJ, Israel TA, Berry DB: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650. Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.

Question 3

Figure 13a shows the radiograph of a 9-year-old girl who sustained complete transverse fractures of the radial and ulnar shafts while in-line skating. A manipulative closed reduction is performed, and the result is seen in Figure 13b. What is the next most appropriate step in management?

Explanation

13b Bayonet apposition of the radius and ulnar shafts is quite acceptable, as long as the angulation is less than 10 degrees. The rotation must be acceptable as well. This patient went on to full healing, with full supination and pronation of the forearm and no cosmetic deformity. Price CT, Scott DS, Kurzner ME, Flynn JC: Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-712.

Question 4

In Figure 14, the primary fracture line in a calcaneal fracture is best depicted by which of the following schematics?

Explanation

The schematic labeled A best depicts the primary fracture line in a calcaneal fracture. The primary fracture line in an axial-loading fracture of the calcaneus occurs from superior-lateral to inferior-medial. This fracture line separates the calcaneus into sustentacular and tuberosity fragments and typically enters the subtalar joint through the posterior facet. Although additional fracture lines typically occur, the primary fracture line is almost always present. If surgical reduction is planned, reducing the primary fracture is always a key step. Macey LR, Benirschke SK, Sangeorzan BJ, Hansen ST: Acute calcaneal fractures: Treatment option and results. J Am Acad Orthop Surg 1994;2:36-43.

Question 5

A 45-year-old man who sustains a medial subtalar dislocation while playing basketball undergoes immediate closed reduction. No fractures or osteochondral defects are noted on postreduction radiographs. The next most appropriate step in management should consist of

Explanation

Most subtalar dislocations can be easily reduced by closed methods. If no fractures or defects are seen on the postreduction radiographs, then the success rate with cast immobilization is good. Medial dislocations have a better prognosis than lateral dislocations. Late instability is rare; therefore, the duration of immobilization should not be excessive. Most subtalar dislocations result in some stiffening of the hindfoot, and painful degenerative arthrosis is the most common serious complication.

Question 6

A 21-year-old woman sustained a minimally displaced traumatic spondylolisthesis of C2 (Hangman's fracture) after striking the windshield with her forehead during a motor vehicle accident. Management should consist of

Explanation

According to the classification of Levine and Edwards, a type I Hangman's fracture is minimally displaced without angulation and represents a stable injury. Good clinical success has been achieved with nonsurgical management consisting of use of a rigid collar until the patient reports pain relief, followed by quick mobilization.

Question 7

A 25-year-old patient who sustained multiple bilateral rib fractures, a pulmonary contusion, a left nondisplaced transtectal acetabular fracture, and a closed humerus fracture in a motor vehicle accident 2 weeks ago is transferred from another hospital. The humerus fracture has been surgically treated. There are no signs of infection, and the trauma surgeon wants to mobilize the patient as soon as possible. Radiographs are shown in Figures 15a and 15b. Management of the humerus fracture should consist of

Explanation

15b The radiographs show a distal third humerus fracture that is angulated, rotated, and not rigidly fixed. Rigid fixation is needed because mobilization is highly desirable to improve pulmonary function. The acetabular fracture is through the weight-bearing dome but is nondisplaced. Nonsurgical management of the acetabular fracture requires at least 6 weeks of touchdown weight bearing to minimize the forces across the hip joint. Open reduction and plate fixation would achieve anatomic reduction and immediate mobilization. A single posterolateral 4.5-mm plate or two 3.5-mm plates at 90 degrees are possible alternatives. Immediate weight bearing on a plated humerus fracture with the use of crutches or a walker has been shown to be safe and would allow touchdown weight bearing, protecting the hip. None of the other options would achieve this goal for this distal fracture.

Question 8

Figure 16 shows the radiograph of a 23-year-old man who has severe right shoulder pain after his motorcyle hit a bridge guardrail. He is neurologically intact. Nonsurgical management will most likely result in

Explanation

Internal fixation of the clavicle, glenoid, or both has been recommended for fractures of the clavicle and glenoid neck (floating shoulders). Recently, the inherent instability of these dual fractures has been questioned in a biomechanical model without further disruption of the coracoclavicular or acromioclavicular ligamentous structures. Nonsurgical management of the majority of combined scapular/glenoid fractures in patients with less than 10 mm of displacement has resulted in excellent shoulder function and will most likely achieve an excellent result in this patient. Egol KA, Connor PM, Karunakar MA, Sims SH, Bosse MJ, Kellam JF: The floating shoulder: Clinical and functional results. J Bone Joint Surg Am 2001;83:1188-1194. Williams GR Jr, Naranja J, Klimkiewicz J, et al: The floating shoulder: A biomechanical basis for classification and management. J Bone Joint Surg Am 2001;83:1182-1187.

Question 9

An 18-year old man has a simple oblique fracture of the humeral shaft that requires surgical stabilization to maintain reduction and facilitate mobilization. Which of the following methods will provide the best outcome?

Explanation

The patient has a simple fracture pattern that can be reduced anatomically and stabilized with absolute stability by interfragmental compression and protection plating. This will guarantee a 95% to 98% union rate with no radial nerve palsy. Intramedullary nailing does not equal these results in a simple fracture pattern in the humerus. Bridge plating is indicated for multifragmented fracture patterns when anatomic reduction and absolute stability cannot be achieved. External fixation is reserved for severe open fractures. Chapman JR, Henley MP, Agel J, Benca PJ: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166. Farragos AF, Schemitsch EH, McKee MD: Complications of intramedullary nailing for fractures of the humeral shaft: A review. J Orthop Trauma 1999;13:258-267.

Question 10

A 28-year-old painter has had increasing pain in his hand and forearm after sustaining a paint injection wound to the tip of his left index finger 24 hours ago. Management should consist of

Explanation

The clinical presentation soon after injury may be surprisingly innocuous, but all high-pressure injection injuries of various materials are best treated by emergent surgical debridement of all foreign material from the flexor tendon sheath as well as the subcutaneous tissues. Subsequent hospital admission, IV antibiotics, and possible repeat debridements usually are necessary. The use of antibiotics alone is inadequate treatment of this severe injury. Pinto MR, Turkula-Pinto LE, Cooney WP, Wood MB, Dobyns JH: High-pressure injection injuries of the hand: Review of 25 patients managed by open wound technique. J Hand Surg Am 1993;18:125-130. Urbaniak JR, Evans JP, Bright DS: Microvascular management of ring avulsion injuries. J Hand Surg Am 1981;6:25-30. Tsai TM, Manstein C, DuBou R, Wolff T, Kutz JE, Kleinert HE: Primary microsurgical repair of ring avulsion amputation injuries. J Hand Surg Am 1984;9:68-72. Kay S, Werntz J, Wolff T: Ring avulsion injuries: Classification and prognosis. J Hand Surg Am 1989;14:204-213.

