Orthopedic Trauma Board Review 2026: MCQs Part 2

Question 1

Figures 14a and 14b show the initial radiographs of an 18-year-old man who fell while snowboarding. Figures 14c and 14d show the radiographs obtained following closed reduction. Examination reveals that the elbow is stable with range of motion. Management should now consist of

Explanation

14b 14c 14d The initial radiographs reveal a simple elbow dislocation without associated fractures. After successful closed reduction, the range of stability should be assessed. If the elbow is stable, nonsurgical management should consist of a short period of immobilization followed by range-of-motion exercises. Immobilization for more than 3 weeks results in significant elbow stiffness. Surgical repair is indicated for dislocations that are irreducible, have associated fractures, or where stability cannot be maintained with closed treatment. Cohen MS, Hastings H II: Acute elbow dislocations: Evaluation and management. J Am Acad Orthop Surg 1998;6:15-23.

Question 2

A 12-year-old boy sustains open comminuted midshaft tibial and fibular fractures while playing indoor soccer. The wound is grossly clean and measures 7 cm with some periosteal stripping. Antibiotics and tetanus toxoid are administered immediately in the emergency department. Following irrigation and debridement of the wound in the operating room, treatment should include

Explanation

Open fractures in children have similar rates of short-term complications such as compartment syndrome, vascular injury, and nerve injury when compared to adult fractures. Primary wound closure should be used for Gustillo and Anderson type 1 or uncomplicated type 2 fractures after surgical debridement. Skeletal stabilization may consist of external fixation, flexible nails, or casting with or without supplementary pin fixation. For an open comminuted midshaft fracture, external fixation is the treatment of choice. Reamed intramedullary nailing is contraindicated in children with an open physis. Plate fixation has a high complication rate in severe open fractures. Jones BG, Duncan RD: Open tibial fractures in children under 13 years of age-10 years experience. Injury 2003;34:776-780. Bartlett CS III, Weiner LS, Yang EC: Treatment of type II and type III open tibia fractures in children. J Orthop Trauma 1997;11:357-362. Robertson P, Karol LA, Rab GT: Open fractures of the tibia and femur in children. J Pediatr Orthop 1996;16:621-626.

Question 3

Which of the following is an advantage of unreamed nailing of the tibia compared to reamed nailing?

Explanation

The debate between reamed versus unreamed intramedullary nailing of the tibia continues. Although unreamed nailing was proposed for open fractures to minimize infection, its simplicity made it appealing for closed fractures. However, most studies to date show that the only advantage of unreamed nailing is less surgical time. All studies show higher nonunion rates with increased hardware failure and increased time to union for unreamed nailing. Even in open fractures graded up to Gustilo Grade IIIA, the reamed tibial nail performs better. Larsen LB, Madsen JE, Hoiness PR, et al: Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow-up. J Orthop Trauma 2004;18:144-149.

Question 4

A 12-year-old boy sustained a both bone forearm fracture 10 weeks ago and underwent closed reduction and casting. Examination now reveals that the injury is healed, but he is unable to extend his little and ring fingers of the injured hand with his wrist extended. Full extension is possible with the wrist flexed. A radiograph and clinical photograph are shown in Figures 15a and 15b. The remainder of his hand and wrist examination and neurologic evaluation in the hand are normal. What is the most likely diagnosis?

Explanation

15b In this patient, examination reveals an inability to extend the fingers with the wrist extended, but full extension is possible with wrist flexion. These findings demonstrate isolated tenodesis of the flexor digitorum to the ring and little fingers. These findings are not consistent with compartment syndrome or nerve injury. Scarring or entrapment of tendons in forearm fractures can occur. Watson PA, Blair W: Entrapment of the index flexor digitorum profundus tendon after fracture of both forearm bones in a child. Iowa Orthop J 1999;19:127-128. Shaw BA, Murphy KM: Flexor tendon entrapment in ulnar shaft fractures. Clin Orthop 1996;330:181-184. Kolkman KA, van Niekerk JL, Rieu PN, et al: A complicated forearm greenstick fracture: Case report. J Trauma 1992;32:116-117.

Question 5

An otherwise healthy 35-year-old woman reports dorsal wrist pain and has trouble extending her thumb after sustaining a minimally displaced fracture of the distal radius 3 months ago. What is the next most appropriate step in management?

Explanation

Extensor pollicis longus tendon rupture can occur after a fracture of the distal radius, even a minimally displaced one. Poor vascularity of the tendon within the third dorsal compartment is the suspected etiology, not the displaced fracture fragments. Tendon transfer will suitably restore active extension of the thumb interphalangeal joint. Christophe K: Rupture of the extensor pollicis longus tendon following Colles fracture. J Bone Joint Surg Am 1953;35:1003-1005.

Question 6

Figure 16a shows the radiograph of a 34-year-old woman who sustained a basicervical fracture of the femoral neck. The fracture was treated with a compression screw and side plate. Seven months postoperatively, she continues to have significant hip pain and cannot bear full weight on her hip. A recent radiograph is shown in Figure 16b. Management should now consist of

Explanation

16b The patient sustained a high-angle femoral neck fracture. The follow-up clinical findings and radiograph show that she now has a nonunion with failed internal fixation. The joint appears preserved. In a healthy, young patient, arthroplasty of the femoral head, although possible, is not ideal. Excellent healing and function can be obtained in 70% to 80% of patients with femoral neck nonunion with a valgus intertrochanteric osteotomy. Marti RK, Schuller HM, Raaymakers EL: Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br 1989;71:782-787.

Question 7

An 18-year-old man was in a motor vehicle accident and sustained a closed head injury, right displaced scapular body and glenoid fractures, a right proximal humeral fracture, fractures of ribs one through three, facial fractures, and bilateral pubic rami fractures with minimal displacement. He has a systolic blood pressure of 80/40 mm Hg despite fluid resuscitation. A radiograph is shown in Figure 17. Spiral CT does not identify any thoracic or abdominal injuries. What is the next most appropriate step in management?

Explanation

The patient has sustained high-energy upper extremity and chest injuries. He continues to remain hemodynamically unstable with no obvious thoracic or abdominal injury responsible for bleeding. The pelvic fracture is unlikely to be causing significant bleeding. A scapulothoracic dissociation and possible disruption of one of the great vessels of the upper extremity should be considered. Evaluation of peripheral pulses or blood pressure indices bilaterally in the upper extremities is a simple way to evaluate the need for further work-up. If there is any discrepancy or further concern, angiography of the involved extremity is necessary. Althausen PL, Lee MA, Finkemeier CG: Scapulothoracic dissociation: Diagnosis and treatment. Clin Orthop 2003;416:237-244.

Question 8

What is the major difference in outcome following open reduction and internal fixation (ORIF) of the tibial plafond at 2 to 5 days versus 10 to 20 days?

Explanation

Long-term outcomes following tibial plafond fractures treated with ORIF are satisfactory in most patients despite a high incidence of posttraumatic osteoarthritis. If ORIF is delayed until 10 to 20 days following injury, the major difference in outcomes is fewer complications associated with wound healing. Ankle strength, pain, range of motion, and the development of arthritis are equal regardless of the time until fixation. Sirkin M, Sanders R, DePasquale T, et al: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 1999;13:78-84.

Question 9

Figure 18a shows the initial lateral radiograph of a 6-year-old girl who sustained a fracture in a motor vehicle accident and was treated in a cast 1 year ago. She now has the valgus deformity seen in Figure 18b. Treatment should consist of

Explanation

18b Proximal tibial metaphyseal fractures may result in late genu valgum as a result of asymmetric growth of the proximal tibia. These patients are best treated with observation because the deformity is likely to remodel. Osteotomy is not indicated and potentially will lead to recurrence. Stapling of the medial tibial physis is appropriate in patients who have a severe and progressive deformity. Cozen L: Knock-knee deformity in children: Congenital and acquired. Clin Orthop 1990;258:191-203. Jackson DW, Cozen L: Genu valgum as a complication of proximal tibial metaphyseal fractures in children. J Bone Joint Surg Am 1971;53:1571-1578. Brammar TJ, Rooker GD: Remodeling of valgus deformity secondary to proximal metaphyseal fracture of the tibia. Injury 1998;29:558-560. Ogden JA, Ogden DA, Pugh L, et al: Tibia valga after proximal metaphyseal fractures in childhood: A normal biologic response. J Pediatr Orthop 1995;15:489-494.

Question 10

Figure 19 shows the radiograph of a 45-year-old woman who has a painful nonunion. Treatment should consist of

Explanation

The radiograph reveals a reverse obliquely subtrochanteric/intertrochanteric fracture. Open reduction and internal fixation should be accomplished with a 95-degree fixed angle device. An intramedullary nail with screw fixation into the head is another possible technique. Either method should correct the varus deformity. Exchange of a high-angled screw and plate device to a longer side plate and bone grafting does not afford any improvement in the mechanical stability. Hardware removal and retrograde intramedullary nailing is not indicated for this level of a proximal femoral injury. Placement of an implantable bone stimulator may change local biologic factors but would not enhance mechanical stability. The patient's femoral head is intact without signs of collapse; therefore, hardware removal, proximal femoral resection, and total hip arthroplasty are not warranted. Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.

Question 11

A 7-year-old boy has a swollen and deformed right arm after falling off his bicycle. Radiographs reveal a completely displaced posterolateral supracondylar humeral fracture. Examination reveals a warm, pink hand and forearm but absent pulses. What is the next most appropriate step in management?

Explanation

The incidence of vascular injury in supracondylar humeral fractures is directly related to the degree and direction of displacement. Significant posterior lateral displacement tends to result in brachial artery and median nerve injuries, and posterior medial displacement may lead to radial nerve injury. The brachial artery is always injured at the level of the fracture; therefore, angiography or MRA will not assist in locating the injury. The treatment of choice is surgical reduction and stabilization of the fracture, followed by reassessment of the vascular status. If the hand is pink and warm or pulses can be detected with doppler, it is reasonable to follow the extremity closely after surgery. If the arm becomes pulseless and white, immediate anterior exploration of the arm is indicated. The artery is often entrapped in the fracture and once extricated, will provide adequate blood flow. If the artery is injured, a primary repair or vein graft is needed. Shaw BA: The role of angiography in assessing vascular injuries associated with supracondylar humerus fractures remains controversial. J Pediatr Orthop 1998;18:273. 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 12

What is the treatment of choice for the injury shown in Figures 20a through 20c?

