A 16-year-old boy has a symptomatic flatfoot deformity that is causing pain, skin breakdown, and shoe wear problems. Shoe modification and an orthosis have failed to provide relief. Examination reveals hindfoot valgus, talonavicular sag, and forefoot

medial soft-tissue tightening with lateral column lengthening.

Which of the following is a significant risk factor for airway complications after anterior cervical surgery? Review Topic

Surgical time of more than 5 hours

Figure 12 shows the radiograph of an 80-year-old woman who has had an 8-month history of back pain after a fall. What is the most likely diagnosis based on the radiographic findings at the fractured vertebrae?

Nonunion of the fracture with osteonecrosis

Prescribing touch (10 to 15 kg) weight-bearing would be most appropriate in the following scenario?

Acute grade II anterior talofibular ligament ankle sprain

Which of the following methodologies has been proven to be effective in reducing the use of homologous blood transfusion following total hip arthroplasty (THA)?

Preoperative autologous blood donation

Well-differentiated liposarcomas never have chromosomal abnormalities.Liposarcomas account for approximately 10% to 15% of sarcomas. Some general statements about liposarcomas are listed below:

Most liposarcomas occur below the fascia.

Orthopedic Ob Trauma Review | Dr Hutaif Trauma & Fractu -... | 100 Random Orthopedic MCQs

Question 1

In the management of a polytraumatized patient, which of the following physiological parameters is the most reliable indicator that the patient is adequately resuscitated and safe to proceed with Early Total Care (ETC) rather than Damage Control Orthopedics (DCO)?

Explanation

A serum lactate level < 2.5 mmol/L is a reliable indicator of adequate tissue perfusion and resuscitation, permitting definitive fracture fixation (ETC). A base deficit > 6, hypothermia, coagulopathy, and thrombocytopenia are signs of a patient 'in extremis' or borderline, which favors a Damage Control Orthopedics (DCO) approach.

Question 2

A macrosomic newborn presents with pseudoparalysis of the right upper extremity following a difficult, prolonged vaginal delivery complicated by shoulder dystocia. On examination, the Moro reflex is absent on the right, but the grasp reflex is intact. Radiographs demonstrate no skeletal fractures. What is the most likely diagnosis?

Explanation

Erb's palsy involves the upper trunk of the brachial plexus (C5-C6). Clinically, it presents with the arm internally rotated and adducted (waiter's tip posture). The Moro reflex is absent due to the inability to abduct and externally rotate the shoulder, but the grasp reflex (C8-T1) remains intact. Klumpke palsy would present with an absent grasp reflex.

Question 3

A hemodynamically unstable 40-year-old male is brought to the trauma bay after a high-speed motorcycle accident. An AP pelvis radiograph reveals an 'open book' anterior-posterior compression (APC) pelvic ring injury. Where is the correct anatomical level to place a non-invasive circumferential pelvic binder?

Explanation

To effectively reduce pelvic volume and control venous bleeding in an unstable pelvic ring injury, the pelvic binder or sheet must be centered directly over the greater trochanters. Placing it over the iliac crests is a common error and can paradoxical widen the pelvic outlet or fail to close the ring adequately.

Question 4

A 30-year-old male sustains a Gustilo-Anderson Type IIIA open tibial shaft fracture after being struck by a car. Which of the following interventions has been proven to be the most critical independent factor in reducing the patient's risk of deep infection?

Explanation

The early administration of systemic antibiotics (ideally within 1-3 hours of injury) is universally recognized as the single most important factor in reducing infection rates in open fractures. The '6-hour rule' for surgical debridement has not been strongly supported by modern evidence as an independent predictor of infection, provided antibiotics are given early.

Question 5

A 25-year-old male sustains a Pauwels type III (highly vertical) intracapsular femoral neck fracture. Which of the following fixation constructs offers the highest biomechanical stability against shear forces for this specific fracture pattern?

Explanation

Biomechanical studies consistently show that for vertical shear fracture patterns (Pauwels III), a sliding hip screw combined with a derotation screw provides superior fixation strength and resistance to shear forces compared to multiple parallel cancellous screws.

Question 6

A 6-year-old boy presents to the emergency department after a fall off monkey bars. Radiographs reveal a widely displaced, extension-type supracondylar humerus fracture. On examination, he is unable to actively flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger. Which nerve is injured?

