2009 Trauma Exam Prep | Q&A Set 4

Question 1

A still active 86-year-old pastry chef falls in her kitchen and notes pain and deformity of her little finger. There are no open wounds. Radiographs are shown in Figures 49a and 49b. What is the most appropriate management?

Explanation

The fracture of the proximal phalanx is clearly displaced. There is slight comminution at the area of the fracture. Closed reduction is likely to fail due to the forces of the extensor, flexor, and intrinsic mechanisms. Percutaneous fixation, unlike open fixation techniques, avoids likely problems with stiffness. Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green's Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.

Question 2

A 32-year-old man has a Glasgow Coma Scale score of 8 and an open pelvic fracture. The patient's family reports that he is a Jehovah's Witness. Initial hemodynamic instability has resolved. In the operating room during a washout, the patient's blood pressure becomes unstable. What is the most appropriate action?

Explanation

Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah's Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah's Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open would is not recommended nor would there likely be enough from an open tibial fracture to salvage. The patient's family may be expressing their own beliefs rather than the patient's beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability. Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.

Question 3

Figure 50 shows the radiograph of a 26-year-old man who sustained an isolated open injury to his foot. Examination reveals no gross contamination in the wound. There is a palpable dorsalis pedis pulse and sensation is present on the dorsal and plantar aspects of the foot. Initial treatment should consist of wound debridement, antibiotics, and

Trauma Board Review 2009: High-Yield MCQs (Set 4) - Figure 3

Explanation

The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures. Smith CS, Nork SE, Sangeorzan BJ: The extruded talus: Results of reimplantation. J Bone Joint Surg Am 2006;88:2418-2424.

Question 4

An 86-year-old woman sustained a fracture of the humerus and underwent surgical fixation 8 weeks ago. There was no radial nerve function below the elbow after surgery. Radiographs are shown in Figures 51a and 51b. What is the most appropriate management at this time?

Explanation

Most radial nerve palsies associated with closed fractures of the humerus resolve spontaneously, including Holstein-Lewis lesions (radial nerve palsy associated with oblique distal third fractures of the humerus). Initial sign of recovery at the brachioradialis may not occur for 4 months. There has been no evidence of deleterious effects occurring during this observation period. There are advocates of early exploration of the nerve. Exploration in the intermediate period between 1 and 4 months is not supported. As overall alignment of the fracture is acceptable, there is no need for hardware exchange until nonunion is clearly identified. Shao YC, Harwood P, Grotz MR, et al: Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br 2005;87:1647-1652.

Question 5

Which of the following long bone fracture patterns occurs after a pure bending force is exerted to the bone?

Explanation

A pure bending force produces a transverse fracture pattern. Spiral fractures are mainly rotational, oblique are uneven bending, segmental are four-point bending, and comminuted are either a high-speed torsion or crush mechanism. Tencer AF, Johnson KD: Biomechanics in Orthopaedic Trauma: Bone Fracture and Fixation. Philadelphia, PA, JB Lippincott, 1994. Gonza ER: Biomechanical long bone injuries, in Gonza ER, Harrington IJ (eds): Biomechanics of Musculoskeletal Injury. Baltimore, MD, Williams & Wilkins, 1982, pp 1-30.

Question 6

A 20-year-old man sustained an isolated displaced type II odontoid fracture in a motor vehicle accident. He is neurologically intact. Treatment consists of placement in halo traction, and the fracture is reduced. What is the next most appropriate step in treatment?

Explanation

The traditional treatment of a reduced type II fracture is a halo vest. A 20-year-old man will tolerate a halo vest better than the elderly or women. Anterior screw fixation has gained increasing support; however, it too has risks and requires a significant learning curve. More recently, C1 lateral mass screws have become more popular. The long-term results and benefits have not yet been determined. Spivak JM, Connolly PF (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 193. Kiovikko MP, Kiuru MJ, Koskinen SK, et al: Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process. J Bone Joint Surg Br 2004;86:1146-1151. Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, p 1091.

Question 7

A 38-year-old woman fell from a ladder onto her right hip. The radiographs and CT scan are shown in Figures 52a through 52d. What is the best surgical approach for this fracture?

Explanation

The fracture is an associated both column fracture. The best approach for this fracture is the ilioinguinal. The Kocher-Langenbeck is best for posterior injuries to the acetabulum and some transverse fractures. The iliofemoral alone is limited to high anterior column injuries. The extended iliofemoral and triradiate approaches although useful for this fracture, have a higher rate of complications. Letournel E: The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res 1993;292:62-76.

Question 8

A 24-year-old man was thrown from a car and is seen in the emergency department with a Glasgow Coma Scale (GCS) score of 8. A CT scan of the head shows no significant bleeding. The patient is hemodynamically stable. The left femur has the closed injury shown on the radiographs in Figures 53a and 53b. What is the best treatment for this patient?

Explanation

Treatment of patients with a closed head injury and a femoral fracture remains controversial but recent data suggest that intramedullary nails done acutely with avoidance of intraoperative hypotension did not compromise the outcome related to the head injury. This was especially true for high-level GCS scores. A GCS score of lower than 8 and intraoperative hypotension have been associated with worsening outcomes following acute intramedullary nailing of the femur. Skin traction and distal femur skeletal traction in a young adult man with a femoral fracture is not well tolerated secondary to spasm and pain. External fixation is an option but an unnecessary step in the treatment of this patient. Ventriculostomy is not necessary in stable patients with no significant bleeding on a CT scan of the head. Starr AJ, Hunt JL, Chason DP, et al: Treatment of femur fracture with associated head injury. J Orthop Trauma 1998;12:38-45. Nau T, Kutscha-Lissberg F, Muellner T, et al: Effects of a femoral shaft fracture on multiply injured patients with a head injury. World J Surg 2003;27:365-369. McKee MD, Schemitsch EH, Vincent LO, et al: The effect of a femoral fracture on concomitant closed head injury in patients with multiple injuries. J Trauma 1997;42:1041-1045.

Question 9

An otherwise healthy 26-year-old woman is involved in a high speed motor vehicle accident and sustains the injury shown in Figure 54 to her dominant right arm. Appropriate treatment of this injury complex includes

Trauma Board Review 2009: High-Yield MCQs (Set 4) - Figure 12

Explanation

This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.

Question 10

A 38-year-old man caught his index finger in a volleyball net. He noted an angular deformity of the finger that was reduced when a teammate pulled on his finger. Three weeks later, he now reports trouble extending his finger. A clinical photograph is shown in Figure 55. What anatomic structure is most likely injured?

Trauma Board Review 2009: High-Yield MCQs (Set 4) - Figure 13

Explanation

The clinical photograph shows a classic boutonniere deformity. It is likely that the patient sustained a volar dislocation of the proximal interphalangeal joint, with a concomitant rupture of the central slip insertion of the extensor tendon. Peimer CA, Sullivan DJ, Wild DR: Palmar dislocation of the proximal interphalangeal joint. J Hand Surg Am 1984;9:39-48.

Question 11

A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?

Explanation

The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence. Sanders R: Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.

Question 12

A 40-year-old woman sustains a flexion injury to her neck. Physical examination is normal. A lateral radiograph of the cervical spine is shown in Figure 57a. MRI scans of the cervical spine are shown in Figures 57b and 57c. Treatment should include

Explanation

This is a classic bilateral facet dislocation. When there is no evidence of a disk herniation, treatment should include careful skeletal traction, closed reduction, and posterior fusion. There is no role for anterior procedures. These fractures are unstable and require surgical intervention. Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, pp 1120-1128.

Question 13

Patients in compensated shock (normal vital signs) are thought to be at risk for which of the following?

Explanation

Patients who are in compensated shock have normal vital signs but still have hypoperfusion of organ beds such as the splanchnic circulation due to preferential perfusion of the heart and brain. The response to this continued hypoperfusion may be the development of a systemic inflammatory response that may lead to multiple organ failure. The patients are thought to be at risk for a "primed" immune system due to the ongoing stimulation of the immune system and may have an exaggerated response to a second stimulus such as surgery or infection. Other markers of resuscitation should be used besides vital signs to determine when resuscitation has been completed. The use of temporizing fixation has been shown to lower systemic complication rates, and the infection and union rate after staged fixation is not altered. Schulman AM, Claridge JA, Carr G, et al: Predictors of patients who will develop prolonged occult hypoperfusion following blunt trauma. J Trauma 2004;57:795-800.

Question 14

A 66-year-old woman was a restrained passenger in an automobile accident. She sustained a direct blow to her nondominant left hand as the airbag in her automobile deployed and she now reports pain, swelling, and difficulty moving her fingers. Radiographs are shown in Figures 58a and 58b. Appropriate definitive treatment should consist of

Explanation

While most isolated metacarpal fractures can be treated nonsurgically, multiple metacarpal fractures are inherently unstable due to the loss of support that an intact adjacent metacarpal provides; therefore, treatment should consist of surgical fixation of all three metacarpal fractures. Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green's Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 286.

