Trauma MCQs 2009 | Solved Board Questions 3

Question 1

A 42-year-old college professor reports persistent pain at the hypothenar eminence 9 months after falling from his bicycle. Initial radiographs were reportedly normal. Use of a wrist splint for the last 2 months has failed to provide relief. A radiograph obtained by his primary care physician prior to referral is seen in Figure 31. What is the most appropriate treatment?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 1

Explanation

The oblique radiograph of the wrist reveals a displaced fracture of the pisiform that usually occurs following a direct blow or sudden contraction of the flexor carpi ulnaris tendon. Persistent pain secondary to pisotriquetral incongruity and degenerative arthritis warrants pisiform excision, which does not compromise wrist flexion strength. Pisiform fractures are usually missed on routine radiographic views. An oblique or carpal tunnel view can be helpful in visualizing the pisotriquetral joint.

Question 2

Figures 32a and 32b show the radiographs of a 13-year-old right hand-dominant boy who sustained a closed Salter-Harris type II fracture of the proximal humerus during a hockey game. The shoulder has significant swelling, but is neurovascularly intact. What treatment offers the best chance of reestablishing normal shoulder motion?

Explanation

The patient has a significantly angulated proximal humerus fracture with a high degree of varus angulation, and rotational malalignment is likely. Failure to correct the varus angulation will result in permanent loss of shoulder abduction because the patient's age limits bony remodeling. These fractures are inherently unstable due to the inability to control the proximal fracture alignment. Shoulder spica casts have a high rate of redisplacement after treatment. Adequate open or closed reduction and pin fixation in the operating room optimizes alignment and all but eliminates the chance of redisplacement. Dobbs MB, Luhmann SJ, Gordon JE, et al: Severely displaced proximal humerus epiphyseal fractures. J Pediatr Orthop 2003;23:208-215. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, p 701.

Question 3

What letter in Figure 33 marks the correct starting point for a transiliac pelvic screw?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 4

Explanation

Iliosacral screws cannot always be placed safely due to variations in pelvic anatomy. Transiliac bars are an alternative method for fixation but are placed using an open technique. A screw can be placed percutaneously through both iliac wings posterior to the posterior border of the sacrum. The starting point is visualized using a lateral C arm shot and is located on the posterior iliac crest at about the level of the S1 body where the crest has its largest area posterior to the sacrum. This area is labeled A in the figure, B represents the sacral canal, C is S1, D is the area cephalad to the iliocortical density, and E is the anterior border of the sacrum. The radiograph demonstrates a well-placed sacroiliac screw. Moed BR, Fissel BA, Jasey G: Percutaneous transiliac pelvic fracture fixation: Cadaver feasibility study and preliminary clinical results. J Trauma 2007;62:357-364.

Question 4

A 57-year-old man involved in a motor vehicle accident sustains an injury to his right shoulder. A spot AP radiograph is shown in Figure 34. What is the next most appropriate step in the orthopaedic management of this patient?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 5

Explanation

The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a "Velpeau" axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.

Question 5

An 8-year-old girl injures her elbow playing soccer. After attempted reduction in the emergency department, radiographs of the elbow are shown in Figures 35a through 35c. What is the next most appropriate step in treatment?

Explanation

Ninety percent of injuries to the proximal radius in children are radial neck fractures, and 50% of these fractures are through the metaphyseal bone. The remaining 50% are Salter-Harris type I or II fractures. These radiographs show a fracture of the radial head and subluxation of the radius anteriorly. Most congenital radial head dislocations are posterior lateral. Nonsurgical treatment modalities are unlikely to be successful due to the wide displacement of the fracture fragments, as well as dislocation of the radial head. 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. Hashemi-Nejad A, Goddard NJ: Radial head fractures. Br J Hosp Med 1994;51:223-226.

Question 6

A 30-year-old woman injured the ring finger of her nondominant hand while playing baseball 5 weeks ago. She now reports pain and limited motion of the proximal interphalangeal (PIP) joint. A lateral fluoroscopy image is shown in Figure 36. Treatment of the PIP joint should consist of

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 9

Explanation

The patient has a neglected PIP joint fracture-dislocation with comminution involving more than 40% of the volar articular surface of the middle phalanx. Volar plate arthroplasty has been advocated for the treatment of acute unstable and chronic dorsal fracture-dislocations. The volar plate is incised laterally and released from the collateral ligaments. The volar fragments of the middle phalanx are removed and a trough is created for advancement of the volar plate, which is secured with sutures secured on the dorsum of the middle phalanx beneath the extensor mechanism. Dionysian E, Eaton RG: The long-term outcome of volar plate arthroplasty of the proximal interphalangeal joint. J Hand Surg Am 2000;25:429-437. Eaton RG, Malerich MM: Volar plate arthroplasty of the proximal interphalangeal joint: A review of ten years' experience. J Hand Surg Am 1980;5:260-268.

Question 7

A 19-year-old woman fell onto her nondominant hand 6 weeks ago. Radiographs are shown in Figures 37a and 37b. A decision has been made to treat this fracture surgically. What is the best approach to treat this fracture?

Explanation

Displaced fractures of the scaphoid are best treated with compression screw fixation. Proximal third fractures (as in this patient) are optimally approached via a dorsal approach to ensure proper reduction and compression. Fractures of the scaphoid waist can be approached either by a volar or a dorsal approach. Kirschner wire fixation is limited to proximal pole fractures that are too small to accommodate the trailing head of a compression screw. Retting ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole fractures. J Hand Surg Am 1999;24:1206-1210.

Question 8

Which of the following findings best describes the acetabular fracture shown in Figure 38?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 12

Explanation

The CT scan shows a posterior wall fracture with impaction of the articular surface and a free fragment within the joint. Proper treatment of this injury requires not only reduction and fixation of the posterior wall fragment but also removal of the free fragment and elevation of the depressed articular segment. Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.

Question 9

In the setting of a proximal tibial plateau fracture and its repair, which of the following materials is an isotropic material?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 13

Explanation

An isotropic material is one that has similar mechanical properties regardless of the orientation of the material. Examples of isotropic materials include metals, plastics, and methacrylate. Most biologic tissues are anisotropic, meaning their mechanical properties alter depending on the materials' orientation to the applied stress.

Question 10

A 28-year-old female firefighter fell from the top of a three-story building in the line of duty. She sustained a displaced pelvic fracture with more than 5 mm displacement. Compared to normal healthy controls, these patients have a higher incidence of

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 14

Explanation

Pelvic trauma in women has been shown to increase the risk of sexual dysfunction and dyspareunia. Additionally, caesarean section childbirth is almost universal following pelvic trauma regardless of whether anterior pelvic hardware is present or not. Copeland CE, Bosse MJ, McCarthy ML et al: Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function. J Orthop Trauma 1997;11:73-81.

Question 11

A 30-year-old man falls off a 7-foot ladder and sustains the injury seen in the radiograph and the CT scan shown in Figures 39a and 39b. Medical history is negative. Management of this injury should include which of the following?

Explanation

A Sanders type 2 intra-articular calcaneus fracture in a young healthy nonsmoker is best treated with open reduction and internal fixation. Whereas nonsurgical management is an option, Buckley and associates have shown that these fractures have a better outcome with surgical care. Percutaneous fixation is reserved for tongue-type fractures and subtalar arthrodesis is used in some type 4 fractures. External fixation has not been shown to be advantageous in closed fractures. Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744. Sanders R: Displaced intraarticular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.

Question 12

A 24-year-old woman fell from a horse and landed on her outstretched right arm. Radiographs reveal an elbow dislocation with a type II coronoid fracture and a nonreconstructable comminuted radial head fracture. What is the most appropriate management?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 17

Explanation

The combination of an elbow dislocation and a fracture of the radial head and coronoid is known as a terrible triad injury. To restore elbow stability, each injury must be addressed. The nonreconstructable radial head fracture requires implant arthroplasty. Open reduction and internal fixation of the coronoid is also necessary as is repair of the lateral collateral ligament complex which is usually avulsed from the lateral epicondyle region. Ring D, Quintero J, Jupiter JB: Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 2002;84:1811-1815. Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551.