Explanation

The anterior interosseous nerve (AIN) is the most frequently injured nerve in extension-type supracondylar humerus fractures. Clinically, it presents as an inability to form the 'A-OK' sign due to weakness of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger.

Question 7

A 32-year-old male with a closed tibial shaft fracture is complaining of out-of-proportion pain 12 hours post-injury. You suspect acute compartment syndrome. Which of the following pressure measurement thresholds is the most accurate indication for emergent fasciotomy?

Explanation

The 'delta p' (Diastolic Blood Pressure minus Compartment Pressure) is the most reliable threshold for diagnosing acute compartment syndrome. A delta p of < 30 mmHg accurately indicates a perfusion deficit requiring emergent fasciotomy, minimizing unnecessary surgeries compared to using an absolute pressure threshold.

Question 8

A 28-year-old male presents with a closed, mid-shaft transverse humerus fracture following an arm-wrestling injury. On initial examination, he has an isolated radial nerve palsy. What is the most appropriate initial management for his nerve injury?

Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture is typically a neurapraxia (Sunderland first or second degree) and recovers spontaneously in up to 90% of cases. Observation and supportive care (e.g., cock-up wrist splint) is the standard of care, regardless of whether the fracture is treated operatively or non-operatively.

Question 9

A 40-year-old male arrives in the trauma bay with a severely deformed left knee after a low-velocity sporting collision. Radiographs show a posterior knee dislocation. The knee is successfully reduced. Pulses are palpable and symmetric. The Ankle-Brachial Index (ABI) on the injured side is 0.85. What is the next most appropriate step in management?

Explanation

An ABI < 0.90 is highly sensitive for arterial injury following a knee dislocation. Even in the presence of palpable pulses (which may persist due to collateral flow or intimal flaps that have not yet fully thrombosed), advanced imaging such as a CT angiogram is mandatory to rule out an occult popliteal artery injury.

Question 10

A 35-year-old male falls from a height and sustains a Hawkins Type III talar neck fracture (fracture with subtalar and tibiotalar dislocation). What is the approximate risk of developing avascular necrosis (AVN) of the talar body in this injury pattern?

Explanation

The Hawkins classification for talar neck fractures directly correlates with the risk of AVN. Type I: 0-10%; Type II (subtalar dislocation): 20-50%; Type III (subtalar and tibiotalar dislocation): near 100% (often cited as 75-100%); Type IV (Type III plus talonavicular dislocation): near 100%.

Question 11

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

Explanation

Flexor pollicis longus (FPL) tendon rupture is a known complication of volar plating for distal radius fractures, typically occurring when the plate is positioned too distally, projecting volar to the 'watershed line', causing mechanical attrition of the tendon.

Question 12

A 45-year-old male is involved in a high-speed motor vehicle collision. Radiographs and CT demonstrate an acetabular fracture. The obturator oblique view reveals a pathognomonic 'spur sign'. This radiographic finding is indicative of which Letournel and Judet fracture pattern?

Explanation

The 'spur sign' represents the stable, intact portion of the ilium that remains attached to the axial skeleton, projecting posterior-inferiorly above the displaced acetabular articular fragments. It is best seen on the obturator oblique radiograph and is pathognomonic for a both-column acetabular fracture.

Question 13

In a patient presenting with an intra-articular calcaneus fracture following a fall from a roof, which of the following radiographic measurements is most consistently decreased or flattened on the lateral radiograph of the foot?

Explanation

Böhler's angle (normal 20-40 degrees) is formed by a line drawn from the highest point of the anterior process to the highest point of the posterior facet, and a second line from the posterior facet to the superior edge of the tuberosity. It is classically decreased (flattened) in compressive intra-articular fractures of the calcaneus.

Question 14

A 50-year-old male sustains a knee injury classified as a Schatzker IV tibial plateau fracture. Which of the following best describes this specific fracture pattern?

Explanation

In the Schatzker classification: I is lateral split, II is lateral split-depression, III is lateral pure depression, IV is medial plateau fracture, V is bicondylar fracture, and VI is plateau fracture with metaphyseal-diaphyseal dissociation. Schatzker IV injuries are often high-energy varus forces with a high risk of vascular injury and compartment syndrome.