Question 15

A 14-year-old boy sustains a right leg injury after being thrown from his motorcycle while racing. He reports diffuse right leg pain starting at his knee and proceeding distally to include his foot. After the injury the patient's mother reports the tibia moving posteriorly then anteriorly while she was supporting the leg. In the emergency department 4 hours after injury, examination reveals a large knee effusion, firm compartments of the leg, a palpable posterior tibialis pulse with a warm, pink foot, and capillary refill of 2 seconds at the toes. His blood pressure is 100/50 mm Hg. Motor examination is intact, but there is decreased sensation in the dorsal first interspace and plantar aspect of the foot. Compartment pressure measurement reveals all four compartments with pressures of 33, 36, 33, and 38 mm Hg respectively. Radiographs are shown in Figure 59a and 59b. The remainder of the skeletal examination is normal. What is the optimal management for this injury?

Explanation

The patient has a compartment syndrome based on the firm compartments of the leg and the elevated compartment pressures measured at the diastolic pressure reading. Muscle ischemia occurs quickly when compartment pressures are elevated, and within 6 hours irreversible damage can occur. Emergent fasciotomies permit decompression of all four compartments and reestablishment of vascular supply to the muscles. Stabilization of the fracture prevents further soft-tissue injury.

Question 16

Resuscitation of a trauma patient who has been in hypovolemic shock is complete when which of the following has occurred?

Explanation

Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems. Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: End point of resuscitation. J Trauma 2004;57:898-912. Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury, a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006;61:82-89.

Question 17

A 12-year-old girl falls in gymnastics and sustains comminuted midshaft radius and ulna fractures. Closed reduction and cast immobilization are attempted but fracture redisplacement with 20 degrees of angulation occurs. Surgical treatment includes closed reduction and intramedullary fixation of both bones. What is the most common long-term complication for this fracture?

Explanation

Healing of forearm fractures in skeletally immature patients is the usual outcome. The use of intramedullary fixation has been reported to result in a lower frequency of refractures when compared to plate osteosynthesis due to the absence of diaphyseal holes after plate removal, which are considered stress risers. Regardless of implant technique, malunion and infection are infrequent. Loss of forearm pronation and supination is a common occurrence in surgically treated fractures due to the higher degree of soft-tissue injury, and periosteal stripping leads to fracture site instability and fracture comminution. Luhmann SJ, Gordon JE, Schoenecker PL: Intramedullary fixation of unstable both-bone forearm fractures in children. J Pediatr Orthop 1998;18:451-456.

Question 18

A 52-year-old woman who is right hand-dominant sustains an injury to her elbow in a fall. A radiograph is shown in Figure 60. The preferred treatment of this injury pattern should include

Trauma Board Review 2009: High-Yield MCQs (Set 4) - Figure 23

Explanation

The patient has a Bado type 2 variant Monteggia fracture with a radial head fracture. The type 2 variant is associated with a higher nonunion rate and poorer outcomes compared to other Bado-type Monteggia fractures. While it is potentially acceptable to repair the radial head, factors such as higher degrees of comminution and older age lead toward replacement as the treatment of choice. Plate and screw fixation is favored over Kirschner wire/tension band fixation because this is not a simple olecranon fracture. Plate placement in a type 2 fracture is dorsal to counteract very high tensile forces associated with fixation failure. Egol KA, Tejwani NC, Bazzi J, et al: Does a Monteggia variant lesion result in a poor functional outcome? A retrospective study. Clin Orthop Relat Res 2005;438:233-238. Jupiter JB, Leibovic SJ, Ribbans W, et al: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.

Question 19

The teardrop shape marked with an asterisk in Figure 61 represents what anatomic structure?

Trauma Board Review 2009: High-Yield MCQs (Set 4) - Figure 24

Explanation

The teardrop can be visualized on the obturator outlet view of the pelvis and represents a thick column of bone that runs from the AIIS to the PSIS. Half pins for eternal fixation frames or screws can be inserted into this column for fixation of fractures. Gardner MJ, Nork SE: Stabilization of unstable pelvic fractures with supra-acetabular compression external fixation. J Orthop Trauma 2007;21:269-273. Haidukewych GJ, Kumar S, Prpa B: Placement of half-pins for supra-acetabular external fixation: An anatomic study. Clin Orthop Relat Res 2003;411:269-273.

Question 20

A patient was treated with a revision reamed intramedullary nail for a nonunion 6 months ago. A current radiograph is shown in Figure 62. Based on these findings, what is the most appropriate treatment?

Trauma Board Review 2009: High-Yield MCQs (Set 4) - Figure 25

Explanation

Nonunions after intramedullary nails are often treated with exchange reamed nailing. In a recent study, this resulted in a union rate of 53%. After failed exchange nailing, bone grafting and compression plating should be used. The other options resulted in less satisfactory results as compared to bone grafting and compression plating. Weresh MJ, Hakanson R, Stover MD, et al: Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma 2000;14:335-338.

Question 21

Figure 63 shows the radiographs of a 23-year-old man who sustained a twisting injury at work. Swelling, tenderness, and ecchymosis are noted about the entire midfoot. What associated injury is most likely to be problematic?

Trauma Board Review 2009: High-Yield MCQs (Set 4) - Figure 26

Explanation

This cuboid compression fracture ("nutcracker" injury) is associated with subtle injury to the Lisfranc complex. This diagnosis must be made to ensure proper treatment.

Question 22

A 24-year-old man is ejected from his motorcycle and sustains a significant hip injury. The fracture shown in Figures 64a through 64e is best described as what type of fracture?

Explanation

The radiographs and CT scans reveal an anterior column acetabular fracture. The fracture has quadrilateral plate extension but does not exit out the posterior column. The CT scans confirm an intact posterior column and no wall fracture. A transverse fracture is best seen on the CT scan and runs in the sagittal plane, not the coronal plane. Letournel E, Judet R: Fractures of the Acetabulum, ed 2. New York, NY, Springer-Verlag, 1993, pp 115-140.

Question 23

A 71-year-old woman who reports long-term use of oral steroids for asthma is referred for treatment of a distal humerus fracture. Radiographs reveal diffuse osteopenia and a severely comminuted intra-articular fracture. What is the most appropriate treatment?

Explanation

Several studies have documented the satisfactory outcomes of total elbow arthroplasty when osteosynthesis is not feasible for fixation of a distal humerus fracture, particularly in the physiologically older patient with low functional demands. Total elbow arthroplasty should be considered when a comminuted intra-articular distal humerus fracture occurs in a woman older than age 65 years, particularly with such associated comorbidities as systemic steroid use, osteoporosis, or rheumatoid arthritis. Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am 2004;86:940-947. Frankle MA, Herscovici D Jr, DiPasquale TG, et al: A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than 65. J Orthop Trauma 2003;17:473-480.

Question 24

A 14-year-old boy sustained a 100% displaced distal radius Salter-Harris type II fracture. Neurologic examination demonstrates normal motor examination and two-point discrimination. He undergoes fracture reduction to the anatomic position with the application of a long arm cast. Postreduction he reports increasing hand and wrist pain with diminution of two-point discrimination to 10 mm over the index and middle fingers over the next several hours after surgery. The cast is bivalved and the padding released relieving all external pressure over the arm. Reevaluation reveals increasing sensory deficit over the affected area. What is the next most appropriate management intervention?

Explanation

The patient has an evolving acute carpal tunnel syndrome. Initial management for this injury is to relieve all external pressure that may elevate the neural compression. Surgical decompression of the median nerve at the carpal tunnel is the optimal intervention. Further nonsurgical interventions (cast removal or further bivalving) are insufficient to alleviate the neural compression. Waters PM, Mih AD: Fractures of the distal radius and ulna, in Beaty JH, Kasser JR (eds): Fractures in Children, ed 6. Philadelphia, PA, Lippincott, 2006, p 361.

Question 25

A 25-year-old male polytrauma patient undergoes initial temporary external fixation for a femoral shaft fracture. He is converted to a femoral nail at 7 days. This management can be expected to result in

Explanation

Recently Harwood and associates investigated the principles of damage control orthopaedics (DCO) as they apply to patients with femoral shaft fractures. When they compared those who underwent initial external fixation of femoral shaft fractures with conversion to an intramedullary nail to those who underwent intramedullary nailing as their initial treatment, they found the following: overall infection rates were comparable in patients receiving DCO versus primary intramedullary fixation; open fracture was an independent risk factor for infection regardless of the treatment method; contamination rates in external fixator pin sites rose considerably when left in place more than 2 weeks and logistic regression analysis suggests that infection rates may increase when conversion to an intramedullary nail occurs after 2 weeks following external fixation; and there was no significant difference in time to union among treatment groups. Harwood PJ, Giannoudis PV, Probst C, et al: The risk of local infective complications after damage control procedures for femoral shaft fracture. J Orthop Trauma 2006;20:181-189.