Question 11

A 21-year-old basketball player inverts his foot during practice. Examination reveals obvious deformity of the hindfoot with a prominence of the talar head dorsolaterally and medial displacement of the forefoot. A radiograph is shown in Figure 17. What is the most likely obstacle to closed reduction?

Explanation

The patient has a medial subtalar dislocation. These injuries should be reduced as soon as possible to minimize risk to the skin. Most often, this can be done easily, and further radiographic evaluation then can be performed as necessary. On rare occasions, closed reduction is not possible because of fractures of the articular surface of the talus, navicular, interposed extensor digitorum brevis, or transverse fibers of the cruciate crural ligament. The posterior tibial tendon is the most common obstruction to closed reduction in lateral subtalar dislocations, which are less common than medial dislocations. The majority of both injuries can be managed by closed reduction and immobilization. Mulroy RD: The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation. J Bone Joint Surg Am 1953;37:859-863. Heckman JD: Fractures and dislocations of the foot, in Rockwood CA, Green DP, Bucholz RW (eds): Fractures in Adults. Philadelphia, PA, JB Lippincott, 1991, pp 2093-2100.

Question 12

A 27-year-old woman sustained a bilateral C5-6 facet subluxation in a motor vehicle accident. Neurologic evaluation reveals normal motor, sensory, and reflex functions. She is awake, alert, and cooperative. Initial management should consist of

Explanation

As long as the patient is alert and cooperative, an attempt can be made to reduce the dislocation. This should not be attempted in a patient who is obtunded, comatose, or uncooperative. If any neurologic changes are noted during the reduction maneuver, the attempt should be stopped, appropriate radiographic studies obtained, and open reduction and stabilization planned in the operating room.

Question 13

A 22-year-old patient sustained a jamming injury to the right little finger. The lateral radiograph shown in Figure 18 reveals comminution of the base of the middle phalanx, with palmar and dorsal metaphyseal cortical involvement. The articular surface also is disrupted. Management should consist of

Explanation

This fracture, known as a pilon fracture, represents comminution of the base of the middle phalanx with both palmar and dorsal cortical disruption. The treatment method that allows the best function and fewest complications is indirect reduction achieved through specific dynamic splinting or the use of specifically designed proximal interphalangeal joint external fixators. Early mobilization can be achieved by either of these techniques. Volar plate arthroplasty is indicated for a simple fracture-dislocation of the proximal interphalangeal joint with comminution of the volar fracture fragment and dorsal dislocation of the remaining articular surface. Open reduction and internal fixation or percutaneous pinning adds surgical risks and scarring and typically will not provide added stability. Cast immobilization will not achieve the goal of early range of motion. Stern PJ, Roman RJ, Kiefhaber TR, McDonough JJ: Pilon fractures of the proximal interphalangeal joint. J Hand Surg Am 1991;16:844-850.

Question 14

Figure 19 shows the radiograph of a 12-year-old boy who sustained an injury to his hand when another child fell on him. Management should consist of

Explanation

The patient has a Salter-Harris type III fracture of the proximal phalanx of the thumb. It is usually caused by an abduction injury where the ulnar collateral ligament avulses a fragment away from the proximal epiphysis and is the most common childhood gamekeeper's injury. If there is greater than 1 mm of separation or a significant articular step-off, an open reduction, performed through an extensor aponeurosis-splitting approach, is required to reestablish joint congruity and stability. Percutaneous or closed methods of reduction are usually ineffective. The dorsal approach avoids the volar neurovascular structures. Since the ulnar collateral ligament is still attached, this area does not need to be visualized. The major goal is to reestablish joint congruity and bony stability. This can be easily performed via the dorsal approach. Carey TP: Fracture and dislocations of the phalanges, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994, pp 435-436.

Question 15

Figures 20a through 20c show the radiographs of a 69-year-old woman who has severe pain in her dominant right arm after falling on the ice. History includes arthritis, hypertension, and heart disease. She is neurovascularly intact. Management should consist of

Explanation

20b 20c The radiographs reveal a severely comminuted distal humerus fracture. A long arm cast, functional bracing, and closed reduction and percutaneous pin fixation all have a poor outcome and could result in a nonunion that will be very difficult to treat. Open reduction and internal fixation is indicated in most supracondylar humerus fractures, but total elbow arthroplasty is a good alternative in elderly patients who have multiple medical problems and when the fracture pattern may preclude stable enough internal fixation to allow postoperative motion. Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997;79:826-832.

Question 16

An 18-year-old man has acute respiratory distress after sustaining injuries in a motorcycle accident. He has a blood pressure of 80/60 mm Hg and a pulse rate of 110/min. Examination reveals chest tympany to percussion, distended neck veins, and deviation of the trachea away from his right hemithorax where the breath sounds are diminished. Heart sounds are regular and normal on auscultation. Initial management should consist of

Explanation

Tension pneumothorax occurs when air trapped in the pleural space between the lung and chest wall achieves sufficient pressure to compress the lungs and shift the mediastinum. Urgent needle decompression of the pleural space air followed by definitive chest tube placement is the treatment of choice.

Question 17

A 27-year-old man has neck pain after being involved in a motor vehicle accident. A lateral cervical radiograph is shown in Figure 21. What would be the most common neurologic finding?

Explanation

The radiographic findings are consistent with a type II Hangman's fracture or traumatic spondylolisthesis of C2. This occurs with more than 3 mm of displacement according to the classification of Levine and Edwards. Even though the radiograph reveals significant displacement, the overall space available for the neural elements is increased, therefore minimizing the risk of neural compromise. Neurologic injury is most frequently encountered in type III injuries that are associated with bilateral facet dislocations of C2 on C3 but is infrequent in type I (less than 3 mm displacement) and type II traumatic spondylolisthesis. When neurologic deficits are associated with type II injuries, it is usually the result of an associated head injury. Cruciate paralysis occurs as a result of the crossover of the motor and sensory tracts at different levels of the cord at the C1-C2 junction. This results in normal sensation but complete loss of motor function. Levine AM: Traumatic spondylolisthesis of the axis (Hangman's fracture), in Levine AM, Eismont FJ, Garfin S, Zigler JE (eds): Spine Trauma. Philadelphia, PA, WB Saunders, 1998, pp 287-288.

Question 18

After stabilizing a bimalleolar ankle fracture with a plate and lag screws for the fibula and two interfragmental compression screws for the medial malleolus, a syndesmosis screw is indicated in which of the following situations?

