Orthopedic Trauma MCQs: AAOS & ABOS Board Review

Question 1

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

Explanation

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

Question 2

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

Explanation

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

Question 3

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

Explanation

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

Question 4

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

Explanation

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

Question 5

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

Explanation

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

Question 6

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

Explanation

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

Question 7

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

Explanation

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

Question 8

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

Explanation

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

Question 9

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

Explanation

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

Question 10

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

Explanation

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

Question 11

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

Explanation

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

Question 12

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

Explanation

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

Question 13

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

Explanation

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

Question 14

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

Explanation

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

Question 15

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

Explanation

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

Question 16

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

Explanation

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

Question 17

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

Explanation

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

Question 18

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

Explanation

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

Question 19

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

Explanation

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

Question 20

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

Explanation

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

Question 21

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

Explanation

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

Question 22

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

Explanation

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

Question 23

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

Explanation

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

Question 24

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

Explanation

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

Question 25

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

Explanation

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

Question 26

A 45-year-old man sustains a bicondylar tibial plateau fracture with a large posteromedial coronal shear fragment. Which surgical approach is most appropriate for direct visualization and buttressing of this specific fragment?

Explanation

A posteromedial approach allows direct visualization, anatomical reduction, and anti-glide plating of a posteromedial shear fragment. These fragments cannot be adequately reduced or buttressed from a standard anterolateral or direct medial approach.

Question 27

A 65-year-old woman treated nonoperatively for a minimally displaced distal radius fracture presents 6 weeks later unable to actively extend her thumb interphalangeal joint. What is the most appropriate definitive management?

Explanation

Extensor pollicis longus (EPL) rupture after nondisplaced distal radius fractures is due to ischemia or attrition within the third dorsal compartment. Because the tendon ends are typically degenerative and retracted, direct repair is contraindicated and an EIP to EPL transfer is the standard of care.

Question 28

A 25-year-old polytrauma patient with a closed femoral shaft fracture is brought to the emergency department. The patient has an Injury Severity Score (ISS) of 36, an initial serum lactate of 4.5 mmol/L, and a platelet count of 80,000/mcL. Which of the following parameters is the strongest physiological indication to pursue Damage Control Orthopedics (DCO) rather than Early Total Care (ETC)?

Explanation

Elevated serum lactate (>2.5 mmol/L) indicates inadequate tissue perfusion and oxygen debt. It is a major physiological trigger for Damage Control Orthopedics (DCO) to prevent a secondary inflammatory "hit" that can lead to ARDS and multisystem organ failure.

Question 29

Which Schatzker classification of tibial plateau fractures is associated with the highest risk of acute compartment syndrome?

Explanation

Schatzker Type VI fractures involve bicondylar pathology with complete metaphyseal-diaphyseal dissociation. This high-energy injury causes extensive soft-tissue stripping, bleeding, and swelling, conferring the highest risk of acute compartment syndrome.

Question 30

In a healthy 40-year-old patient with a closed distal radius fracture, which of the following radiographic parameters is universally considered a primary indication for operative intervention to minimize post-traumatic arthritis?

Explanation

An intra-articular step-off or gap of 2 mm or greater in the radiocarpal joint significantly alters joint contact mechanics and is a universally accepted indication for surgical fixation to reduce the risk of post-traumatic arthritis.

Question 31

A 22-year-old man with bilateral femur fractures develops hypoxia, a petechial rash on his axillae, and confusion 36 hours after his injury. Which initial management strategy has been best proven to decrease the incidence of this specific syndrome in polytrauma patients?

Explanation

The patient is exhibiting the classic triad of Fat Embolism Syndrome (FES). Early operative stabilization (within 24 hours) of long bone fractures is the most effective and proven method to decrease the incidence of FES in polytrauma patients.

Question 32

A 38-year-old skier sustains a Schatzker II tibial plateau fracture. During surgical fixation, which of the following associated soft-tissue injuries is most commonly identified?

Explanation

Schatzker II fractures (split-depression of the lateral plateau) are highly associated with peripheral tears of the lateral meniscus. The meniscus can become entrapped in the fracture site, blocking anatomic reduction of the articular surface.

Question 33

When performing the standard volar Henry approach for fixation of a distal radius fracture, which structure is at greatest risk of iatrogenic injury if the dissection inappropriately strays ulnar to the flexor carpi radialis (FCR) tendon sheath?

