AAOS Orthopedic Trauma Board Review MCQs (Set 1)

Question 1

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

Explanation

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

Question 2

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

Explanation

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

Question 3

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

Explanation

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

Question 4

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

Explanation

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

Question 5

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

Explanation

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

Question 6

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

Explanation

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

Question 7

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

Explanation

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

Question 8

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

Explanation

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

Question 9

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

Explanation

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

Question 10

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

Explanation

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

Question 11

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

Explanation

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

Question 12

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

Explanation

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

Question 13

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

Explanation

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

Question 14

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

Explanation

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

Question 15

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

Explanation

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

Question 16

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

Explanation

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

Question 17

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

Explanation

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

Question 18

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

Explanation

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

Question 19

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

Explanation

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

Question 20

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

Explanation

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

Question 21

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

Explanation

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

Question 22

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

Explanation

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

Question 23

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

Explanation

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

Question 24

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

Explanation

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

Question 25

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

Explanation

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

Question 26

A 25-year-old male is brought to the ED after a motorcycle collision. He is hemodynamically unstable. A pelvic radiograph shows an APC-III pelvic ring injury. Where should a pelvic binder be applied to most effectively reduce the pelvic volume?

Explanation

Pelvic binders should be placed centered over the greater trochanters to effectively reduce the pelvic volume in open-book pelvic fractures. Placement over the iliac crests is less effective and may paradoxically open the pelvis further.

Question 27

A 42-year-old construction worker sustains a Gustilo-Anderson Type IIIB open tibia fracture. Which of the following factors has been shown to be the most critical in reducing the risk of subsequent infection?

Explanation

The single most important factor in reducing infection rates in open fractures is the early administration of systemic antibiotics. Strict adherence to the '6-hour rule' for debridement has not been proven to be as critical as immediate antibiotic delivery.

Question 28

A 30-year-old male presents with a closed tibial shaft fracture. He complains of severe pain out of proportion to the injury. Which of the following intracompartmental pressure measurements is an absolute indication for fasciotomy?

Explanation

A delta pressure (diastolic blood pressure minus compartment pressure) of less than 30 mm Hg is widely accepted as a strong indication for urgent fasciotomy. Absolute pressures are less reliable, especially in hypotensive patients.

Question 29

A 22-year-old football player sustains an ultra-low velocity knee dislocation that spontaneously reduces. His pedal pulses are palpable, but his Ankle-Brachial Index (ABI) is 0.8. What is the most appropriate next step in management?

Explanation

In the setting of a knee dislocation, an ABI of < 0.9 is highly suspicious for a vascular injury and warrants an immediate CT angiogram. Palpable pulses do not rule out an intimal flap or pending vascular occlusion.

Question 30

A 45-year-old polytrauma patient presents with bilateral femoral shaft fractures, severe closed head injury, and pulmonary contusions. Which of the following laboratory values is a specific indication for damage control orthopedics (external fixation) rather than early total care?

Explanation

Indications for Damage Control Orthopedics (DCO) include acidosis (pH < 7.24), hypothermia (< 35 degrees C), coagulopathy, and inadequate perfusion markers such as a serum lactate > 2.5 mmol/L. These patients are at high risk for the 'second hit' phenomenon.

Question 31

A 19-year-old male with an isolated closed femoral shaft fracture develops confusion, a respiratory rate of 30 breaths/min, and a petechial rash over his axillae 24 hours after injury. What is the most appropriate initial management?

Explanation

The patient presents with Fat Embolism Syndrome, displaying the classic triad of hypoxemia, neurologic abnormalities, and a petechial rash. The mainstay of treatment is supportive care, primarily focusing on maintaining adequate oxygenation.

Question 32

A 28-year-old male sustains a low-velocity gunshot wound to the thigh resulting in a comminuted femoral shaft fracture. The entrance and exit wounds are 1 cm clean punctures. He has intact distal pulses and no neurologic deficits. What is the most appropriate definitive management?

Explanation

Low-velocity gunshot wounds resulting in femur fractures without vascular injury or severe contamination can be treated similarly to closed fractures. Local wound care, tetanus prophylaxis, and standard intramedullary nailing yield excellent outcomes without formal tract debridement.

Question 33

A 32-year-old female sustains a displaced, completely off-ended, transcervical femoral neck fracture (Pauwels type III). What is the preferred surgical treatment and timing to minimize the risk of avascular necrosis (AVN)?