Explanation

It is imperative to recognize the need for a position screw (syndesmosis screw) to hold the syndesmosis in proper alignment when surgically stabilizing an ankle fracture. Although many different fracture patterns are suspicious for a disrupted syndesmosis, the only sure way to assess the syndesmosis is to stress it with abduction and external rotation of the talus and attempt to displace the fibula from the incisura fibularis. Under fluoroscopy, the talus will move laterally and displace the fibula, show a valgus talar tilt, or show an increase in the medial clear space. If any or all of these signs occur, a syndesmosis screw is inserted after making sure that the fibula is reduced into the incisura fibularis. This screw may traverse three or four cortices but must not act as a lag screw. It usually is inserted with the ankle in maximal dorsiflexion, although this is probably not necessary because it is almost impossible to overcompress the syndesmosis. The diameter of the screw does not make any difference. It may or may not be removed but not before 3 months. Tornetta P III, Spoo JE, Reynolds FA, Lee C: Overtightening of the ankle syndesmosis: Is it really possible? J Bone Joint Surg Am 2001;83:489-492. Stover MD, Kellam JF: Articular fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 105-119. Hahn DM, Colton CL: Malleolar fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 559-581.

Question 19

A 32-year-old man sustains multiple injuries in a motorcycle accident including ipsilateral open right femur and comminuted tibia fractures. He has acute abdominal distention and tenderness to palpation. The pelvis is stable to examination. He has a blood pressure of 70/40 mm Hg despite appropriate fluid resuscitation and a pulse rate of 120/min; the pulse is thready. Which of the following procedures is considered the highest priority in the management of this patient?

Explanation

The patient is in hemorrhagic shock, and timely hemostasis in the operating room should be the highest priority. Further imaging and insertion of central lines carry the risk of further delays in arresting the source of the patient's bleeding. Albumin (colloid) solutions have questionable indications, are expensive, and have been associated with increased mortality. Crystalloid solutions such as normal saline or lactated Ringer's solution are the initial resuscitative fluid of choice until blood becomes available. Pneumatic antishock garments have been associated with higher mortality rates, particularly in patients with cardiac and thoracic vascular injuries. Krettek C, Simon RG, Tscherne H: Management priorities in patients with polytrauma. Langenbecks Arch Surg 1998;383:220-227.

Question 20

A 35-year-old man sustained an injury to his lower extremity after falling 10 feet from a ladder; initial management was nonsurgical. He now reports chronic hindfoot and anterior ankle pain. Radiographs are shown in Figures 22a and 22b. Surgical reconstruction of this painful process should consist of

Explanation

22b The radiographs reveal a hindfoot deformity that developed following a severe, comminuted, intra-articular fracture of the calcaneus. There is deformity of the calcaneal body and collapse of the talus into the calcaneus, leading to dorsiflexion of the talus and anterior ankle joint impingement. Distraction bone block subtalar joint arthrodesis will assist with correction of the calcaneal height and will allow for an improved talar declination angle. With this procedure, care must be taken to avoid placing the hindfoot into further varus. A similar reconstruction option not listed would be a calcaneal osteotomy and arthrodesis as described by Romash. Talectomy and tibiocalcaneal arthrodesis are not warranted because the primary structure of the talus and ankle joint is well preserved. In situ subtalar joint arthrodesis will not correct the deformity, and symptoms about the ankle and hindfoot would most likely persist. Lateral wall calcaneal exostectomy may decrease pain from subfibular impingement but will not deal directly with subtalar joint arthrosis and deformity. Carr JB, Hansen ST , Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86. Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.

Question 21

An 8-year-old boy falls and injures his thumb. A radiograph is shown in Figure 23. Initial management should consist of

Explanation

The radiograph shows a complete simple dislocation of the metacarpophalangeal joint. The clue to this injury is the perpendicular alignment of the proximal phalanx to the metacarpal on the lateral radiograph. This must be differentiated from the complete complex dislocation pattern that is irreducible because of the interposed volar plate. In lateral radiographs of these injuries, the long axes of the proximal phalanx and the metacarpal are parallel. Simple dislocations are amenable to closed reduction and casting. Some authors have recommended ulnar collateral ligament repair if instability is detected on examination after reduction. O'Brien ET: Part IV: Dislocations of hand and carpus, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 429-431.

Question 22

A 28-year-old anesthesia resident has aching pain in his dominant right forearm after injuring it while playing basketball 1 week ago. He reports that he is unable to perform regional anesthesia that requires manipulation of a needle. Examination reveals that he is unable to flex the interphalangeal joint of the thumb, and flexion of the distal interphalangeal joint of the index finger is weak. Management should consist of

Explanation

The patient has anterior interosseous nerve palsy. Initial management should consist of splinting followed by observation; surgical decompression may be required if there is no improvement in the functional deficit in 6 months. Anterior interosseous nerve palsy is classically described as an inability to flex the interphalangeal joint of the thumb because of flexor pollicis longus paralysis and a weakness or inability to flex the distal interphalangeal joint of the index finger because of weakness and/or paralysis of the flexor digitorum profundus to the index finger. There has been some controversy in the literature as to whether this represents a true peripheral compression neuropathy or neuritis. Recent recommendations have been to extend the period of observation from 3 to 6 months before surgical decompression, as most cases will resolve within 6 months. Miller-Breslow A, Terrono A, Millender LH: Nonoperative treatment of anterior interosseous nerve paralysis. J Hand Surg Am 1990;15:493-496.

Question 23

A 5-year-old girl sustains an isolated injury to the right shoulder area after falling off the monkey bars. Examination reveals intact neurovascular function in the extremity distally, but she is quite uncomfortable. An AP radiograph of the proximal humerus is shown in Figure 24. Her parents state that she is a very talented gymnast. Considering her age and potential athletic career, management should consist of

Explanation

In this age group, bayonet apposition can produce very good results. Healing occurs rapidly, and remodeling usually is complete in less than 1 year. All of the other methods have significant risks of complications and are unnecessary for this fracture. Martin RF: Fractures of the proximal humerus and humeral shaft, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994, pp 144-148.

Question 24

The cortical injury to the posterolateral distal fibula shown in Figure 25 indicates involvement of which of the following structures?

Explanation

The patient has a rim avulsion fracture that is the result of a forceful twisting injury as the superior peroneal retinaculum is avulsed from its fibular attachment along with a small rim of bone. Injuries to the anterior talofibular ligament or calcaneal fibular ligament would show cortical avulsions more anteriorly or distally at the fibular tip. Deltoid ligament injuries would reveal medial radiographic changes. In a true injury to the syndesmosis, if osseous structures do show avulsion, it would be more directly posterior or anterior on the distal fibula or would occur on the tibial surface. Murr S: Dislocation of the peroneal tendons with marginal fracture of the lateral malleolus. J Bone Joint Surg Br 1961;43:563-565.

Question 25

A 52-year-old woman underwent open reduction and internal fixation for radial and ulnar shaft fractures 2 months ago. In a second fall she refractured her forearm and required revision surgery with bone grafting. One month after the second operation she notes erythema, swelling, and drainage from the volar radial incision. In addition to antibiotic treatment, management should consist of

Explanation

Deep infections after plating of closed fractures of the forearm are unusual. However, the risk increases with repeat surgeries. Debridement of all infected, nonviable tissue is the initial step in management. The fixation may be retained if it is stable, but if the plate and screws are loose, they should be removed and revision performed after removal of nonviable bone. Either external fixation or repeat plating may be performed. Late infections after fracture union may be treated with plate and screw removal, debridement, and IV antibiotics. Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 53-63. Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr: Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am 1986;68:1008-1017.