Question 15

A 22-year-old male is evaluated in the ER after sustaining a low-velocity civilian gunshot wound to the thigh, resulting in a midshaft femur fracture. The bullet tracked directly through the thigh with no gross wound contamination or expanding hematoma. What is the standard of care for definitive management?

Explanation

Low-velocity gunshot fractures of the femur without gross contamination or vascular injury are treated similarly to closed fractures. Standard management involves superficial local wound care, a short course of IV antibiotics, and antegrade intramedullary nailing. Extensive excisional debridement of the bullet track is unnecessary and can increase morbidity.

Question 16

A 28-year-old athlete undergoes evaluation for a suspected syndesmotic injury. Intraoperative fluoroscopy is utilized to check the integrity of the distal tibiofibular joint. On a proper mortise view of the ankle, which of the following radiographic relationships indicates an anatomically reduced syndesmosis?

Explanation

On an AP radiograph, tibiofibular overlap should be > 6 mm. On a mortise radiograph, the normal tibiofibular overlap should be > 1 mm. The tibiofibular clear space (measured 1 cm proximal to the plafond) should be < 5 mm on both AP and mortise views.

Question 17

A 14-month-old child who is barely pulling to stand presents to the emergency department with a spiral fracture of the midshaft femur. The parents state the child 'tripped over a toy.' What is the most appropriate initial management step?

Explanation

A femur fracture in a non-ambulatory child or one who has barely started cruising, especially with an inconsistent history, is highly suspicious for non-accidental trauma (NAT). The most critical initial step is to ensure the child's safety by admitting them, ordering a full skeletal survey, and consulting child protective services.

Question 18

A 35-year-old male is involved in a severe motor vehicle accident and sustains a Levine-Edwards Type II traumatic spondylolisthesis of the axis (Hangman's fracture), demonstrating significant translation and angulation. What is the classic mechanism of injury for this specific fracture subtype?

Explanation

Levine-Edwards classification of Hangman's fractures: Type I is caused by hyperextension/axial loading. Type II is caused by initial hyperextension-loading (fracturing the pars) followed by severe rebound flexion and axial compression, tearing the C2-C3 disc and posterior longitudinal ligament, leading to translation. Type IIA is flexion-distraction.

Question 19

When evaluating a subtle Lisfranc injury on weight-bearing radiographs of the foot, checking anatomical alignment is crucial. On the 30-degree internal oblique view, normal anatomical alignment dictates that the medial border of the cuboid should align perfectly with the medial border of which structure?

Explanation

On a standard AP view of the foot, the medial border of the 2nd metatarsal aligns with the medial border of the middle cuneiform. On the 30-degree internal oblique view, the medial border of the 4th metatarsal should align with the medial border of the cuboid. Any step-off indicates a midfoot dislocation/Lisfranc injury.

Question 20

In the concept of Damage Control Orthopedics (DCO), the 'second hit' phenomenon can precipitate systemic inflammatory response syndrome (SIRS) and acute respiratory distress syndrome (ARDS). Which of the following cytokines is most strongly correlated with the severity of this secondary inflammatory response and is routinely measured in European trauma protocols to guide timing of definitive surgery?

Explanation

Interleukin-6 (IL-6) is a key mediator and the most sensitive inflammatory marker for predicting the severity of the systemic inflammatory response following major trauma (the 'first hit') and the magnitude of the 'second hit' induced by extensive surgery. An IL-6 level > 500 pg/mL is often considered a threshold favoring DCO over ETC.

Question 21

A 28-year-old polytrauma patient sustains bilateral femur fractures and a blunt chest injury. He is initially managed with temporary external fixation (Damage Control Orthopedics). Which of the following biochemical parameters most reliably indicates that the patient is physiologically optimized for conversion to definitive intramedullary nailing (Early Total Care)?

Explanation

According to the principles of Damage Control Orthopedics (DCO) vs. Early Total Care (ETC), optimal timing for definitive fixation in a polytrauma patient relies heavily on adequate physiological resuscitation. The most reliable systemic markers of adequate tissue perfusion and resuscitation are a cleared serum lactate (< 2.5 mmol/L) and a normalized base deficit (typically > -2.0 mmol/L or resolving to normal limits). Operating during the 'window of opportunity' (days 5-10) when these parameters are normal minimizes the 'second hit' of surgery.