Explanation

Displaced femoral neck fractures in young adults are orthopedic emergencies. Urgent open reduction and internal fixation (ORIF) is required to achieve anatomic reduction, provide stable fixation, and minimize the high risks of AVN and nonunion.

Question 34

A 35-year-old male sustains a closed spiral fracture of the distal third of the humerus (Holstein-Lewis fracture). On initial examination in the ED, he has a dense radial nerve palsy. What is the most appropriate initial management?

Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture is typically treated nonoperatively with closed reduction and a coaptation splint, as the majority are neuropraxias that will recover spontaneously. Exploration is indicated if the palsy develops AFTER a reduction attempt.

Question 35

A 24-year-old cyclist falls onto his shoulder, sustaining a midshaft clavicle fracture. Which of the following is considered an absolute indication for operative fixation?

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, neurovascular compromise, and impending skin compromise (severe skin tenting with blanching/ischemia). Shortening and 100% displacement are relative indications.

Question 36

A 45-year-old man presents with a hemodynamically unstable APC-III pelvic ring injury. A pelvic binder is applied in the trauma bay. To optimally reduce pelvic volume and stabilize the fracture, the binder should be centered over which of the following anatomic landmarks?

Explanation

Pelvic binders should be placed at the level of the greater trochanters to effectively close the pelvic ring and reduce pelvic volume. Placement over the iliac crests is less effective and may exacerbate certain fracture patterns.

Question 37

A 25-year-old polytrauma patient sustains bilateral closed femoral shaft fractures and pulmonary contusions. His initial lactate is 5.2 mmol/L, pH is 7.21, and base excess is -8. What is the most appropriate initial management of his bilateral femur fractures?

Explanation

In a polytraumatized patient with physiologic instability (acidosis, elevated lactate), Damage Control Orthopedics (DCO) is indicated. Bilateral external fixation provides rapid stabilization while minimizing additional physiologic surgical burden.

Question 38

A 30-year-old man sustains a Gustilo-Anderson Type IIIA open tibial shaft fracture following a motorcycle collision. What is the standard antibiotic prophylaxis recommended?

Explanation

Current guidelines recommend a first-generation cephalosporin and an aminoglycoside (or a third-generation cephalosporin alone) for Gustilo-Anderson Type III open fractures to cover both Gram-positive and Gram-negative organisms. Penicillin is typically added only for gross agricultural contamination.

Question 39

A 28-year-old man presents with a closed midshaft tibia fracture. Four hours post-admission, he complains of severe leg pain out of proportion to the injury, exacerbated by passive toe stretch. His diastolic blood pressure is 70 mm Hg. What intracompartmental pressure reading strongly indicates the need for an emergent four-compartment fasciotomy?

Explanation

Compartment syndrome is clinically diagnosed, but when measuring pressures, a delta pressure (Diastolic Blood Pressure minus Compartment Pressure) of less than 30 mm Hg is a strong indication for fasciotomy. Absolute pressure alone is less reliable than delta pressure.

Question 40

A 60-year-old woman with a history of severe osteoporosis sustains a comminuted distal femur fracture (OTA/AO 33-C2). She has a well-fixed total knee arthroplasty in place. The fracture involves the bone immediately proximal to the prosthesis. What is the preferred surgical treatment?

Explanation

For a periprosthetic distal femur fracture around a well-fixed total knee arthroplasty, open reduction and internal fixation with a lateral locking plate is the standard of care. Distal femoral replacement is reserved for loose components or unsalvageable bone stock.

Question 41

A 22-year-old man sustains a low-velocity gunshot wound to the thigh resulting in a closed, midshaft spiral femoral fracture. Neurovascular exam is normal. What is the most appropriate management?

Explanation

Low-velocity gunshot wounds resulting in femur fractures without neurovascular compromise are treated as closed fractures. Local wound care, tetanus prophylaxis, and early intramedullary nailing yield excellent outcomes without the need for formal bullet track debridement.

Question 42

A 35-year-old woman is evaluated 6 weeks after sustaining a talar neck fracture treated with open reduction and internal fixation. A mortise radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome (Hawkins sign). What does this radiographic finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucent band seen 6-8 weeks post-injury in talar neck fractures. It represents subchondral atrophy, which requires an intact blood supply, thereby ruling out avascular necrosis.