Question 26

A 35-year-old male presents with a hemodynamically unstable APC-III pelvic ring injury following a motorcycle collision. What is the correct anatomical landmark to center a pelvic circumferential compression device?

Explanation

Pelvic binders must be centered over the greater trochanters to effectively reduce pelvic volume and stabilize the fracture, minimizing internal hemorrhage. Placement over the iliac crests can paradoxically worsen the deformity.

Question 27

A 28-year-old cyclist falls onto his shoulder. Radiographs show a midshaft clavicle fracture. Which of the following is considered a widely accepted relative indication for operative intervention?

Explanation

Operative fixation of midshaft clavicle fractures is generally indicated for shortening greater than 2 cm, 100% displacement (Z-deformity), skin tenting, or open fractures. These factors are associated with higher rates of nonunion and symptomatic malunion.

Question 28

A 40-year-old male sustains a Gustilo-Anderson Type IIIA open tibia fracture in a motor vehicle accident. What is the most critical initial factor in preventing deep infection?

Explanation

The most critical factor in reducing infection rates in open fractures is the early administration of systemic antibiotics, ideally within 1 hour of injury. While early debridement is also important, timely antibiotic administration has the strongest correlation with reduced infection risk.

Question 29

A 25-year-old man with a closed tibial shaft fracture complains of severe leg pain out of proportion to the injury. Which of the following pressure measurements is an absolute indication for emergency four-compartment fasciotomy?

Explanation

A delta pressure (Diastolic Blood Pressure minus Compartment Pressure) of less than 30 mmHg is the diagnostic threshold for acute compartment syndrome. Delta pressure is a more reliable indicator for fasciotomy than absolute compartment pressure alone as it accounts for tissue perfusion.

Question 30

A 30-year-old female sustains a displaced, vertically oriented (Pauwels type III) femoral neck fracture. Which of the following internal fixation constructs offers the highest biomechanical stability for this specific fracture pattern?

Explanation

For vertically oriented (high shear angle/Pauwels type III) femoral neck fractures in young adults, a sliding hip screw combined with a derotational screw provides superior biomechanical stability. This construct best resists the high vertical shear forces compared to multiple cancellous screws.

Question 31

A 65-year-old woman is 6 months post-ORIF of a distal radius fracture with a volar locking plate. She presents with inability to actively flex the interphalangeal joint of her thumb. What is the most likely cause of this complication?

Explanation

Placement of a volar plate distal to the watershed line can lead to hardware prominence against the flexor tendons. This frequently causes tenosynovitis and subsequent attritional rupture of the flexor pollicis longus (FPL) tendon.

Question 32

A 35-year-old man sustains a Hawkins type III talar neck fracture following a fall from height. What is the approximate risk of developing avascular necrosis (AVN) of the talar body?

Explanation

Hawkins Type III fractures involve dislocation of the talar body from both the subtalar and ankle joints, disrupting all three major blood supplies to the talus. Consequently, the risk of developing AVN is exceedingly high, approaching 75-100%.

Question 33

An 82-year-old osteoporotic woman sustains a highly comminuted, intra-articular distal femur fracture (OTA/AO 33-C3). She has severe pre-existing osteoarthritis of the same knee. What is the most appropriate definitive management?

Explanation

In elderly patients with severe osteopenia, pre-existing symptomatic knee osteoarthritis, and highly comminuted intra-articular distal femur fractures, distal femoral replacement is preferred. It addresses the baseline arthritis and allows for immediate weight-bearing, avoiding the high failure rates of internal fixation.

Question 34

A 45-year-old pedestrian is struck by a car and sustains a displaced medial tibial plateau fracture (Schatzker IV). Which of the following associated injuries must be evaluated with high clinical suspicion?

Explanation

Schatzker IV (medial plateau) fractures are typically high-energy injuries resulting from varus and hyperextension forces, representing a knee dislocation equivalent. They carry a significant risk of popliteal artery injury or disruption of the peroneal nerve.

Question 35

A 50-year-old male sustains a high-energy closed tibial pilon fracture with severe soft tissue swelling and extensive fracture blisters. What is the most appropriate initial management strategy?

Explanation

High-energy pilon fractures with severe soft tissue compromise are best managed with a staged approach. Immediate spanning external fixation restores length and alignment, followed by definitive ORIF once the soft tissues heal and the "wrinkle sign" appears.

Question 36

In a polytrauma patient, which of the following laboratory parameters is the most reliable indicator of adequate physiologic resuscitation prior to converting from damage control orthopedics to definitive fracture fixation?

Explanation

Serum lactate clearance (< 2.0 mmol/L) and correction of base deficit are reliable markers of restored tissue perfusion. Normalizing these parameters indicates the patient is physiologically optimized to withstand the surgical stress of definitive fixation.

Question 37

A 30-year-old male suffers a posterior hip dislocation with a posterior wall acetabular fracture. Following closed reduction, a CT scan shows a posterior wall defect involving 45% of the articular surface. What is the most appropriate treatment?

Explanation

Indications for open reduction and internal fixation of a posterior wall acetabular fracture include joint instability on dynamic stress testing, an intra-articular loose body, and wall defects involving >20-40% of the posterior articular surface.

Question 38

A 65-year-old woman on long-term alendronate presents with a completely displaced transverse fracture of the proximal femoral diaphysis after a simple fall. Which characteristic radiographic feature is typically seen prior to displacement in these atypical injuries?

Explanation

Atypical femur fractures related to prolonged bisphosphonate use typically begin as a stress fracture on the tension (lateral) side of the femur. This appears radiographically as focal lateral cortical thickening or "beaking" before progressing to a complete fracture.

Question 39

A 28-year-old male sustains a high-energy motor vehicle collision resulting in a closed, displaced talar neck fracture. Radiographs and CT scan demonstrate displacement of both the subtalar and tibiotalar joints, while the talonavicular joint remains congruent. Based on the Hawkins classification, what is the approximate rate of avascular necrosis (AVN) of the talar body associated with this specific injury pattern?

Explanation

This describes a Hawkins Type III talar neck fracture, which involves subluxation or dislocation of both the subtalar and tibiotalar joints. The risk of AVN for Hawkins Type III fractures is historically reported between 70% and 100% due to the disruption of multiple major blood supplies to the talar body.

Question 40

A 72-year-old female presents with thigh pain and a subsequent low-energy transverse femur fracture showing cortical thickening and a lateral cortical beak. She has been taking alendronate for 10 years. What is the primary underlying pathophysiology responsible for this specific fracture pattern?

Explanation

Atypical femur fractures (AFFs) are strongly associated with long-term bisphosphonate use. These antiresorptive agents profoundly suppress targeted bone remodeling, preventing the repair of physiological microdamage which accumulates over time and weakens the bone.