Question 13

A 30-year-old man is brought to the emergency department after a motor vehicle accident. He has a closed midshaft femoral fracture and an intra-abdominal injury. He is currently in the operating room and the exploration of his abdomen has been completed. His initial blood pressure was 70/30 mm Hg and is now 90/50 mm Hg after 4 liters of fluid and 2 units of blood. His initial serum lactate was 3.0 mmol/L (normal < 2.5), 1 hour postinjury it was 3.5 mmol/L, and it is now 5 mmol/L. His core temperature is 93 degrees F (34 degrees C). What is the most appropriate management for the femoral shaft fracture at this point?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 18

Explanation

The patient has several indications that he is not ready for definitive fixation of the femoral shaft fracture at this point. He is cold with a core temperature of 93 degrees F, and hypothermia of less than 95 degrees F (35 degrees C) has been shown to be associated with an increased mortality rate in trauma patients. The patient has also not been resuscitated based on his increasing lactate levels and although controversial, it has been shown that temporary external fixation leads to a lower incidence of multiple organ failure and acute respiratory distress syndrome. Shafi S, Elliot AC, Gentilello L: Is hypothermia simply a marker of shock and injury severity or an independent risk factor for mortality in trauma patients? Analysis of a large national trauma registry. J Trauma 2005;59:1081-1085. Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461.

Question 14

A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?

Explanation

The most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.

Question 15

A 100-lb 9-year-old boy has a closed midshaft transverse femoral fracture. The oblique fracture is shortened by 3 cm with a 10-degree varus angulation. Surgical management consists of intramedullary, retrograde flexible titanium nailing. To optimize fracture stability, the surgeon should

Explanation

The technique of intramedullary nailing with titanium elastic nails is based on the concept of balanced forces across the fracture site with two equally sized nails. Implantation of the largest sized nails possible, with two equally sized nails, maximizes the stiffness at the fracture site, thereby optimizing fracture alignment and stability. Impacting the nails into the medullary canal can impact the fixation by minimizing distal purchase of the nail at the cortical insertion site. Closed reduction commonly permits bony reduction and passage of the nails; open reduction is reserved for inability to align the fracture. Luhmann SJ, Schootman M, Schoenecker PL, et al: Complications of titanium elastic nails for pediatric femur fractures. J Pediatr Orthop 2003;23:443-447. Lascombes P, Haumont T, Journeau P: Use and abuse of flexible intramedullary nailing in children and adolescents. J Pediatr Orthop 2006;26:827-834.

Question 16

A 16-year-old girl was involved in a motorcycle accident that resulted in a significant right tibial fracture with soft-tissue loss over the distal 4 cm of the anterior medial tibia. The patient has had two irrigations and debridements and recently had an intramedullary nail placed for the skeletal injury. Vacuum-assisted closure (VAC) has been used to cover the defect since the injury. The risk of infection developing in the tibia is

Explanation

The risk of infection in a 3B open tibia fracture is most directly related to the timing of the soft-tissue coverage and less related to the size or location of the wound. The wound VAC does not lower or raise the risk of infection in open fractures. It does appear to increase the window of time to obtain coverage without increasing the risk of infection. Additionally, the wound VAC may decrease the probability of needing free tissue coverage. Intramedullary nailing has not been shown to lower the risk of infection in 3B fractures. Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-292. Dedmond BT, Kortesis B, Punger K, et al: The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibia shaft fractures. J Orthop Trauma 2007;21:11-17.

Question 17

A 12-year-old boy falls from a bicycle. A radiograph of his injured shoulder is shown in Figure 41. What is the optimal method of treatment?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 22

Explanation

The radiograph reveals a distal clavicle fracture. In children, a periosteal sleeve will remain attached to the intact coracoclavicular ligament, and as such, remodeling can be expected. Therefore, nonsurgical management with a sling is preferred. Surgical treatment is not necessary, and a shoulder spica cast offers no advantage over a simple sling.

Question 18

The major benefit of irrigation with a castile soap solution over irrigation with bacitracin solution for the treatment of the open fracture shown in Figure 42 can be seen in which of the following outcomes?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 23

Explanation

The mainstay of early treatment of open fractures includes irrigation and debridement. Prior to the development of antibiotics, this was traditionally accomplished with some form of detergent irrigation. Antibiotic irrigation has been in favor more recently but has mixed scientific results related to its use. Results of at least one major study show the use of a nonsterile liquid soap additive (castile soap) is at least as effective as the use of bacitracin with regards to the rate of postoperative infection and fracture healing, and shows a significant decrease in problems with soft-tissue healing.

Question 19

A 22-year-old cheerleader who fell from the top of a pyramid now reports anterior and posterior pelvic pain. A radiograph and CT scans are shown in Figures 43a through 43c. What is the best treatment for this injury?

Explanation

Symphyseal widening of greater than 2.5 cm and less than 5 cm denotes an AP II injury and a rotationally unstable pelvis. An AP II pelvic ring injury is best treated with anterior open reduction and internal fixation. Nonsurgical management is reserved for AP I injuries. Pelvic binders are used only acutely and should not be used for definitive management. Iliosacral screws usually are not necessary in the acute management of AP II injuries. Matta JM: Indications for anterior fixation of pelvic fractures. Clin Orthop Relat Res 1996;329:88-96. Templeman DC, Schmidt AH, Sems AS, et al: Diastasis of the symphysis pubis: Open reduction internal fixation, in Wiss D (ed): Masters Techniques in Orthopaedic Surgery-Fractures, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 639-648.

Question 20

What vessel is marked with an asterisk in Figure 44?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 27

Explanation

The superior gluteal artery is a branch of the posterior division of the internal iliac artery and exits the pelvis through the greater sciatic notch. It can be injured as a result of a pelvic ring fracture or acetabular fracture that has a fracture of the posterior column. Agur AM, Dalley AF (eds): Grant's Atlas of Anatomy, ed 12. Philadelphia, PA, Lippincott Williams and Wilkins, 2008.

Question 21

Figures 45a and 45b show the radiographs of a 14-year-old boy who sustained a distal radius fracture while playing hockey. After 1 year the patient is asymptomatic. Follow-up and comparison radiographs and an MRI scan are shown in Figures 45c and 45d. What is the next most appropriate step in management?

Explanation

The patient sustained a growth plate fracture of the distal radius and ulna. Although treated with closed reduction and casting, the follow-up radiographs demonstrate shortening of the radius in comparison to the ulna, and the MRI scan confirms thinning of the distal radius growth plate and bony bars consistent with a growth arrest. At this time, the discrepancy in length is too minor to consider lengthening of the radius; in addition, excision of a physeal bar with minimal growth potential is not likely to restore the gross discrepancy. Ulnar styloid fractures are rarely symptomatic and do not require treatment in the asymptomatic patient. Closure of the distal ulna growth plate will prevent further discrepancy between the radius and ulna. Vanheest A: Wrist deformities after fracture. Hand Clin 2006;22:113-120.

Question 22

A 13-year-old girl sustained an isolated midshaft left femoral fracture in a motor vehicle accident. The fracture was treated with a rigid, antegrade intramedullary nail placed through the piriformis fossa. The fracture healed uneventfully, as shown in Figure 46a; however, at 12 months postoperatively she now reports left hip pain. A current AP radiograph and MRI scan are shown in Figures 46b and 46c. What complication occurred in this patient?

Explanation

The development of femoral head ischemic necrosis is the iatrogenically created complication in this skeletally immature patient. Placement of a rigid, antegrade intramedullary nail through the piriformis fossa is likely to damage the vascular supply to the femoral head as the vessels ascend the femoral neck on the way to the femoral head. The MRI scan reveals ischemic necrosis with early collapse of the femoral head. The joint space is preserved on the MRI scan, ruling out chondrolysis. Letts M, Jarvis J, Lawton L, et al: Complications of rigid intramedullary rodding of femoral shaft fractures in children. J Trauma 2002;52:504-516. Buckley SL: Current trends in the treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 1997;338:60-73.

Question 23

A 30-year-old man caught his dominant little finger on the straps of his windsurfing board 10 days ago. He reports swelling about the distal phalanx and has difficulty completely extending the distal interphalangeal joint. A radiograph is shown in Figure 47. What is the most appropriate treatment for this injury?