Question 22

During an ilioinguinal approach for the fixation of an anterior column acetabular fracture, significant arterial hemorrhage is encountered upon dissection over the superior pubic ramus. This bleeding is most likely originating from an aberrant anastomotic vessel known as the 'corona mortis'. Between which two vascular systems does this anastomosis typically occur?

Explanation

The corona mortis ('crown of death') is a significant vascular anastomosis between the external iliac system (or inferior epigastric vessels) and the obturator system. It is located over the superior pubic ramus at a distance of roughly 4-9 cm from the pubic symphysis. Disruption of this vessel during the ilioinguinal approach or Stoppa approach can lead to massive, difficult-to-control hemorrhage, as the vessel can retract into the true pelvis.

Question 23

A 40-year-old male sustains a high-energy posterior shear fracture of the medial tibial plateau (Schatzker IV variant).

What is the optimal surgical approach to directly visualize and buttress this specific posteromedial fragment?

Explanation

Posteromedial shear fractures of the tibial plateau cannot be effectively reduced or buttressed via an anterior or anterolateral approach. The optimal approach is the posteromedial approach, which utilizes the interval between the medial head of the gastrocnemius (retracted laterally with the neurovascular bundle) and the pes anserinus/semimembranosus (retracted medially). This allows direct application of an anti-glide or buttress plate to the posterior aspect of the medial plateau.

Question 24

A 75-year-old female with a previous total hip arthroplasty sustains a fall.

Radiographs show a periprosthetic fracture originating at the tip of the femoral stem. Comparison with prior radiographs reveals the stem has subsided by 1.5 cm. However, the surrounding proximal diaphyseal and metaphyseal bone stock remains adequate. According to the Vancouver classification, what is the most appropriate management?

Explanation

This is a Vancouver B2 periprosthetic femur fracture: 'B' indicates the fracture is around or just below the stem tip; '2' indicates the stem is loose (subsided 1.5 cm) but with adequate bone stock. The standard of care for a Vancouver B2 fracture is revision of the femoral component to a long stem that bypasses the fracture by at least two cortical diameters, achieving distal fixation. ORIF alone (without revision) is contraindicated as the loose stem will lead to construct failure.

Question 25

A 35-year-old presents with a Grade IIIB open tibia fracture requiring a local rotational flap for coverage. Following current evidence-based guidelines (e.g., the EAST guidelines/Surgical Infection Society), what is the currently recommended protocol for systemic antibiotic prophylaxis duration following definitive soft-tissue wound closure?

Explanation

For severe open fractures (Gustilo-Anderson Grade III), updated guidelines from the Surgical Infection Society and Eastern Association for the Surgery of Trauma (EAST) recommend stopping prophylactic systemic antibiotics either 72 hours after the initial injury or within 24 hours of successful, definitive soft-tissue coverage (whichever occurs first). Prolonging antibiotic prophylaxis beyond this timeframe does not decrease infection rates and increases the risk of antimicrobial resistance and C. difficile infections.

Question 26

A 65-year-old female who has been taking alendronate for 8 years complains of prodromal aching pain in her left thigh for 3 months. Radiographs demonstrate focal lateral cortical thickening of the proximal femoral diaphysis with a subtle transverse radiolucent line, without complete fracture. What is the most appropriate next step in management?

Explanation

The patient presents with a symptomatic incomplete atypical femur fracture (AFF), classically associated with long-term bisphosphonate use (lateral cortical thickening, transverse radiolucency, prodromal thigh pain). Because she is symptomatic (thigh pain), the risk of progression to a complete, displaced fracture is very high. The standard of care for a symptomatic incomplete AFF is prophylactic intramedullary nailing. Bisphosphonates should also be discontinued, and anabolic agents (like teriparatide) may be considered adjunctively, but surgery is the definitive management.

Question 27

A 22-year-old male polytrauma patient presents with severe traumatic brain injury (GCS 6, ICP 25 mmHg) and bilateral closed femoral shaft fractures. He has been hemodynamically resuscitated in the ICU. Which of the following is the most appropriate orthopedic management strategy for his femur fractures?