Explanation

The palmar cutaneous branch of the median nerve lies just ulnar to the FCR tendon. Retracting the FCR tendon ulnarly or splitting its sheath and dissecting radially protects this nerve and the median nerve proper.

Question 34

In the early management of a severely injured polytrauma patient, which of the following is considered the most reliable clinical indicator of adequate tissue resuscitation and the clearance of oxygen debt?

Explanation

Base deficit and serum lactate are the most accurate and reliable markers for assessing global tissue perfusion. Normalization of these laboratory values indicates successful clearance of oxygen debt during trauma resuscitation.

Question 35

A 30-year-old man presents with a Schatzker IV tibial plateau fracture resulting from a high-energy varus directed force. The examiner notes diminished distal pulses. Which vascular structure is most likely compromised?

Explanation

High-energy medial tibial plateau fractures (Schatzker IV) share a similar mechanism to knee dislocations. The popliteal artery is firmly tethered between the adductor hiatus proximally and the soleus arch distally, making it highly susceptible to traction or transection.

Question 36

A 55-year-old man sustains a highly comminuted, intra-articular distal radius fracture with severe metaphyseal comminution. The surgeon opts for a dorsal spanning distraction plate. Distally, where should the screws of this bridge plate be primarily anchored?

Explanation

A dorsal spanning plate relies on ligamentotaxis to maintain length and alignment. It is typically anchored proximally to the radial diaphysis and distally to the sturdy diaphyses of the second or third metacarpal.

Question 37

In a hemodynamically unstable polytrauma patient with an anteroposterior compression (APC) pelvic ring injury, what is the correct anatomical landmark for the placement of a circumferential pelvic binder?

Explanation

Pelvic binders must be centered directly over the greater trochanters to effectively close the pelvic ring and reduce intrapelvic volume. Placing the binder higher, such as over the iliac crests, is a common error that can actually worsen the pelvic deformity.

Question 38

Six weeks following volar plate fixation of a distal radius fracture, a patient presents with severe disproportionate hand pain, joint stiffness, skin color changes, and hyperhidrosis. Which of the following daily supplements has been shown in some studies to decrease the risk of developing this condition?

Explanation

The patient is exhibiting signs of Complex Regional Pain Syndrome (CRPS). Administration of Vitamin C (500 mg daily for 50 days) after distal radius fractures has been shown in some randomized controlled trials to significantly reduce the incidence of CRPS.

Question 39

When applying a lateral locking plate for a depressed Schatzker II tibial plateau fracture, what is the primary biomechanical rationale for ensuring the proximal row of screws is placed in a subchondral position?

Explanation

Proximal locking screws in a tibial plateau plate act as a fixed-angle scaffold or "raft." Placing them immediately subchondral supports the newly elevated articular fragments, preventing post-operative subsidence and loss of reduction.

Question 40

The "Lethal Triad" in a severely injured trauma patient undergoing damage control resuscitation is characterized by hypothermia, coagulopathy, and which of the following?

Explanation

The lethal triad of trauma consists of hypothermia, coagulopathy, and metabolic acidosis. These three conditions propagate a vicious physiological cycle that rapidly leads to mortality if surgical intervention is not curtailed via damage control principles.

Question 41

Following volar plate fixation of a distal radius fracture, which tendon is most at risk for attrition and eventual rupture if screws prominently penetrate the dorsal cortex?

Explanation

The extensor pollicis longus (EPL) tendon wraps around Lister's tubercle on the dorsal radius. It is uniquely vulnerable to attrition and rupture if dorsal screw penetration occurs during volar plating.

Question 42

When evaluating a comminuted tibial plateau fracture, what is the primary advantage of obtaining a pre-operative CT scan compared to orthogonal plain radiographs alone?

Explanation

CT scans are essential for surgical planning in complex tibial plateau fractures because plain radiographs frequently underestimate the severity of injury. CT precisely defines articular depression, fragmentation, and specific fracture planes, dictating surgical approach and implant choice.

Question 43

A polytrauma patient is admitted with a severe traumatic brain injury (GCS 7) and a closed femoral shaft fracture. Which intraoperative physiological combination is most critical to avoid during early femoral fixation to prevent secondary brain injury?

Explanation

In patients with severe traumatic brain injury, avoiding systemic hypotension (SBP < 90 mmHg) and hypoxia is paramount. Even a single intraoperative episode of either can double the mortality rate by causing profound secondary ischemic brain injury.