Trauma 2009 Practice Questions: Set 3 (Solved) - Figure 35

Explanation

The radiograph reveals a "bony mallet injury." As the distal phalanx is not volarly subluxated, extension splinting, similar to a classic mallet injury without bony involvement, is appropriate. If there is volar subluxation associated with a large bony fragment, surgical intervention is appropriate. Baratz ME, Schmidt CC, Hughes TB: Extensor tendon injuries, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green's Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 192.

Question 24

A 40-year-old man sustains a fracture-dislocation of C4-5. Examination reveals no motor or sensory function below the C5 level. All extremities are areflexic. The bulbocavernosus reflex is absent. The prognosis for this patient's neurologic recovery can be best determined by

Explanation

The patient has spinal shock. Steroid administration and MRI are appropriate therapeutic and diagnostic procedures. Myelography with CT is of little value unless there is an unusual skeletal variant. Spinal cord-evoked potentials have no value. The best method to determine the patient's neurologic recovery is repeated physical examinations over the first 48 to 72 hours. Spivak JM, Connolly PF (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 183-184.

Question 25

Figures 48a and 48b show the radiographs of a 26-year-old woman who fell down two steps and twisted her foot and ankle. What is the most appropriate treatment for this injury?

Explanation

The patient has a zone 1 base of the fifth metatarsal fracture (Pseudojones) that represents a less serious injury compared to zone 2 and 3 fractures with regard to healing potential. Treatment is symptomatic and casting is not necessary. These fractures are well treated with a hard-soled shoe for comfort and weight bearing as tolerated. Surgical intervention is not warranted. Vorlat P, Achtergael W, Haentjens P: Predictors of outcome of non-displaced fractures of the base of the fifth metatarsal. Int Orthop 2007;31:5-10. Wiener BD, Linder JF, Giattini JF: Treatment of fractures of the fifth metatarsal: A prospective study. Foot Ankle Int 1997;18:267-269.

Question 26

A 35-year-old man is brought to the emergency department after a motorcycle collision. He is hemodynamically unstable, and a pelvic binder is ordered. Which of the following landmarks is the most appropriate location to center the pelvic binder?

Explanation

A pelvic binder should be centered over the greater trochanters to effectively reduce the pelvic volume and stabilize the pelvic ring, particularly in the setting of an anteroposterior compression (open-book) injury. Placement over the iliac crests is a common clinical error and can paradoxically widen the pelvic inlet, exacerbating the deformity and bleeding.

Question 27

A 28-year-old man sustains a closed spiral fracture of the tibial shaft. On examination, he is extremely anxious and requires increasing doses of opioid analgesia. Which of the following is the most sensitive early clinical finding of acute compartment syndrome?

Explanation

Pain with passive stretch of the muscles in the involved compartment and pain out of proportion to the apparent injury are considered the earliest and most sensitive clinical signs of acute compartment syndrome. Pulselessness, pallor, and paralysis are late signs, often indicating irreversible tissue necrosis. Paresthesias can be an early sign of nerve ischemia but pain with passive stretch remains the most reliable early clinical indicator.

Question 28

A 65-year-old woman falls on her outstretched dominant hand and sustains a distal radius fracture. Closed reduction is performed in the emergency department. Which of the following post-reduction radiographic parameters falls outside the acceptable criteria for nonoperative management in an active adult?

Explanation

The generally accepted radiographic criteria for nonoperative management of distal radius fractures include radial shortening <5 mm, dorsal tilt <5-10 degrees (or within 15 degrees of normal volar tilt), and intra-articular step-off <2 mm. A dorsal tilt of 15 degrees is unacceptable and is a strong indication for surgical intervention to prevent symptomatic malunion.

Question 29

A 6-year-old boy sustains a completely displaced extension-type supracondylar humerus fracture. On examination, the hand is pink and warm, with brisk capillary refill, but the radial pulse is not palpable. What is the most appropriate next step in management?

Explanation

In a child with a displaced supracondylar humerus fracture and a 'pulseless, pink' hand, the limb is adequately perfused through collateral circulation. The most appropriate next step is urgent closed reduction and percutaneous pinning, as the pulse frequently returns following anatomic reduction. Vascular exploration is indicated if the hand becomes or remains poorly perfused (white and cool) after reduction.

Question 30

A 30-year-old man sustains a displaced, Pauwels type III (highly vertical) femoral neck fracture after a fall from a height. What is the most appropriate surgical strategy to optimize biomechanical stability for this specific fracture pattern?

Explanation

Pauwels type III femoral neck fractures have a vertical orientation and are subjected to high shear forces. In young adults, head-preserving surgery is indicated. Biomechanical studies have demonstrated that a sliding hip screw (often supplemented with an anti-rotation screw) provides superior resistance to shear forces and vertical displacement for this fracture pattern compared to multiple cancellous screws.

Question 31

A 45-year-old man sustains a Grade IIIB open tibia fracture from a farming accident involving heavy soil contamination. In addition to emergent surgical debridement, which of the following prophylactic antibiotic regimens is most appropriate?

Explanation

For a Gustilo-Anderson Grade III open fracture, standard antibiotic prophylaxis includes a first-generation cephalosporin and an aminoglycoside to cover both Gram-positive and Gram-negative organisms. Because this is a farm injury with soil contamination, there is a significantly increased risk for clostridial infection (gas gangrene); thus, high-dose penicillin should be added to the regimen for anaerobic coverage.

Question 32

A 22-year-old male athlete falls on his outstretched hand and sustains a scaphoid fracture. Which of the following fracture characteristics is associated with the highest risk of nonunion and avascular necrosis?

Explanation

The blood supply to the scaphoid is predominantly retrograde, entering the distal portion of the bone and perfusing the proximal pole. Fractures of the proximal pole disrupt this precarious blood supply, leading to a high rate of avascular necrosis and nonunion. Fractures of the distal pole and tuberosity have an excellent blood supply and a high rate of union with conservative management.

Question 33

A 25-year-old unrestrained driver is involved in a head-on motor vehicle collision. He presents to the trauma bay with a shortened, internally rotated, and adducted left lower extremity. A radiograph confirms a posterior hip dislocation. Which of the following nerve injuries is most commonly associated with this injury?

Explanation

Posterior hip dislocations are classically associated with injury to the sciatic nerve. Within the sciatic nerve, the peroneal division is significantly more vulnerable to injury than the tibial division because its fibers are located more laterally, have less connective tissue protection, and are more securely tethered distally at the fibular head.

Question 34

A 32-year-old male sustains a twisting injury to his midfoot while playing soccer. He has swelling, plantar ecchymosis, and tenderness over the tarsometatarsal joints. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. What is the most appropriate definitive management?

Explanation

A diastasis of >2 mm between the first and second metatarsal bases on weight-bearing radiographs is diagnostic of an unstable Lisfranc injury. The standard of care for displaced or unstable Lisfranc injuries in an active patient is anatomical reduction and stabilization, typically achieved with open reduction and internal fixation (ORIF). Rigid immobilization alone is reserved for strictly nondisplaced, stable sprains.

Question 35

A 28-year-old man falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the anatomical displacement associated with this injury?

Explanation

According to the Hawkins classification for talar neck fractures: Type I is nondisplaced; Type II involves subluxation or dislocation of the subtalar joint; Type III involves dislocation of both the subtalar and tibiotalar (ankle) joints; and Type IV (Canale and Kelly modification) adds talonavicular joint dislocation. Type III fractures are associated with a very high rate of avascular necrosis of the talar body.

Question 36

A 42-year-old man sustains a severe closed tibial shaft fracture. He undergoes reamed intramedullary nailing. Which of the following intraoperative techniques is most effective in minimizing the elevation of intramedullary pressure and subsequent risk of fat embolism?

Explanation

The use of sharp reamers with deep flutes, combined with slow and steady advancement, allows for optimal clearance of reamings and minimizes both heat generation and peaks in intramedullary pressure, effectively reducing the risk of fat embolism.

Question 37

A 26-year-old male presents with an isolated, closed, displaced transverse fracture of the femoral shaft following a motorcycle collision. He is hemodynamically stable. Antegrade intramedullary nailing is planned. What is the most critical intraoperative factor in preventing a nonunion?

Explanation

A residual fracture gap greater than 2 mm has been shown to be the most significant independent predictor of nonunion following intramedullary nailing of femoral shaft fractures. Reamed nails have actually demonstrated a lower rate of nonunion compared to unreamed nails in robust literature.