Question 26

A 28-year-old man is involved in a high-speed motor vehicle collision. Radiographs and computed tomography (CT) scan reveal a displaced talar neck fracture with subluxation of the subtalar joint, but an intact tibiotalar joint. According to the Hawkins classification, what is the approximate expected rate of avascular necrosis (AVN) of the talar body for this injury?

Explanation

This injury describes a Hawkins Type II talar neck fracture (displaced fracture of the talar neck with subluxation or dislocation of the subtalar joint, but an intact ankle joint). The blood supply to the talar body is disrupted primarily from the artery of the tarsal canal. The risk of AVN for a Hawkins Type II fracture is traditionally taught to be between 20% and 50%. Hawkins Type I (nondisplaced) has a 0-10% risk, Type III (subtalar and tibiotalar dislocation) has a 70-100% risk, and Type IV (Type III plus talonavicular subluxation/dislocation) has a near 100% risk of AVN.

Question 27

A 45-year-old male presents in hemorrhagic shock following a crush injury. A pelvic binder is applied. Secondary survey reveals blood at the urethral meatus and a high-riding prostate on digital rectal examination. Pelvic radiographs show a displaced pubic symphysis diastasis. Which of the following is the most appropriate next step in the urologic management of this patient?

Explanation

Blood at the urethral meatus, scrotal/perineal ecchymosis, and a high-riding prostate are classic signs of a posterior urethral injury, which is highly associated with anterior pelvic ring injuries (e.g., APC patterns). Blind insertion of a Foley catheter is contraindicated as it may convert a partial urethral tear into a complete tear. A retrograde urethrogram (RUG) is the gold standard diagnostic study and must be performed prior to any attempt at transurethral catheterization.

Question 28

A 32-year-old male sustains a closed comminuted tibial shaft fracture. Twelve hours post-injury, he develops increasing pain out of proportion to his injury and severe pain with passive stretch of his toes. You suspect acute compartment syndrome and obtain compartment pressure measurements. Which of the following criteria is generally considered the most reliable threshold for performing a four-compartment fasciotomy?

Explanation

Acute compartment syndrome is primarily a clinical diagnosis, but in equivocal cases or in obtunded patients, compartment pressure measurements are critical. The delta pressure, calculated as Diastolic Blood Pressure minus Compartment Pressure, is considered the most reliable indicator for tissue perfusion. A delta pressure of less than 30 mm Hg indicates inadequate perfusion and is an absolute indication for emergency fasciotomy. Absolute pressures can be misleading, particularly in hypotensive or hypertensive patients.

Question 29

A 75-year-old, independently living, highly active community-ambulating female sustains a displaced femoral neck fracture. Compared to treatment with unipolar or bipolar hemiarthroplasty, total hip arthroplasty (THA) for this patient is associated with:

Explanation

In the active, physiologically young, older patient with a displaced femoral neck fracture, Total Hip Arthroplasty (THA) provides better functional outcomes and lower rates of reoperation compared to hemiarthroplasty. Reoperations following hemiarthroplasty are often due to acetabular wear, groin pain, or loosening. However, THA is associated with a higher risk of dislocation, longer operative times, and greater blood loss. Mortality rates at 1 year are generally comparable between the two procedures in properly selected patients.

Question 30

A 25-year-old multiple trauma patient with a closed head injury (GCS 7), bilateral pulmonary contusions, and bilateral femoral shaft fractures presents to the trauma bay. Initial labs show a lactate of 4.5 mmol/L and a base deficit of -8. After initial fluid resuscitation, his vitals are HR 115 and BP 90/60. What is the most appropriate initial orthopedic management of his bilateral femur fractures?

Explanation

This patient is physiologically unstable ('borderline' or 'in extremis') with a severe head injury, chest trauma, hypoperfusion (lactate 4.5, base deficit -8), and hemodynamic instability. The concept of Damage Control Orthopedics (DCO) dictates that early definitive fracture care (like reamed IM nailing) can cause a second hit, leading to ARDS or exacerbation of traumatic brain injury. The most appropriate initial management is rapid temporary stabilization with bilateral external fixation until the patient's physiology optimizes.

Question 31

Six weeks after undergoing closed reduction and cast application for a nondisplaced distal radius fracture, a 55-year-old woman suddenly loses the ability to actively extend her thumb at the interphalangeal joint. She denies any new trauma. What is the most appropriate definitive management?

Explanation

This patient has sustained a delayed spontaneous rupture of the extensor pollicis longus (EPL) tendon, a well-known complication of nondisplaced or minimally displaced distal radius fractures. Primary end-to-end repair is generally not feasible because the tendon ends rapidly retract and the involved tendon is structurally attenuated or necrotic over Lister's tubercle. The gold standard treatment is a tendon transfer utilizing the extensor indicis proprius (EIP) to the EPL, which restores thumb extension with excellent functional outcomes.

Question 32

A 40-year-old agricultural worker sustains a Grade IIIb open tibia fracture after his leg is caught in a tractor mechanism, resulting in heavy soil and manure contamination. In addition to a first-generation cephalosporin and an aminoglycoside, what additional intravenous antibiotic coverage is strictly indicated?

Explanation

Farm injuries, especially those contaminated with soil, feces, or standing water, carry a high risk of infection with anaerobic organisms, most notably Clostridium perfringens, which can cause devastating gas gangrene. The standard prophylactic antibiotic regimen for a Gustilo-Anderson Grade III open fracture is a first-generation cephalosporin (for Gram-positives) plus an aminoglycoside (for Gram-negatives). High-dose Penicillin is added specifically for farm-related or heavily soil-contaminated injuries to provide adequate Clostridial coverage.

Question 33

A 22-year-old collegiate football player sustains a violent axial load to a plantar-flexed foot during a tackle.

Weight-bearing radiographs of the foot demonstrate a 3.5 mm diastasis between the base of the first and second metatarsals. There are no associated fractures visible. What is the most appropriate definitive management?

Explanation

This scenario describes a purely ligamentous Lisfranc injury (disruption of the tarsometatarsal articulation). A diastasis of greater than 2 mm between the bases of the first and second metatarsals on weight-bearing radiographs indicates instability. Nonoperative management leads to midfoot collapse, chronic pain, and post-traumatic arthritis. Therefore, surgical stabilization via ORIF or primary arthrodesis (increasingly preferred for purely ligamentous injuries due to lower rates of hardware failure and midfoot arthritis) is the standard of care.

Question 34

A 35-year-old male sustains a closed, low-energy transverse fracture of the middle third of the humeral shaft. In the emergency department, he exhibits a complete wrist drop and absent sensation in the first dorsal web space of the hand. His skin is intact. What is the most appropriate initial management of the nerve injury?

Explanation

Radial nerve palsy associated with a closed humeral shaft fracture occurs in up to 18% of cases, most commonly neuropraxia. The standard of care for a primary radial nerve palsy in the setting of a closed humeral shaft fracture is expectant management, as spontaneous recovery occurs in >70-85% of cases. Immediate surgical exploration is generally reserved for open fractures, severe vascular injuries, or secondary palsies (nerve function lost after a closed reduction attempt). An EMG is typically ordered if there is no clinical sign of recovery by 3 to 4 months.

Question 35

A 28-year-old male sustains a low-velocity civilian gunshot wound to the right thigh, resulting in a comminuted femoral shaft fracture. The bullet passed cleanly through the thigh, leaving isolated 1 cm entry and exit wounds. Examination reveals a neurologically intact extremity with strong distal pulses. Which of the following is the most appropriate management strategy?

Explanation

Low-velocity civilian gunshot wounds (GSWs) causing femoral shaft fractures are generally treated as closed fractures in terms of internal fixation timing and methodology. Extensive formal debridement of the entire missile tract is unnecessary and increases morbidity. Superficial local debridement/wound care followed by early reamed intramedullary nailing provides excellent clinical outcomes, comparable to those of closed fractures. Plating or traction are not standard for diaphyseal femur fractures in this setting.

Question 36

A 45-year-old man sustains an unstable anteroposterior compression (APC-II) pelvic ring injury requiring anterior symphyseal plating. During exposure via a Pfannenstiel approach, brisk arterial bleeding is encountered on the posterior aspect of the superior pubic ramus. Which of the following is the most likely source of this bleeding?

Explanation

The 'corona mortis' (crown of death) is an important vascular anastomosis between the external iliac or inferior epigastric system and the obturator system. It courses over the posterior aspect of the superior pubic ramus. Iatrogenic injury during a Pfannenstiel or ilioinguinal exposure can lead to significant hemorrhage that is difficult to control.

Question 37

A 35-year-old man is involved in a high-speed motorcycle collision. Radiographs demonstrate a comminuted bicondylar tibial plateau fracture with metaphyseal-diaphyseal dissociation.