Question 44

A 45-year-old male sustains a high-energy trauma resulting in a Schatzker VI bicondylar tibial plateau fracture. Examination reveals massive swelling, tense compartments, and multiple fracture blisters over the proximal tibia. What is the most appropriate initial orthopaedic management?

Explanation

High-energy tibial plateau fractures with severe soft tissue compromise (e.g., fracture blisters, massive swelling) should be treated with Damage Control Orthopedics. A spanning external fixator provides temporary stability until soft tissues recover enough to permit safe definitive internal fixation.

Question 45

A 35-year-old male presents with a medial tibial plateau fracture-dislocation (Schatzker IV) following a high-energy varus injury. Which of the following neurovascular structures is at the highest risk of injury in this specific fracture pattern?

Explanation

Schatzker IV (medial tibial plateau) fractures typically result from high-energy varus forces and are essentially knee fracture-dislocations. They are highly associated with injury to the popliteal artery and common peroneal nerve.

Question 46

A 28-year-old female sustains an intra-articular distal radius fracture with a 3 mm articular step-off. If left unreduced, which of the following is the most likely long-term clinical consequence?

Explanation

Articular incongruity of greater than 2 mm in the distal radius is a primary indication for operative intervention. Failure to restore joint congruity is strongly associated with the development of early post-traumatic radiocarpal arthritis.

Question 47

During open reduction and internal fixation of a volar Barton's fracture, the surgeon decides to use a classic volar Henry approach. Which surgical interval is primarily utilized for this approach?

Explanation

The classic volar Henry approach to the distal radius uses the internervous plane between the flexor carpi radialis (median nerve) and the brachioradialis (radial nerve). The radial artery is carefully identified and retracted radially with the brachioradialis.

Question 48

A polytrauma patient arrives with an Injury Severity Score (ISS) of 36, a severe closed head injury (GCS 7), and bilateral femoral shaft fractures. The initial serum lactate is 4.5 mmol/L. What is the most appropriate management of the femur fractures?

Explanation

In an unstable or borderline polytrauma patient with elevated lactate and severe head injury, Early Total Care (ETC) with reamed nailing is contraindicated. Damage control external fixation minimizes the systemic 'second hit' of surgery.

Question 49

Which of the following physiologic derangements is a classic component of the 'lethal triad' in trauma patients?

Explanation

The lethal triad of trauma consists of coagulopathy, hypothermia, and metabolic acidosis. Preventing and reversing these conditions is the core principle behind damage control resuscitation in polytrauma.

Question 50

A 65-year-old female presents with a non-displaced distal radius fracture treated successfully in a cast. Six weeks later, she suddenly develops the inability to actively extend her thumb interphalangeal joint. What is the most likely cause?

Explanation

Extensor pollicis longus (EPL) tendon rupture classically occurs weeks after a non-displaced distal radius fracture. It is caused by mechanical attrition from fracture callus at Lister's tubercle or local ischemia in the third dorsal compartment.

Question 51

A 40-year-old man sustains a severe tibial plateau fracture. Four hours post-injury, he exhibits extreme pain with passive toe extension, but distal pulses are intact. What is the most reliable method to confirm the suspected diagnosis?

Explanation

The patient is exhibiting classic signs of acute compartment syndrome. Intracompartmental pressure measurement is the most reliable diagnostic tool to confirm elevated pressures requiring fasciotomy, especially when the clinical picture is evolving.

Question 52

A patient undergoes internal fixation for a complex distal radius fracture using a volar locking plate. Postoperatively, he has persistent numbness and tingling in the thumb, index, and middle fingers. Which of the following is the most likely cause?

Explanation

Median neuropathy is the most common neurologic complication following distal radius fractures and their surgical treatment. It is often due to fracture hematoma, post-injury swelling, or iatrogenic traction during surgery.

Question 53

What is the optimal surgical approach to directly visualize and buttress a posteromedial shear fragment in a bicondylar tibial plateau fracture?

Explanation

A posteromedial shear fragment must be buttressed from behind to prevent varus collapse and subluxation. This is best achieved via a direct posteromedial approach, utilizing the interval between the medial gastrocnemius and the pes anserinus.

Question 54

A 55-year-old woman sustained a distal radius fracture. To minimize the risk of developing complex regional pain syndrome (CRPS), which of the following oral medications has been shown in prospective studies to be beneficial?