Explanation

20b 20c The radiographs show multiple carpometacarpal dislocations. Reduction is often obtainable but difficult to maintain. Internal fixation is required to maintain the reduction, preferably with Kirschner wires. Closed reduction and percutaneous pinning is preferred by some surgeons. Others recommend open reduction to remove irreconstructable osteochondral fragments from the individual joints and to ensure correct reduction of the carpometacarpal joints. Kirschner wires are removed at 6 to 8 weeks. Prokuski LJ, Eglseder WA Jr: Concurrent dorsal dislocations and fracture-dislocations of the index, long, ring, and small (second to fifth) carpometacarpal joints. J Orthop Trauma 2001;15:549-554.

Question 13

A 32-year-old man has intense right hand and wrist pain, a deformed wrist, and numbness in his fingers after falling off his motorcycle. This is an isolated injury. Examination reveals a swollen wrist, normal capillary refill to all fingers, and limited flexion of all fingers. Radiographs are shown in Figures 21a and 21b. Neurologic examination of the hand will most likely reveal

Explanation

21b The patient has a perilunate dislocation. A volar dislocation of the lunate is often associated with median nerve dysfunction. This injury to the wrist is often overlooked because of its benign clinical appearance and the presence of other injuries, as it is caused by high-energy mechanisms. Ruby LK, Cassidy C: Fractures and dislocations of the carpus, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1297-1300.

Question 14

A 55-year-old woman fell and sustained an elbow dislocation with a coronoid fracture and a radial head fracture. The elbow is reduced and splinted. What is the most common early complication?

Explanation

The patient has a dislocation of the elbow with displaced coronoid process and radial head fractures. The elbow is extremely unstable after this injury, and recurrent dislocation in a splint is the most common early complication. Skeletal stabilization of the fractures is required to restore stability of the joint. Characteristics of the fractures will determine the techniques required to restore stability. 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 15

A 25-year-old man sustained the closed injury shown in Figures 22a and 22b. Examination reveals that this is an isolated injury, and he is hemodynamically stable. Treatment should consist of

Explanation

22b The treatment of choice for closed diaphyseal femoral fractures in adults is reamed intramedullary nailing with static interlocking. Reaming allows placement of a larger, stronger implant and offers better healing rates than unreamed nailing. Static interlocking ensures that there is no loss of reduction because of underappreciated fracture lines or comminution. Brumback RJ, Virkus WW: Intramedullary nailing of the femur: Reamed versus nonreamed. J Am Acad Orthop Surg 2000;8:83-90.

Question 16

Figure 23 shows the radiograph of an elderly man who fell on his right arm. What is the most important determinate of a good outcome following this injury?

Explanation

Minimally displaced fractures of the proximal humerus have a good outcome if physical therapy is initiated within 2 weeks of the injury. Results are not affected by age, open reduction and internal fixation, or involvement of the greater tuberosity. Immobilization for longer than 3 weeks will often result in stiffness. Koval KJ, Gallagher MA, Marsicano JG, et al: Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am 1997;79:203-207.

Question 17

A 40 year-old-man was involved in a motor vehicle accident and sustained the pelvic injury seen in Figures 24a and 24b. Definitive management of the injury should consist of reduction by

Explanation

24b The radiograph reveals disruption of the symphysis pubis and a displaced left sacral fracture. A posterior injury with displacement of greater than 1 cm is unstable, and a sacral fracture is particularly unstable. Surgical stabilization is required for these unstable anterior and posterior injuries. External fixation provides little stability to an unstable posterior pelvic injury. Reduction and internal fixation of the symphysis pubis and sacral fracture will provide the most stable pelvis with the least resultant deformity and allow patient mobilization. Tile M: Management of pelvic ring injuries, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 168-202.

Question 18

A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most reliable method of predicting a tear of the interosseous membrane?

Explanation

The Weber and Lauge-Hansen fracture classifications suggest that the interosseous membrane (IOM) is torn with certain fracture patterns. In a recent study that evaluated ankle fractures with MRI, Nielson and associates identified 30 patients with IOM tears. Ten of the tears did not correspond with the level of the fibular fracture. The authors concluded that stability of the syndesmosis should not be based on the level of the fibular fracture alone but should also include an intraoperative stress test. Transsyndesmotic fixation should be considered for those fractures where the intraoperative stress test demonstrates instability. A widened medial clear space may occur with a deltoid injury and distal fibular fracture in the absence of a significant tear of the interosseous membrane.

Question 19

When performing a flexor tendon repair of a digit other than the thumb, what structures of the flexor tendon sheath should be preserved?

Explanation

The A2 and A4 pulleys are considered the most important parts of the pulley system. If these two structures are preserved, 80% of finger flexion can be maintained. If the pulley system is not left intact or is not reconstructed, "bow-stringing" of the flexor tendons occurs with loss of full flexion. The A2 pulley is over the proximal phalanx and the A4 pulley is over the middle phalanx. Doyle JR: Anatomy of the finger flexor tendon sheath and pulley system. J Hand Surg Am 1988;13:473-484.

Question 20

A distal radius fracture in an elderly man is strongly predictive for what subsequent injury?

Explanation

Fractures of the distal radius increase the relative risk of a subsequent hip fracture significantly more in men than in women. A previous spinal fracture has an equally important impact on the risk of a subsequent hip fracture in both genders.

Question 21

A 13-year-old girl injures her ankle playing soccer. Radiographs reveal a displaced Tillaux fracture. CT scans are shown in Figure 25. What is the most important consideration for appropriate management?

Explanation

Tillaux and triplane fractures occur in adolescents as the result of an external rotation injury of the ankle. As seen on the CT scan, the growth plate starts to close during adolescence; therefore, growth arrest resulting in limb-length discrepancy or angulation is less of a concern in this age group than achieving joint congruity. The joint should be surgically reduced if displacement is greater than 2 mm to minimize the chances of late arthrosis. Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment. J Am Acad Orthop Surg 2001;9:268-278. Kling TF Jr: Operative treatment of ankle fractures in children. Orthop Clin North Am 1990;21:381-392.

Question 22

What measure of physiologic status best evaluates whether an injured patient is fully resuscitated and best predicts that perioperative complications will be minimized following definitive stabilization of long bone fractures?

Explanation

Serum lactate levels can be used to evaluate the effectiveness of the resuscitation of patients who have multiple injuries. Even after resuscitation, patients may have occult hypoperfusion as defined by a serum lactate level of greater than 2.5 mmol/L. The studies referenced indicate that these patients are at increased risk of perioperative complications such as organ failure or adult respiratory distress syndrome if definitive surgical fixation of the orthopaedic injuries is pursued prior to correction of the occult hypoperfusion. The other markers may be an indication of current physiology but have not been correlated with perioperative risks. Blow O, Magliore L, Claridge JA, et al: The golden hour and silver day: Detection and correction of occult hypoperfusion within 24 hours improves outcomes from major trauma. J Trauma 1999;47:964-977. Crowl A, Young JS, Kahler DM, et al: Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J Trauma 2000;48:260-267.

Question 23

Based on the findings seen in the radiograph in Figure 26, emergent management should consist of

Explanation

The radiograph shows a volarly dislocated lunate. Initial emergent treatment of perilunate dislocations should consist of closed reduction and splinting, especially if the patient exhibits median nerve compression. Open reduction and pinning or ligament repair are necessary but are not emergent. A dorsal approach is sometimes required for ligament repair or bony visualization; however, this can be done in a more semi-elective manner. Isenberg J, Prokop A, Schellhammer F, et al: Palmar lunate dislocation. Unfallchirurg 2002;105:1133-1138.

Question 24

A 10-year-old girl has a midshaft both bone forearm fracture. After attempted closed reduction, alignment consists of bayonet apposition, 10 degrees of malrotation, and 8 degrees of volar angulation. Management should now consist of

Explanation

Acceptable alignment in both bone forearm fractures is related to age and location. In children younger than age 9 years, angulations of 15 degrees and malrotation of 45 degrees are acceptable. In children older than age 9 years, acceptable alignment is 10 degrees of angulation and 30 degrees of malrotation. Bayonet apposition is acceptable provided that the angular and rotational reductions are held within these guidelines. A long arm cast provides better control of deforming forces than a short arm cast. Do TT, Strub WM, Foad SL, et al: Reduction versus remodeling in pediatric distal forearm fractures: A preliminary cost analysis. J Pediatr Orthop B 2003;12:109-115. Flynn JM: Pediatric forearm fractures: Decision making, surgical techniques, and complications. Instr Course Lect 2002;51:355-360. Ring D, Waters PM, Hotchkiss RN, et al: Pediatric floating elbow. J Pediatr Orthop 2001;21:456-459.

Question 25

In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by

Explanation

In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by the use of a direct lateral approach to the ankle. The superficial peroneal nerve and its branches exit the fascial hiatus approximately 9 cm to 10 cm proximal to the tip of the distal fibula with a range of 4 cm to 13 cm, and their course is typically anterior to the midlateral plane of the fibula. However, small branches may course across the surgical plane directly laterally. A posterior-lateral approach diminishes the risk of injury to the superficial peroneal nerve and its branches; however, by moving farther posterior, the sural nerve and its branches may be at increased risk. Cast immobilization may injure the cutaneous nerves about the ankle; however, the risks are greater with surgical intervention. A medial or anterior-medial approach to the ankle will not injure the superficial peroneal nerve at the ankle level. Redfern DJ, Sauve PS, Sakellariou A: Investigation of incidence of superficial peroneal nerve injury following ankle fracture. Foot Ankle Int 2003;24:771-774.