Question 38

A 35-year-old man sustains a displaced Hawkins type III talar neck fracture. Which of the following surgical strategies provides the best biomechanical stability and allows for optimal visualization of the reduction?

Explanation

Hawkins type III talar neck fractures are highly displaced and often comminuted. Dual approaches (anteromedial and anterolateral) are necessary to accurately assess and reduce the medial and lateral columns of the talar neck. Biomechanically, screw fixation is best when multiple columns are stabilized.

Question 39

A 68-year-old woman with a history of severe osteoporosis is treated with a locking plate for a 3-part proximal humerus fracture. Four weeks postoperatively, radiographs demonstrate varus collapse of the humeral head and screw cutout. Which of the following technical errors during the index procedure is most likely responsible for this complication?

Explanation

In locked plating of proximal humerus fractures, the lack of medial support (comminuted or unreduced medial calcar) is the primary cause of varus collapse. Placement of inferomedial calcar screws in the locking plate is critical to provide mechanical support against varus deforming forces.

Question 40

A 25-year-old man arrives at the trauma center hemodynamically unstable with an anteroposterior compression type III (APC-III) pelvic ring injury. A pelvic binder is applied, and he receives massive transfusion protocol. His FAST exam is negative, but he remains hypotensive. What is the most likely anatomic source of his ongoing pelvic hemorrhage?

Explanation

While arterial bleeding (such as from the superior gluteal artery or internal pudendal artery) can cause rapid exsanguination, the presacral and perivesical venous plexuses, along with cancellous bone bleeding, account for 80-90% of all pelvic hemorrhage in major pelvic ring injuries.

Question 41

A 22-year-old male sustains a pelvic fracture in a motor vehicle accident. The AP pelvic radiograph demonstrates disruption of both the iliopectineal and ilioischial lines on the right side. The obturator ring is intact. Which of the following Judet-Letournel classifications best describes this fracture pattern?

Explanation

A transverse acetabular fracture involves both the anterior and posterior columns, dividing the innominate bone into upper and lower halves. Radiographically, this disrupts both the iliopectineal line (anterior column) and ilioischial line (posterior column). The intact obturator ring differentiates it from a T-type or both-column fracture.

Question 42

The Sanders classification is utilized for preoperative planning in calcaneus fractures. Which of the following imaging modalities and views is essential for applying this classification system?

Explanation

The Sanders classification for calcaneus fractures is based exclusively on the number and location of articular fracture lines extending through the posterior facet as seen on coronal CT images. It dictates the surgical approach and offers prognostic value.

Question 43

A 55-year-old woman sustains a highly comminuted intra-articular distal radius fracture. She undergoes open reduction and internal fixation with a volar locking plate. To minimize her risk of developing post-traumatic radiocarpal arthrosis, which of the following radiographic parameters is most critical to accurately restore?

Explanation

While restoration of radial length, volar tilt, and radial inclination are important for wrist kinematics and function, articular congruity is the most critical parameter to minimize post-traumatic arthritis. An articular step-off greater than 2 mm is strongly correlated with the rapid development of radiocarpal arthrosis.

Question 44

A 38-year-old male falls from a ladder and sustains an isolated, closed, displaced 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 severe skin tenting that acutely threatens skin viability. Displacement, shortening, comminution (Z-deformity), and floating shoulder are relative indications.

Question 45

A 40-year-old man sustains an extra-articular distal third tibia fracture. Intramedullary nailing is planned. To prevent the most common malalignment associated with this specific fracture pattern during nailing, which of the following techniques should be primarily employed?

Explanation

Distal third tibia fractures are notoriously prone to malalignment (particularly valgus and procurvatum deformities) due to the wide metaphysis and lack of tight endosteal fit for the nail. Blocking screws (Poller screws) placed on the concave side of the expected deformity narrow the medullary canal, help direct the nail centrally, and prevent angular malalignment.

Question 46

A 25-year-old male sustains a purely ligamentous Lisfranc injury after a twisting mechanism while playing football. Which of the following fixation constructs has been shown to provide the best long-term clinical outcomes for this specific injury pattern?

Explanation

Purely ligamentous Lisfranc injuries have historically demonstrated poor outcomes with ORIF due to the lack of bone-to-bone healing and reliance on ligamentous scar tissue. Prospective randomized controlled trials (such as Ly and Coetzee, JBJS 2006) have shown that primary arthrodesis of the medial two or three rays results in better functional outcomes and a lower rate of planned secondary surgeries compared to ORIF.

Question 47

A 45-year-old female presents with a closed, displaced intra-articular calcaneus fracture (Sanders Type III). The surgeon is considering an extensile lateral approach for open reduction and internal fixation. Which of the following is considered an absolute contraindication to utilizing this specific approach?

Explanation

The extensile lateral approach for calcaneus fractures carries a significant risk of wound complications. Absolute contraindications for this approach include poorly controlled diabetes mellitus with peripheral neuropathy, severe peripheral vascular disease, and active infection. Smoking is a strong relative contraindication due to increased wound healing risks. Fracture blisters dictate the timing of surgery (waiting for re-epithelialization) rather than acting as an absolute contraindication to the approach.

Question 48

A 30-year-old construction worker sustains a severe pilon fracture and is initially treated with a spanning external fixator. At 14 days, the soft tissue envelope has improved and he undergoes definitive ORIF via an anterolateral approach to the distal tibia. During the superficial dissection, which of the following structures is most at risk of iatrogenic injury?

Explanation

The anterolateral approach to the distal tibia is commonly used for pilon fractures. The superficial peroneal nerve crosses the surgical interval from lateral to medial as it descends toward the foot and is at high risk of iatrogenic injury. The deep peroneal nerve and anterior tibial artery are located deeper and more medially between the tibialis anterior and extensor hallucis longus.

Question 49

During the percutaneous placement of an S1 transiliac-transsacral screw for a posterior pelvic ring injury, the surgeon must be aware of sacral dysmorphism. Which of the following is a radiographic sign of sacral dysmorphism that indicates the S1 osseous corridor may be restricted or unsafe?

Explanation

Sacral dysmorphism refers to anatomic variations that make standard placement of S1 iliosacral screws difficult or unsafe. Radiographic signs include an acute upward angulation of the sacral ala (alar slope), a non-recessed (flush) upper sacrum, tongue-in-groove sacroiliac joints, non-circular (often teardrop-shaped) upper sacral neural foramina on the outlet view, and residual upper sacral disc spaces. These features result in a narrow, oblique osseous corridor.

Question 50

A 22-year-old male sustains a low-velocity handgun wound to the mid-thigh. Radiographs reveal a comminuted midshaft femur fracture. The patient has a normal neurovascular examination and the wounds are clean with 5 mm entry and exit holes. What is the most appropriate definitive management?

Explanation

Low-velocity gunshot wounds resulting in diaphyseal femur fractures are generally treated similarly to closed fractures, provided there is no gross contamination or severe soft tissue compromise. Immediate reamed intramedullary nailing after local wound care (superficial debridement of the entry/exit wounds) and short-course intravenous antibiotics has been shown to be safe and highly effective. Formal deep surgical tract debridement is unnecessary and increases morbidity.

Question 51

A 65-year-old female sustains a valgus-impacted proximal humerus fracture. The medial calcar hinge is completely disrupted. According to recent quantitative anatomical studies, which of the following blood vessels provides the primary vascular supply to the humeral head articular segment?

Explanation

Recent quantitative anatomical studies (Hettrich et al.) have demonstrated that the posterior circumflex humeral artery (PCHA) provides the majority (approximately 64%) of the blood supply to the humeral head, predominantly perfusing the posteroinferior, posterosuperior, and central portions. The anterior circumflex humeral artery (ACHA), historically taught as the primary supplier via the arcuate artery, actually contributes significantly less. Preservation of the PCHA is critical during surgical intervention.

Question 52

A 40-year-old male presents with a closed midshaft clavicle fracture with 100% displacement and 2.5 cm of shortening. Compared to nonoperative management with a sling, what is the most significant clinical advantage of open reduction and internal fixation for this patient?