Question 43

A 40-year-old man falls from a height and sustains a displaced, intra-articular calcaneus fracture. Which of the following surgical approaches is most commonly associated with wound healing complications and requires careful handling of the sural nerve?

Explanation

The extensile lateral approach for calcaneus fractures is associated with a high rate of wound breakdown and places the sural nerve at risk. Careful full-thickness flap elevation and subperiosteal dissection are required to minimize these risks.

Question 44

In the staged management of severe pilon fractures (OTA/AO 43-C), what is the primary rationale for initial application of a spanning external fixator and fibular fixation, followed by delayed definitive tibial articular reconstruction?

Explanation

Severe pilon fractures typically present with significant soft tissue compromise. Initial spanning external fixation stabilizes the fracture while allowing the soft tissue envelope to recover, reducing the high risk of wound necrosis and infection associated with immediate ORIF.

Question 45

A 42-year-old woman is struck by a motor vehicle and sustains a closed Schatzker VI bicondylar tibial plateau fracture. Severe soft tissue swelling and fracture blisters are present. What is the most appropriate initial management?

Explanation

Bicondylar tibial plateau fractures with severe soft tissue injury (blisters, extreme swelling) should be managed with staged treatment. Immediate application of a spanning external fixator allows the soft tissues to heal before definitive internal fixation is performed.

Question 46

A 55-year-old man sustains a severe crush injury to his leg resulting in a mangled extremity. The surgeon is calculating the Mangled Extremity Severity Score (MESS) to help guide the decision between amputation and salvage. Which of the following is NOT a component of the MESS?

Explanation

The Mangled Extremity Severity Score (MESS) evaluates skeletal and soft-tissue damage, limb ischemia, shock, and patient age. While peripheral nerve injury affects functional outcomes, it is not an independent parameter in the MESS calculation.

Question 47

A 26-year-old man sustains an anterior shoulder dislocation. After successful closed reduction, he is noted to have weakness with shoulder abduction and decreased sensation over the lateral aspect of the deltoid. Which nerve is most likely injured?

Explanation

The axillary nerve is the most commonly injured nerve in anterior shoulder dislocations. It innervates the deltoid and teres minor, providing sensation to the lateral shoulder.

Question 48

A 50-year-old polytrauma patient develops petechial hemorrhages over the axillae and chest, progressive hypoxemia, and confusion 36 hours after sustaining bilateral femoral shaft fractures. What is the most likely diagnosis?

Explanation

Fat embolism syndrome classic triad includes petechial rash, hypoxemia, and neurologic abnormalities (confusion). It commonly occurs 24-72 hours after long bone fractures.

Question 49

A 32-year-old woman sustains a closed, isolated midshaft humerus fracture. She presents with a wrist drop and inability to extend her metacarpophalangeal joints. What is the most appropriate initial management of her nerve injury?

Explanation

Primary radial nerve palsies associated with closed humeral shaft fractures are mostly neuropraxias and typically recover spontaneously. Observation and supportive splinting for 3-4 months is the initial management of choice.

Question 50

A 75-year-old man with a history of falls presents with a displaced, intracapsular femoral neck fracture. He is previously an independent community ambulator with minimal comorbidities. What is the most appropriate surgical treatment?

Explanation

Displaced intracapsular femoral neck fractures in active, community-ambulating elderly patients are best treated with arthroplasty (Hemiarthroplasty or THA). This allows early weight-bearing and avoids the high risk of nonunion and avascular necrosis.

Question 51

Where is the optimal anatomical location to place a pelvic binder in a hemodynamically unstable patient with an anteroposterior compression pelvic ring injury?

Explanation

Pelvic binders are most effective at reducing pelvic volume when centered directly over the greater trochanters. Placement over the iliac crests can paradoxically open the true pelvis further in some fracture patterns.

Question 52

A 25-year-old farmer sustains an open tibial shaft fracture with massive soft tissue stripping and heavy soil contamination. In addition to a first-generation cephalosporin and an aminoglycoside, which of the following antibiotics should be added for appropriate prophylaxis?

Explanation

Farm-related or heavily soil-contaminated injuries carry a high risk of Clostridium infection. High-dose Penicillin should be added to the standard regimen of a first-generation cephalosporin and an aminoglycoside for these Gustilo Type III open fractures.