Question 26

A 35-year-old male is brought to the emergency department after a high-speed motorcycle collision. He is hypotensive (BP 80/40 mmHg) and tachycardic (HR 130 bpm). Primary survey reveals an unstable pelvis with an anteroposterior compression (APC) type III pattern on a plain anteroposterior radiograph. A pelvic binder is appropriately applied, but he remains hemodynamically unstable despite receiving 2 units of uncrossmatched blood. A FAST exam is negative for intra-abdominal fluid. What is the most appropriate next step in management?

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST exam (ruling out massive intra-abdominal hemorrhage), the source of bleeding is presumed to be the pelvis (venous plexus or arterial injury). Current ATLS and orthopedic trauma guidelines recommend preperitoneal pelvic packing (PPP) and/or pelvic angiography with embolization as the primary interventions for hemorrhage control. A CT scan is contraindicated in a hemodynamically unstable patient. While an external fixator can help reduce pelvic volume, PPP or angioembolization provides definitive intervention for the hemorrhage.

Question 27

A 42-year-old female sustains a transverse posterior wall acetabular fracture. Radiographs and CT demonstrate a large posterior wall fragment and a medially displaced transverse component. The surgeon selects a Kocher-Langenbeck approach for fixation. During the procedure, the surgeon attempts to access the anterior extent of the transverse fracture line. Which of the following anatomic structures represents the primary limitation to the anterior/superior extension of the Kocher-Langenbeck approach?

Explanation

The Kocher-Langenbeck approach provides excellent exposure to the posterior column and posterior wall. When extending the exposure superiorly and anteriorly along the ilium, the superior gluteal neurovascular bundle is the primary limiting structure. It exits the greater sciatic notch superior to the piriformis. Vigorous retraction or excessive anterior extension can cause stretching, avulsion, or iatrogenic injury to these vessels and nerves, potentially leading to denervation of the abductor musculature.

Question 28

A 28-year-old male sustains a completely displaced, vertically oriented (Pauwels type III) femoral neck fracture after a fall from a height. He has no significant past medical history. He is taken to the operating room 6 hours after the injury. What is the most biomechanically appropriate surgical management to preserve the native hip?

Explanation

In a young adult with a Pauwels type III (high shear angle) displaced femoral neck fracture, preservation of the native hip is the absolute goal. Parallel cancellous screws are associated with a high failure rate for vertically oriented shear fractures due to inadequate biomechanical stability. A sliding hip screw (SHS) with an adjunctive anti-rotation screw, or a length-stable construct, provides superior biomechanical stability against vertical shear forces compared to multiple cancellous screws. Arthroplasty is reserved for older, lower-demand patients or unfixable highly comminuted fractures.

Question 29

A 40-year-old female sustains a high-energy supracondylar distal femur fracture (OTA/AO 33-C2). The CT scan demonstrates an associated coronal plane fracture of the lateral femoral condyle. When planning internal fixation for this specific coronal plane fragment, what biomechanical force must primarily be addressed by the implant construct?

Explanation

A coronal plane fracture of the femoral condyle is known as a Hoffa fracture (OTA/AO 33-B3). By nature of its coronal orientation, it is primarily subjected to vertical shear forces during weight-bearing and physiologic knee motion. Fixation typically requires anterior-to-posterior (or posterior-to-anterior) directed lag screws to compress the fracture and effectively resist these shear forces. An adjunctive antiglide plate is frequently utilized for supplemental stability.

Question 30

A 32-year-old male is recovering on the surgical ward 12 hours after reamed intramedullary nailing of a closed diaphyseal tibia fracture. He complains of severe, escalating leg pain that is out of proportion to the injury and unresponsive to IV opioids. On examination, he experiences extreme pain with passive stretch of the hallux and has diminished sensation in the first web space. His blood pressure is 110/70 mmHg. Intracompartmental pressure of the anterior compartment is measured at 45 mmHg. What is the delta pressure, and what is the most appropriate next step in management?

Explanation

Acute compartment syndrome is a surgical emergency. The delta pressure is calculated as the Diastolic Blood Pressure minus the Intracompartmental Pressure (70 - 45 = 25 mmHg). A delta pressure of 30 mmHg or less is generally accepted as an absolute indication for fasciotomy. Furthermore, this patient exhibits classic clinical signs (pain out of proportion, pain on passive stretch, and sensory deficit in the deep peroneal nerve distribution). The standard of care for tibial compartment syndrome is an emergent four-compartment fasciotomy.

Question 31

A 25-year-old agricultural worker sustains a severe open tibia fracture after his leg gets caught in a tractor power take-off. The wound measures 12 cm with extensive muscle devitalization, and there is gross contamination with soil and organic farm debris. The patient has normal renal function and no known drug allergies. According to standard orthopedic trauma guidelines, what is the most appropriate initial empiric antibiotic regimen?

Explanation

This is a Gustilo-Anderson Type III open fracture with heavy soil/farm contamination. Traditional guidelines strongly recommend a first-generation cephalosporin (e.g., cefazolin) for Gram-positive coverage, an aminoglycoside (e.g., gentamicin) for expanded Gram-negative coverage, and high-dose penicillin specifically to cover Clostridium species to mitigate the risk of gas gangrene associated with agricultural or soil injuries.

Question 32

A 29-year-old male falls from a ladder and sustains a displaced fracture of the talar neck. Plain radiographs and CT imaging demonstrate displacement of the talar neck with subluxation of the subtalar joint, while the tibiotalar (ankle) joint remains completely congruous. According to the Hawkins classification, what is the type of fracture and the approximate risk of avascular necrosis (AVN) of the talar body?

Explanation

The Hawkins classification describes talar neck fractures based on displacement and joint subluxation/dislocation. Type I is non-displaced (AVN risk 0-10%). Type II involves displacement of the talar neck with subluxation or dislocation of the subtalar joint, while the ankle joint remains intact (AVN risk 20-50%). Type III involves dislocation of both the subtalar and ankle joints (AVN risk >70%). Type IV includes additional subluxation or dislocation of the talonavicular joint. The described injury matches a Type II fracture.

Question 33

A 45-year-old male is undergoing open reduction and internal fixation of a Sanders Type III calcaneus fracture via an extensile lateral approach. Which of the following technical execution aspects is most critical for minimizing the risk of postoperative skin edge necrosis and wound breakdown?

Explanation

Wound complications are a significant risk with the extensile lateral approach to the calcaneus. To minimize this risk, the flap must be raised as a single, full-thickness subperiosteal envelope that includes the sural nerve, lesser saphenous vein, and peroneal tendons to preserve its tenuous vascular supply. Dissecting the flap in distinct layers, rather than full-thickness to bone, drastically increases the risk of necrosis. A 'no-touch' technique utilizing K-wires for retraction is heavily favored over handling the tissue with forceps.

Question 34

A 50-year-old male presents to the trauma bay after a high-energy motor vehicle collision. Radiographs demonstrate a highly comminuted bicondylar tibial plateau fracture with metaphyseal-diaphyseal dissociation (Schatzker VI). Examination reveals a tensely swollen calf, multiple fracture blisters, and a delta pressure of 45 mmHg. What is the most appropriate initial orthopedic management of this injury?

Explanation

High-energy tibial plateau fractures (Schatzker V and VI) frequently present with severe soft tissue envelope compromise. Immediate open reduction and internal fixation in the presence of severe swelling and fracture blisters carries an unacceptably high risk of catastrophic wound breakdown and deep infection. The standard of care ('damage control orthopedics') mandates the application of a knee-spanning external fixator to temporarily stabilize the fracture and restore length/alignment, allowing the soft tissues to adequately recover prior to definitive ORIF 10 to 14 days later.

Question 35

A 38-year-old male sustains a closed, highly comminuted tibial pilon fracture (OTA/AO 43-C3) with an associated displaced distal third fibula fracture following a 15-foot fall. The treating surgeon plans a standard two-stage protocol. During the initial application of the joint-spanning external fixator, what is the current consensus regarding the role of immediate open reduction and internal fixation of the fibula?

Explanation

In the staged management of severe pilon fractures, early fibular fixation was traditionally advocated to restore length and act as a template. However, modern consensus indicates that immediate open fibular fixation should be avoided if the lateral incision will compromise the angiosomes or adequate skin bridges needed for future definitive anterior, anterolateral, or posterolateral approaches to the tibia. Many surgeons now rely entirely on the spanning external fixator to maintain length and alignment during the damage control phase to minimize additional soft tissue insults.

Question 36

An 82-year-old community-ambulating woman sustains a displaced femoral neck fracture after a mechanical fall. She has a history of controlled hypertension and diet-controlled type 2 diabetes. What is the primary clinical benefit of performing surgical management (hemiarthroplasty) within 24 to 48 hours of her presentation?

Explanation

Early surgical intervention (typically defined as within 24 to 48 hours of admission) for geriatric hip fractures is heavily supported by the literature to decrease 30-day and 1-year mortality rates, reduce the incidence of pressure ulcers, and shorten hospital lengths of stay. The rate of avascular necrosis and nonunion are not primarily mitigated by timing in the context of arthroplasty, and dislocation risk is largely dependent on the surgical approach and implant positioning.

Question 37

A 26-year-old male polytrauma patient sustains a severe traumatic brain injury, multiple rib fractures, and a closed comminuted midshaft femur fracture. He is initially treated with Damage Control Orthopedics (DCO) using a spanning external fixator for his femur. Before converting the external fixator to a definitive intramedullary nail, which of the following physiological parameters is the most reliable indicator of adequate resuscitation?

Explanation

Normalization of serum lactate (typically < 2.0 or 2.5 mmol/L) and/or resolution of base deficit are considered the most reliable objective markers of adequate global tissue perfusion and resuscitation in polytrauma patients. Proceeding with definitive major surgery (Early Total Care or conversion from DCO) in an under-resuscitated patient with elevated lactate or high base deficit significantly increases the risk of acute respiratory distress syndrome (ARDS), multiple organ failure (MOF), and mortality.