Explanation

In a patient with severe Traumatic Brain Injury (GCS < 8) and elevated intracranial pressure (ICP), prolonged surgical procedures and physiological insults (like femoral reaming) can precipitate secondary brain injury (the 'second hit') by inducing hypotension, hypoxia, or severe inflammatory responses. Damage Control Orthopedics (DCO) using rapid external fixation is the treatment of choice. Definitive IM nailing is deferred until the neurologic status and ICP have stabilized.

Question 28

A 45-year-old male with a high-energy Pilon fracture is initially managed with a spanning external fixator to allow for soft tissue resuscitation. What clinical physical exam finding most reliably indicates that the soft tissue envelope is sufficiently recovered to safely proceed with definitive open reduction and internal fixation (ORIF)?

Explanation

The 'wrinkle sign' is a classic clinical indicator used to assess the resolution of soft tissue edema following lower extremity trauma, particularly Pilon and calcaneus fractures. When skin wrinkles appear upon dorsiflexion or movement, it signifies that the interstitial edema has resolved sufficiently to safely make surgical incisions with a lower risk of wound dehiscence and infection. Blisters must re-epithelialize, not just change fluid type. Pin sites do not dictate incision readiness for the primary fracture.

Question 29

A 30-year-old male is admitted with a closed tibia fracture. Over the next 12 hours, he complains of worsening leg pain out of proportion to the injury. His blood pressure is 110/70 mmHg. Compartment pressures are measured. Which of the following absolute or differential pressure measurements represents a strict, widely accepted indication for immediate four-compartment fasciotomy?

Explanation

The diagnosis of acute compartment syndrome is strongly supported by a delta pressure (Diastolic Blood Pressure minus intra-compartmental pressure) of less than 30 mmHg (some sources cite < 20-30 mmHg). An absolute pressure > 30 mmHg was historically used, but it leads to overtreatment, particularly in hypotensive trauma patients. A delta pressure of 20 mmHg means the compartment pressure is dangerously close to the diastolic pressure, compromising capillary perfusion, and mandates fasciotomy.

Question 30

A 40-year-old motorcyclist sustains a closed lateral compression pelvic fracture. Examination reveals a large, soft, fluctuant swelling over the greater trochanter with localized ecchymosis and decreased cutaneous sensation. What is the precise pathophysiology underlying this specific soft tissue lesion?

Explanation

This presentation describes a Morel-Lavallée lesion, which is a closed internal degloving injury. The pathophysiology involves the shearing of the skin and subcutaneous tissue from the rigidly fixed underlying deep fascia. This mechanism disrupts the perforating vascular and lymphatic vessels, leading to the accumulation of a serosanguineous, hemolymphatic collection in the newly created potential space. It is highly associated with pelvic and acetabular trauma.

Question 31

A patient falls from a height of 20 feet and sustains a complex spinopelvic dissociation, specifically a U-type sacral fracture (bilateral vertical sacral fractures connected by a transverse fracture component). Due to the anatomic location of the transverse limb of this fracture, which neurological deficit is most frequently encountered?

Explanation

U-type sacral fractures result in spinopelvic dissociation, where the upper sacrum (and attached spine) dissociates from the lower sacrum and pelvis. The transverse component of the fracture most commonly crosses through the upper sacral foramina (S1, S2, or S3). This displacement severely compromises the sacral nerve roots running in the central canal, heavily associating this injury with Cauda Equina Syndrome (manifesting as bowel, bladder dysfunction, and saddle anesthesia).

Question 32

In a severely displaced intra-articular calcaneus fracture, the anteromedial fragment (which includes the sustentaculum tali) typically remains anatomically aligned with the talus, earning it the moniker 'the constant fragment'. Which critical ligamentous structure is primarily responsible for maintaining this relationship?

Explanation

The sustentaculum tali is referred to as the 'constant fragment' because it remains strongly tethered to the talus despite massive displacement of the rest of the calcaneus. This relationship is maintained primarily by the very strong interosseous talocalcaneal ligament (along with contributions from the medial talocalcaneal ligament and deltoid ligament). Recognizing the position of this fragment is essential for surgical reduction, as the tuberosity fragment is brought to the constant fragment.

Question 33

A 25-year-old sustains a talar neck fracture. To assess the viability of the talar body, a physician notes the presence of a subchondral radiolucent band in the dome of the talus on an AP ankle radiograph taken 6-8 weeks post-injury. What does this radiographic finding (Hawkins sign) indicate regarding the talus?