Question 41

A 35-year-old hypotensive polytrauma patient is brought into the trauma bay with an anteroposterior compression (APC) pelvic ring injury. The trauma team decides to place a non-invasive circumferential pelvic binder. To effectively reduce the pelvic volume and stabilize the fracture, the binder must be centered over which of the following anatomic landmarks?

Explanation

Pelvic binders must be placed centered over the greater trochanters to generate an effective internal rotational force through the femurs to close the pelvic ring. Placement over the iliac crests is a common error that can paradoxically widen the pelvis and worsen instability.

Question 42

A 22-year-old male sustains a closed tibia shaft fracture. Four hours post-admission, he complains of severe leg pain refractory to intravenous narcotics. You suspect acute compartment syndrome. When utilizing continuous intracompartmental pressure monitoring, which of the following parameters is the most reliable threshold for diagnosing compartment syndrome and indicating the need for immediate fasciotomy?

Explanation

The Delta P (diastolic blood pressure minus the intracompartmental pressure) is the most reliable physiologic threshold for diagnosing compartment syndrome. A Delta P of less than 30 mmHg correlates with critical tissue ischemia and is an absolute indication for fasciotomy.

Question 43

A 40-year-old male construction worker sustains a Gustilo-Anderson Type IIIB open tibia fracture requiring a free tissue transfer for soft tissue coverage. According to established orthopedic trauma literature, early definitive soft tissue coverage is associated with decreased infection rates. Flap coverage should ideally be performed within what maximum timeframe to optimize outcomes?

Explanation

For Gustilo Type IIIB open tibia fractures, soft tissue coverage within 7 days (early coverage) is associated with the lowest rates of deep infection and flap failure. Delaying coverage beyond this window significantly increases complication rates.

Question 44

A 55-year-old female sustains a complex elbow injury consisting of a radial head fracture, a coronoid process fracture, and elbow dislocation. What is the standard algorithmic sequence of surgical reconstruction for this terrible triad injury?

Explanation

The standard surgical algorithm for a terrible triad injury builds stability from deep/anterior to superficial/lateral. The accepted sequence is fixation or replacement of the coronoid, followed by the radial head, and finally repair of the lateral ulnar collateral ligament (LUCL).

Question 45

A 65-year-old female sustains a severe proximal humerus fracture.

Which of the following radiographic findings is considered the most reliable predictor of subsequent avascular necrosis (AVN) of the humeral head according to Hertel criteria?

Explanation

Hertel identified specific predictors of ischemia in proximal humerus fractures. The combination of a disrupted medial hinge and a short medial calcar segment (less than 8 mm) is highly predictive of disruption of the blood supply to the articular segment, leading to AVN.

Question 46

A 45-year-old male sustains a severe closed high-energy distal tibia fracture extending into the ankle joint (pilon fracture). He presents with profound soft tissue swelling, fracture blisters, and skin ecchymosis. The decision is made to perform a staged protocol starting with a spanning external fixator. What is the primary advantage of this staged management approach?

Explanation

Staged management of high-energy pilon fractures (spanning external fixation followed by delayed definitive ORIF 1-3 weeks later) allows the soft tissue envelope to recover. This approach has drastically reduced the historically high rates of severe wound complications and deep infections.

Question 47

A 25-year-old male falls from a significant height and sustains a U-shaped sacral fracture with transverse extension through the S1-S2 bodies (spinopelvic dissociation). Neurological examination reveals bilateral loss of ankle plantar flexion and absent perianal sensation. What is the most appropriate definitive surgical management for this unstable injury pattern?

Explanation

Spinopelvic dissociation implies a mechanical disconnection of the axial spine from the pelvic ring, making simple iliosacral screws biomechanically insufficient. Triangular osteosynthesis or lumbopelvic fixation (pedicle screws in lumbar spine connected to iliac screws) is required to restore stability.

Question 48

A 30-year-old male sustains a vertically oriented (Pauwels type III) basicervical femoral neck fracture. To minimize the risk of varus collapse, nonunion, and implant failure in this high-shear angle fracture in a young adult, what is the biomechanically optimal internal fixation construct?

Explanation

Pauwels type III fractures exhibit high shear forces that frequently cause failure of standard multiple cancellous screw constructs. A fixed-angle device, such as a sliding hip screw, provides superior resistance to varus collapse, often supplemented by a derotational screw for rotational control.

Question 49

A 19-year-old male cyclist falls directly onto his left shoulder, sustaining a displaced midshaft clavicle fracture. While many of these injuries can be treated non-operatively, which of the following clinical or radiographic findings represents an absolute indication for operative fixation?

Explanation

Absolute indications for open reduction and internal fixation of a clavicle fracture include open fractures, progressive neurovascular deficits, and significant skin tenting causing skin blanching and impending necrosis. Shortening and displacement are relative indications.

Question 50

A severely injured polytrauma patient is resuscitated in the trauma bay following a high-speed motorcycle crash. He has bilateral femur fractures and a severe pelvic injury. The surgical team is debating between Early Total Care (ETC) and Damage Control Orthopedics (DCO). Which of the following physiologic parameters is an established trigger indicating the need for a DCO approach?

Explanation

Damage Control Orthopedics (DCO) is indicated in physiologically unstable or borderline patients to prevent the fatal triad of trauma. Triggers for DCO instead of Early Total Care include prolonged hypothermia (< 35 C), severe acidosis (pH < 7.2), coagulopathy, and a serum lactate > 4.0 mmol/L.

Question 51

A 75-year-old osteoporotic patient undergoes distal femur fracture stabilization with a lateral locking bridge plate. Six months post-operatively, radiographs demonstrate failure of the plate with breakage at the fracture level and a clinical nonunion. Assuming appropriate reduction, what technical error regarding plate construct stiffness most commonly predisposes to this failure?

Explanation

In bridge plating techniques, utilizing a short working length (placing screws too close to the fracture gap) creates an excessively stiff construct. This stiffness concentrates stress on a short segment of the plate, leading to fatigue failure and fracture nonunion.

Question 52

A 45-year-old male presents with a high-energy transverse subtrochanteric femur fracture. To achieve an anatomic reduction intraoperatively using an intramedullary nail, the surgeon must overcome significant deforming forces acting on the proximal fracture fragment. Which combination of muscles represents the primary deforming forces on the proximal fragment?

Explanation

The proximal fragment in a subtrochanteric fracture is classically displaced into flexion, abduction, and external rotation. This classic deformity is driven by the unopposed pull of the iliopsoas, the gluteus medius/minimus, and the short external rotators respectively.

Question 53

A 38-year-old female struck by a vehicle presents with a massive, fluctuant, soft tissue swelling over her greater trochanter with intact overlying skin. MRI confirms a Morel-Lavallée lesion. What is the fundamental pathophysiology defining this soft tissue injury?

Explanation

A Morel-Lavallée lesion is a closed internal degloving injury. It is caused by severe shear forces that abruptly separate the subcutaneous fat from the underlying non-yielding deep fascia, creating a potential space that fills with blood, lymph, and necrotic fat.