Question 53

A 32-year-old man presents with a closed diaphyseal tibia fracture and is intubated in the ICU. Intracompartmental pressure measurements show a diastolic blood pressure of 70 mm Hg and an anterior compartment pressure of 45 mm Hg. What is the most appropriate next step in management?

Explanation

The diagnosis of compartment syndrome in an obtunded patient is confirmed when the Delta P (diastolic blood pressure minus compartment pressure) is less than 30 mm Hg. In this patient, Delta P is 25 mm Hg, necessitating an emergent four-compartment fasciotomy.

Question 54

A 24-year-old man sustains a multiligamentous knee injury with a suspected spontaneous reduction of a knee dislocation. Pulses are palpable but asymmetric, and his ankle-brachial index (ABI) is measured at 0.8. What is the next most appropriate step in management?

Explanation

An ABI < 0.9 in the setting of a knee dislocation is highly sensitive for an occult popliteal artery injury. The patient should undergo emergent CT angiography to define the vascular lesion and consult vascular surgery.

Question 55

Which of the following physiologic parameters is an absolute indication for 'Damage Control Orthopedics' (provisional external fixation) rather than Early Total Care for a displaced femoral shaft fracture?

Explanation

Damage Control Orthopedics (DCO) is indicated in 'in extremis' or borderline trauma patients. Severe hypothermia (temperature < 35°C), severe coagulopathy, and profound acidosis are absolute indications to proceed with DCO to avoid a fatal second hit.

Question 56

A 28-year-old man with bilateral femur fractures develops confusion, a petechial rash on the axilla, and hypoxemia 48 hours after injury. Which of the following is the most effective management strategy for the underlying syndrome?

Explanation

The patient has Fat Embolism Syndrome, characterized by the triad of hypoxemia, neurologic compromise, and petechial rash. The most effective treatment is prevention via early fracture stabilization, followed by meticulous supportive respiratory care.

Question 57

A 40-year-old man presents with a boggy, fluctuant mass over his greater trochanter following a high-speed motorcycle collision. Radiographs show no underlying fracture. What is the pathophysiology of this clinical finding?

Explanation

A Morel-Lavallée lesion is a traumatic closed degloving injury where the skin and subcutaneous tissue are separated from the underlying fascia. This creates a potential space that fills with a mixture of blood, lymph, and necrotic fat.

Question 58

Which mechanism of injury is classically associated with a traumatic spondylolisthesis of the axis (Hangman's fracture)?

Explanation

A Hangman's fracture involves bilateral pars interarticularis fractures of C2. In modern blunt trauma, it is most commonly caused by hyperextension and axial loading, typically seen in motor vehicle collisions.

Question 59

A 30-year-old man falls from a height and sustains a Hawkins Type III fracture of the talar neck. What is the approximate risk of developing avascular necrosis (AVN) of the talar body?

Explanation

A Hawkins Type III talar neck fracture involves dislocation of the talar body from both the subtalar and tibiotalar joints. This completely disrupts the major retrograde blood supplies, leading to an AVN risk approaching 80-100%.

Question 60

A 25-year-old man sustains a completely displaced, vertically oriented femoral neck fracture (Pauwels Type III). What is the optimal surgical management to minimize the risk of fixation failure?

Explanation

In young adults, joint preservation with anatomic reduction and stable internal fixation is mandatory. Pauwels Type III fractures experience massive vertical shear forces, making a fixed-angle device like a sliding hip screw biomechanically superior to cancellous screws alone.

Question 61

A 65-year-old woman sustains a volar-displaced distal radius fracture. Which nerve is at greatest risk of iatrogenic injury during a standard Henry (volar) surgical approach for plate osteosynthesis?

Explanation

The palmar cutaneous branch of the median nerve courses in the interval between the flexor carpi radialis (FCR) and palmaris longus. It is at high risk of injury during the volar Henry approach if retractors are carelessly placed ulnar to the FCR tendon.

Question 62

Blood supply to the scaphoid primarily enters through the dorsal ridge and supplies the proximal pole in a retrograde fashion. Which artery provides this dominant intraosseous supply?

Explanation

The primary blood supply to the scaphoid arises from dorsal branches of the radial artery entering at the dorsal ridge. This leaves the proximal pole highly reliant on fragile retrograde flow, explaining the high rate of nonunion and AVN in proximal pole fractures.