On examination, the leg is extremely tense, and he has agonizing pain with passive extension of the hallux. If a four-compartment fasciotomy of the leg is performed using a standard two-incision technique, which compartment is most at risk for inadequate decompression?

Explanation

The deep posterior compartment is the most commonly missed or inadequately decompressed compartment during two-incision lower extremity fasciotomies. It is located deep to the superficial posterior compartment and must be accessed by taking the soleus off the posterior aspect of the tibia. Failure to fully decompress this compartment can lead to irreversible muscle necrosis and claw toe deformities.

Question 38

A 65-year-old woman sustained a supracondylar femur fracture treated with a lateral locked plate. Six months postoperatively, she presents with progressive thigh pain. Radiographs demonstrate a broken plate at the fracture site and a lack of bridging callus. Which technical error during the initial surgery is most strongly associated with this specific mode of implant failure?

Explanation

Locked plating of comminuted metaphyseal/diaphyseal fractures relies on the principle of relative stability and secondary bone healing via callus formation. A construct that is too stiff (e.g., short working length, filling all the screw holes adjacent to the fracture site) suppresses micromotion, inhibiting callus formation. This leads to nonunion and eventual fatigue failure of the implant.

Question 39

A 28-year-old construction worker sustains a Gustilo-Anderson IIIB open fracture of the middle third of the tibia. After serial debridements, the wound bed is healthy, but there is a 6 cm x 4 cm area of exposed anterior tibia devoid of periosteum. Which of the following soft tissue coverage options is most appropriate for this specific defect?

Explanation

Local muscle flap coverage for exposed tibia fractures without periosteum depends on the anatomical zone. The proximal third is typically covered by the medial gastrocnemius flap, the middle third by the soleus flap, and the distal third generally requires a free tissue transfer or a distally based reverse sural flap, as local muscle bellies are inadequate.

Question 40

A 22-year-old snowboarder sustained a Hawkins type II talar neck fracture treated with open reduction and internal fixation. At his 8-week postoperative visit, an anteroposterior radiograph of the ankle reveals a subchondral radiolucent band in the talar dome. What is the clinical significance of this radiographic finding?

Explanation

The subchondral radiolucent band is known as the Hawkins sign. It represents subchondral osteopenia secondary to hyperemia, which proves that the vascular supply to the body of the talus is intact or has been successfully restored. Its presence is highly predictive of the absence of avascular necrosis (AVN).

Question 41

A 24-year-old man has a displaced waist fracture of the scaphoid.

You plan for percutaneous fixation and request a CT scan to accurately evaluate the fracture morphology and degree of humpback deformity. To optimally visualize the true anatomy, the CT scan images should be reconstructed in which of the following planes?

Explanation

Because the scaphoid lies at a 45-degree angle to both the coronal and sagittal planes of the wrist, standard wrist CT reconstructions do not accurately portray scaphoid anatomy or displacement. Scaphoid-specific CT scans must be reconstructed along the longitudinal axis of the scaphoid to properly assess for humpback deformity and fracture gap.

Question 42

A 6-year-old boy sustains a widely displaced, extension-type supracondylar humerus fracture. On presentation, his hand is pink and warm, with a capillary refill of 2 seconds, but the radial pulse is not palpable. Following closed reduction and percutaneous pinning in the operating room, the hand remains pink and well-perfused, but the radial pulse remains absent. What is the most appropriate next step in management?

Explanation

In the setting of a pediatric supracondylar humerus fracture with a 'pulseless, pink' hand, current guidelines support closed reduction and percutaneous pinning. If the hand remains pink and well-perfused (capillary refill < 2 seconds) post-reduction, the collateral circulation is sufficient. Observation is appropriate without immediate vascular exploration. Vascular exploration is indicated for a 'pulseless, white' (ischemic) hand that does not improve after reduction.

Question 43

A 55-year-old woman sustains a severely displaced 4-part proximal humerus fracture.

When considering the risk of avascular necrosis of the humeral head, which of the following arterial branches provides the predominant blood supply to the articular segment?

Explanation

Historically, the anterior humeral circumflex artery (via the arcuate branch) was taught to be the primary blood supply to the humeral head. However, anatomic perfusion studies by Brooks et al. and Hettrich et al. conclusively demonstrated that the posterior humeral circumflex artery provides the vast majority (up to 64%) of the blood supply to the humeral head.

Question 44

A 25-year-old man presents following a high-speed collision with a closed left femoral shaft fracture, multiple rib fractures, bilateral pulmonary contusions, and a grade III spleen laceration. Initial vitals: BP 85/50 mmHg, HR 120 bpm. Lactate is 4.5 mmol/L. After 2 liters of crystalloid and splenic embolization, his BP is 95/60 mmHg, and repeat lactate is 3.8 mmol/L. What is the most appropriate management of his femur fracture?

Explanation

This patient is a 'borderline' or 'unstable' polytrauma patient (persistent hypotension, elevated lactate, severe chest trauma). Damage Control Orthopedics (DCO), consisting of temporizing external fixation, is indicated to limit the systemic inflammatory response ('second hit') associated with prolonged surgery or canal reaming. Early Total Care (e.g., IM nailing) in this setting heavily increases the risk of ARDS, multi-organ failure, and death.

Question 45

A 30-year-old athlete sustains a supination-external rotation (Weber B) ankle fracture. Intraoperatively, after anatomic fixation of the lateral malleolus, the surgeon utilizes a 'hook test' to assess the integrity of the syndesmosis under fluoroscopy. Which of the following radiographic parameters during the stress maneuver most reliably indicates syndesmotic instability necessitating fixation?

Explanation

Intraoperative assessment of the syndesmosis is performed using the hook test (lateral pull on the fibula) or external rotation stress. The most reliable and clinically relevant indicator of syndesmotic incompetence (and deep deltoid ligament rupture) during these maneuvers is the asymmetric widening of the medial clear space, typically greater than 4-5 mm on the mortise view.

Question 46

A 35-year-old male is brought into the trauma bay following a high-speed motor vehicle collision. He is hemodynamically unstable with a blood pressure of 80/50 mmHg. Pelvic compression reveals instability, and an anteroposterior pelvic radiograph demonstrates a wide symphyseal diastasis. An emergency responder placed a pelvic binder in the field.

What is the most common anatomical error in the placement of a circumferential pelvic binder?

Explanation

The most common error in applying a pelvic binder or sheet is placing it too proximally over the iliac crests. This can be ineffective or even paradoxically open the pelvic ring further. To optimally close an open-book pelvic fracture and reduce pelvic volume, the binder must be centered directly over the greater trochanters.

Question 47

A 30-year-old man is struck by a motor vehicle and sustains a closed Pauwels type III (high shear angle) femoral neck fracture.

To minimize the risk of mechanical failure and nonunion, what is the most biomechanically stable fixation construct for this specific fracture pattern?

Explanation

Vertical femoral neck fractures (Pauwels type III) in young adults experience high vertical shear forces. Biomechanical studies have consistently shown that a fixed-angle device, such as a sliding hip screw (often supplemented with a derotation screw), provides superior stability and higher load-to-failure rates compared to three parallel cannulated screws for high-angle sheer fractures.

Question 48

A 25-year-old male is evaluated in the emergency department after sustaining an isolated low-velocity civilian gunshot wound to the right thigh. Radiographs demonstrate a midshaft femur fracture. He is hemodynamically stable, has palpable distal pulses, no sensory deficits, and the entrance and exit wounds are less than 1 cm with minimal contamination. What is the standard of care for definitive management?

Explanation

Low-velocity civilian gunshot wounds resulting in femur fractures without neurovascular compromise or massive soft tissue destruction can be treated safely similarly to closed fractures. Local superficial wound care, tetanus prophylaxis, intravenous antibiotics, and early reamed intramedullary nailing yield excellent union rates without an increased risk of deep infection. Formal deep debridement of the fracture site is generally unnecessary.

Question 49

A 28-year-old man sustains an anterior knee dislocation following a motorcycle crash. The knee is successfully reduced in the trauma bay. Distal pulses are palpable and symmetric to the uninjured side. However, an Ankle-Brachial Index (ABI) is measured at 0.8.

What is the most appropriate next step in management?

Explanation

In the setting of a knee dislocation, an Ankle-Brachial Index (ABI) of less than 0.9 is highly predictive of an arterial injury, even in the presence of palpable distal pulses. An intimal tear may permit sufficient flow to maintain a pulse but reduces the pressure index. The most appropriate next step is advanced vascular imaging, typically CT angiography, to identify the injury before thrombosis or critical ischemia occurs.

Question 50

A 40-year-old man presents with a closed, highly comminuted midshaft tibia fracture. His blood pressure is 110/70 mmHg. He requires large amounts of analgesics for leg pain and has pain on passive stretch of his toes. His anterior compartment pressure is measured at 45 mmHg. Which of the following statements regarding his diagnosis and management is most accurate?