Question 54

During open reduction and internal fixation of a complex intra-articular distal radius fracture using a volar extended flexor carpi radialis (FCR) approach, the surgeon identifies a displaced radial styloid fragment. Releasing the insertion of which of the following muscles is most critical to neutralize the primary deforming force on this specific fragment?

Explanation

The brachioradialis inserts directly onto the base of the radial styloid. Its persistent pull is the primary deforming force causing proximal and radial displacement of the radial styloid fragment, necessitating its release (or fractional lengthening) during surgical reduction.

Question 55

A 40-year-old male is evaluated following a posterior hip dislocation with an associated posterior wall acetabular fracture. The hip is reduced in the emergency department. Which of the following findings is an absolute indication for operative fixation of the posterior wall fracture rather than non-operative management?

Explanation

The most critical determinant for fixing a posterior wall acetabular fracture is hip joint instability. A dynamic stress exam demonstrating subluxation of the femoral head (often occurring with >20-50% wall involvement) is an absolute indication for operative fixation.

Question 56

A 45-year-old recreational athlete sustains an acute Achilles tendon rupture and opts for non-operative management. According to high-level evidence and current consensus guidelines, which specific rehabilitation strategy most effectively mitigates the higher re-rupture rate traditionally associated with non-operative treatment?

Explanation

Recent high-quality studies show that when early functional rehabilitation (protected weight-bearing and early range of motion) is employed, the re-rupture rates of non-operatively managed Achilles ruptures are equivalent to those managed operatively, while avoiding surgical wound complications.

Question 57

A 25-year-old male trauma patient presents with massive swelling of the left shoulder girdle, absent radial pulse, and complete flaccidity of the left arm. Chest radiograph reveals marked lateral displacement of the scapula. What is this syndrome, and what specific injury dictates the long-term functional prognosis of the limb?

Explanation

This is scapulothoracic dissociation, characterized by lateral displacement of the scapula and massive trauma to the shoulder girdle. It is highly associated with subclavian vascular injuries and severe, often complete, brachial plexus avulsions, which ultimately dictate the poor functional prognosis.

Question 58

A 28-year-old male presents with bilateral femur fractures and a blunt chest injury after a motor vehicle collision. His serum lactate is 4.5 mmol/L and base deficit is -8. What is the most appropriate initial management of his femoral fractures?

Explanation

This patient is in a borderline to unstable physiologic state with a lactate > 4.0 and base deficit < -6.0. Damage Control Orthopedics (DCO) with rapid external fixation is indicated to minimize the systemic inflammatory response and avoid the "second hit" phenomenon.

Question 59

A 35-year-old man sustains an acetabular fracture as seen in the representative imaging

. CT reveals a fracture involving the anterior column and posterior hemitransverse with the "gull sign" present on the anteroposterior view. Which surgical approach is most appropriate?

Explanation

An anterior column and posterior hemitransverse fracture is best approached anteriorly (Ilioinguinal or modified Stoppa) to directly reduce the anterior column. The "gull sign" indicates superomedial dome impaction, which must be addressed through an anterior approach.

Question 60

A 42-year-old female undergoes open reduction and internal fixation of a Schatzker VI tibial plateau fracture. Postoperatively, she develops severe pain out of proportion to examination and paresthesias in her first web space. What is the most reliable method to diagnose the suspected complication?

Explanation

The patient exhibits classic signs of acute compartment syndrome affecting the deep peroneal nerve territory. Intracompartmental pressure monitoring is the most reliable objective diagnostic tool, particularly when clinical signs are ambiguous post-surgery or in obtunded patients.

Question 61

During fixation of a supracondylar distal femur fracture (OTA/AO 33-C), a coronal plane fracture of the lateral femoral condyle is identified. What is the optimal fixation strategy for this specific articular fragment?

Explanation

A Hoffa fracture is a coronal plane fracture of the femoral condyle. It is biomechanically best treated with anterior-to-posterior directed lag screws placed perpendicular to the fracture line to achieve compression prior to application of a lateral neutralization plate.

Question 62

A 25-year-old male sustains a Hawkins Type III talar neck fracture. Which of the following sources of blood supply to the talus is most likely to remain intact?

Explanation

A Hawkins Type III fracture involves subluxation or dislocation of the subtalar and tibiotalar joints, disrupting the artery of the tarsal canal and tarsal sinus. The deltoid branch is often the only remaining blood supply, making preservation of the medial soft tissues critical.

Question 63

A 30-year-old female presents in hemorrhagic shock after a crush injury. Pelvic radiograph shows an APC-III injury with pubic symphysis diastasis of 4 cm and complete disruption of the sacroiliac joints bilaterally. After applying a pelvic binder, her hemodynamics remain unstable. What is the next most appropriate step?

Explanation

In an unstable pelvic ring injury with ongoing hemorrhagic shock despite mechanical stabilization, immediate hemorrhage control is mandatory. Preperitoneal pelvic packing or angioembolization are the standard interventions for refractory hemodynamic instability.

Question 64

A 45-year-old woman falls on an outstretched hand and sustains a "terrible triad" injury of the elbow. What is the recommended surgical sequence for reconstructing this injury?

Explanation

The standard surgical algorithm for terrible triad injuries follows a deep-to-superficial approach. The surgeon should first fix the coronoid, then repair or replace the radial head, and finally reconstruct the lateral ulnar collateral ligament (LUCL/LCL complex).

Question 65

A 72-year-old woman on long-term alendronate presents with lateral thigh pain. Radiographs reveal focal lateral cortical thickening and a transverse radiolucent line in the subtrochanteric femur. What is the most appropriate management?

Explanation

This patient has an impending atypical femur fracture (AFF) associated with prolonged bisphosphonate use. Given the high risk of completion and significant morbidity, prophylactic cephalomedullary or intramedullary nailing is the treatment of choice.

Question 66

An extensile lateral approach is planned for a severely displaced intra-articular calcaneus fracture. Which of the following structures is at highest risk of iatrogenic injury during the full-thickness flap elevation?

Explanation

The sural nerve crosses the lateral aspect of the hindfoot and is at significant risk during the initial incision and elevation of the L-shaped full-thickness flap utilized in the extensile lateral approach to the calcaneus.

Question 67

A 35-year-old male sustains a Gustilo-Anderson Grade IIIA open tibial shaft fracture. What is the single most critical factor in reducing his risk of deep infection?

Explanation

The early administration of systemic intravenous antibiotics (ideally within 1 hour of injury) is the most critical and extensively proven factor in decreasing infection rates in open fractures.

Question 68

A 40-year-old male sustains a displaced fracture of the scapular neck. Which of the following is a generally accepted indication for operative management of this injury?

Explanation

Operative indications for scapular neck fractures typically include medial translation > 20 mm, angular deformity > 40 degrees, or a glenopolar angle < 22 degrees, as these significantly alter glenohumeral biomechanics and rotator cuff tension.