Explanation

The Hawkins sign is the appearance of a subchondral radiolucent band in the dome of the talus, typically seen 6-8 weeks following a talar neck fracture on an AP or Mortise radiograph. This radiolucency represents subchondral osteopenia secondary to bone resorption. Because bone resorption requires an active blood supply, the presence of the Hawkins sign is a highly reliable indicator that the talar body remains vascularized, predicting a very low risk of Avascular Necrosis (AVN).

Question 34

In the Masquelet technique for managing segmental bone defects, the first stage involves placing a polymethylmethacrylate (PMMA) spacer. Six to eight weeks later, the spacer is removed, and bone graft is placed inside the newly formed 'induced membrane'. What is the critical biological function of this induced membrane?

Explanation

The Masquelet technique relies on a biologically active 'induced membrane' that forms around the PMMA spacer. This membrane is not just a physical barrier; it is highly vascularized and actively secretes key osteogenic and angiogenic growth factors, including Vascular Endothelial Growth Factor (VEGF), Bone Morphogenetic Protein 2 (BMP-2), and TGF-beta. When the spacer is removed, this membrane creates an optimal biological chamber that supports the consolidation of the subsequently placed autologous bone graft and prevents its rapid resorption.

Question 35

A 35-year-old male presents with a closed, distal third spiral fracture of the humerus (Holstein-Lewis fracture). On initial evaluation in the emergency department, his radial nerve function is completely intact. Following closed reduction and the application of a coaptation splint, repeat examination demonstrates a new complete loss of wrist and finger extension. What is the most appropriate next step in management?

Explanation

A Holstein-Lewis fracture is a spiral fracture of the distal one-third of the humeral shaft, which carries a high risk of radial nerve entrapment as the nerve passes through the lateral intermuscular septum. While primary radial nerve palsies associated with closed humerus fractures are generally observed, a secondary nerve palsy that develops after a closed reduction maneuver strongly suggests iatrogenic entrapment or laceration of the nerve in the fracture site. This is an absolute indication for immediate surgical exploration and fracture fixation.

Question 36

A 42-year-old cyclist falls and sustains a 'floating shoulder' consisting of ipsilateral displaced fractures of the midshaft clavicle and the surgical neck of the scapula. Which of the following factors represents the primary indication for operative fixation of this combined injury pattern?

Explanation

A 'floating shoulder' disrupts the superior shoulder suspensory complex. However, not all require surgery. The primary indication for operative intervention (usually fixation of the clavicle, sometimes both) is significant displacement of the scapular neck/glenoid. Specifically, medial translation > 1 cm, angular deformity > 40 degrees, or double disruption of the superior shoulder suspensory complex with profound instability. Fixation of the clavicle alone often indirectly reduces and stabilizes the scapular neck.

Question 37

A 25-year-old male is involved in a motorcycle collision.

A CT scan reveals a coronal plane fracture of the lateral femoral condyle. What is the standard operative fixation principle for this specific intra-articular fragment?

Explanation

A coronal plane fracture of the femoral condyle is known as a Hoffa fracture (typically type 33-B3 in the AO classification). Because the fracture line runs in the coronal plane (separating anterior from posterior), standard lateral-to-medial screw fixation will be parallel to the fracture line and fail to provide compression. The correct biomechanical fixation principle requires interfragmentary lag screws placed in an anterior-to-posterior (or posterior-to-anterior) direction, perpendicular to the fracture line.

Question 38

In a Young-Burgess Anteroposterior Compression (APC) Type III pelvic ring injury, the mechanism involves severe external rotation of the hemipelvis. Which of the following ligamentous complexes are completely disrupted, distinguishing it from an APC II injury and resulting in complete global (rotational and vertical) instability?

Explanation

In the Young-Burgess classification, APC injuries occur in a sequential cascade. APC I involves symphyseal diastasis < 2.5 cm. APC II involves symphyseal widening > 2.5 cm with tearing of the anterior SI ligaments, sacrospinous, and sacrotuberous ligaments, causing rotational instability but maintaining vertical stability because the posterior SI ligaments remain intact. An APC III injury implies complete disruption of both the anterior AND posterior SI ligaments (along with the pelvic floor ligaments), leading to complete spinopelvic dissociation and both rotational and vertical instability.