Explanation

The diagnosis of acute compartment syndrome is largely clinical, but pressure measurements are essential when the clinical picture is ambiguous or in uncooperative patients. The 'delta p' concept is the most reliable threshold: a difference of less than 30 mmHg between the diastolic blood pressure and the compartment pressure is an indication for emergent fasciotomy. In this case, 70 mmHg (diastolic BP) - 45 mmHg (compartment pressure) = 25 mmHg, which dictates surgical intervention.

Question 51

A 38-year-old woman falls from a ladder and sustains a complex intra-articular distal femur fracture. CT scanning identifies a Hoffa fracture fragment.

Which of the following statements accurately characterizes this specific injury component?

Explanation

A Hoffa fracture is a coronal plane fracture of the distal femoral condyle (most commonly the lateral condyle). Because it is an intra-articular shear fracture, it requires anatomical reduction and independent interfragmentary compression (typically with anterior-to-posterior or posterior-to-anterior lag screws) prior to the application of a neutralization or buttress plate for the main distal femur fracture.

Question 52

A 25-year-old snowboarder sustains a Hawkins Type III fracture of the talar neck after a high-energy landing. Which of the following accurately describes the anticipated rate of avascular necrosis (AVN) of the talar body for this specific injury pattern?

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar body from both the subtalar and tibiotalar joints. This displacement typically ruptures the major blood supplies to the talar body (artery of the tarsal canal, branches of the deltoid artery, and dorsal pedis supply). The reported rate of avascular necrosis (AVN) for a Type III injury is very high, historically cited between 75% and 100%.

Question 53

A 22-year-old collegiate athlete sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate widening of the first and second intermetatarsal space with no evidence of fracture on CT.

Based on prospective randomized data, what is the recommended surgical management for this purely ligamentous injury?

Explanation

For purely ligamentous Lisfranc injuries, prospective randomized studies (most notably Ly and Coetzee, JBJS 2006) have demonstrated that primary arthrodesis yields better functional outcomes, a higher rate of return to pre-injury activity levels, and fewer reoperations compared to open reduction and internal fixation (ORIF). ORIF remains the standard of care for primarily bony Lisfranc fracture-dislocations.

Question 54

A 19-year-old male is ejected during a motor vehicle rollover. On presentation, his right upper extremity is flail, massively swollen, and pulseless. Chest radiograph shows significant lateral displacement of the right scapula relative to the thoracic spine compared to the uninjured side. The mortality associated with this specific syndrome is most closely tied to which complication?

Explanation

This patient has scapulothoracic dissociation, essentially a closed forequarter amputation. It is characterized by lateral displacement of the scapula, massive tearing of the shoulder girdle musculature, and severe stretch or complete avulsion of the brachial plexus and subclavian/axillary vessels. Mortality is significant (approx. 10-20%) and is predominantly a consequence of acute exsanguinating hemorrhage from the disrupted large vessels.

Question 55

A 65-year-old woman underwent volar locking plate fixation for a displaced intra-articular distal radius fracture six months ago.

She presents to the clinic complaining of a sudden inability to actively lift her thumb off the table when the hand is resting flat. Which of the following technical errors during the index procedure is the most likely cause of this complication?

Explanation

The sudden inability to actively retropulse/extend the thumb after distal radius plating is the classic presentation of an Extensor Pollicis Longus (EPL) tendon rupture. In the setting of volar plating, this is most commonly caused by distal locking screws that are too long, protruding through the dorsal cortex and causing mechanical attrition of the EPL tendon as it rounds Lister's tubercle. Placement of the plate distal to the watershed line risks flexor tendon irritation (e.g., FPL rupture).

Question 56

A 42-year-old man is brought to the emergency department after a high-speed motorcycle collision. His blood pressure is 80/50 mm Hg and heart rate is 120 bpm. Primary survey reveals an unstable pelvis. The trauma team decides to apply a pelvic binder. To be maximally effective in reducing pelvic volume, the binder should be centered over which of the following anatomic landmarks?

Explanation

Pelvic binders are most effective in reducing pelvic volume and controlling hemorrhage in anterior-posterior compression pelvic ring injuries when they are centered over the greater trochanters. Placement over the iliac crests or anterior superior iliac spines can paradoxically open the pelvis further or be less effective in creating the necessary compression.

Question 57

A 72-year-old woman presents with a 3-month history of vague, progressively worsening thigh pain. She denies any recent trauma but has been taking alendronate for the last 8 years. Radiographs reveal cortical thickening of the lateral femoral shaft with a transverse radiolucent line. What is the most appropriate next step in management?

Explanation

Atypical femur fractures (AFFs) are associated with prolonged bisphosphonate use. Patients presenting with prodromal pain and radiographic signs of an impending fracture, such as lateral cortical thickening and a transverse stress line (the "dreaded black line"), are at a high risk of progression to a complete fracture. The standard of care for an impending atypical femur fracture is prophylactic intramedullary nailing. Bisphosphonates should also be discontinued, and anabolic agents like teriparatide can be considered, but surgical stabilization is the primary orthopedic intervention.

Question 58

A 24-year-old man sustains a closed midshaft tibia fracture following a soccer injury and undergoes antegrade intramedullary nailing. Postoperatively, he develops severe leg pain out of proportion to his injury. Passive extension of his great toe elicits excruciating pain. Which of the following compartments is most likely affected?

Explanation

Pain with passive extension of the toes, particularly the great toe via the flexor hallucis longus, is a hallmark clinical sign of deep posterior compartment syndrome. The deep posterior compartment of the leg contains the flexor digitorum longus, flexor hallucis longus, tibialis posterior, and the tibial nerve. While the anterior compartment is the most commonly affected overall, the deep posterior compartment is frequently missed, making a careful physical examination critical.

Question 59

A 35-year-old construction worker sustains a severe open tibia fracture with extensive soft tissue stripping and a 12 cm laceration (Gustilo-Anderson Type IIIB). According to current evidence-based guidelines, which of the following is the most critical factor in preventing deep infection?

Explanation

The prompt administration of systemic intravenous antibiotics (ideally within 1 hour of injury) has consistently been shown to be the single most important factor in reducing the rate of infection in open fractures. While the historic "6-hour rule" for surgical debridement was taught for decades, recent literature demonstrates that early administration of antibiotics outweighs the strict adherence to the 6-hour surgical window, although urgent debridement is still recommended.

Question 60

A 40-year-old man falls from a height of 15 feet and sustains a highly comminuted, intra-articular distal tibia (pilon) fracture. On presentation, there is severe swelling and hemorrhagic fracture blisters. What is the most appropriate initial management?

Explanation

High-energy pilon fractures often present with severe soft tissue compromise. Immediate open reduction and internal fixation (ORIF) in this setting is associated with unacceptably high rates of wound breakdown, necrosis, and deep infection. The standard of care is a staged protocol: initial application of a spanning external fixator (with or without limited internal fixation of the fibula) to restore length and alignment, followed by delayed definitive ORIF 10-21 days later once the soft tissue swelling has subsided and the "wrinkle sign" appears.

Question 61

A 28-year-old motorcyclist is struck by a car and thrown 30 feet. He presents with a completely flail, pulseless left upper extremity. Radiographs demonstrate marked lateral displacement of the scapula relative to the thoracic spine and a displaced clavicle fracture. Which of the following associated injuries is responsible for the highest early mortality rate in this condition?

Explanation

Scapulothoracic dissociation is effectively a closed, traumatic forequarter amputation. It is characterized by severe trauma to the shoulder girdle with lateral displacement of the scapula. This injury carries a high incidence of devastating vascular and neurologic injuries. The most immediate life-threatening component, and the one with the highest early mortality, is catastrophic hemorrhage secondary to subclavian or axillary artery disruption.

Question 62

A 30-year-old man sustains a completely displaced, vertically oriented (Pauwels type III) femoral neck fracture in a motor vehicle accident. He undergoes closed reduction and internal fixation. Which of the following biomechanical constructs provides the most stable fixation for this specific high-shear fracture pattern?

Explanation

Vertical shear (Pauwels type III) femoral neck fractures in young adults are notoriously difficult to treat and have a high rate of nonunion and hardware failure due to massive shear forces across the fracture site. Biomechanical studies have demonstrated that a sliding hip screw (often supplemented with a derotational screw) provides superior biomechanical stability and increased resistance to shear forces compared to multiple parallel cancellous screws for this vertically oriented pattern.

Question 63

A 25-year-old snowboarder sustains a displaced talar neck fracture with subluxation of the subtalar joint (Hawkins Type II). He undergoes prompt open reduction and internal fixation. Six weeks later, an AP radiograph of the ankle demonstrates a subchondral radiolucent band in the dome of the talus. What does this radiographic finding indicate?

Explanation

The finding described is the Hawkins sign, which is a subchondral radiolucent band seen on the AP or mortise radiograph of the ankle, typically 6-8 weeks following a talus fracture. It represents subchondral osteopenia secondary to disuse and hyperemia. The presence of the Hawkins sign is a positive prognostic indicator; it demonstrates that the talar body has an intact blood supply and is undergoing revascularization, making avascular necrosis highly unlikely.