Explanation

Daily administration of 500 mg of Vitamin C for 50 days post-injury has been shown in some prospective studies to significantly reduce the incidence of CRPS following distal radius fractures.

Question 55

A 25-year-old male is brought in hemodynamically unstable (BP 85/40 mmHg) after a motorcycle crash, with clinical concern for an open-book pelvic ring injury. A pelvic binder is applied. To be most effective, where must the binder be centered?

Explanation

Pelvic binders must be centered directly over the greater trochanters to effectively reduce pelvic volume and control venous bleeding. Placement over the iliac crests is incorrect and can paradoxically open the pelvis further.

Question 56

A 35-year-old polytrauma patient presents with a severe head injury (GCS 7) and a closed diaphyseal femur fracture. He is hemodynamically stable. What is the most appropriate management of his femur fracture to optimize neurologic outcomes?

Explanation

Damage control orthopedics, such as external fixation, is favored in severe head injuries. It helps prevent secondary brain insults from hypotension, hypoxemia, or embolic showers during lengthy procedures like intramedullary nailing.

Question 57

A 45-year-old man sustains a Schatzker II tibial plateau fracture.

Which associated intra-articular injury is most commonly encountered during surgical fixation?

Explanation

The lateral meniscus is torn in approximately 50% of split-depressed (Schatzker II) lateral tibial plateau fractures. It must be addressed during articular elevation to ensure joint congruity.

Question 58

In a patient with a distal radius fracture, which radiographic parameter is considered unacceptable for non-operative management and warrants surgical intervention?

Explanation

An intra-articular step-off of > 2 mm is generally considered unacceptable as it significantly increases the risk of post-traumatic arthritis, making it an indication for operative fixation.

Question 59

A 28-year-old polytrauma patient is resuscitated in the trauma bay. Which of the following parameters is the most reliable indicator of adequate global tissue perfusion and endpoint of resuscitation?

Explanation

Serum lactate and base deficit are the most reliable indicators of tissue hypoperfusion. Normalization of serum lactate indicates adequate global tissue resuscitation and readiness for definitive surgery.

Question 60

A 60-year-old woman sustains a volar Barton's fracture of the distal radius.

Biomechanically, what is the primary role of a volar buttress plate in this fracture pattern?

Explanation

A volar buttress plate is primarily designed to resist the axial shear forces that cause the volar displacement of the carpus alongside the volar marginal fragment in Barton's fractures.

Question 61

A 50-year-old man sustains a high-energy bicondylar tibial plateau fracture (Schatzker VI).

On physical examination, he has tense leg compartments and severe pain with passive stretch of the toes. What is the most appropriate next step in management?

Explanation

In the presence of classic clinical signs of acute compartment syndrome, immediate surgical decompression via four-compartment fasciotomy is indicated. Obtaining compartment pressures is unnecessary and delays treatment.

Question 62

In a patient sustaining multiple injuries, Damage Control Orthopedics (DCO) relies on early temporary stabilization followed by definitive fixation. Which inflammatory marker is thought to peak on day 2-3 and correlates with the "second hit" phenomenon?

Explanation

Interleukin-6 (IL-6) is a well-established marker for the systemic inflammatory response in trauma. It peaks 2-3 days post-injury and helps predict the magnitude of the immune "second hit."

Question 63

A 25-year-old man is struck by a motor vehicle and sustains a closed displaced midshaft femur fracture. He is hemodynamically stable with a GCS of 15. Pulmonary function is normal. What is the most appropriate definitive management?

Explanation

Early Total Care (ETC) with reamed intramedullary nailing within 24 hours is the standard of care for hemodynamically stable patients without severe head or chest injuries.

Question 64

A 40-year-old woman is treated with a volar locking plate for a comminuted intra-articular distal radius fracture.

At 6 weeks postoperatively, she complains of an inability to actively flex the interphalangeal joint of her thumb. What is the most likely cause?

Explanation

Volar plate prominence distal to the watershed line can cause mechanical attrition and subsequent rupture of the flexor pollicis longus (FPL) tendon.

Question 65

A 30-year-old polytrauma patient develops petechiae, confusion, and hypoxemia 48 hours after sustaining bilateral femur fractures. What is the most likely underlying pathophysiologic mechanism for this syndrome?

Explanation

The classic triad of Fat Embolism Syndrome (FES) includes hypoxemia, neurologic abnormalities, and a petechial rash. It is caused by fat emboli creating both mechanical occlusion and biochemical endothelial injury.