Question 38

A 72-year-old woman with an 8-year history of alendronate use presents with a 3-month history of insidious onset right lateral thigh pain. Radiographs demonstrate lateral cortical thickening and a transverse radiolucent line in the subtrochanteric region of the right femur, without complete displacement. What is the most appropriate management?

Explanation

This patient is presenting with an impending atypical femur fracture (AFF), which is strongly associated with long-term bisphosphonate use (usually > 5 years). The classic radiographic findings are lateral cortical thickening ("beaking") and a transverse radiolucent line. If the patient has prodromal pain (impending fracture), the recommended treatment is discontinuation of the bisphosphonate and prophylactic intramedullary nailing to prevent a complete fracture, which has a significantly higher complication and nonunion rate.

Question 39

A 45-year-old man falls from a ladder and sustains a high-energy closed tibial pilon fracture. On examination in the emergency department, the ankle is grossly deformed with tense soft tissues and early fracture blister formation. No open wounds are present. What is the most appropriate initial management?

Explanation

High-energy tibial pilon fractures are associated with profound soft tissue injury. Early definitive open reduction and internal fixation (ORIF) in the presence of compromised soft tissues (tense swelling, blisters) is associated with unacceptably high rates of wound breakdown and deep infection. The standard of care is a staged approach: initial application of a joint-spanning external fixator to restore length and alignment (with or without definitive fibular fixation), followed by definitive tibial ORIF once the soft tissues have recovered (usually 10 to 21 days later), marked by the reappearance of skin wrinkles.

Question 40

A 35-year-old woman falls onto an outstretched hand and presents with a 'terrible triad' injury of the elbow (elbow dislocation, radial head fracture, and coronoid process fracture). Which of the following describes the most universally accepted surgical sequence for reconstructing this injury?

Explanation

The standard surgical protocol for a terrible triad injury of the elbow follows an 'inside-out' or deep-to-superficial approach. First, the coronoid is fixed (or the anterior capsule is repaired) to restore anterior stability. Second, the radial head is repaired or replaced to restore the anterior radiocapitellar buttress and valgus stability. Finally, the lateral ulnar collateral ligament (LUCL/LCL complex) is repaired to restore posterolateral rotatory stability. If the elbow remains unstable after these steps, medial collateral ligament (MCL) repair or a hinged external fixator is considered.

Question 41

A 28-year-old male is brought to the trauma bay after a high-speed motorcycle collision. His blood pressure is 80/50 mmHg, and his heart rate is 130 bpm. FAST examination is negative. Pelvic radiographs demonstrate an anteroposterior compression type III (APC-III) pelvic ring injury. A pelvic binder is applied appropriately, and he receives 2 units of uncrossmatched packed RBCs, but his blood pressure remains 85/55 mmHg. What is the most appropriate next step in management?

Explanation

This patient is hemodynamically unstable due to a major pelvic ring disruption (likely venous plexus bleeding or arterial injury), with no evidence of intra-abdominal hemorrhage (negative FAST). Mechanical stabilization with a pelvic binder is the first step. If the patient remains hemodynamically unstable despite a binder and initial volume resuscitation, emergent hemorrhage control is required. According to advanced trauma protocols, this should be achieved via pre-peritoneal pelvic packing (PPP) and/or pelvic angiography with embolization. CT is contraindicated in a persistently hemodynamically unstable patient.

Question 42

When utilizing a laterally based locking plate for a highly comminuted supracondylar distal femur fracture (AO/OTA type 33-C), which of the following technical modifications decreases the construct stiffness and promotes secondary bone healing through callus formation?

Explanation

In comminuted fractures bridged by a locking plate, secondary bone healing (callus formation) relies on relative stability, which requires a small amount of controlled interfragmentary motion. 'Working length' is the distance between the two innermost screws flanking the fracture. Increasing the working length (leaving screw holes empty near the fracture site) decreases the rigidity of the construct, allowing for micro-motion and promoting robust callus formation. Filling all holes or using short plates makes the construct too stiff, leading to a high risk of nonunion or implant failure.

Question 43

A 25-year-old intubated polytrauma patient has a closed, comminuted midshaft tibia fracture. The leg is tense and significantly swollen. Compartment pressure measurements are obtained using a handheld manometer: Anterior 45 mmHg, Lateral 40 mmHg, Deep Posterior 50 mmHg, Superficial Posterior 30 mmHg. The patient's blood pressure is 110/65 mmHg (MAP 80 mmHg). What is the most appropriate next step in management?

Explanation

The diagnosis of acute compartment syndrome in an obtunded or intubated patient relies on objective pressure measurements. The most reliable criterion is the 'Delta P' (ΔP), which is calculated as the Diastolic Blood Pressure minus the highest intracompartmental pressure. A ΔP of less than 30 mmHg is an absolute indication for fasciotomy. In this patient, the diastolic BP is 65 mmHg, and the highest compartment pressure is 50 mmHg (Deep Posterior). The ΔP is 15 mmHg (65 - 50 = 15), which is well below the 30 mmHg threshold, indicating acute compartment syndrome. The definitive treatment is an urgent four-compartment fasciotomy.

Question 44

A 30-year-old man sustains a Gustilo-Anderson IIIB open tibia fracture following an industrial accident. He undergoes immediate aggressive surgical debridement, irrigation, and application of a spanning external fixator. A second-look debridement confirms a clean, viable wound bed with exposed bone devoid of periosteum. To minimize the risk of deep infection, what is the optimal timeframe for performing definitive soft-tissue coverage (e.g., a free tissue transfer)?

Explanation

Timing of soft-tissue coverage is critical in Gustilo IIIB open fractures. Classic studies by Godina, and more recently supported by the LEAP (Lower Extremity Assessment Project) study, demonstrate that early soft tissue coverage—optimally within 3 to 7 days (or at least less than 7 days)—significantly reduces the rates of deep infection, flap failure, and nonunion. Delaying coverage beyond this 'subacute' window allows bacterial colonization and fibrosis, dramatically increasing complication rates.

Question 45

A 55-year-old man is involved in a motor vehicle collision and sustains an associated both-column acetabular fracture. CT imaging demonstrates profound displacement of the anterior column, significant medial subluxation of the femoral head, and severe comminution of the quadrilateral plate. There is minimal displacement of the posterior column. Which of the following surgical approaches provides the most direct access for buttressing the quadrilateral plate to prevent medial subluxation?

Explanation

The anterior intrapelvic approach (Modified Stoppa) provides excellent, direct visualization of the true pelvis, the pelvic brim, and critically, the quadrilateral plate. It allows the surgeon to directly place an infrapectineal buttress plate to support the comminuted quadrilateral plate and prevent medial subluxation of the femoral head. While the classic ilioinguinal approach also accesses the anterior column, it provides only indirect, tangential access to the quadrilateral plate. The Kocher-Langenbeck approach is indicated for posterior wall/column injuries and does not provide access to the anterior column or quadrilateral surface.

Question 46

A 42-year-old male is brought to the trauma bay after a high-speed motorcycle collision. He has an anteroposterior compression type III (APC-III) pelvic ring injury. His initial blood pressure is 70/40 mmHg. A pelvic binder is applied appropriately at the level of the greater trochanters, and 2 units of uncrossmatched packed red blood cells are administered. The FAST (Focused Assessment with Sonography for Trauma) exam is negative, and his chest radiograph is unremarkable. Despite these measures, his blood pressure remains 75/45 mmHg. What is the most appropriate next step in management?

Explanation

According to Advanced Trauma Life Support (ATLS) and current orthopedic trauma guidelines, a hemodynamically unstable patient with a pelvic ring disruption and a negative FAST exam (ruling out massive intra-abdominal hemorrhage) requires immediate pelvic hemorrhage control. After mechanical stabilization with a binder, the next step for persistent shock is preperitoneal pelvic packing or pelvic angioembolization. Exploratory laparotomy is incorrect in the setting of a negative FAST, as opening the peritoneum can release the tamponade effect on the retroperitoneal hematoma. External fixation alone is insufficient for severe hemodynamic instability once a binder is already in place.

Question 47

A 25-year-old male sustains a vertically oriented, displaced basicervical femoral neck fracture (Pauwels III) following a fall from a height. Which of the following fixation constructs provides the greatest biomechanical stability and highest resistance to vertical shear forces for this specific fracture pattern?

Explanation

Pauwels III fractures are vertically oriented (angle > 50 degrees) and experience high vertical shear forces, leading to a high rate of varus collapse, nonunion, and failure when treated with multiple cancellous screws alone. Biomechanical studies have consistently demonstrated that a fixed-angle device, such as a sliding hip screw (SHS), provides superior resistance to vertical shear compared to cancellous screws. A derotational cancellous screw is typically added superior to the SHS to prevent rotation of the femoral head during insertion and weight-bearing.

Question 48

A 45-year-old male smoker sustains a high-energy closed tibial pilon fracture (OTA/AO 43C3) with severe soft tissue swelling and fracture blisters. A spanning external fixator is placed on the day of injury. Definitive open reduction and internal fixation (ORIF) is planned. Which of the following physical examination findings is the most reliable clinical indicator that the soft tissues are ready for definitive surgical incisions?

Explanation

In high-energy pilon fractures, the single most important factor in preventing catastrophic postoperative wound complications is respecting the soft tissue envelope. The 'wrinkle sign'—the appearance of fine skin lines/wrinkles when the ankle is dorsiflexed or naturally resting—is the most reliable clinical indicator that swelling has subsided sufficiently to allow for safe surgical incisions. This typically takes 10 to 21 days. Fracture blisters should be allowed to re-epithelialize, but the wrinkle sign is the definitive metric for overall tissue tension.

Question 49

During a two-incision, four-compartment fasciotomy for acute compartment syndrome of the lower leg, a surgeon releases the anterior and lateral compartments through an anterolateral incision, and the superficial posterior compartment through a posteromedial incision. However, the patient later develops claw toes and contractures. Which compartment was most likely missed or inadequately released due to failure to detach the soleus bridge from the fibula?