Question 63

Which of the following scenarios is considered an absolute indication for operative fixation of an acute midshaft clavicle fracture?

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, vascular injury requiring repair, and progressive neurologic deficit. Shortening, displacement, and athletic status are relative indications.

Question 64

A 22-year-old man sustains a low-velocity civilian gunshot wound to the thigh, resulting in a comminuted midshaft femur fracture. The 1 cm wounds are clean, with no active bleeding or neurovascular deficit. Which of the following is the most appropriate initial management?

Explanation

Low-velocity gunshot wounds resulting in femur fractures without gross contamination or vascular injury can safely undergo local wound debridement in the ED, tetanus prophylaxis, and immediate intramedullary nailing. Formal operative tract debridement is unnecessary.

Question 65

A patient with a mechanically unstable pelvic ring injury remains hemodynamically unstable despite a pelvic binder and massive transfusion protocol. A FAST exam is negative. What is the most appropriate next step in management?

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST exam, the source of bleeding is typically the retroperitoneal venous plexus or arterial branches. Preperitoneal pelvic packing and/or angioembolization are the treatments of choice.

Question 66

A 45-year-old unrestrained driver is involved in a head-on collision and sustains a traumatic posterior hip dislocation. Which of the following physical examination findings is most likely present in the affected lower extremity?

Explanation

Posterior hip dislocations classically present with the affected limb shortened, internally rotated, and adducted. Conversely, anterior hip dislocations typically present with the leg externally rotated and abducted.

Question 67

A 50-year-old man sustains a severe closed tibial pilon fracture with significant fracture blisters and profound soft tissue swelling. What is the preferred initial management strategy?

Explanation

High-energy pilon fractures are associated with severe soft tissue compromise that precludes immediate internal fixation. The standard of care is a staged approach: immediate spanning external fixation to restore length, followed by definitive ORIF once soft tissues recover.

Question 68

An 80-year-old woman sustains a Vancouver B2 periprosthetic femur fracture around her cementless total hip arthroplasty stem. Radiographs reveal a loose stem with adequate proximal bone stock. What is the most appropriate surgical treatment?

Explanation

A Vancouver B2 fracture is located around or just distal to a loose stem with adequate bone stock. The standard treatment is revision to a longer, cementless diaphyseal-engaging stem to achieve stability and bypass the fracture site.

Question 69

Which of the following statements best describes the fundamental pathophysiologic mechanism of acute compartment syndrome?

Explanation

Compartment syndrome occurs when tissue pressure within a closed fascial space exceeds capillary perfusion pressure. This primarily blocks venous outflow, which exacerbates edema, further increasing pressure until arterial inflow is ultimately compromised.

Question 70

A 25-year-old athlete sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. What is the primary anatomic structure disrupted in this injury?

Explanation

The Lisfranc ligament is an interosseous ligament that connects the medial cuneiform to the base of the second metatarsal. There is no direct ligamentous connection between the bases of the first and second metatarsals, making the Lisfranc ligament the critical stabilizer of this complex.

Question 71

A 42-year-old male arrives hypotensive after a motorcycle crash. Pelvic radiograph shows an APC-III pelvic ring injury. After ATLS protocol, he remains hemodynamically unstable despite initial fluid resuscitation. What is the most appropriate next step in orthopedic management?

Explanation

Pelvic binders should be centered over the greater trochanters to effectively reduce pelvic volume in anteroposterior compression injuries. Placement over the iliac crests can inadvertently exacerbate the rotational deformity.

Question 72

A 28-year-old male sustains a Gustilo-Anderson Type IIIA open tibia fracture. What is the most critical factor in reducing the risk of deep infection in this patient?

Explanation

The early administration of systemic antibiotics is the single most important factor in decreasing infection rates in open fractures. Recent literature shows the traditional "6-hour rule" for debridement is less critical than the immediate delivery of appropriate antibiotics.

Question 73

A 30-year-old male presents with a severely comminuted closed tibial shaft fracture and pain out of proportion to his injury. His diastolic blood pressure is 75 mmHg. Intracompartmental pressure testing yields: Anterior 40 mmHg, Lateral 35 mmHg, Superficial posterior 20 mmHg, Deep posterior 45 mmHg. What is the most appropriate management?