Question 66

A 38-year-old man undergoes open reduction and internal fixation of a Schatzker IV (medial) tibial plateau fracture.

Which surgical approach is most appropriate for direct visualization and buttress plating of the posteromedial fragment?

Explanation

The posteromedial approach allows direct visualization and application of an anti-glide or buttress plate to the apex of the posteromedial fragment, effectively resisting the shear forces.

Question 67

A 22-year-old male presents with a highly comminuted, severely shortened distal radius fracture and an associated ipsilateral diaphyseal ulna fracture after a high-speed motorcycle crash. He requires multiple surgeries for other life-threatening injuries. What is the most appropriate temporary or definitive construct for the wrist?

Explanation

A dorsal spanning bridge plate is ideal for highly comminuted distal radius fractures or in polytrauma patients requiring immediate upper extremity weight-bearing and rapid surgical stabilization.

Question 68

A 35-year-old male requires open reduction and internal fixation of a displaced posteromedial tibial plateau fracture. A posteromedial approach is utilized. Which of the following structures is at greatest risk of iatrogenic injury during the superficial dissection?

Explanation

The posteromedial approach to the tibial plateau utilizes an interval between the medial gastrocnemius and the pes anserinus. The great saphenous vein and saphenous nerve are superficial structures at high risk during the initial dissection.

Question 69

A 25-year-old multiply injured patient is brought to the trauma bay after a motorcycle collision. He has bilateral femur fractures and a severe closed head injury. Which of the following physiological markers is the most reliable indicator of adequate global tissue perfusion and resuscitation prior to proceeding with Early Total Care (ETC)?

Explanation

Clearance of serum lactate (to < 2.5 mmol/L) and normalization of base deficit are the most reliable indicators of adequate tissue resuscitation. Relying solely on vital signs or urine output can mask compensated shock.

Question 70

A 60-year-old female presents with an inability to flex the interphalangeal joint of her thumb 6 months after undergoing volar locked plating of a distal radius fracture.

Radiographs show the plate is positioned distal to the watershed line. Attritional rupture of which of the following tendons has most likely occurred?

Explanation

Volar plates placed distal to the watershed line can impinge on the flexor tendons, most commonly the flexor pollicis longus (FPL). This prominent hardware leads to tenosynovitis and subsequent attritional tendon rupture.

Question 71

A 45-year-old male sustains a distal radius fracture. Closed reduction and cast application are performed. Which of the following radiographic parameters is generally considered the maximum acceptable threshold for radial shortening to minimize the risk of symptomatic distal radioulnar joint (DRUJ) arthrosis?

Explanation

Acceptable radiographic parameters for distal radius fractures include radial shortening of less than 5 mm, dorsal tilt of less than 10 degrees, and intra-articular step-off of less than 2 mm. Shortening >5 mm significantly alters DRUJ kinematics and increases load transmission through the ulna.

Question 72

A 32-year-old male sustains a Schatzker VI bicondylar tibial plateau fracture. Twelve hours post-admission, he develops severe, unrelenting leg pain exacerbated by passive stretch of the great toe. Intra-compartmental pressure monitoring reveals a pressure of 45 mm Hg in the anterior compartment, with a diastolic blood pressure of 60 mm Hg. What is the most appropriate next step in management?

Explanation

The patient is exhibiting signs of acute compartment syndrome with an absolute pressure of 45 mm Hg and a Delta P (diastolic BP - compartment pressure) of 15 mm Hg. A Delta P less than 30 mm Hg is an absolute indication for emergent 4-compartment fasciotomy.

Question 73

In the initial management of a hemodynamically unstable polytrauma patient with an open-book pelvic ring injury (APC III), a pelvic binder is applied. To achieve optimal mechanical closure of the pelvic volume, the binder should be centered over which of the following anatomic landmarks?

Explanation

Pelvic binders must be centered over the greater trochanters to effectively close the pelvic ring and reduce pelvic volume. Placement over the iliac crests or ASIS is less effective and can paradoxically open the true pelvis further.

Question 74

A 45-year-old male presents with a severely displaced bicondylar tibial plateau fracture and massive soft tissue swelling with fracture blisters over the anterolateral and medial aspects of the proximal leg. What is the most appropriate initial management of this fracture?