Question 69

A 28-year-old male sustains a Pauwels type III (vertical) femoral neck fracture. What is the biomechanical rationale for utilizing a sliding hip screw with a derotational screw rather than three parallel cancellous screws?

Explanation

Pauwels type III fractures have a highly vertical fracture line, subjecting them to massive vertical shear forces. A fixed-angle device like a sliding hip screw provides superior biomechanical resistance to these shear forces compared to parallel cancellous screws.

Question 70

A 33-year-old man sustains a closed spiral fracture of the distal third of the humerus (Holstein-Lewis) and presents with a dense radial nerve palsy. What is the most appropriate initial management?

Explanation

Most radial nerve palsies associated with closed humeral shaft fractures (including the Holstein-Lewis type) are neuropraxias that recover spontaneously. Initial management is closed reduction with functional bracing and observation for 3-4 months before considering exploration.

Question 71

During fixation of a pronation-external rotation ankle fracture, the syndesmosis is found to be unstable after medial and lateral malleolar fixation, and a syndesmotic screw is placed. According to current literature, what dictates the most appropriate time for routine removal of the syndesmotic screw?

Explanation

Current orthopedic literature demonstrates no significant functional difference between retained versus removed syndesmotic screws. Routine removal is generally not required and is reserved for cases where the implant breaks, backs out, or causes local irritation.

Question 72

A 24-year-old male lacerates his index finger flexor digitorum profundus (FDP) and superficialis (FDS) in Zone II. What is the optimal timing and method for repair to ensure the best functional outcome?

Explanation

Zone II flexor tendon lacerations are optimally managed with early primary repair (within days) utilizing a robust multi-strand (4 or 6) core suture plus an epitendinous suture. This provides sufficient tensile strength to allow early active rehabilitation protocols, preventing adhesions.

Question 73

A 32-year-old male sustains a closed Hawkins type III talar neck fracture. Following prompt open reduction and internal fixation, what is the most reliable early radiographic indicator that the talar body has maintained its vascular supply?

Explanation

Hawkins sign, a subchondral radiolucency in the talar dome seen 6-8 weeks post-injury, indicates intact vascularity and active bone resorption. Its presence makes the development of avascular necrosis highly unlikely.

Question 74

According to Hertel's criteria, which combination of radiographic findings most accurately predicts humeral head ischemia following a proximal humerus fracture?

Explanation

Hertel identified a metaphyseal head extension (calcar length) of < 8 mm and a disrupted medial hinge as the most reliable predictors of humeral head ischemia. Combined, these findings have a positive predictive value of nearly 97% for ischemia.

Question 75

A 25-year-old man is treated with an intramedullary nail for a proximal third tibial shaft fracture. To prevent the most common malalignment associated with this procedure, how should blocking (Poller) screws be placed relative to the nail?

Explanation

Blocking screws are placed on the concave side of the anticipated deformity (or the acute angle of the fracture) to direct the nail toward the central axis. For proximal tibia fractures, this typically means placing the screw posterior and lateral to the nail.

Question 76

A 40-year-old man presents with a terrible triad injury of the elbow. During surgical reconstruction, what is the most widely accepted sequence of structural repair to restore elbow stability?

Explanation

The standard surgical sequence for a terrible triad injury follows a deep-to-superficial approach. The coronoid is fixed first, followed by the radial head (fixation or arthroplasty), and finally the lateral collateral ligament (LCL) complex is repaired.

Question 77

A 55-year-old woman sustains a highly comminuted, purely ligamentous Lisfranc injury. Current evidence suggests that which of the following treatments provides the best long-term functional outcome for this specific injury pattern?

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the first, second, and third tarsometatarsal joints yields superior functional outcomes. It also demonstrates lower reoperation rates compared to traditional ORIF.

Question 78

A 35-year-old man sustains a completely displaced diaphyseal fracture of the radius and ulna (both-bone forearm fracture). During open reduction and internal fixation, which of the following principles is critical for restoring maximum forearm rotation?

Explanation

Restoring the normal anatomical radial bow is essential during the fixation of both-bone forearm fractures. Failure to restore this bow is highly correlated with restricted pronation and supination.

Question 79

A 42-year-old trauma patient has an unstable pelvic ring injury with a widened pubic symphysis (APC-III). A pelvic binder is applied in the trauma bay. For maximal mechanical effectiveness in reducing the pelvic volume, at what anatomical landmark should the binder be centered?

Explanation

To effectively reduce pelvic volume and stabilize the bony ring, a pelvic binder must be centered directly over the greater trochanters. Placement higher over the iliac crests is less mechanically effective and can limit abdominal access.

Question 80

During the treatment of a distal radius fracture via a volar Henry approach, a prominent volar plate is placed distal to the watershed line (Soong grade 2). Which of the following complications is the patient at the highest risk of developing?

Explanation

Placement of a volar plate distal to the watershed line significantly increases the risk of flexor tendon irritation and attrition. The flexor pollicis longus (FPL) is the most commonly affected tendon due to its anatomical proximity.

Question 81

A 28-year-old male sustains a vertically oriented (Pauwels III) femoral neck fracture. When treating this with multiple cancellous screws, which of the following describes the most biomechanically stable screw configuration?

Explanation

The inverted triangle configuration (two superior screws and one inferior screw resting on the calcar) is the most biomechanically stable pattern for fixing femoral neck fractures. It optimally resists both shear forces and varus displacement.

Question 82

A 45-year-old man sustains a comminuted distal femur fracture. CT imaging reveals a coronal plane fracture of the lateral femoral condyle (Hoffa fragment). Which of the following describes the most appropriate fixation strategy for this specific fragment?

Explanation

A Hoffa fracture is a coronal shear fracture of the femoral condyle. It is best stabilized with anterior-to-posterior (AP) directed lag screws, placed perpendicular to the fracture plane to provide interfragmentary compression.

Question 83

A 30-year-old patient with an open tibial shaft fracture (Gustilo-Anderson Grade IIIA) is brought to the emergency department. According to current guidelines, what is the optimal timing and regimen for prophylactic antibiotic administration?

Explanation

For severe open fractures (Gustilo Type III), early antibiotic administration within 1 hour is critical. The recommended regimen includes a first-generation cephalosporin for Gram-positives, plus an aminoglycoside or third-generation cephalosporin for Gram-negatives.

Question 84

A 36-year-old male undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Which of the following patient factors is most strongly associated with postoperative wound complications in this scenario?

Explanation

Tobacco smoking drastically increases the risk of wound complications, infection, and flap necrosis after an extensile lateral approach to the calcaneus. The risk of wound healing problems in smokers can be up to three times higher than in non-smokers.

Question 85

A 50-year-old patient sustains a diaphyseal humerus fracture and is noted to have a radial nerve palsy upon presentation. Closed reduction and splinting are performed. Post-reduction radiographs show acceptable alignment, but the radial nerve deficit persists. 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 resolves spontaneously. Observation is indicated initially; surgical exploration is reserved for open fractures, penetrating injuries, or failure to recover by 3-4 months.