Explanation

The deep posterior compartment is the most commonly missed or inadequately released compartment during a lower extremity fasciotomy. It contains the tibialis posterior, flexor hallucis longus, flexor digitorum longus, and the posterior tibial neurovascular bundle. To adequately release this compartment through the posteromedial incision, the surgeon must identify and release the fascial attachments of the soleus muscle off the posterior aspect of the tibia and ensure the deep fascia covering the tibialis posterior is fully opened.

Question 50

A 30-year-old farmer sustains a severe open midshaft tibia fracture (Gustilo-Anderson Grade IIIA) after his leg is caught in a tractor mechanism. The wound is heavily contaminated with soil and manure. According to classic orthopedic trauma guidelines, what is the most appropriate initial prophylactic antibiotic regimen?

Explanation

For severe open fractures heavily contaminated with farm material, soil, or stagnant water, there is a high risk of anaerobic infection, particularly Clostridium species, in addition to standard Gram-positive and Gram-negative organisms. The classic board-tested regimen for farm injuries is a first-generation cephalosporin (Cefazolin) for Gram-positives, an aminoglycoside (e.g., Gentamicin) for Gram-negatives, and Penicillin to cover anaerobes like Clostridium perfringens. While modern practices sometimes substitute this with Ceftriaxone/Metronidazole or Piperacillin-Tazobactam, the triple-therapy option remains the classic standard correct answer for farm contamination.

Question 51

A 28-year-old male sustains a closed spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). In the emergency department, he is noted to have a complete radial nerve palsy that was present immediately upon injury. What is the most appropriate initial management?

Explanation

A primary radial nerve palsy in the setting of a closed humeral shaft fracture (including the Holstein-Lewis distal third spiral variant) is generally treated expectantly with closed reduction and functional bracing or splinting. The vast majority (>70-80%) of these nerve injuries are neuropraxias that will spontaneously recover within 3 to 4 months. Immediate nerve exploration is indicated for open fractures, penetrating injuries, or a secondary palsy (one that occurs after a closed reduction attempt). EMG is not useful in the acute setting as Wallerian degeneration takes 3-4 weeks to become evident.

Question 52

A 55-year-old woman returns to the clinic 6 weeks after a non-displaced distal radius fracture that was treated successfully in a short-arm cast. She reports a sudden inability to actively extend the interphalangeal joint of her right thumb. Examination confirms an isolated loss of active thumb extension. What is the most appropriate surgical treatment?

Explanation

This patient has suffered an extensor pollicis longus (EPL) tendon rupture, a known complication following non-displaced distal radius fractures. The rupture occurs at Lister's tubercle due to a combination of mechanical attrition and a zone of hypovascularity within the intact third dorsal compartment. Primary end-to-end repair is usually impossible due to tendon retraction and degeneration. The gold standard surgical treatment is a tendon transfer using the Extensor Indicis Proprius (EIP) to the EPL.

Question 53

A 40-year-old male sustains an isolated transverse acetabular fracture with a large, displaced posterior wall component. Preoperative computed tomography confirms the predominant displacement is posterior. Which surgical approach provides the most optimal visualization for direct reduction and fixation of this specific fracture pattern?

Explanation

The Kocher-Langenbeck approach is the workhorse for posterior acetabular pathology. It provides direct access to the posterior column and the posterior wall. A transverse fracture involves both the anterior and posterior columns; however, when it is associated with a posterior wall fracture and dominant posterior displacement, the Kocher-Langenbeck approach is preferred. It allows for direct reduction of the posterior wall and column, while the anterior column component of the transverse fracture can often be reduced indirectly or fixed with a column screw.

Question 54

A 22-year-old polytrauma patient presents with bilateral closed femoral shaft fractures, severe bilateral pulmonary contusions, and a closed head injury with a GCS of 8. His initial lactate is 4.8 mmol/L, and his base excess is -8. Based on the principles of Damage Control Orthopedics (DCO), what is the most appropriate initial management of his femur fractures?

Explanation

This patient is classified as borderline or 'in extremis' based on his severe chest trauma, closed head injury, high lactate, and significant base deficit. Early Total Care (ETC) with intramedullary nailing can act as a 'second hit,' leading to ARDS or exacerbating secondary brain injury due to systemic inflammatory response and embolic showers. Damage Control Orthopedics (DCO) dictates rapid, temporary stabilization of major long bone fractures with external fixation to minimize physiological burden while the patient is resuscitated in the ICU.

Question 55

A 32-year-old male sustains a high-energy fall, resulting in a Hawkins Type III fracture of the talar neck. What is the approximate risk of avascular necrosis (AVN) of the talar body associated with this specific injury pattern, and what vascular supply is primarily disrupted?

Explanation

A Hawkins Type III fracture of the talar neck is characterized by a displaced fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints. This severe displacement predictably disrupts the three major sources of blood supply to the talar body: the artery of the tarsal canal (from the posterior tibial artery), the artery of the tarsal sinus (anastomotic sling), and the deltoid branches. Because of this catastrophic devascularization, the risk of avascular necrosis (AVN) of the talar body is extremely high, approaching 70-100%.

Question 56

A 42-year-old male is brought to the emergency department after a high-speed motor vehicle collision. He is hemodynamically unstable with a blood pressure of 75/40 mmHg. Pelvic radiographs reveal an anteroposterior compression (APC) type III pelvic ring injury. A pelvic binder is applied, and he receives massive transfusion protocol. His FAST exam is negative. What is the most common anatomical source of massive hemorrhage in this specific clinical presentation?

Explanation

In pelvic ring injuries, particularly those involving widening of the sacroiliac joints and disruption of the posterior ligamentous complex (like APC III and vertical shear injuries), the most common source of massive pelvic hemorrhage (up to 80-90% of cases) is the presacral and prevesical venous plexuses, followed by cancellous bone bleeding. Arterial bleeding accounts for only 10-20% of cases. The superior gluteal artery is the most commonly injured artery, but overall venous bleeding remains the predominant source of hemodynamic instability.

Question 57

A 28-year-old male presents with a high-energy Pauwels type III (vertical) femoral neck fracture.

To minimize the risk of shear-induced displacement and nonunion, which of the following internal fixation constructs provides the highest biomechanical stability for this specific fracture pattern?

Explanation

Pauwels type III femoral neck fractures have a fracture line angle greater than 50 degrees from the horizontal, subjecting the fracture to high vertical shear forces rather than compressive forces. Biomechanical studies have consistently demonstrated that a fixed-angle sliding hip screw (SHS) combined with a supplemental derotational screw provides superior stability, highest load to failure, and least shear displacement compared to three parallel cancellous screws.

Question 58

A 35-year-old man sustains a Gustilo-Anderson Type IIIB open fracture of the distal third of the tibia following a motorcycle crash. After aggressive serial debridement and skeletal stabilization with an intramedullary nail, a soft tissue defect measuring 8x10 cm with exposed bone devoid of periosteum remains over the anterior distal tibia. Which of the following represents the most appropriate soft-tissue coverage option?

Explanation

Soft tissue defects of the distal third of the lower extremity that expose bone stripped of periosteum, tendon, or hardware typically require free tissue transfer, as local muscle flap options are limited. The medial gastrocnemius flap is ideal for the proximal third, and the soleus flap is used for the middle third of the tibia. A free flap, such as the anterolateral thigh (ALT) flap or latissimus dorsi flap, is the gold standard for coverage of the distal third of the tibia.

Question 59

A 25-year-old male falls from a height of 15 feet and sustains a Hawkins type III talar neck fracture (talar neck fracture with subtalar and tibiotalar dislocations).

The primary blood supply to the talar body, which is at the highest risk of disruption in this specific injury pattern, is derived from which of the following structures?

Explanation

The artery of the tarsal canal is a branch of the posterior tibial artery and provides the dominant blood supply to the talar body. In a Hawkins type III fracture, the fracture of the neck disrupts the intraosseous antegrade supply, the subtalar dislocation disrupts the artery of the tarsal canal and sinus tarsi, and the tibiotalar dislocation disrupts the deltoid branches. Because the artery of the tarsal canal supplies the majority of the talar body, its disruption heavily contributes to the high rate of avascular necrosis (AVN) seen in Hawkins III fractures.

Question 60

A 40-year-old male is intubated and sedated in the intensive care unit following multiple trauma, including a closed comminuted midshaft tibia fracture. The orthopedic surgeon is concerned about acute compartment syndrome. Which of the following parameters is the most reliable threshold for indicating the need for a four-compartment fasciotomy of the lower leg?

Explanation

Current literature supports the use of the 'delta pressure' (ΔP) rather than an absolute pressure measurement to diagnose acute compartment syndrome. A delta pressure (Diastolic Blood Pressure minus absolute Compartment Pressure) of less than or equal to 30 mmHg is considered the most reliable and specific threshold indicating inadequate tissue perfusion and the need for emergent fasciotomy. Relying on absolute pressures alone often leads to overtreatment, particularly in hypotensive patients.

Question 61

A 22-year-old motorcyclist sustains a high-energy traction injury to his right shoulder. He presents with massive soft tissue swelling, profound ecchymosis over the shoulder girdle, and an entirely flail, pulseless right upper extremity. A chest radiograph demonstrates marked lateral displacement of the right scapula relative to the spinous processes. What represents the most critical determinant of eventual limb survival and meaningful function in this condition?

Explanation

The clinical scenario and radiographic findings are pathognomonic for scapulothoracic dissociation. This is a severe, high-energy traction injury. While vascular injuries (typically the subclavian or axillary artery) dictate immediate limb survival and require emergent attention, the ultimate functional outcome and usefulness of the salvaged limb are almost entirely dependent on the severity of the associated brachial plexus injury. Complete avulsions of the brachial plexus carry a dismal functional prognosis, often eventually requiring amputation despite successful vascular repair.