Explanation

In the presence of severely compromised soft tissue envelopes (massive swelling, fracture blisters), temporary spanning external fixation is indicated. This stabilizes the fracture while allowing the soft tissues to recover, preventing devastating wound complications from early open surgery.

Question 75

A 22-year-old male sustains closed bilateral femur fractures in an ATV accident. On post-admission day 2, he develops acute hypoxia, a petechial rash over his axillae, and confusion. Which of the following interventions is the most effective definitive method to prevent the development of this syndrome?

Explanation

The patient has Fat Embolism Syndrome, characterized by the classic triad of hypoxemia, neurological abnormalities, and petechial rash. Early operative stabilization (within 24 hours) of long bone fractures is the most effective method for decreasing the incidence of this syndrome.

Question 76

A 55-year-old woman is evaluated 8 weeks following a nondisplaced distal radius fracture treated in a short arm cast. She suddenly loses the ability to actively extend the interphalangeal joint of her thumb. Radiographs reveal a healed fracture. What is the most appropriate surgical treatment?

Explanation

Attritional rupture of the Extensor Pollicis Longus (EPL) can occur after nondisplaced distal radius fractures due to ischemia or mechanical friction at Lister's tubercle. Because the tendon ends are degenerated and retracted, direct repair is unfeasible; an EIP to EPL transfer is the standard treatment.

Question 77

A 42-year-old female sustains a split-depression lateral tibial plateau fracture (Schatzker type II). During surgical fixation, a submeniscal arthrotomy is performed. Which of the following intra-articular injuries is most frequently encountered with this specific fracture pattern?

Explanation

Lateral meniscal tears are the most common associated intra-articular injuries in Schatzker type II (split-depression) tibial plateau fractures, occurring in up to 50% of cases. The meniscus often becomes incarcerated in the fracture site.

Question 78

A polytrauma patient with multiple long-bone fractures, pulmonary contusions, and a severe head injury is initially managed with damage control orthopedics (DCO). According to the classic "two-hit" model of systemic inflammation, definitive fracture fixation should ideally be performed during which window to minimize the risk of ARDS and multiple organ failure?

Explanation

The optimal "window of opportunity" for definitive surgery in polytrauma patients managed with DCO is typically between days 5 and 10. Surgery between days 2 and 4 coincides with the peak systemic inflammatory response syndrome (SIRS) and increases the risk of ARDS as a "second hit."

Question 79

A 25-year-old male is brought to the emergency department after a high-speed motor vehicle collision. He has a severe traumatic brain injury, multiple rib fractures, and a comminuted midshaft femur fracture. Which of the following systemic markers best indicates that the patient has been adequately resuscitated and is a suitable candidate for early total care?

Explanation

Serum lactate and base deficit are the most reliable indicators of systemic tissue perfusion and adequate resuscitation in polytrauma. Normalization of lactate (< 2.0 mmol/L) suggests the patient is clear of the systemic inflammatory danger zone and can tolerate definitive fixation.

Question 80

A 55-year-old woman undergoes volar locked plating for a comminuted intra-articular distal radius fracture. At 6-month follow-up, she is unable to actively flex the interphalangeal joint of her thumb. What is the most likely cause of this complication?

Explanation

Placement of a volar plate distal to the watershed line risks impingement and subsequent attrition rupture of the flexor pollicis longus (FPL) tendon. The watershed line marks the distal margin of the pronator quadratus, beyond which the tendons lie directly on the bone.

Question 81

A 40-year-old man sustains a bicondylar tibial plateau fracture (Schatzker VI) with a displaced posteromedial coronal split fragment. Standard anterolateral plating alone is planned. What is the most likely consequence of failing to specifically address the posteromedial fragment?

Explanation

The posteromedial fragment involves the medial articular surface and supports the medial femoral condyle. Failure to anatomically buttress this fragment typically leads to varus collapse and posterior subluxation of the tibia.

Question 82

A 62-year-old woman sustains a nondisplaced Colles fracture treated in a short arm cast. Six weeks later, she reports sudden loss of ability to extend her thumb. Which of the following is the most appropriate management?

Explanation

Nondisplaced distal radius fractures can lead to EPL tendon rupture due to attrition or watershed ischemia within the third dorsal compartment. Because the tendon ends are typically retracted and frayed, an EIP to EPL transfer is the standard treatment rather than primary repair.

Question 83

A hypotensive 30-year-old polytrauma patient presents with an anteroposterior compression (APC) type III pelvic ring injury. To effectively reduce the pelvic volume and control hemorrhage, a pelvic binder should be centered over which of the following anatomic landmarks?