Question 64

A 22-year-old man sustains a low-velocity gunshot wound to the right thigh resulting in a comminuted midshaft femur fracture. The entrance and exit wounds are 1 cm in diameter with no active bleeding or expanding hematoma. His neurovascular examination is entirely intact. What is the most appropriate orthopedic management?

Explanation

Low-velocity gunshot wounds resulting in femur fractures, without signs of neurovascular compromise or massive tissue destruction/contamination, can be safely managed in a manner similar to closed fractures. Standard management includes local wound care, tetanus prophylaxis, a short course of intravenous antibiotics, and definitive stabilization with an intramedullary nail. Extensive surgical debridement of the missile tract is unnecessary for low-velocity, non-cavitating injuries.

Question 65

A 35-year-old man presents with a severe crush injury to his lower leg with a completely ischemic foot. The trauma team is deciding between limb salvage and primary amputation. Which of the following statements regarding the Mangled Extremity Severity Score (MESS) is most accurate according to the Lower Extremity Assessment Project (LEAP) study?

Explanation

The Lower Extremity Assessment Project (LEAP) study was a landmark multicenter prospective study that investigated severe lower extremity trauma. It concluded that commonly used injury severity scores, including the MESS, were not predictive of functional outcomes or the eventual need for amputation. While a high MESS score historically dictated primary amputation, modern trauma literature emphasizes that these scores should not be used as the sole determinant for clinical decision-making regarding amputation versus limb salvage.

Question 66

A 42-year-old man arrives in the emergency department hypotensive and tachycardic following a high-speed motor vehicle collision. A pelvic radiograph reveals an anteroposterior compression (APC) type III pelvic ring injury. A pelvic binder is applied, and a FAST scan is negative for intra-abdominal fluid. Despite fluid resuscitation, he remains hypotensive. What is the most common anatomic source of hemorrhage in this clinical scenario?

Explanation

The most common source of bleeding in pelvic ring injuries is the presacral venous plexus and bleeding from the cancellous bone edges, accounting for up to 80% of cases. Arterial bleeding (e.g., from the superior gluteal or internal pudendal arteries) occurs in only 10% to 20% of cases but is more likely to be the culprit in a patient who remains hemodynamically unstable despite mechanical stabilization with a binder. However, standard board teaching dictates that overall, the venous plexus and cancellous bone are the most frequent sources of hemorrhage in pelvic fractures.

Question 67

A 28-year-old man sustains a displaced, highly vertical femoral neck fracture (Pauwels III) following a fall from a roof.

Which of the following internal fixation constructs provides the greatest biomechanical stability to resist the high shear forces inherent in this specific fracture pattern?

Explanation

Pauwels III fractures are characterized by a highly vertical fracture line (angle > 50 degrees), which subjects the fracture site to significant shear forces rather than compressive forces. Biomechanical studies have consistently demonstrated that a fixed-angle construct, such as a sliding hip screw (with an additional anti-rotation screw), provides superior mechanical stability and higher load-to-failure compared to three parallel cancellous screws for vertical shear fracture patterns in young adults.

Question 68

A 35-year-old motorcyclist sustains a complex intra-articular fracture of the distal femur. Computed tomography (CT) reveals a coronal plane fracture of the lateral femoral condyle (Hoffa fracture).

What is the optimal method of internal fixation for this specific articular fragment?

Explanation

A Hoffa fracture is a coronal plane fracture of the femoral condyle, most commonly involving the lateral condyle. Because the fracture line runs in the coronal plane, medial-to-lateral fixation (like standard plating or transverse screws) will not effectively compress the fragment. It requires anterior-to-posterior (AP) or posterior-to-anterior (PA) lag screws placed perpendicular to the fracture plane to achieve anatomic reduction and interfragmentary compression.

Question 69

A 40-year-old man falls from a height of 15 feet and presents with a severely swollen leg. Radiographs demonstrate a bicondylar tibial plateau fracture with diaphyseal-metaphyseal dissociation (Schatzker VI).

On physical examination, he has severe pain with passive stretch of his toes and decreased sensation in the first web space. His calf is extremely tense. What is the most appropriate next step in management?

Explanation

The patient exhibits classic signs of acute compartment syndrome (pain out of proportion, pain with passive stretch, tense compartments, and early sensory deficits in the deep peroneal nerve distribution—first web space). When the clinical diagnosis of compartment syndrome is unequivocal, immediate four-compartment fasciotomy is indicated. Compartment pressure measurements are unnecessary and delay limb-saving treatment in clinically obvious cases.

Question 70

A 30-year-old man undergoes open reduction and internal fixation for a displaced talar neck fracture (Hawkins type II).

Eight weeks postoperatively, an anteroposterior mortise radiograph of the ankle reveals a subchondral radiolucent band localized to the dome of the talus (Hawkins sign). What does this radiographic finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucent band seen in the talar dome on AP or mortise radiographs, typically appearing 6 to 8 weeks after a talar neck fracture. It represents subchondral atrophy/resorption of bone secondary to disuse hyperemia. Its presence is a highly reliable indicator that the vascular supply to the talar body is intact, thereby effectively ruling out the development of avascular necrosis (AVN).

Question 71

A 25-year-old man with a closed tibial shaft fracture develops acute compartment syndrome. If left untreated, irreversible muscle necrosis will typically begin to occur after how many hours of continuous ischemia?

Explanation

Muscle tissue is highly sensitive to ischemia. Studies show that irreversible muscle necrosis typically begins after 4 to 6 hours of continuous complete ischemia (with significant necrosis evident by 8 hours). Peripheral nerves may show reversible changes (neurapraxia) within 30 minutes to 2 hours, but irreversible nerve damage generally parallels muscle necrosis timelines. Urgent fasciotomy is required well before this window closes.

Question 72

A 65-year-old right-hand-dominant woman is treated nonoperatively in a short arm cast for a nondisplaced distal radius fracture.

Six weeks post-injury, her cast is removed, and she immediately notes an inability to actively extend the interphalangeal joint of her right thumb, with her thumb adopting a dropped posture. What is the most appropriate surgical management?

Explanation

Delayed rupture of the extensor pollicis longus (EPL) tendon is a known complication of nondisplaced distal radius fractures due to ischemia or attrition as it passes around Lister's tubercle. Because the tendon ends are often frayed and retracted, primary end-to-end repair is usually impossible or prone to failure. The gold standard surgical treatment is an extensor indicis proprius (EIP) to EPL tendon transfer, which reliably restores independent thumb extension.

Question 73

A 45-year-old pedestrian is struck by a vehicle and sustains a Gustilo-Anderson Type IIIB open fracture of the distal third of the tibia. Following serial debridements, a clean 6 cm x 4 cm soft tissue defect remains with exposed bone completely devoid of periosteum.

What is the most appropriate method for providing definitive soft tissue coverage for this specific location?

Explanation

Soft tissue coverage for the tibia is classically based on the level of the defect. Proximal third defects are covered with a gastrocnemius rotational flap; middle third defects use a soleus flap. Distal third defects with exposed bone devoid of periosteum (Gustilo IIIB) lack local muscle bulk for rotational flaps and routinely require free tissue transfer (free flap) for adequate and reliable coverage.

Question 74

A 6-year-old boy presents to the emergency department after falling from monkey bars, sustaining a severely displaced, extension-type supracondylar humerus fracture. On initial examination, the radial pulse is absent, but the hand is warm and pink with a capillary refill time of less than 2 seconds. The fracture is taken to the operating room for closed reduction and percutaneous pinning. Postoperatively, the hand remains warm and pink with brisk capillary refill, but the radial pulse remains unpalpable. What is the most appropriate next step in management?

Explanation

The management of a "pulseless, pink hand" following reduction and pinning of a pediatric supracondylar humerus fracture is observation. The collateral circulation around the elbow is robust enough to maintain distal perfusion even if the brachial artery is in spasm or compressed. Immediate exploration is indicated only if the hand is pulseless and white/ischemic (poor perfusion) after a technically adequate fracture reduction.

Question 75

A 24-year-old collegiate football player presents with severe midfoot pain and inability to bear weight after his foot was axially loaded in plantar flexion. Physical examination reveals midfoot swelling and pathognomonic plantar ecchymosis. Anteroposterior radiographs demonstrate a 'fleck sign' in the space between the medial and middle cuneiforms.

This avulsion fracture indicates disruption of a critical stabilizing ligament. From which anatomical structure does this specific bone fragment typically originate?

Explanation

The patient has a Lisfranc injury, indicated by the mechanism, plantar ecchymosis, and radiographic 'fleck sign'. The Lisfranc ligament is an interosseous ligament that originates from the lateral aspect of the medial cuneiform and inserts on the medial aspect of the base of the second metatarsal. The 'fleck sign' represents an avulsion fracture of the ligament's insertion at the base of the second metatarsal.