Question 62

A 78-year-old independent community-ambulating female sustains an anterior column and posterior hemitransverse acetabular fracture after a mechanical fall. Radiographs and CT demonstrate medial displacement of the femoral head, significant superomedial dome impaction ('gull sign'), and profound osteopenia. Which of the following represents the most appropriate surgical management to minimize prolonged morbidity and allow early mobilization?

Explanation

In elderly patients with osteopenic bone, acetabular fractures that present with poor prognostic factors for ORIF—such as significant medial displacement, superomedial dome impaction ('gull sign'), comminution, and femoral head damage—are at high risk of rapid post-traumatic arthrosis and fixation failure. Acute total hip arthroplasty (THA) supported by simultaneous column stabilization (e.g., cup-cage construct or internal fixation) is the treatment of choice. It allows immediate weight-bearing and avoids the complications of prolonged immobilization or multiple surgeries.

Question 63

During surgical management of a 'terrible triad' elbow injury (elbow dislocation, radial head fracture, and coronoid fracture), the surgeon sequentially fixes the coronoid process fracture, replaces the highly comminuted radial head with an arthroplasty, and meticulously repairs the lateral ulnar collateral ligament (LUCL) to the lateral epicondyle. Upon examination under fluoroscopy, the elbow remains persistently unstable and subluxates posteriorly in extension. What is the most appropriate next step in the standard surgical algorithm?

Explanation

The standard surgical algorithm for a terrible triad injury of the elbow involves restoring the structures from deep to superficial: coronoid fixation, radial head fixation or replacement, and LUCL repair. If the elbow remains unstable in extension after these steps, the medial-sided stabilizers must be addressed. The appropriate next step is either open repair of the medial collateral ligament (MCL) or the application of a hinged elbow external fixator to maintain joint concentricity while allowing range of motion.

Question 64

A 32-year-old male is undergoing intramedullary nailing of a closed, proximal-third extra-articular tibia fracture (OTA/AO 41-A).

Which of the following typical malalignment deformities is most commonly encountered during traditional infrapatellar intramedullary nailing of this specific fracture pattern, and what is an effective strategy to prevent it?

Explanation

Proximal third tibia fractures notoriously tend to displace into apex anterior (procurvatum) and valgus deformity during traditional infrapatellar intramedullary nailing. The procurvatum is caused by the pull of the patellar tendon on the proximal fragment and the posteriorly directed force of the nail insertion angle. Valgus is caused by the relatively wide proximal metaphysis failing to constrain the nail. Prevention strategies include using a suprapatellar (semi-extended) nailing technique, which neutralizes the extensor mechanism, or utilizing blocking (Poller) screws placed posteriorly and laterally in the proximal segment.

Question 65

A 68-year-old female presents with atraumatic vague thigh pain and is found to have an incomplete atypical femoral fracture on radiographs. She has a 10-year history of alendronate therapy for osteoporosis. According to the ASBMR (American Society for Bone and Mineral Research) criteria, which of the following is considered a 'major' criterion required for the diagnosis of an atypical femoral fracture?

Explanation

According to the revised ASBMR criteria for atypical femoral fractures (AFFs), localized periosteal or endosteal thickening of the lateral cortex ('beaking' or 'flaring') is a MAJOR criterion. Other major criteria include: minimal or no trauma, a fracture line originating at the lateral cortex that is substantially transverse (though it may become oblique medially), noncomminuted or minimally comminuted, and complete fractures extending through both cortices (often with a medial spike) or incomplete fractures involving only the lateral cortex. Bilateral fractures, delayed healing, prodromal pain, and use of certain drugs (glucocorticoids, bisphosphonates) are considered MINOR criteria.

Question 66

A 45-year-old male sustains a dashboard injury resulting in a posterior hip dislocation and a posterior wall acetabular fracture. Closed reduction of the hip is performed in the emergency department. Post-reduction CT scan demonstrates a posterior wall fracture involving 25% of the articular surface, with a 5mm area of marginal impaction. What is the most appropriate definitive management?

Explanation

Marginal impaction refers to articular cartilage and subchondral bone that are driven into the underlying cancellous bone of the acetabulum during dislocation. Failure to recognize and elevate this segment leads to joint incongruity, instability, and early post-traumatic arthritis. The correct management is ORIF via a posterior (Kocher-Langenbeck) approach, where the impacted segment is elevated, the void is filled with bone graft, and the posterior wall is anatomically reduced and buttressed with a plate.

Question 67

A 28-year-old female presents to the clinic 8 weeks after sustaining a Hawkins type II talar neck fracture treated with open reduction and internal fixation. She is currently non-weight-bearing. Anteroposterior radiographs of the ankle demonstrate a distinct subchondral radiolucent band extending across the dome of the talus. What is the most likely clinical significance of this radiographic finding?

Explanation

This radiographic finding describes the 'Hawkins sign', which is a subchondral radiolucent band in the talar dome that typically appears 6 to 8 weeks post-injury. The lucency is a result of subchondral bone resorption (disuse osteopenia), which can only occur if the bone has an intact vascular supply. Therefore, a positive Hawkins sign is a highly reliable indicator that avascular necrosis (AVN) of the talar body will not occur.

Question 68

A 65-year-old female with a 10-year history of alendronate use presents with a 2-month history of insidious onset, aching pain in her right thigh. She denies any recent trauma. Radiographs of the right femur demonstrate a localized periosteal reaction with lateral cortical thickening and a transverse radiolucent line spanning approximately 30% of the lateral cortex in the subtrochanteric region. What is the most appropriate next step in management?

Explanation

This patient presents with a painful, incomplete atypical femur fracture (AFF) associated with long-term bisphosphonate use. Given the presence of prodromal thigh pain combined with an incomplete fracture line (radiolucent line on the lateral cortex), the risk of progression to a complete fracture is extremely high. The standard of care for a painful incomplete AFF with a visible fracture line is prophylactic stabilization, most commonly with a cephalomedullary or intramedullary nail. Medical management alone is insufficient for symptomatic impending complete fractures.

Question 69

A 32-year-old male is evaluated in the emergency department after sustaining a closed spiral fracture of the distal third of the humeral shaft. His initial neurologic examination is completely intact. The fracture is managed with a closed reduction and application of a coaptation splint. Upon re-examination 30 minutes later, the patient is unable to extend his wrist or metacarpophalangeal joints, and has decreased sensation over the dorsal first web space. What is the most appropriate management of this neurologic deficit?

Explanation

The development of a radial nerve palsy after a closed reduction attempt (secondary nerve palsy) is a classic indication for surgical exploration. The concern is that the nerve may have become incarcerated within the fracture site during the reduction maneuver. Primary radial nerve palsies (present before reduction) in closed humerus fractures are generally observed, but secondary palsies require surgical intervention.

Question 70

A 24-year-old collegiate football player sustains a high-energy hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate a 3mm diastasis between the base of the first and second metatarsals, without any obvious bony fractures. MRI confirms a complete, purely ligamentous rupture of the Lisfranc ligament complex. What is the most appropriate surgical management to minimize long-term reoperation rates and maximize functional outcome?

Explanation

Recent high-level evidence, including landmark studies by Ly and Coetzee, has demonstrated that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial column (1st-3rd tarsometatarsal joints) yields superior functional outcomes and significantly lower reoperation rates compared to open reduction and internal fixation (ORIF). ORIF is generally preferred for bony Lisfranc fracture-dislocations.

Question 71

A 40-year-old male sustains a Gustilo-Anderson Type IIIB open fracture of the tibial shaft. Following serial irrigation and debridements, he is left with a clean, 10 x 8 cm soft tissue defect overlying the middle third of the tibia. There is exposed cortical bone completely devoid of periosteum. Which of the following soft tissue coverage options is most appropriate for this specific anatomical location?

Explanation

Soft tissue coverage for the leg is classically divided into thirds. Defects of the proximal third are optimally covered with a medial gastrocnemius rotational flap. The soleus rotational flap is the workhorse for middle third defects. Distal third defects typically require free tissue transfer (e.g., anterolateral thigh or latissimus dorsi flaps) due to the lack of adequate local muscle bulk, though reverse sural flaps can sometimes be used. Bare cortical bone will not support a split-thickness skin graft.

Question 72

A 29-year-old male falls from a height of 15 feet and sustains an isolated, vertically oriented, displaced femoral neck fracture with an angle of 75 degrees relative to the horizontal (Pauwels Type III). He is brought to the operating room for urgent fixation. To minimize the risk of varus collapse and nonunion, which of the following internal fixation constructs provides the most biomechanically stable fixation for this fracture pattern?

Explanation

Pauwels Type III femoral neck fractures are highly vertical and experience massive shear forces, leading to high rates of varus collapse, shortening, and nonunion when treated with multiple cancellous screws alone. Biomechanical studies have consistently shown that a fixed-angle construct, such as a sliding hip screw (DHS) supplemented with a derotation screw, provides superior stability against vertical shear forces compared to multiple parallel cancellous screws.

Question 73

A 35-year-old skier sustains a high-energy medial tibial plateau fracture (Schatzker IV). Upon arrival at the emergency department, his knee is grossly swollen. The foot is warm and pink, and a dorsalis pedis pulse is palpable. However, an Ankle-Brachial Index (ABI) is performed and measured at 0.8. The calf compartments are soft and compressible. What is the most appropriate next step in management?

Explanation

High-energy knee injuries, such as knee dislocations and Schatzker IV (medial) tibial plateau fractures, have a high association with popliteal artery injuries. Even in the presence of palpable pulses and a well-perfused extremity, an asymmetric or abnormal ABI (< 0.9) warrants further definitive vascular imaging. CT angiography is indicated to rule out flow-limiting lesions, intimal flaps, or pseudoaneurysms. Fasciotomy is not indicated if the compartments are soft and there are no clinical signs of compartment syndrome.