Explanation

Historically, nonoperative management of midshaft clavicle fractures carried a low assumed nonunion rate. However, prospective trials (e.g., COTS) demonstrated that completely displaced, shortened (>2 cm) midshaft clavicle fractures have a nonunion rate of approximately 15% when treated nonoperatively. Open reduction and internal fixation significantly decreases the rate of nonunion to less than 2% and improves early functional outcomes, though it carries surgical risks such as hardware prominence.

Question 53

A 55-year-old man sustains a perilunate dislocation and undergoes open reduction and ligament repair. To restore carpal stability, the surgeon identifies and repairs the primary ligamentous stabilizers. Which of the following intrinsic/extrinsic ligaments is considered the primary volar stabilizer of the lunate to the radius?

Explanation

The short radiolunate ligament is a thick, stout structure that serves as the primary volar stabilizer of the lunate to the distal radius. During a classic Mayfield perilunate dislocation, the carpus dislocates dorsally while the lunate is typically held in position (or rotated into the carpal tunnel) by the intact short radiolunate ligament. Recognizing its integrity is crucial for understanding carpal kinematics and surgical repair.

Question 54

A 35-year-old woman sustains a closed, isolated transverse fracture of the middle third of the humeral shaft. She is initially treated with a coaptation splint and transitioned to a functional fracture brace. Which of the following represents an absolute contraindication to continued nonoperative treatment with functional bracing?

Explanation

Functional bracing (Sarmiento bracing) relies on soft tissue compression to maintain fracture alignment and has a high union rate for closed humeral shaft fractures. Acceptable alignment parameters include up to 20 degrees of anterior angulation, 30 degrees of varus angulation, and up to 3 centimeters of shortening. The inability to maintain these parameters is an absolute contraindication to continued bracing. Initial closed radial nerve palsy is not a contraindication, as most will spontaneously resolve.

Question 55

A 50-year-old male is involved in a high-speed collision and sustains an APC II (anteroposterior compression) pelvic ring injury with widening of the symphysis pubis. If isolated internal fixation is planned for the anterior ring, which of the following statements regarding the biomechanics of symphyseal plating is correct?

Explanation

Biomechanical studies have consistently demonstrated that a plate placed on the superior surface of the symphysis pubis provides superior mechanical stability compared to an anteriorly placed plate. This is due to the thicker and denser bone available for screw purchase on the superior pubic rami, as well as an improved mechanical advantage against the deforming forces of the pelvic ring. Routine removal is not indicated unless symptomatic.

Question 56

A 25-year-old man sustains a subtrochanteric femur fracture following a motor vehicle collision. During closed reduction and intramedullary nailing, the proximal fracture fragment is notoriously difficult to reduce due to the deforming forces of the attached musculature. Which of the following muscles is primarily responsible for the external rotation deformity of the proximal segment?

Explanation

In a subtrochanteric femur fracture, the proximal fragment is subjected to distinct muscular deforming forces. It is typically flexed by the iliopsoas, abducted by the gluteus medius and minimus, and externally rotated by the short external rotators (piriformis, gemelli, obturator internus/externus, quadratus femoris). Understanding these deforming forces is critical for obtaining an anatomic reduction.

Question 57

A 35-year-old male is brought to the trauma bay after a motorcycle collision.

He is hypotensive (BP 75/40 mmHg) and tachycardic (HR 130 bpm). A FAST exam is negative. A pelvic radiograph shows an anteroposterior compression type III (APC-III) pelvic ring injury. A pelvic binder is applied, and he receives 2 units of uncrossmatched blood, but his hemodynamics remain unstable. What is the most appropriate next step in management?

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and a negative FAST exam (excluding intra-abdominal hemorrhage), the source of bleeding is presumed to be the pelvis. After application of a pelvic binder and initial fluid/blood resuscitation, pelvic angiography with embolization (or preperitoneal pelvic packing, depending on institutional protocol) is the most appropriate next step to address life-threatening arterial bleeding.

Question 58

A 28-year-old woman sustains a displaced talar neck fracture following a fall from a height. The surgeon plans an open reduction and internal fixation to restore articular congruity and mitigate the risk of avascular necrosis (AVN). The primary blood supply to the body of the talus, which is at risk in this injury, is derived from the:

Explanation

The artery of the tarsal canal, which is a branch of the posterior tibial artery, provides the dominant blood supply to the body of the talus. Disruption of this blood supply, along with the other extraosseous vessels, contributes significantly to the high rate of avascular necrosis seen in displaced talar neck fractures.

Question 59

A 45-year-old male sustains a bicondylar tibial plateau fracture.

Preoperative computed tomography (CT) scan reveals a large, displaced posteromedial coronal shear fragment. What is the most appropriate surgical approach to anatomically reduce and buttress this specific fragment?

Explanation

A posteromedial coronal shear fragment in a bicondylar tibial plateau fracture cannot be adequately addressed or buttressed through standard anterolateral or pure anteromedial approaches. A posteromedial approach allows direct visualization, anatomic reduction, and optimal anti-glide or buttress plating of the fragment at the apex of the deformity.

Question 60

A 55-year-old woman presents with the inability to flex the interphalangeal joint of her thumb 6 months after undergoing open reduction and internal fixation of a distal radius fracture. Radiographs show a healed fracture, but the volar locking plate is positioned distal to the watershed line of the radius. Which of the following tendons is most likely injured?

Explanation

Placement of a volar locking plate distal to the watershed line of the distal radius places the flexor tendons at significant risk for attrition and spontaneous rupture. The flexor pollicis longus (FPL) tendon is the most commonly injured tendon in this scenario due to its direct proximity to the prominent hardware on the volar surface.

Question 61

A 30-year-old male sustains a severe open tibial shaft fracture (Gustilo-Anderson Type IIIB) following a high-speed motor vehicle collision. He is brought to the trauma center 45 minutes after the injury. According to current evidence, which of the following interventions has the greatest impact on reducing his risk of deep infection?

Explanation

Extensive literature review has demonstrated that early administration of intravenous antibiotics is the single most critical factor in reducing the risk of deep infection following open fractures. While early surgical debridement is important, the strict '6-hour rule' has not been substantiated as an independent predictor of infection risk when compared to the timing of antibiotic administration.

Question 62

A 28-year-old male sustains a displaced, vertically oriented (Pauwels type III) femoral neck fracture.

Which of the following fixation constructs provides the most biomechanical stability for this specific fracture pattern?

Explanation

Pauwels type III femoral neck fractures are characterized by a highly vertical orientation, making them subjected to extremely high shear forces. Biomechanical studies have shown that a fixed-angle construct, such as a sliding hip screw (DHS) combined with a derotational screw, provides significantly superior biomechanical stability and lowers the risk of fixation failure compared to multiple parallel cancellous screws.

Question 63

A 22-year-old athlete sustains a hyperplantarflexion injury to his midfoot with severe pain and swelling. Radiographs demonstrate widening of the space between the first and second metatarsal bases and a small bony avulsion in this interval ('fleck sign'). The avulsed bone fragment originates from the attachment of the Lisfranc ligament. This ligament connects which of the following structures?

Explanation

The Lisfranc ligament is a critical stabilizing intra-articular ligament of the midfoot that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. Disruption of this ligament leads to a Lisfranc injury, which often necessitates operative stabilization.

Question 64

A 40-year-old construction worker undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via a standard extensile lateral approach. Postoperatively, he complains of numbness and tingling along the lateral aspect of his hindfoot. Which of the following nerves was most likely injured during the surgical approach?

Explanation

The sural nerve courses distally along the lateral aspect of the hindfoot and is at significant risk for injury during the extensile lateral approach to the calcaneus. The incision must be carefully planned (typically L-shaped) and full-thickness subperiosteal flaps created to protect the sural nerve and the vascular supply to the lateral skin flap.

Question 65

A 24-year-old patient undergoes arthroscopic stabilization for recurrent anterior shoulder instability. Preoperative imaging reveals a large Hill-Sachs lesion that engages the anterior glenoid rim with the arm in abduction and external rotation. Glenoid bone loss is estimated at 10%. In addition to an arthroscopic Bankart repair, which of the following procedures is most appropriate to address the humeral head defect?