Question 86

A 25-year-old man falls from a height and sustains an unstable burst fracture of L1 with retropulsion of bone into the spinal canal. He is neurologically intact. Which of the following is considered an absolute indication for operative stabilization?

Explanation

A translational or rotatory deformity indicates failure of all three columns and profound mechanical instability, which is an absolute indication for operative stabilization. Canal compromise alone in a neurologically intact patient is not an absolute surgical indication.

Question 87

A 40-year-old female presents with an isolated closed transverse fracture of the midshaft humerus. Which of the following is generally considered an absolute indication for operative fixation?

Explanation

An ipsilateral forearm fracture ('floating elbow') is an absolute indication for surgical fixation of a humeral shaft fracture. This allows for early mobilization and stable restoration of the extremity, whereas an initial radial nerve palsy is not an absolute indication.

Question 88

A 45-year-old male is brought to the trauma bay in hemorrhagic shock following a motorcycle collision. An anteroposterior pelvic radiograph demonstrates an anteroposterior compression (APC) type III pelvic ring injury. A pelvic binder is to be applied. What is the correct anatomical landmark for the optimal placement of the pelvic binder?

Explanation

Pelvic binders must be centered over the greater trochanters to effectively reduce pelvic volume and control hemorrhage. Placement over the iliac crests is a common error and can paradoxically widen the true pelvis in APC injuries.

Question 89

A 28-year-old male sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III). Which of the following fixation constructs provides the most biomechanically stable fixation for this specific fracture pattern?

Explanation

Vertical femoral neck fractures (Pauwels type III) experience high shear forces. A sliding hip screw combined with a derotational screw provides superior biomechanical stability against shear stress compared to multiple parallel cannulated screws.

Question 90

A 32-year-old construction worker sustains a Grade IIIB open tibial shaft fracture. According to recent literature, which of the following factors has the most significant impact on reducing the risk of deep infection?

Explanation

The single most critical factor in preventing infection in open fractures is the early administration of systemic intravenous antibiotics, ideally within 1 hour of injury. The strict 6-hour rule for surgical debridement has not been shown to independently alter infection rates if antibiotics are given promptly.

Question 91

A 24-year-old male presents with a comminuted tibial plateau fracture. He is obtunded due to a concurrent traumatic brain injury. Intracompartmental pressure monitoring of the leg is performed. Which of the following parameters is most diagnostic of acute compartment syndrome requiring fasciotomy?

Explanation

The most reliable diagnostic parameter for acute compartment syndrome is a delta pressure (diastolic blood pressure minus intracompartmental pressure) of less than 30 mm Hg. Relying solely on absolute pressure can lead to misdiagnosis depending on the patient's systemic blood pressure.

Question 92

Review the radiograph provided.

In a patient with an isolated, closed extra-articular fracture of the scapula body, which of the following is generally considered an accepted absolute indication for operative fixation?

Explanation

Operative indications for extra-articular scapular neck/body fractures include severe medial displacement (generally >20-25 mm) or profound angular deformity (>45 degrees). Lesser degrees of displacement are typically managed non-operatively with excellent functional outcomes.

Question 93

A 19-year-old football player sustains a high-energy knee dislocation. The knee is reduced in the emergency department. The pedal pulses are palpable and symmetric to the contralateral side. What is the most appropriate next step in management to evaluate the vascular status?

Explanation

After a knee dislocation, even with normal palpable pulses, an Ankle-Brachial Index (ABI) should be measured. If the ABI is >0.9, serial examinations are appropriate; if it is <0.9, a CT angiogram or formal vascular surgery consultation is required.

Question 94

A 35-year-old female falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the articulations disrupted in this injury pattern?

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar body with subluxation or dislocation of both the subtalar and tibiotalar joints. The risk of avascular necrosis (AVN) in Type III injuries is extremely high, approaching 80-100%.

Question 95

A 72-year-old female presents with a displaced supracondylar femur fracture just proximal to a well-fixed posterior-stabilized total knee arthroplasty (TKA). If retrograde intramedullary nailing is planned, which TKA design feature is the most critical to evaluate preoperatively?

Explanation

In posterior-stabilized TKA designs, the closed intercondylar box restricts access to the medullary canal. The width and configuration of this box must be evaluated preoperatively to ensure a retrograde nail can pass through without impinging.

Question 96

Review the clinical image provided.

A patient presents with midfoot pain and swelling after a fall. Radiographs show a "fleck sign" in the first intermetatarsal space. The primary ligament ruptured in this injury originates from the lateral aspect of the medial cuneiform and inserts onto which structure?

Explanation

The fleck sign is pathognomonic for a Lisfranc injury and represents an avulsion of the Lisfranc ligament. This critical stabilizing ligament courses from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal.

Question 97

A 40-year-old male presents with a closed middle-third humeral shaft fracture. On initial examination, he has normal wrist and finger extension. Following a closed reduction and application of a coaptation splint, the patient is noted to have a complete wrist drop and inability to extend his MCP joints. What is the most appropriate management?

Explanation

A secondary (iatrogenic) radial nerve palsy that develops immediately following a closed reduction attempt of a humerus fracture is an absolute indication for surgical exploration. This is to extract the nerve if it has become entrapped within the fracture site.

Question 98

In the Young-Burgess classification of pelvic ring injuries, which of the following ligamentous structures remains completely intact in an anteroposterior compression type II (APC II) injury?

Explanation

An APC II pelvic ring injury is characterized by rupture of the symphyseal, anterior sacroiliac, sacrotuberous, and sacrospinous ligaments. The strong posterior sacroiliac ligaments remain intact, providing continued vertical stability to the hemipelvis.

Question 99

An extensile lateral approach is planned for the open reduction and internal fixation of a displaced intra-articular calcaneus fracture. The vascular supply to the lateral soft-tissue flap is primarily dependent on which of the following arteries?

Explanation

The lateral calcaneal artery, a terminal branch of the peroneal artery, provides the primary blood supply to the apex of the standard extensile lateral approach flap. Preserving this supply and utilizing a full-thickness "no-touch" subperiosteal flap minimizes the high risk of wound necrosis.

Question 100

A 25-year-old male sustains an isolated, low-velocity gunshot wound to the thigh resulting in a comminuted midshaft femur fracture. The entrance and exit wounds are clean and approximately 1 cm in diameter. There are no vascular deficits. What is the most appropriate initial treatment?

Explanation

Low-velocity gunshot wounds resulting in femur fractures without gross contamination or neurovascular injury are treated similarly to closed fractures. Local wound care, appropriate antibiotics, and standard immediate intramedullary nailing yield excellent outcomes without formal tract excision.

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

Orthopedic Trauma 2026 MCQs: Board Review Questions & Answers (Part 2)

Key Takeaway

Orthopedic Trauma 2026 MCQs: Board Review Questions & Answers (Part 2)

Chapter Index