Explanation

The patient has acute compartment syndrome, indicated by a delta pressure (diastolic BP minus compartment pressure) of 30 mmHg or less (75 - 45 = 30 mmHg). Immediate four-compartment fasciotomy is required to prevent irreversible ischemic necrosis.

Question 74

A 24-year-old male sustains a vertically oriented (Pauwels type III) displaced femoral neck fracture. To maximize biomechanical stability and minimize shear forces, what is the preferred fixation construct?

Explanation

Vertically oriented (Pauwels type III) fractures experience high shear forces. A sliding hip screw paired with a derotational screw provides superior biomechanical stability against shear compared to multiple cancellous screws.

Question 75

A 45-year-old construction worker falls from a height, sustaining a closed, highly comminuted distal tibia (Pilon) fracture with significant soft tissue swelling and fracture blisters. What is the most appropriate initial management?

Explanation

In high-energy Pilon fractures with significant soft tissue compromise, immediate ORIF carries an unacceptably high rate of wound necrosis and infection. The standard of care is a staged approach using a spanning external fixator until the soft tissue envelope recovers.

Question 76

A 32-year-old female sustains a Hawkins Type III talar neck fracture. Which of the following statements regarding her risk of avascular necrosis (AVN) and the presence of a positive Hawkins sign is correct?

Explanation

A Hawkins Type III fracture carries a nearly 100 percent risk of AVN. A positive Hawkins sign (subchondral osteopenia in the talar dome on AP/mortise views at 6-8 weeks) indicates active bone resorption, which confirms an intact vascular supply.

Question 77

A 25-year-old male sustains a high-energy knee dislocation. After reduction, his foot is warm and pink, but pedal pulses are asymmetric. The Ankle-Brachial Index (ABI) is measured at 0.85. What is the most appropriate next step?

Explanation

An ABI less than 0.90 following a knee dislocation is highly sensitive for a clinically significant vascular injury. The patient requires emergent vascular imaging (CT angiography) to delineate the injury before any potential surgical intervention.

Question 78

A 35-year-old polytrauma patient presents with closed bilateral femur fractures, multiple rib fractures, and pulmonary contusions. His serum lactate is 4.5 mmol/L, pH is 7.20, and base excess is -8. What is the most appropriate initial management of his femur fractures?

Explanation

This patient is physiologically unstable (acidotic, elevated lactate, base excess less than -4), meeting indications for Damage Control Orthopedics (DCO). Rapid provisional stabilization with external fixation avoids the systemic inflammatory "second hit" associated with definitive intramedullary nailing.

Question 79

A 40-year-old male is scheduled for open reduction and internal fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Which of the following structures is most at risk during the initial surgical dissection of the full-thickness flap?

Explanation

The sural nerve is at significant risk during the extensile lateral approach to the calcaneus, particularly at the proximal and distal limbs of the incision. A full-thickness subperiosteal flap must be carefully elevated to protect the nerve and the delicate vascular supply to the skin.

Question 80

A 22-year-old cyclist falls onto his left shoulder, sustaining a midshaft clavicle fracture. Which of the following is an absolute indication for operative fixation of this injury?

Explanation

Absolute indications for operative fixation of clavicle fractures include open fractures, vascular compromise, progressive neurologic deficit, and skin tenting causing impending necrosis. Displacement and shortening are relative indications.

Question 81

A 50-year-old male presents with a posterior hip dislocation and an associated posterior wall acetabular fracture following an MVC. Post-reduction CT reveals a posterior wall fragment comprising 45 percent of the posterior articular surface. The joint is congruent. What is the definitive management?

Explanation

Posterior wall fractures involving greater than 40 percent of the articular surface are biomechanically unstable. Operative fixation (ORIF) is required to restore joint stability, prevent recurrent dislocation, and minimize post-traumatic arthrosis.

Question 82

A 29-year-old male sustains a low-velocity gunshot wound to the right thigh, resulting in a minimally displaced diaphyseal femur fracture. The entry and exit wounds are small and clean. Neurovascular exam is normal. What is the most appropriate initial management?

Explanation

Low-velocity gunshot wounds resulting in femur fractures without gross contamination or vascular injury do not require formal operative track debridement. They are managed safely with local wound care, tetanus prophylaxis, and standard intramedullary nailing.