Question 76

A 28-year-old polytrauma patient presents after a high-speed motor vehicle collision with bilateral femur fractures, a pelvic ring injury, and a grade IV splenic laceration. Following initial damage control surgery and splenectomy, the patient is in the ICU. Which of the following parameters is the most reliable indicator of adequate global tissue perfusion and resuscitation prior to proceeding with definitive orthopedic fixation?

Explanation

Serum lactate and base deficit are the most reliable markers of global tissue perfusion and resolution of shock. Normalization of lactate (< 2.0 mmol/L) and base deficit (>-2) indicates adequate resuscitation and is utilized by orthopedic trauma surgeons to determine the safe timing for definitive fixation in polytrauma patients, transitioning them from damage control to definitive care.

Question 77

A 45-year-old man is brought to the emergency department after falling from a 20-foot scaffold. He is hemodynamically unstable with a blood pressure of 80/40 mm Hg. Radiographs reveal an APC-III pelvic ring injury. A pelvic binder is to be applied. What is the most appropriate anatomical landmark for the optimal placement of the pelvic binder to effectively reduce pelvic volume?

Explanation

The optimal placement of a pelvic binder or sheet is centered over the greater trochanters. Biomechanical and clinical studies have shown that placing the binder at the level of the greater trochanters most effectively closes the pelvic ring and reduces pelvic volume. Placement higher, such as over the iliac crests or ASIS, is less effective and may paradoxically widen the pelvis in certain fracture patterns.

Question 78

A 22-year-old motorcycle rider is ejected and sustains a massive traction injury to his right upper extremity. Physical examination reveals a completely flail, anesthetic right arm, and severe swelling over the shoulder girdle. Radiographs show significant lateral displacement of the scapula relative to the spinous processes, an intact clavicle, and disruption of the acromioclavicular joint. What is the most likely associated limb-threatening vascular injury?

Explanation

Scapulothoracic dissociation is a high-energy closed traction injury characterized by complete disruption of the scapulothoracic articulation. It is often accompanied by devastating injuries to the brachial plexus and the subclavian or axillary vessels. The subclavian artery is particularly vulnerable as it is tethered over the first rib and under the clavicle, making it the most common critical vascular injury associated with this pattern.

Question 79

A 35-year-old man sustains a completely displaced, vertically oriented (Pauwels Type III) femoral neck fracture after a fall from a roof. Which of the following fixation constructs offers the greatest biomechanical stability and highest rate of union for this specific fracture pattern?

Explanation

Young patients with displaced, high-shear (Pauwels Type III) femoral neck fractures require rigid fixation to prevent shear displacement at the fracture site. Biomechanical studies have shown that fixed-angle constructs, such as a sliding hip screw with a derotational screw, provide superior biomechanical stability compared to three parallel cannulated screws for vertical fracture patterns, leading to lower rates of nonunion and displacement.

Question 80

A 27-year-old man sustains a closed midshaft tibia fracture treated with intramedullary nailing. Postoperatively, he develops severe pain out of proportion to the injury, significantly worsened by passive stretch of the hallux. His blood pressure is 110/70 mm Hg. Intracompartmental pressure monitoring is performed. Which of the following pressure readings most strongly dictates the need for an emergent four-compartment fasciotomy?

Explanation

The decision to perform a fasciotomy for acute compartment syndrome is largely based on clinical signs, but when measuring pressures, the 'delta pressure' is the most reliable indicator. A delta pressure (Diastolic Blood Pressure minus Intracompartmental Pressure) of 30 mm Hg or less is the widely accepted threshold for diagnosing compartment syndrome and indicating the need for emergent fasciotomy.

Question 81

A 30-year-old man presents with a gunshot wound to the distal thigh. He has an expanding hematoma, absent popliteal and pedal pulses, and a comminuted fracture of the distal femoral diaphysis. In the operating room, what is the most appropriate sequence of management?

Explanation

In the setting of a combined skeletal and arterial injury with hard signs of ischemia, minimizing ischemic time is paramount. The recommended sequence is the placement of a temporary intravascular shunt to rapidly restore perfusion, followed by quick skeletal stabilization (often with external fixation), and finally definitive vascular repair. This sequence limits total warm ischemia time and prevents disruption of the vascular repair during orthopedic manipulation.

Question 82

A 40-year-old pedestrian is struck by a car and sustains a Gustilo-Anderson Type IIIB open fracture of the distal third of the tibia. Following serial thorough debridement and skeletal stabilization with an external fixator, the wound requires soft tissue coverage. Which of the following is the most appropriate flap option for a large defect over the distal third of the tibia?

Explanation

Soft tissue coverage of the tibia is dictated by the anatomical location of the defect. The proximal third is typically covered by a gastrocnemius rotational flap. The middle third is covered by a soleus rotational flap. The distal third of the tibia lacks adequate local muscle bulk for rotational flaps and usually requires a free tissue transfer (free flap) such as an anterolateral thigh (ALT) or latissimus dorsi flap.

Question 83

A 25-year-old man falls from a height and sustains a displaced fracture of the talar neck. He undergoes open reduction and internal fixation. At the 8-week postoperative visit, an anteroposterior radiograph of the ankle reveals subchondral radiolucency in the dome of the talus. What does this radiographic finding indicate?

Explanation

The presence of a subchondral radiolucent line in the dome of the talus at 6 to 8 weeks post-injury is known as the Hawkins sign. It represents subchondral osteopenia secondary to hyperemia and disuse. The presence of a positive Hawkins sign is a highly reliable indicator that the talar body has maintained its vascular supply and is unlikely to develop avascular necrosis.

Question 84

A 24-year-old professional football player sustains an axial load to a plantar-flexed foot. Radiographs and subsequent MRI confirm a purely ligamentous Lisfranc injury with 3 mm of diastasis between the base of the first and second metatarsals. What is the most appropriate definitive management for this patient?

Explanation

Purely ligamentous Lisfranc injuries have a significantly higher rate of failure, hardware breakage, loss of reduction, and post-traumatic arthritis when treated with open reduction and internal fixation (ORIF) compared to primarily bony avulsion injuries. Current evidence strongly supports primary arthrodesis of the medial column over ORIF for purely ligamentous Lisfranc injuries, especially in young, active patients or athletes, to provide a stable, durable outcome.

Question 85

An 82-year-old woman with severe osteoporosis falls and sustains a Type II odontoid fracture. She is neurologically intact. Which of the following treatment modalities is associated with the highest rate of morbidity and mortality in this specific patient population, and is therefore generally contraindicated?

Explanation

In the elderly population (typically >65 or >80 years of age), halo vest immobilization for cervical spine fractures is associated with a significantly increased risk of major complications, including aspiration pneumonia, cardiac arrest, respiratory failure, and death. Mortality rates in the elderly treated with a halo vest have been reported as high as 40%. Therefore, halo vest immobilization is generally contraindicated in this age group.

Question 86

A 35-year-old male sustains a high-energy motor vehicle collision. Radiographs demonstrate a displaced talar neck fracture with subluxation of the subtalar joint (Hawkins type II). Regarding the vascular supply to the talus and the risk of osteonecrosis, which of the following statements is true?

Explanation

The talus has a precarious blood supply. The primary blood supply to the talar body is the artery of the tarsal canal, a branch of the posterior tibial artery. In displaced talar neck fractures (Hawkins II-IV), the major blood supply is often disrupted. The deltoid branch of the posterior tibial artery is consistently preserved as long as the deltoid ligament is intact; therefore, preserving the deltoid ligament during a medial approach is critical to avoid devascularizing the remaining bone. Recent literature shows that the incidence of osteonecrosis is dictated by the initial displacement (trauma) rather than the timing of surgical fixation. Osteonecrosis rates for Hawkins II fractures are historically around 20-50%, not >90%.

Question 87

A 42-year-old construction worker is crushed by a heavy machine. On arrival, his blood pressure is 70/40 mmHg. A FAST examination is positive for intra-abdominal fluid, and a portable pelvic radiograph shows a widened pubic symphysis with disruption of the posterior sacroiliac complex (APC III injury). A commercial pelvic binder is ordered. To optimally reduce the pelvic volume and stabilize the fracture, the binder should be centered over which of the following anatomic landmarks?

Explanation

For emergent stabilization of an unstable pelvic ring injury, pelvic binders or sheets should be centered strictly over the greater trochanters. Placement higher over the iliac crests or anterior superior iliac spines is less effective at reducing pelvic volume, can paradoxical open the true pelvis further in some fracture patterns, and may restrict abdominal access for exploratory laparotomy.

Question 88

A 45-year-old woman presents to the emergency department after falling on an outstretched hand. She is diagnosed with a 'terrible triad' injury of the elbow. Operative management is planned. According to standard biomechanical principles, which of the following represents the optimal surgical sequence of repair for this injury pattern?