Question 74

A 45-year-old male is brought to the trauma bay after being crushed by heavy machinery. He is hemodynamically stable. Radiographs reveal an 'open-book' anterior-posterior compression (APC-II) pelvic ring injury. During the secondary survey, blood is noted at the urethral meatus, and a high-riding prostate is palpated on digital rectal examination. What is the most appropriate immediate step in the urologic evaluation?

Explanation

Blood at the urethral meatus, a high-riding/non-palpable prostate, or perineal hematoma in the setting of pelvic trauma are classic cardinal signs of a urethral injury. A retrograde urethrogram (RUG) must be performed to evaluate urethral integrity before any attempt is made to pass a transurethral catheter, as blind catheterization can convert a partial urethral tear into a complete transection.

Question 75

A 50-year-old male sustains a displaced, intra-articular calcaneus fracture (Sanders Type III) after falling from a roof. He is scheduled for open reduction and internal fixation via an extensile lateral approach once the soft tissue swelling subsides. When counseling the patient preoperatively, which of the following patient-specific factors should be identified as the single greatest independent risk factor for postoperative wound healing complications?

Explanation

Wound breakdown and infection are devastating complications following the extensile lateral approach to the calcaneus. Multiple large orthopedic trauma studies have consistently identified active smoking as the most significant independent risk factor for wound healing complications, increasing the risk up to threefold compared to non-smokers due to nicotine-induced microvascular vasoconstriction and delayed cellular healing.

Question 76

A 35-year-old male is brought to the emergency department after a high-speed motorcycle collision. He is hemodynamically unstable with a blood pressure of 80/50 mmHg and a heart rate of 120 beats per minute. Primary survey reveals a mechanically unstable pelvic ring injury with a widened symphysis pubis. A pelvic binder is applied, but his blood pressure only marginally improves to 85/55 mmHg. A Focused Assessment with Sonography for Trauma (FAST) scan is negative. What is the most appropriate next step in management?

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic fracture and a negative FAST scan, the source of bleeding is highly likely to be the presacral venous plexus or pelvic arterial injury. Once a binder is placed, if the patient remains hemodynamically unstable, immediate hemorrhage control is required. Depending on institutional protocol, this is achieved via pelvic packing or emergent angiography and embolization.

Question 77

A 28-year-old man sustains a closed Hawkins Type III fracture of the talar neck after falling from a height. He undergoes urgent open reduction and internal fixation. Six weeks postoperatively, an anteroposterior radiograph of the ankle shows a subchondral radiolucent band in the talar dome. What does this radiographic finding most likely indicate?

Explanation

The presence of a subchondral radiolucent band in the talar dome at 6 to 8 weeks post-injury is known as the Hawkins sign. It represents subchondral atrophy (osteopenia) resulting from disuse. Because bone resorption is an active process that requires an intact blood supply, this finding is a favorable prognostic indicator, indicating that the talar body has intact vascularity and is unlikely to develop avascular necrosis.

Question 78

A 24-year-old man sustains a closed midshaft humerus fracture during an arm-wrestling match. On initial examination in the emergency department, his radial nerve motor and sensory functions are completely intact. A closed reduction is performed and a coaptation splint is applied. On post-reduction examination, the patient is unable to extend his wrist or fingers and has numbness in the first dorsal web space. What is the most appropriate next step in management?

Explanation

A secondary (post-reduction) radial nerve palsy is an absolute indication for surgical exploration of the radial nerve and stabilization of the fracture. The nerve may have become entrapped in the fracture site during the reduction maneuver. Primary radial nerve palsies (present on initial presentation) in closed humerus fractures are generally observed, but a palsy that develops following manipulation requires prompt surgical intervention.

Question 79

A 30-year-old woman sustains a displaced, highly vertical (Pauwels type III) femoral neck fracture after a motor vehicle collision. Which of the following fixation constructs provides the greatest biomechanical stability for this specific fracture pattern?

Explanation

Pauwels type III fractures are vertically oriented and subject to high shear forces during weight-bearing. Biomechanical studies have consistently demonstrated that for vertical, high-shear femoral neck fractures in young adults, a fixed-angle construct such as a sliding hip screw (often supplemented with a derotational screw) provides superior biomechanical stability and a lower risk of varus collapse compared to multiple parallel cancellous screws.

Question 80

A 45-year-old male presents with a high-energy closed bicondylar tibial plateau fracture (Schatzker VI). Examination reveals severe soft tissue swelling, hemorrhagic fracture blisters, and a tense calf compartment. Compartment pressures are measured at 15 mmHg, with a diastolic blood pressure of 80 mmHg. The most appropriate initial surgical management is:

Explanation

Schatzker VI fractures involve severe high-energy soft tissue injury. The presence of significant swelling and fracture blisters precludes early definitive internal fixation due to an unacceptably high risk of wound breakdown and deep infection. The standard of care is a staged protocol: initial temporization with a spanning external fixator across the knee to maintain length, alignment, and joint distraction, followed by delayed definitive open reduction and internal fixation (usually 1-3 weeks later) once the soft tissue envelope has healed.

Question 81

A 65-year-old female undergoes volar locked plating for a displaced intra-articular distal radius fracture. Four months postoperatively, she returns to the clinic with a sudden inability to actively flex the interphalangeal joint of her thumb. Which of the following surgical technique errors is most likely responsible for this complication?

Explanation

The sudden inability to flex the thumb IP joint indicates a rupture of the flexor pollicis longus (FPL) tendon. In volar plating of the distal radius, the FPL tendon is at high risk of attrition and spontaneous rupture if the volar plate is placed too distally, projecting anteriorly over the 'watershed line' of the distal radius. Penetration of the dorsal cortex by screws puts the extensor tendons (such as the EPL) at risk, not the flexors.

Question 82

A 34-year-old man sustains a Gustilo-Anderson Type IIIA open tibia fracture. In the evidence-based management of open fractures, which of the following interventions has been shown to have the most significant impact on reducing the patient's overall risk of deep fracture-related infection?

Explanation

Extensive orthopedic literature (including foundational studies by Patzakis et al.) demonstrates that the single most critical factor in reducing the infection rate in open fractures is the early administration of systemic intravenous antibiotics (ideally within the first hour after injury). The historic '6-hour rule' for operative debridement has been largely challenged by modern evidence, which shows that a delay beyond 6 hours does not significantly increase infection rates as long as antibiotics are administered promptly.

Question 83

A 42-year-old woman is involved in a motor vehicle collision and sustains a highly comminuted intra-articular distal femur fracture. A CT scan confirms a displaced coronal shear fracture of the lateral femoral condyle (Hoffa fragment). When planning surgical fixation, what is the most biomechanically sound and appropriate technique to stabilize the Hoffa fragment?

Explanation

A Hoffa fragment is a coronal plane shear fracture of the femoral condyle. Being an intra-articular fracture, it requires precise anatomical reduction and absolute stability. This is best achieved using anterior-to-posterior (or posterior-to-anterior depending on exposure) interfragmentary lag screws placed perpendicular to the fracture line. These screws must be countersunk beneath the articular cartilage if placed through the joint surface. A lateral locking plate alone provides inadequate compression across a coronal fracture and is used mainly to neutralize the supracondylar component.

Question 84

A 22-year-old collegiate athlete presents with midfoot pain after his foot was axially loaded while plantarflexed. On examination, there is pronounced plantar ecchymosis and tenderness over the tarsometatarsal joints. Non-weight-bearing radiographs of the foot are interpreted as normal. What is the most appropriate next step to evaluate for a subtle Lisfranc injury?

Explanation

Subtle Lisfranc (tarsometatarsal) injuries may not be apparent on standard non-weight-bearing radiographs. Plantar ecchymosis is a highly specific clinical sign for a Lisfranc injury. The recommended next step in diagnosis is to obtain weight-bearing (stress) radiographs, as the axial load stresses the midfoot ligaments and can unmask subtle diastasis (often seen between the bases of the first and second metatarsals). If these are equivocal, advanced imaging like weight-bearing CT or MRI may then be considered.

Question 85

A 40-year-old man falls from a ladder and sustains a closed, displaced intra-articular calcaneus fracture. Surgical intervention is planned via an extensile lateral approach. To minimize the high risk of wound healing complications associated with this approach, which of the following surgical principles is paramount?

Explanation

The extensile lateral approach to the calcaneus carries a significant risk of wound necrosis and infection. The most critical technical factor to preserve the blood supply to the skin flap is the creation of a full-thickness fasciocutaneous flap. Dissection must be performed sharply down to bone, taking the periosteum off the lateral wall of the calcaneus in a single thick layer. Retraction should be achieved using 'no-touch' techniques (e.g., placing K-wires into the talus and fibula) rather than hand-held retractors that crush the skin edges.

Question 86

A 28-year-old man is brought to the emergency department after a motorcycle collision resulting in a comminuted midshaft tibia fracture. He is currently intubated and sedated for head injuries. His blood pressure is 110/70 mmHg. The orthopedic surgeon is concerned about acute compartment syndrome and measures intracompartmental pressures (ICP) of the leg. Which of the following findings is an absolute indication for a four-compartment fasciotomy in this patient?

Explanation

The diagnosis of acute compartment syndrome in an obtunded or intubated patient is heavily reliant on objective pressure measurements. The widely accepted threshold for performing a fasciotomy is a Delta P (Diastolic Blood Pressure - Intracompartmental Pressure) of less than 30 mmHg. In this scenario, a difference of 25 mmHg between the diastolic blood pressure and the highest measured ICP falls below the 30 mmHg threshold, indicating inadequate tissue perfusion and an absolute need for emergency fasciotomy.

Question 87

A 55-year-old woman undergoes volar locked plating for a comminuted intra-articular distal radius fracture. Six months postoperatively, she presents with a sudden inability to actively flex the interphalangeal joint of her thumb. Radiographs confirm that the fracture has healed in anatomic alignment. What is the most likely cause of this complication?

Explanation

The flexor pollicis longus (FPL) tendon lies in close proximity to the volar aspect of the distal radius. If a volar plate is placed too distally (prominent anterior to the watershed line), it can cause mechanical friction against the FPL tendon during wrist and thumb motion. Over time, this leads to attritional tenosynovitis and eventual rupture of the FPL tendon, presenting as a loss of active thumb interphalangeal joint flexion.