Explanation

Pelvic binders must be centered directly over the greater trochanters to effectively reduce the pelvic ring volume and stabilize the symphysis pubis. Placement over the iliac crests is less effective and may paradoxically open the pelvis in certain fracture patterns.

Question 84

A 35-year-old man undergoes staged management of a high-energy Schatzker VI tibial plateau fracture. He is initially placed in a knee-spanning external fixator. Within 12 hours, he develops severe, unrelenting leg pain exacerbated by passive stretch of the hallux. What is the next most appropriate step in management?

Explanation

Severe pain out of proportion to the injury and exacerbated by passive stretch is the hallmark of acute compartment syndrome. Immediate four-compartment fasciotomies are required to prevent irreversible ischemic necrosis.

Question 85

What is the maximum acceptable limit for intra-articular step-off when evaluating the reduction of a distal radius fracture to minimize the risk of post-traumatic radiocarpal arthrosis?

Explanation

An intra-articular step-off greater than 2 mm is highly correlated with the development of early post-traumatic radiocarpal arthritis. Surgical intervention is generally indicated if a step-off of 2 mm or greater cannot be reduced closed.

Question 86

According to the principles of Damage Control Orthopedics (DCO), which of the following clinical scenarios represents a borderline patient where temporary external fixation of a femoral shaft fracture is favored over early intramedullary nailing?

Explanation

Bilateral pulmonary contusions and elevated initial lactate indicate a high-risk borderline polytrauma patient. Early total care (e.g., IM nailing) in this setting risks a fatal second hit such as ARDS, making DCO the safer strategy.

Question 87

A 45-year-old man sustains a Schatzker II (split-depression) fracture of the lateral tibial plateau. During operative fixation, a peripheral tear of the lateral meniscus is identified. What is the most appropriate management of the meniscus?

Explanation

The lateral meniscus is torn in a significant percentage of Schatzker II fractures, most often peripherally. The meniscus must be elevated to visualize and reduce the joint surface, followed by secure repair to restore hoop stresses and protect the articular cartilage.

Question 88

A 78-year-old polytrauma patient with bilateral lower extremity fractures sustains a highly comminuted, intra-articular fracture of the distal radius extending into the metadiaphysis. The patient requires the use of the upper extremities for weight-bearing transfers. What is the most appropriate fixation strategy for the wrist?

Explanation

A dorsal spanning plate provides excellent load-sharing stability in highly comminuted fractures or in patients requiring early weight-bearing through the upper extremities. It bridges the radiocarpal joint, allowing early transfer mobility while protecting the articular reduction.

Question 89

A 45-year-old male sustains a high-energy Schatzker VI bicondylar tibial plateau fracture. Thirty-six hours after undergoing open reduction and internal fixation with dual plating, he develops severe, unrelenting leg pain that is exacerbated by passive plantar flexion of the toes. Examination reveals decreased sensation in the first dorsal web space. Which of the following compartments is most likely affected, and which nerve is at greatest risk?

Explanation

High-energy tibial plateau fractures carry a significant risk for compartment syndrome, most commonly affecting the anterior compartment. The deep peroneal nerve courses through the anterior compartment, and ischemia leads to weakness in toe extension and paresthesias in the first dorsal web space.

Question 90

A 28-year-old male presents as a polytrauma following a high-speed motor vehicle collision. He sustains a closed comminuted midshaft femur fracture and bilateral pulmonary contusions. Initial laboratories demonstrate a serum lactate of 4.8 mmol/L, a pH of 7.21, and a base excess of -8. According to the principles of damage control orthopedics, what is the most appropriate initial management of his femur fracture?

Explanation

This patient is considered "borderline" or "unstable" due to his elevated lactate, significant acidosis, and pulmonary contusions, precluding Early Total Care. Damage Control Orthopedics with rapid external fixation is indicated to provide skeletal stability while avoiding the "second hit" phenomenon associated with intramedullary nailing.

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

AAOS & ABOS Orthopedic Trauma MCQs (Set 2): Tibial Plateau, Distal Radius Fractures & Polytrauma | 2000 Board Review

Key Takeaway

AAOS & ABOS Orthopedic Trauma MCQs (Set 2): Tibial Plateau, Distal Radius Fractures & Polytrauma | 2000 Board Review

Chapter Index