Question 83

A 65-year-old female sustains a significantly displaced distal radius fracture. Upon presentation, she has profound numbness in her thumb, index, and long fingers. The fracture is reduced and splinted, but her neurologic symptoms progressively worsen over the next 2 hours. What is the most appropriate next step?

Explanation

Progressive or unrelenting median nerve symptoms after closed reduction of a distal radius fracture indicate acute carpal tunnel syndrome. This requires urgent surgical decompression of the carpal tunnel to prevent permanent nerve damage.

Question 84

A 38-year-old male is involved in a high-speed collision. Imaging reveals a fracture through the bilateral pars interarticularis of C2 with 4 mm of anterior translation of C2 on C3 and no severe angulation (Levine-Edwards Type II). What is the preferred initial management?

Explanation

A Levine-Edwards Type II Hangman's fracture features displacement with angulation due to disruption of the C2-C3 disc. Initial treatment typically consists of reduction under traction followed by Halo vest immobilization.

Question 85

A 25-year-old man sustains a displaced, basicervical femoral neck fracture in a motor vehicle collision. What is the most appropriate definitive management to provide biomechanical stability and minimize the risk of nonunion?

Explanation

Basicervical femoral neck fractures are biomechanically unstable and behave similarly to intertrochanteric fractures. A sliding hip screw (with or without a derotational screw) or a cephalomedullary nail provides superior biomechanical stability compared to multiple cancellous screws for this specific fracture pattern.

Question 86

A 42-year-old male is involved in a motorcycle collision and sustains a severe crush injury to his right lower leg. Clinical exam shows a tense, swollen leg with severe pain on passive stretch of the toes. Which of the following is the most accurate parameter for diagnosing acute compartment syndrome?

Explanation

The delta pressure (diastolic blood pressure minus intracompartmental pressure) is the most reliable parameter for diagnosing acute compartment syndrome. A delta pressure less than 30 mm Hg is a standard threshold indicating the need for emergent fasciotomy.

Question 87

A 30-year-old trauma patient arrives with an anterior-posterior compression (APC-III) pelvic ring injury and is hemodynamically unstable. Where is the most biomechanically effective anatomical location to apply a noninvasive pelvic circumferential compression device (pelvic binder)?

Explanation

Pelvic binders are most effective at reducing pelvic volume and controlling hemorrhage when centered directly over the greater trochanters. Application higher up over the iliac crests or abdomen is less effective and can potentially worsen certain pelvic ring displacements.

Question 88

A 22-year-old male sustains a high-energy knee dislocation. Following emergent closed reduction, his foot is well-perfused, but his Ankle-Brachial Index (ABI) is measured at 0.8. What is the next most appropriate step in management?

Explanation

An ABI less than 0.9 following a knee dislocation strongly suggests an underlying arterial injury, even in the presence of palpable pulses or a well-perfused foot. CT angiography is indicated to accurately evaluate the popliteal artery and plan necessary surgical intervention.

Question 89

A 45-year-old woman who has been taking alendronate for 8 years presents with a prodrome of lateral thigh pain followed by a low-energy displaced subtrochanteric femur fracture. Her radiograph shows lateral cortical thickening and a transverse fracture with a medial spike. What is the most appropriate surgical management?

Explanation

Atypical femur fractures (AFF) are associated with prolonged bisphosphonate use and exhibit specific radiographic features like lateral cortical thickening. Intramedullary nailing (such as cephalomedullary nailing) is the treatment of choice as it load-shares and protects the entire diseased femoral diaphysis.

Question 90

A 38-year-old male falls from a roof and sustains a closed, displaced intra-articular calcaneus fracture (Sanders type II). Open reduction and internal fixation via an extensile lateral approach is planned. To minimize severe wound complications, what is the optimal timing for surgery?

Explanation

To minimize the high risk of wound dehiscence and deep infection associated with the extensile lateral approach for calcaneus fractures, surgery should be delayed until soft tissue swelling subsides. This is typically indicated by the presence of a positive "wrinkle sign" at 7 to 14 days post-injury.

Question 91

A 28-year-old male suffers a closed, mid-shaft humeral fracture. Neurological examination reveals a wrist drop and inability to extend the metacarpophalangeal joints. The fracture is treated with a functional brace. At 12 weeks, there is no clinical or electromyographic (EMG) evidence of radial nerve recovery. What is the next best step?