Question 88

A 30-year-old man sustains a completely displaced, vertically oriented (Pauwels Type III) femoral neck fracture. He is medically stable and taken to the operating room for closed reduction and internal fixation. To maximize the biomechanical stability of the construct and minimize the risk of varus collapse, which of the following fixation strategies is most appropriate?

Explanation

Pauwels Type III femoral neck fractures are characterized by a highly vertical fracture line, which creates massive shear forces across the fracture site. Multiple cancellous screws alone offer poor resistance to these shear forces, leading to a high rate of varus collapse, nonunion, and failure. A fixed-angle device such as a sliding hip screw (often supplemented with an anti-rotation screw) provides superior biomechanical stability by converting shear forces into compressive forces, making it the preferred construct for young patients with vertical femoral neck fractures.

Question 89

A 40-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. He is hemodynamically unstable with a blood pressure of 75/40 mmHg. Pelvic radiographs demonstrate an anteroposterior compression (APC) type III pelvic ring injury. The trauma team decides to apply a circumferential pelvic binder. Where should the pelvic binder be centered to most effectively reduce the pelvic volume and stabilize the fracture?

Explanation

To optimally reduce pelvic volume and stabilize an "open-book" pelvic ring injury, the pelvic binder must be applied directly over the greater trochanters. Applying the binder over the iliac crests is a common error; it can paradoxically push the superior hemipelvis inward while flaring the inferior aspect outward, failing to reduce the volume of the true pelvis and potentially exacerbating bleeding.

Question 90

A 45-year-old woman presents with a Schatzker type IV tibial plateau fracture involving a large posteromedial coronal shear fragment. Which of the following surgical approaches is most appropriate for direct visualization and buttress plating of this specific fragment?

Explanation

Schatzker IV fractures commonly involve the medial plateau. When a coronal shear fragment is present posteriorly (posteromedial fragment), traditional anteromedial or anterolateral approaches do not allow adequate access for reduction or perpendicular implant application. A posteromedial approach allows direct visualization of the apex of the fracture and permits the application of a posterior buttress plate, which mechanically opposes the posteroinferior shear forces during weight-bearing.

Question 91

A 25-year-old man sustains a Gustilo-Anderson Type IIIB open tibia fracture in a motorcycle collision. According to current evidence and trauma guidelines regarding the management of open fractures, which of the following factors has the greatest impact on reducing the rate of deep infection?

Explanation

Extensive literature, notably supported by findings from the LEAP (Lower Extremity Assessment Project) study, has shifted the paradigm of open fracture management. The most critical determinant for reducing infection rates is the early administration of systemic antibiotics (ideally within 1 hour of injury). The historical "6-hour rule" for surgical debridement has been shown to be less strongly correlated with infection rates compared to the prompt initiation of antibiotic therapy.

Question 92

A 32-year-old man sustains a Hawkins type III talar neck fracture following a fall from a height. Which of the following statements regarding this specific injury is most accurate?

Explanation

In the Hawkins classification of talar neck fractures: Type I is nondisplaced; Type II involves subtalar subluxation/dislocation; Type III involves dislocation of both the subtalar and tibiotalar joints; and Type IV additionally involves talonavicular subluxation/dislocation. The risk of AVN for Type III fractures is high (often cited as 50-90%), whereas Type IV approaches 100%. The "Hawkins sign" (subchondral radiolucency in the talar dome at 6-8 weeks) is a positive prognostic indicator, signifying intact vascularity and bone resorption, which rules out AVN.

Question 93

An 82-year-old woman with severe osteoporosis and pre-existing tricompartmental osteoarthritis of the knee sustains a comminuted, intra-articular distal femur fracture (OTA/AO 33-C2). Prior to the injury, she was an independent community ambulator. What is the most appropriate definitive management to allow for immediate weight-bearing and minimize complications?

Explanation

In elderly patients with severe osteopenia, comminuted intra-articular distal femur fractures, and pre-existing severe osteoarthritis, internal fixation (ORIF) carries a notoriously high risk of failure, nonunion, and prolonged immobility. Distal femoral replacement (DFR) successfully addresses both the fracture and the underlying arthritis in a single procedure, reliably allowing for immediate post-operative weight-bearing and early mobilization, which is vital for survival in the geriatric population.

Question 94

A 42-year-old roofer falls from a ladder and sustains a displaced, intra-articular calcaneus fracture (Sanders type III). He has a heavy smoking history (2 packs per day) and poorly controlled type 2 diabetes mellitus (HbA1c 9.5%). Which of the following treatment approaches is most appropriate for this patient?

Explanation

The extensile lateral approach for calcaneus fractures carries a significant baseline risk of wound necrosis and deep infection. Heavy smoking and poorly controlled diabetes are absolute or strong relative contraindications to this approach due to an unacceptably high rate of catastrophic wound complications, osteomyelitis, and secondary amputation. Despite the intra-articular displacement, non-operative management is the safest and most appropriate course for this high-risk patient.

Question 95

A 22-year-old professional rugby player presents with recurrent anterior shoulder instability. Advanced imaging reveals a bony Bankart lesion with 28% glenoid bone loss and an engaging Hill-Sachs lesion. What is the most appropriate surgical management for this patient to prevent recurrent dislocation?

Explanation

Critical glenoid bone loss (typically defined as >20-25%) in a contact athlete with recurrent instability dictates the need for a bony augmentation procedure. Soft-tissue repairs (arthroscopic or open Bankart) have an unacceptably high failure rate in the setting of critical bone loss and an engaging Hill-Sachs lesion. The Latarjet procedure (coracoid transfer) extends the glenoid arc and provides a "sling" effect from the conjoint tendon, making it the standard of care for this clinical scenario.

Question 96

A 42-year-old male falls from a ladder and sustains a closed, highly comminuted intra-articular distal tibia fracture (Tscherne Grade 2). Initial management includes application of a spanning external fixator. What is the most appropriate indicator that the patient's soft tissue envelope is ready for definitive open reduction and internal fixation (ORIF)?

Explanation

The timing of definitive fixation for high-energy pilon fractures is dictated by the condition of the soft tissue envelope, not a strict timeline. The 'wrinkle sign' (appearance of skin wrinkles and re-epithelialization of fracture blisters) indicates that acute edema has subsided enough to safely allow surgical incisions with a minimized risk of wound dehiscence and deep infection. Normalization of inflammatory markers or reaching day 7 are not reliable standalone indicators of soft tissue readiness.

Question 97

A 28-year-old male presents in hemorrhagic shock following a high-speed motorcycle crash. A pelvic radiograph reveals an anterior-posterior compression type III (APC-III) pelvic ring injury. A pelvic binder is immediately applied, and a massive transfusion protocol is initiated. A FAST (Focused Assessment with Sonography for Trauma) scan is negative. His blood pressure remains 70/40 mm Hg. What is the most appropriate next step in management?

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and a negative FAST scan, the primary source of hemorrhage is presumed to be the retroperitoneal venous plexus or pelvic arterial branches. Following initial volume reduction with a binder, the next most appropriate step in a patient who remains hypotensive is retroperitoneal pelvic packing (RPP) or pelvic angioembolization to achieve direct hemostasis. CT scanning is contraindicated in hemodynamically unstable patients. Laparotomy is indicated if the FAST scan is positive (intra-abdominal bleeding).

Question 98

A 30-year-old female sustains a completely displaced, vertical femoral neck fracture (Pauwels Type III, 70-degree angle) following a motor vehicle collision. The fracture is closed. Which of the following fixation constructs provides the most biomechanically stable construct to resist the high shear forces inherent to this specific fracture pattern?

Explanation

Pauwels Type III fractures are highly vertical and experience significant vertical shear forces during loading. Multiple parallel cancellous screws have a high failure rate in this pattern because they cannot adequately resist vertical shear, often leading to varus collapse and nonunion. A fixed-angle device, such as a sliding hip screw (SHS), provides superior biomechanical stability against vertical shear. An additional derotational screw is often used to prevent rotation of the femoral head during insertion. Arthroplasty is generally reserved for older, low-demand patients.

Question 99

A 25-year-old male is intubated in the ICU following a severe traumatic brain injury and a closed, comminuted midshaft tibia fracture. The limb is splinted. On examination, the calf is tense and non-compressible. The patient is obtunded and unable to report pain. The patient's blood pressure is 110/70 mm Hg (MAP 83 mm Hg). Compartment pressure monitoring is initiated. Which of the following intracompartmental pressure findings is an absolute indication for an emergent four-compartment fasciotomy?

Explanation

The diagnosis of compartment syndrome in an obtunded patient relies heavily on objective pressure measurements. The generally accepted threshold for fasciotomy is a differential pressure (Delta P) of 30 mm Hg or less (Delta P = Diastolic Blood Pressure minus Compartment Pressure). A Delta P of 20 mm Hg indicates critically impaired local tissue perfusion and is an absolute indication for emergent fasciotomy. Relying solely on absolute pressures can be misleading, particularly in hypotensive patients.

Question 100

A 55-year-old woman was treated non-operatively in a cast for 6 weeks for a minimally displaced, extra-articular distal radius fracture. Three weeks after cast removal, she reports a sudden inability to actively extend her thumb interphalangeal joint. She denies any new trauma. Radiographs show a healing distal radius fracture with maintained alignment. What is the most appropriate surgical management for this complication?

Explanation

This patient has experienced an attrition rupture of the extensor pollicis longus (EPL) tendon, a classic complication following both non-operative and operative management of distal radius fractures. The tendon degenerates due to mechanical attrition at Lister's tubercle and focal ischemia. Because the tendon ends are typically frayed and retracted, primary end-to-end repair is rarely possible. The gold standard treatment is a tendon transfer using the extensor indicis proprius (EIP) to the EPL, which effectively restores thumb extension without causing significant functional deficit to the index finger.

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