Explanation

A terrible triad injury of the elbow consists of a posterior elbow dislocation, radial head fracture, and coronoid fracture. The standard surgical sequence works from deep to superficial and inside-out. The widely accepted sequence is 1) fixation of the coronoid fracture or anterior capsule to restore anterior stability, 2) repair or replacement of the radial head, and 3) repair of the lateral collateral ligament (LCL) complex. MCL repair or hinged external fixation is only added if the elbow remains unstable after these three steps.

Question 89

A 28-year-old male is admitted to the intensive care unit with a closed midshaft tibia fracture and a severe closed head injury. He is intubated and obtunded. His current blood pressure is 110/70 mmHg. Due to a tense leg on examination, intracompartmental pressure monitoring is initiated. Which of the following thresholds is the most widely accepted absolute indication for a four-compartment fasciotomy in this patient?

Explanation

In an obtunded or uncooperative patient, compartment pressure monitoring is indicated if clinical suspicion is high. The absolute pressure is less reliable than the delta pressure (perfusion pressure). McQueen et al. demonstrated that a delta pressure (calculated as Diastolic Blood Pressure minus the intracompartmental pressure) of less than 30 mmHg is the most reliable threshold to indicate the need for fasciotomy, minimizing missed cases and unnecessary surgeries.

Question 90

A 22-year-old motorcyclist is thrown from his bike at highway speeds. A chest radiograph in the trauma bay reveals lateral displacement of the right scapula and a widely displaced midshaft clavicle fracture. Examination of the right upper extremity shows absent pulses, pallor, and a complete lack of motor and sensory function throughout the limb. Which of the following is the most likely neurologic injury associated with this clinical picture?

Explanation

This clinical picture describes scapulothoracic dissociation, a severe, high-energy traction injury characterized by lateral displacement of the scapula with intact skin. It is frequently accompanied by a fractured clavicle or AC/SC joint disruptions. It carries a dismal prognosis for the upper extremity due to the extremely high rate of complete brachial plexus avulsions and concomitant subclavian or axillary vascular injuries. An isolated nerve injury is incorrect given the complete loss of sensory and motor function.

Question 91

A 38-year-old man sustains a Gustilo-Anderson type IIIB open fracture of the proximal third of the tibia after a severe crush injury. Following aggressive surgical debridement, there is a 6 cm by 5 cm anterior soft-tissue defect exposing bare bone devoid of periosteum. Which of the following is the most appropriate soft-tissue coverage option for this specific anatomic location?

Explanation

For soft-tissue coverage of the lower extremity, local rotational flaps are often selected based on the level of the defect. The classic algorithm utilizes the medial or lateral gastrocnemius rotational flap for defects of the proximal third of the tibia. For the middle third, the soleus flap is preferred. For the distal third, there is insufficient local muscle bulk, usually necessitating a free tissue transfer (e.g., ALT or latissimus dorsi) or a reverse sural fasciocutaneous flap.

Question 92

A 24-year-old man is evaluated in the emergency department for a gunshot wound to the right hip. Plain radiographs demonstrate a retained bullet resting entirely within the intra-articular space of the hip joint. CT imaging confirms the bullet is intracapsular, with no major osseous fracture. Which of the following represents the most appropriate initial management?

Explanation

A retained bullet within a synovial joint (such as the hip or knee) is an absolute indication for surgical retrieval. Intra-articular bullets are bathed in synovial fluid, which dissolves the lead, increasing the risk of systemic lead toxicity (plumbism) and severe mechanical third-body wear to the articular cartilage. Observation or antibiotics alone are inappropriate. Chelation is not indicated unless systemic toxicity is confirmed and the source cannot be removed.

Question 93

A 65-year-old woman is seen in the outpatient clinic 6 weeks after sustaining a non-displaced distal radius fracture treated with a short arm cast. She now complains of a sudden inability to actively extend the interphalangeal joint of her thumb. She denies any new trauma. What is the most appropriate definitive surgical management for her condition?

Explanation

This patient has suffered a spontaneous rupture of the extensor pollicis longus (EPL) tendon. This is a known complication following distal radius fractures, notably non-displaced fractures. The rupture is usually due to ischemia or mechanical attrition within the third dorsal compartment. Because the tendon ends are often retracted and degenerated, primary end-to-end repair is rarely possible. The standard of care is a tendon transfer utilizing the extensor indicis proprius (EIP) to the EPL.

Question 94

A 30-year-old male sustains a severe midfoot sprain while playing American football. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. The primary ligamentous structure injured in this pattern originates from which bone and inserts onto which bone?

Explanation

The Lisfranc ligament is an intra-articular ligament that provides critical stability to the midfoot. It originates on the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. There is no direct ligamentous connection between the first and second metatarsal bases, making the Lisfranc ligament the primary stabilizer preventing lateral subluxation of the lesser metatarsals.

Question 95

A 42-year-old man sustains a high-energy distal femur fracture. A computed tomography (CT) scan is obtained, revealing a distinct coronal plane fracture of the lateral femoral condyle that was difficult to visualize on plain radiographs. What is the standard eponym for this specific fracture pattern, and how should interfragmentary lag screws generally be oriented for optimal fixation?

Explanation

A coronal shear fracture of the femoral condyle is known as a Hoffa fracture (most commonly involving the lateral condyle). Because the fracture plane is coronal, lag screws must be placed orthogonally to the fracture line to achieve compression. This requires placement in an anteroposterior (AP) or posteroanterior (PA) direction. Placing screws from medial to lateral would be parallel to the fracture plane and would fail to provide interfragmentary compression.

Question 96

A 45-year-old man sustains a severe closed pilon fracture (OTA 43-C3) after a fall from a ladder. Examination in the emergency department reveals massive soft tissue swelling, fracture blisters, and a shortened extremity. What is the most appropriate initial surgical management?

Explanation

Pilon fractures with significant soft-tissue swelling and fracture blisters are best treated with staged management. This involves temporary spanning external fixation to allow for soft-tissue resuscitation and resolution of swelling, followed by delayed definitive open reduction and internal fixation. Primary ORIF in this setting is associated with unacceptably high rates of wound breakdown and deep infection.

Question 97

A 35-year-old farmer is brought to the trauma bay after his leg was caught in a tractor power take-off. He sustains a grade IIIb open diaphyseal tibia fracture with gross soil and organic matter contamination. In addition to surgical debridement, which of the following is the most appropriate empiric intravenous antibiotic regimen?

Explanation

For open fractures with gross soil or agricultural contamination (farm injuries), there is a significant risk of Clostridium infection. The standard of care recommended by orthopedic trauma guidelines includes a first-generation cephalosporin (for gram-positive coverage), an aminoglycoside (for gram-negative coverage), and high-dose penicillin (for anaerobic coverage, specifically Clostridium species).

Question 98

A 28-year-old man sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III) following a high-energy motor vehicle collision. Which of the following internal fixation constructs provides the greatest biomechanical stability for this specific fracture pattern?

Explanation

Pauwels type III fractures are highly vertically oriented (angle > 50 degrees from the horizontal) and experience significant shear forces, increasing the risk of varus collapse and nonunion. Biomechanical studies have demonstrated that a fixed-angle construct, such as a sliding hip screw (SHS) with an additional derotational cancellous screw, provides superior biomechanical stability and increased resistance to shear forces compared to three parallel cancellous screws.

Question 99

A 30-year-old man who is intubated and sedated in the intensive care unit is noted to have a tense, significantly swollen left lower extremity 24 hours after sustaining a closed, comminuted tibial shaft fracture. Pedal pulses are palpable. What is the most appropriate next step in management?

Explanation

In an obtunded, intubated, or otherwise unexaminable patient, clinical signs of compartment syndrome (such as pain out of proportion or pain with passive stretch) cannot be reliably assessed. The most appropriate next step is to measure the intracompartmental pressures and calculate the delta pressure (diastolic blood pressure minus compartment pressure). A delta pressure of 30 mm Hg or less is generally considered an absolute indication for a four-compartment fasciotomy. Relying on absolute pressure alone is less accurate than delta pressure.

Question 100

A 40-year-old construction worker falls 20 feet from scaffolding, landing on his feet. He sustains bilateral displaced, intra-articular calcaneus fractures. Which of the following is the most common associated skeletal injury in this clinical scenario?

Explanation

Patients who sustain calcaneus fractures from an axial load mechanism, such as a fall from a height, have a high incidence of associated injuries due to the transmission of force up the axial skeleton. Approximately 10% of patients with calcaneus fractures also have an associated thoracolumbar spine fracture, most commonly a burst or compression fracture. A thorough evaluation of the spine is mandatory in these patients.

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

Trauma Board Review 2009: High-Yield MCQs (Set 4)

Key Takeaway

Trauma Board Review 2009: High-Yield MCQs (Set 4)

Chapter Index