Explanation

For an engaging Hill-Sachs lesion in the setting of subcritical glenoid bone loss (<20%), an arthroscopic Remplissage (tenodesis of the infraspinatus and posterior capsule into the humeral head defect) combined with an anterior Bankart repair is indicated. This prevents the defect from engaging the anterior glenoid rim. If significant glenoid bone loss (>20-25%) was present, a bony augmentation procedure like a Latarjet would be required.

Question 66

A 45-year-old farmer sustains a highly contaminated open fracture of the tibial shaft after his leg is caught in a tractor mechanism. The wound is 12 cm long with extensive soft tissue stripping, but adequate soft tissue coverage is achievable. According to the Gustilo-Anderson classification, what is the most appropriate initial intravenous antibiotic regimen?

Explanation

This is a Gustilo-Anderson Type IIIA open fracture (high energy, >10 cm wound, extensive soft tissue damage but adequate coverage). Because it is a farm injury, there is a high risk of anaerobic infection, specifically Clostridium species. The standard recommendation for farm injuries or highly contaminated open fractures is a first-generation cephalosporin (for Gram-positives), an aminoglycoside (for Gram-negatives), and penicillin (for anaerobes).

Question 67

A 35-year-old man involved in a high-speed motor vehicle collision sustains a closed subtrochanteric femur fracture. During closed reduction and intramedullary nailing, the proximal fragment is noted to be highly displaced. Which of the following muscles is primarily responsible for the flexion and external rotation of the proximal fracture fragment?

Explanation

In subtrochanteric femur fractures, the proximal fragment is subjected to strong deforming forces. The iliopsoas attaches to the lesser trochanter and causes flexion and external rotation of the proximal fragment. The gluteus medius and minimus attach to the greater trochanter and cause abduction. The adductors pull the distal fragment medially.

Question 68

A 55-year-old woman is evaluated 4 months after undergoing open reduction and internal fixation of a distal radius fracture with a volar locking plate. She complains of new-onset inability to actively flex the interphalangeal (IP) joint of her thumb. Radiographs reveal the volar plate is positioned distal to the watershed line. What is the most likely cause of her symptom?

Explanation

Placement of a volar plate distal to the watershed line of the distal radius increases the risk of flexor tendon attrition and rupture. The flexor pollicis longus (FPL) tendon is at the highest risk due to its anatomical proximity to the plate on the volar surface. EPL ruptures are typically associated with prominent dorsal screws or unreduced dorsal cortical fragments, not volar prominence.

Question 69

A 25-year-old man sustains a completely displaced Pauwels type III (vertical shear) fracture of the femoral neck. He is otherwise healthy. To minimize the risk of nonunion and avascular necrosis, what is the most biomechanically sound surgical construct for this patient?

Explanation

In young patients, joint-preserving surgery is mandated for femoral neck fractures. Pauwels type III fractures have a highly vertical fracture line (>50 degrees), subjecting them to significant shear forces. Three parallel cancellous screws offer poor biomechanical stability against shear in this pattern. A fixed-angle device, such as a sliding hip screw (with an additional derotational screw), provides superior biomechanical resistance to vertical shear forces and decreases the rate of nonunion and displacement.

Question 70

A 40-year-old man is brought to the trauma bay after a motorcycle crash. His blood pressure is 80/40 mmHg and heart rate is 130 bpm. Pelvic radiographs demonstrate an anteroposterior compression type III (APC-III) pelvic ring injury with marked symphyseal diastasis. A FAST exam is negative. What is the most appropriate initial step to acutely reduce pelvic volume and aid hemodynamic stability?

Explanation

In an unstable patient with an open-book pelvic fracture (APC injury), the initial mechanical intervention is to reduce pelvic volume. A pelvic binder or sheet must be applied centered directly over the greater trochanters. Placing it over the iliac crests is incorrect and can paradoxically open the pelvis further or fail to provide adequate mechanical advantage to close the posterior ring.

Question 71

A 30-year-old man sustains a closed midshaft humerus fracture after a fall. On examination in the emergency department, he exhibits a complete wrist drop and inability to actively extend his metacarpophalangeal joints, but has palpable distal pulses. What is the most appropriate initial management of his neurologic deficit?

Explanation

A primary radial nerve palsy in the setting of a closed humeral shaft fracture (without vascular injury or severe soft tissue compromise) is generally treated nonoperatively. Most primary radial nerve palsies are neuropraxias or axonotmeses that spontaneously recover. Functional bracing of the fracture and supportive splinting of the wrist/hand is the standard of care. Surgical exploration is indicated for open fractures, associated vascular injuries, or a secondary palsy that develops after a closed reduction.

Question 72

A 28-year-old roofer falls 15 feet, landing on his feet, and sustains a Hawkins Type III fracture of the talar neck. According to the Hawkins classification, what anatomic disruptions define a Type III fracture, and what is the approximate risk of avascular necrosis (AVN) of the talar body?

Explanation

The Hawkins classification describes talar neck fractures. Type I is nondisplaced (0-10% AVN risk). Type II involves subluxation or dislocation of the subtalar joint (20-50% AVN risk). Type III involves dislocation of both the subtalar and tibiotalar (ankle) joints, with the talar body typically extruded posteromedially (near 100% AVN risk). Type IV adds talonavicular dislocation.

Question 73

A 22-year-old collegiate football player sustains an anterior knee dislocation which is immediately reduced on the field. In the emergency department, his knee is splinted. His dorsalis pedis and posterior tibial pulses are palpable but diminished compared to the contralateral side. The ankle-brachial index (ABI) is calculated to be 0.82. What is the most appropriate next step in management?

Explanation

In the setting of a knee dislocation, vascular status must be carefully assessed. Hard signs of arterial injury (expanding hematoma, absent pulses, pulsatile bleeding, cold/pale limb) mandate immediate surgical exploration. Soft signs, such as diminished pulses or an ABI < 0.9, indicate the need for advanced vascular imaging, most commonly a CTA. Serial examinations are reserved for patients with symmetric normal pulses and an ABI > 0.9.

Question 74

A 45-year-old man sustains a complex tibial plateau fracture. CT imaging demonstrates a large, displaced posteromedial shear fragment. To adequately visualize and anatomically reduce this fragment using a buttress plate, which surgical approach is most appropriate?

Explanation

A posteromedial shear fragment of the tibial plateau cannot be adequately reduced or buttressed from an anterolateral or direct medial approach. The posteromedial approach utilizes the interval between the medial head of the gastrocnemius and the pes anserinus. This allows direct access to the posterior aspect of the medial tibial plateau for application of an anti-glide or buttress plate to counteract vertical shear forces.

Question 75

A 35-year-old driver is involved in a severe motor vehicle collision. Pelvic radiographs and computed tomography (CT) reveal an acetabular fracture. The fracture line disrupts the anterior column and extends inferiorly through the anterior wall. A separate transverse fracture line is noted traversing the posterior column, but the superior portion of the posterior column and the ilium remain solidly attached to the axial skeleton. According to the Judet-Letournel classification, what is the correct diagnosis?

Explanation

This describes an anterior column and posterior hemitransverse fracture, one of the five associated patterns in the Judet-Letournel classification. It features an anterior column (or anterior wall) fracture associated with a transverse fracture through the posterior half of the acetabulum. It is distinguished from a T-type fracture (which has a true transverse component and a vertical stem splitting the obturator ring) and from a both-column fracture, where no part of the articular surface remains attached to the intact posterior ilium (the 'spur sign').

Question 76

A 35-year-old man is brought to the emergency department after a motorcycle collision. He is hypotensive with a blood pressure of 80/50 mm Hg. A pelvic radiograph shows a widened pubic symphysis consistent with an anteroposterior compression (APC) injury. You decide to apply a pelvic binder to provide temporary stability. To most effectively reduce the pelvic volume, at what anatomical level should the binder be centered?

Explanation

The most effective placement of a pelvic binder or sheet to reduce pelvic volume in anteroposterior compression (APC) and open-book pelvic fractures is at the level of the greater trochanters. Placing the binder higher, at the level of the iliac crests, is a common error that is less effective and may inadvertently worsen the pelvic deformity by everting the lower pelvis.

Question 77

A 28-year-old male sustains an isolated, closed, low-velocity gunshot wound to the midshaft femur. Radiographs reveal a comminuted midshaft femur fracture. He is neurovascularly intact, and there is no evidence of a compartment syndrome. Which of the following is the most appropriate management?