Explanation

Most radial nerve palsies associated with closed humeral shaft fractures represent a neuropraxia and resolve spontaneously. However, the lack of clinical and EMG recovery at 12 to 16 weeks is a strict indication for surgical exploration of the radial nerve.

Question 92

A 34-year-old woman presents to the ER with an open tibia fracture after a high-speed motor vehicle collision. The wound is 12 cm long with significant periosteal stripping. According to evidence-based guidelines, when should systemic antibiotics be administered?

Explanation

Early administration of systemic antibiotics is the single most important factor in reducing infection rates in open fractures. Guidelines strongly recommend administering appropriate intravenous antibiotics within 1 hour of injury or emergency department arrival.

Question 93

A 55-year-old female presents with a displaced fracture of the distal radius treated with a volar locking plate. Six months postoperatively, she suddenly loses the ability to actively flex the interphalangeal joint of her thumb. What is the most likely cause of this complication?

Explanation

Flexor pollicis longus (FPL) tendon rupture is a well-documented complication of volar locking plates used for distal radius fractures. This attritional rupture occurs when the plate is placed too distally, prominent beyond the anatomical watershed line of the distal radius.

Question 94

A 40-year-old polytrauma patient with a severe traumatic brain injury (GCS 6), bilateral pulmonary contusions, and a closed right femoral shaft fracture is brought to the trauma bay. His lactate is 4.5 mmol/L and base deficit is -8. What is the most appropriate initial management of his femur fracture?

Explanation

In a "borderline" or unstable polytrauma patient (indicated by elevated lactate, negative base deficit, severe TBI, and chest trauma), damage control orthopedics (DCO) is indicated. Rapid temporary stabilization with external fixation avoids the systemic "second hit" associated with early total care like intramedullary nailing.

Question 95

A 30-year-old man sustains a Hawkins Type III talar neck fracture. What does this classification indicate regarding the specific fracture pattern and its associated risk of avascular necrosis (AVN)?

Explanation

A Hawkins Type III fracture involves a displaced talar neck fracture with dislocation of both the subtalar and tibiotalar joints. This severe injury disrupts the major blood supply to the talar body, leading to a very high rate of avascular necrosis, often approaching 100%.

Question 96

During the preparation for intramedullary nailing of a diaphyseal femur fracture, the surgeon notices a coronal plane fracture of the lateral femoral condyle extending into the knee joint on the lateral radiograph. This specific articular injury is commonly referred to as a:

Explanation

A Hoffa fracture is an intra-articular coronal plane fracture of the femoral condyle, most commonly involving the lateral condyle. It is frequently associated with distal femur or diaphyseal fractures and requires specific fixation (often anterior-to-posterior lag screws) to restore joint congruity.

Question 97

A 65-year-old male presents with severe right shoulder pain after experiencing a grand mal seizure. Radiographs reveal a posterior shoulder dislocation on the axillary view. What associated bony defect is most likely present on the anteromedial aspect of the humeral head?

Explanation

Posterior shoulder dislocations, frequently caused by seizures or electrocution due to violent internal rotator muscle contraction, are commonly associated with an impaction fracture on the anteromedial aspect of the humeral head. This specific defect is known as a reverse Hill-Sachs lesion.

Question 98

A 25-year-old male sustains a low-velocity civilian gunshot wound to the midshaft femur, resulting in a comminuted fracture. The bullet passed cleanly through the thigh. His neurovascular exam is normal, and the wounds are small without gross contamination. What is the most appropriate management?

Explanation

Low-velocity gunshot wounds causing femur fractures without significant contamination or vascular injury are effectively managed similarly to closed fractures. Treatment involves superficial local wound care, appropriate antibiotics, tetanus prophylaxis, and standard intramedullary nailing.

Question 99

A 45-year-old male laborer falls from a height and sustains a completely displaced, closed transverse fracture of the acetabulum with a large posterior wall component. Which surgical approach provides the most direct access to visualize and reduce the posterior wall and posterior column?

Explanation

The Kocher-Langenbeck approach is the standard and most frequently used posterior approach to the acetabulum. It provides excellent direct visualization for the anatomical reduction and stable internal fixation of posterior column and posterior wall fractures.

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

AAOS Orthopedic Trauma MCQs (Set 1): Emergency & Fracture Management | Board Review

Key Takeaway

AAOS Orthopedic Trauma MCQs (Set 1): Emergency & Fracture Management | Board Review

Chapter Index