Explanation

Low-velocity gunshot wounds resulting in diaphyseal femur fractures do not typically require extensive debridement of the bullet track. Standard evidence-based treatment includes superficial local wound care, tetanus prophylaxis, and standard reamed intramedullary nailing. Routine bullet removal is not indicated unless the bullet is intra-articular or causing direct neurovascular compromise.

Question 78

A 72-year-old female presents with severe groin pain and an inability to bear weight after a mechanical fall from standing. Radiographs reveal a displaced intracapsular femoral neck fracture. She has a history of mild hypertension, lives independently, and was an active community ambulator who played tennis twice a week prior to the injury. Which of the following treatments provides the lowest rate of reoperation and best functional outcome?

Explanation

In healthy, active, community-ambulating elderly patients with displaced femoral neck fractures, total hip arthroplasty (THA) yields superior functional outcomes (e.g., higher Harris Hip Scores) and significantly lower reoperation rates compared to hemiarthroplasty, despite a slightly higher risk of early dislocation. Internal fixation for displaced fractures in this age group has an unacceptably high rate of failure and reoperation.

Question 79

A 45-year-old male falls from a height of 15 feet and sustains a high-energy closed pilon fracture. Clinical examination reveals severe swelling, tense skin, and hemorrhagic fracture blisters over the medial and lateral aspects of the ankle. Which of the following represents the most appropriate initial management?

Explanation

High-energy pilon fractures often present with severe soft tissue injury. Immediate open reduction and internal fixation (ORIF) is contraindicated due to high rates of wound breakdown, necrosis, and deep infection. The standard of care is temporary spanning external fixation across the ankle joint to restore length and alignment, allowing the soft tissues to recover before definitive fixation is performed (usually 10-21 days later).

Question 80

A 28-year-old male sustains a displaced talar neck fracture following a high-energy snowboard crash. You counsel him on the high risk of avascular necrosis (AVN) of the talar body due to the disruption of its precarious blood supply. Which of the following vessels provides the predominant blood supply to the body of the talus?

Explanation

The body of the talus receives its blood supply from an anastomotic vascular ring formed by the artery of the tarsal canal (a branch of the posterior tibial artery) and the artery of the tarsal sinus (derived from the anterior tibial and peroneal arteries). The artery of the tarsal canal provides the predominant blood supply to the talar body. Displaced talar neck fractures often disrupt this supply, leading to high rates of AVN.

Question 81

A 22-year-old male is struck by a motor vehicle and sustains a closed transverse midshaft tibia fracture, treated with reamed intramedullary nailing. Postoperatively, he requires rapidly increasing doses of opioids for leg pain. Examination reveals a tense leg, and passive extension of the great toe elicits excruciating pain. Which of the following compartments is most likely experiencing critically elevated pressures?

Explanation

The deep posterior compartment of the leg contains the tibialis posterior, flexor digitorum longus, and flexor hallucis longus. Passive extension of the hallux stretches the flexor hallucis longus, eliciting severe pain out of proportion to the injury. This clinical finding is a classic hallmark for deep posterior compartment syndrome.

Question 82

A 54-year-old male sustains a traumatic anterior shoulder dislocation. Post-reduction radiographs demonstrate a concentric reduction of the glenohumeral joint, but reveal an associated greater tuberosity fracture with 8 mm of superior displacement. What is the most appropriate management plan?

Explanation

The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor. Superior displacement of >5 mm in active individuals (or >10 mm in older, less active patients) is an absolute indication for surgical fixation. Failure to reduce and fix the tuberosity leads to subacromial impingement and severe rotator cuff dysfunction.

Question 83

A 34-year-old man sustains a pelvic injury following a high-speed motor vehicle collision. An anteroposterior radiograph of the pelvis demonstrates a complex fracture involving the acetabulum. An obturator oblique radiograph clearly demonstrates a 'spur sign'. This radiographic finding is pathognomonic for which of the following acetabular fracture patterns?

Explanation

The 'spur sign' is pathognomonic for a both-column fracture of the acetabulum. It represents the intact portion of the ilium that remains attached to the axial skeleton (sacrum), projecting posteriorly relative to the medially displaced articular segment when viewed on the obturator oblique radiograph.

Question 84

A 30-year-old man sustains a severe open tibia fracture (Gustilo-Anderson IIIB) requiring a free tissue transfer for soft-tissue coverage. To minimize the risk of deep infection and maximize flap survival, the classic study by Godina demonstrated the best outcomes when coverage is performed within what timeframe?

Explanation

The classic principle described by Marko Godina emphasizes that early microsurgical reconstruction of complex lower extremity trauma—specifically within 72 hours of injury—yields significantly lower infection rates, higher flap survival, and better overall bone healing compared to delayed coverage.

Question 85

A 22-year-old collegiate football player sustains a severe axial load to a plantarflexed foot. Radiographs reveal widening of the space between the medial and middle cuneiforms, with dorsal displacement of the second metatarsal base. The primary stabilizing structure of the Lisfranc joint complex connects which two bones?

Explanation

The Lisfranc ligament is the strongest and most critical primary stabilizer of the tarsometatarsal joint complex. It is a stout interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal.

Question 86

A 35-year-old male is involved in a motor vehicle collision and sustains a posterior hip dislocation. Closed reduction is performed in the emergency department within 2 hours. A post-reduction CT scan demonstrates a posterior wall fracture involving 15% of the articular surface. There are no intra-articular fragments, and the joint is congruous. Dynamic fluoroscopic stress examination reveals a stable hip. What is the most appropriate definitive management?

Explanation

The primary indication for surgical fixation of a posterior wall acetabular fracture is hip instability. The standard evaluation for stability involves a dynamic stress examination under fluoroscopy under anesthesia. If the hip is stable and the posterior wall fragment involves less than 20% of the articular surface with no retained intra-articular loose bodies, non-operative management with protected weight-bearing (touchdown weight-bearing) for 6-8 weeks is appropriate and yields excellent long-term functional results.

Question 87

A 45-year-old female sustains a closed, midshaft humerus fracture and is treated with a functional brace. At 12 weeks follow-up, she complains of persistent pain and mobility at the fracture site. Radiographs demonstrate no bridging callus formation. Which of the following factors is most strongly associated with nonunion in humeral shaft fractures treated with functional bracing?

Explanation

Functional bracing (Sarmiento bracing) is the gold standard for most closed humeral shaft fractures. Risk factors for nonunion with non-operative management include transverse fracture patterns (which lack the surface area and intrinsic stability of oblique or spiral fractures), soft tissue interposition, and over-distraction. Over-distraction can easily occur if the arm is not properly supported or if gravity pulls the distal fragment inferiorly, leading to a gap that inhibits secondary bone healing.

Question 88

A 22-year-old healthy male presents with a completely displaced midshaft clavicle fracture. Which of the following is considered a widely accepted relative indication for open reduction and internal fixation to improve functional outcomes and decrease nonunion risk?

Explanation

Recent high-level evidence has demonstrated that completely displaced, significantly shortened (>2 cm or 20 mm) midshaft clavicle fractures treated non-operatively have a higher rate of nonunion, symptomatic malunion, and decreased long-term shoulder strength/endurance compared to those treated with ORIF. Therefore, >2 cm of shortening and 100% displacement are widely accepted relative indications for operative fixation in young, active patients.

Question 89

A 68-year-old female undergoes open reduction and internal fixation of a distal femur fracture using a lateral locking plate. Six months postoperatively, she presents with implant failure and a nonunion. Radiographs reveal plate breakage at the level of the fracture. Which of the following surgical technique errors most likely contributed to this complication?

Explanation

Locking plates provide rigid, fixed-angle constructs ideal for osteoporotic bone. However, if a construct is excessively rigid (e.g., a short working length with locking screws placed too close to the fracture site) and a fracture gap is left, the stress is concentrated entirely on the plate at the level of the gap. This extreme rigidity prevents the micromotion necessary for secondary bone healing (callus formation), ultimately leading to fatigue failure and breakage of the plate before union can occur.

Question 90

Which of the following physical examination findings is considered the most reliable and earliest clinical indicator of acute compartment syndrome in an alert patient with a closed tibial shaft fracture?

Explanation

Acute compartment syndrome is a surgical emergency characterized by increased pressure within a closed fascial space. While the classic '5 Ps' (pain, pallor, pulselessness, paresthesias, paralysis) are traditionally taught, pain out of proportion to the apparent injury and excruciating pain elicited by passive stretch of the ischemic muscles are the earliest and most sensitive clinical signs. Pulselessness and paralysis are late signs indicating severe and often irreversible tissue necrosis.

Question 91

A 30-year-old male sustains a mechanically and hemodynamically unstable anteroposterior compression (APC-III) pelvic ring injury. A circumferential pelvic binder is applied in the trauma bay. To achieve optimal mechanical stability and maximal reduction in pelvic volume, over which anatomical landmark should the center of the binder be positioned?

Explanation

In hemodynamically unstable patients with open-book pelvic ring injuries, rapid application of a pelvic binder is crucial to reduce pelvic volume and promote the tamponade of venous and cancellous bone bleeding. Biomechanical and clinical studies have definitively shown that positioning the binder directly over the greater trochanters provides the most effective mechanical advantage for closing the symphysis pubis. Placement over the iliac crests is less effective and can paradoxically widen the true pelvis.

Question 92

In the surgical treatment of a young adult with a displaced, intracapsular femoral neck fracture, which of the following factors is most consistently associated with minimizing the risk of osteonecrosis (AVN) of the femoral head?

Explanation

Osteonecrosis of the femoral head is a devastating complication following displaced intracapsular femoral neck fractures in young adults. The single most critical, surgeon-controlled factor for minimizing the risk of AVN is achieving an exact, anatomic reduction. A non-anatomic reduction creates abnormal biomechanical stresses and can further kink or compromise the remaining tenuous retinacular blood supply. The roles of capsulotomy and the strict timing of surgery remain debated, but anatomic reduction is universally supported.

Question 93

A 45-year-old male sustains a closed tongue-type calcaneus fracture. Physical examination reveals tense, blanched skin over the posterior heel. What is the most appropriate next step in management?

Explanation

A tongue-type calcaneus fracture involves a fracture line extending posteriorly through the tuberosity. The pull of the Achilles tendon on the superior tuberosity fragment causes it to displace superiorly and posteriorly, creating severe tension on the posterior heel skin. This can rapidly lead to skin blanching, ischemia, and full-thickness necrosis. This presentation is an orthopedic soft-tissue emergency requiring immediate reduction (often via a percutaneous or limited open approach) to relieve skin tension and prevent catastrophic wound complications.

Question 94

During open reduction and internal fixation of a completely displaced, transverse patella fracture, a tension band wiring technique is utilized. What is the primary biomechanical function of the anteriorly placed tension band wire during active knee flexion?

Explanation

The tension band principle relies on placing the fixation implant on the tension side of a fractured bone. In the patella, the anterior surface is subjected to significant tensile forces by the extensor mechanism during knee flexion. By applying a wire construct anteriorly, these distractive tensile forces are biomechanically converted into compressive forces across the articular surface. This dynamic compression promotes stability and allows for early active range of motion and primary bone healing.

Question 95

A 55-year-old male sustains a traumatic posterior hip dislocation. Following a successful closed reduction in the emergency department, what is the most appropriate imaging modality to evaluate for intra-articular loose bodies and ensure concentric reduction?

Explanation

Following the reduction of a traumatic hip dislocation, an unenhanced Computed Tomography (CT) scan of the pelvis is the gold standard imaging modality. It is highly sensitive for confirming concentric reduction, detecting subtle retained intra-articular osteochondral fragments (loose bodies), and delineating associated fractures of the acetabulum (such as posterior wall fractures) or femoral head that may not be apparent on standard plain radiographs. This guides the need for subsequent surgical intervention.

Question 96

A 34-year-old female sustains a Denis Zone I sacral fracture with 1.5 cm of cephalad displacement following a fall from a height. She complains of weakness in foot dorsiflexion and big toe extension. Which nerve root is most likely injured in this specific fracture pattern?

Explanation

Denis Zone I sacral fractures occur lateral to the neural foramina and typically involve the sacral ala. Due to the proximity of the L5 nerve root, which courses over the sacral ala, it is highly susceptible to traction or direct injury, particularly in vertical shear patterns with cephalad displacement. Injury to the L5 root classically presents with weakness in the extensor hallucis longus (EHL) and tibialis anterior. Denis Zone II fractures involve the foramina and commonly cause sciatica (S1, S2 roots), while Zone III fractures involve the central canal and can cause saddle anesthesia and bowel/bladder dysfunction.

Question 97

A 32-year-old male sustains a displaced basicervical femoral neck fracture following a high-energy trauma. Which of the following internal fixation constructs provides the greatest biomechanical stability for this specific fracture pattern?

Explanation

Basicervical femoral neck fractures behave biomechanically more like intertrochanteric fractures than traditional intracapsular femoral neck fractures. They are highly unstable and subjected to significant shear forces. Studies have consistently demonstrated that a dynamic hip screw (DHS), combined with an anti-rotation screw to control the proximal fragment during engagement and weight-bearing, provides superior biomechanical stability and a lower rate of failure compared to multiple parallel cancellous screws. Cancellous screws alone have an unacceptably high rate of cut-out and nonunion in basicervical patterns.

Question 98

A 28-year-old man sustains a talar neck fracture following a high-energy motor vehicle collision. Radiographs demonstrate displacement of the talar neck with subluxation of the subtalar joint, but the tibiotalar and talonavicular joints remain congruent. According to the Hawkins classification, what is the approximate risk of developing avascular necrosis (AVN) of the talar body?

Explanation

The clinical scenario describes a Hawkins Type II talar neck fracture, which is characterized by a displaced talar neck fracture with subluxation or dislocation of the subtalar joint, while the tibiotalar and talonavicular joints remain normal. The blood supply to the talar body is tenuous, relying heavily on the artery of the tarsal canal. The risk of avascular necrosis (AVN) of the talar body correlates with the Hawkins classification: Type I (nondisplaced) is 0-10%; Type II is approximately 20-50%; Type III (subtalar and tibiotalar dislocation) is 70-90%; and Type IV (Type III plus talonavicular dislocation) approaches 100%.

Question 99

A 40-year-old farmer sustains an open midshaft tibia fracture after his leg is caught in a tractor mechanism. The wound is 8 cm long with moderate soft-tissue damage, but there is adequate periosteal coverage of the bone. He is taken to the operating room within 6 hours for surgical debridement. Which of the following intravenous antibiotic regimens is most appropriate for initial management?

Explanation

The patient has a farm-related open fracture, which carries a high risk of profound contamination, particularly with soil-dwelling anaerobes such as Clostridium perfringens, the causative organism of gas gangrene. According to established trauma guidelines for open fractures, standard Grade I or II injuries require a first-generation cephalosporin. Grade III fractures require the addition of Gram-negative coverage (traditionally an aminoglycoside). However, farm injuries, injuries with heavy soil contamination, or those with significant ischemic tissue demand the addition of high-dose penicillin (or ampicillin) to provide prophylactic anaerobic coverage.

Question 100

A 22-year-old male presents with a closed proximal third tibia fracture. Eight hours post-injury, he complains of severe leg pain out of proportion to the injury that is refractory to intravenous opioids. His leg is swollen and tense, and passive stretch of the great toe severely exacerbates his pain. Pulses remain palpable. Intracompartmental pressure testing is performed. Which of the following pressure measurements establishes an absolute indication for emergent four-compartment fasciotomy?

Explanation

Acute compartment syndrome is primarily a clinical diagnosis (pain out of proportion, pain with passive stretch, tense compartments), but pressure measurements are vital for confirmation, especially in obtunded patients or borderline cases. The most reliable indicator for fasciotomy is the Delta P (differential pressure), calculated as Diastolic Blood Pressure minus Intracompartmental Pressure. A Delta P of less than or equal to 30 mmHg represents critical tissue ischemia and is an absolute indication for emergent fasciotomy. A Delta P of 20 mmHg clearly falls below this critical threshold. Palpable pulses often remain intact even in advanced compartment syndrome and should not be used to rule out the condition.

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

Trauma 2009 Practice Questions: Set 3 (Solved)

Key Takeaway

Trauma 2009 Practice Questions: Set 3 (Solved)

Chapter Index