Question 39

A 6-year-old boy presents with a completely displaced, extension-type supracondylar humerus fracture (Gartland Type III). On examination, his hand is pink, warm, and has a brisk capillary refill, but the radial pulse is completely absent by palpation and Doppler. What is the most appropriate initial management?

Explanation

This is a classic 'pink, pulseless' hand scenario in a pediatric supracondylar humerus fracture. The limb is well-perfused via collateral circulation, but the main brachial artery is kinked or in spasm over the fracture site. The standard of care is urgent closed reduction and percutaneous pinning. In the vast majority of cases, anatomic reduction relieves the kinking, and the pulse returns. If the hand remains pink and well-perfused post-reduction despite an absent pulse, observation is appropriate. Open exploration is indicated only if the hand is persistently 'pale and pulseless' after reduction.

Question 40

A 65-year-old female on prolonged bisphosphonate therapy presents with a displaced atypical femoral fracture (AFF). Radiographs demonstrate marked anterolateral bowing of the femur. During cephalomedullary nailing of this fracture, which technical complication is most likely to occur due to the mismatch between the implant and the patient's altered anatomy?

Explanation

Patients with atypical femur fractures (AFFs) due to prolonged bisphosphonate use often exhibit exaggerated anterolateral bowing of the femur. Standard intramedullary nails are relatively straight compared to this geometry. When a straight, rigid nail is driven into a bowed femur, the tip of the nail impinges on the anterior cortex distally, frequently leading to an iatrogenic perforation or fracture of the anterior cortex. To prevent this, surgeons must carefully match the nail's radius of curvature, use a shorter nail, over-ream, or perform a correcting osteotomy.

Question 41

A 2-day-old infant presents with decreased movement of the left arm following a difficult vaginal delivery. Examination reveals a palpable mass and crepitus over the middle third of the left clavicle. The Moro reflex is asymmetric. What is the most appropriate management?

Explanation

Neonatal clavicle fractures are the most common obstetrical fractures. They are benign and heal rapidly with minimal intervention, typically requiring only supportive care such as pinning the sleeve to the shirt to minimize arm movement and reduce pain.

Question 42

A macrosomic newborn presents with decreased spontaneous motion of the left upper extremity after a difficult breech delivery. Radiographs show a normal glenohumeral relationship but medial displacement of the proximal humeral shaft relative to the glenoid. What is the most appropriate next step in diagnosis or management?

Explanation

This presentation is highly suspicious for a proximal humerus physeal separation, often confused with a shoulder dislocation in newborns. Ultrasound is the imaging modality of choice to visualize the unossified epiphysis and confirm the diagnosis.

Question 43

A 28-year-old polytrauma patient with a bilateral femur fracture and pulmonary contusion is evaluated for surgery. Which of the following laboratory values is an established threshold indicating a 'borderline' or 'unstable' patient, favoring Damage Control Orthopedics (DCO) over Early Total Care (ETC)?

Explanation

A base deficit > 6 mmol/L, lactate > 2.5 mmol/L, pH < 7.24, and platelets < 90,000/mm3 are physiologic indicators of a borderline or unstable patient. These derangements suggest the patient is not adequately resuscitated, favoring DCO to avoid the 'second hit' of prolonged surgery.

Question 44

A 4.5 kg neonate is delivered via normal vaginal delivery complicated by shoulder dystocia. Postnatally, the infant exhibits absent active movement of the right hand and fingers, a claw-like hand deformity, and ptosis and miosis of the right eye. The shoulder and elbow movements are relatively preserved. Which nerve roots are most likely injured?

Explanation

Klumpke's palsy involves the lower roots (C8, T1), presenting with intrinsic hand muscle paralysis and an absent grasp reflex. The associated Horner's syndrome (ptosis, miosis, anhidrosis) confirms T1 sympathetic root preganglionic involvement.

Question 45

During resuscitation of a polytraumatized patient with severe pelvic and lower extremity crush injuries, a Massive Transfusion Protocol (MTP) is initiated. Based on current trauma guidelines, what is the optimal ratio of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets to improve early survival?

Explanation

The PROPPR trial demonstrated that a 1:1:1 ratio of PRBCs to FFP to platelets results in improved early hemostasis and reduces mortality from exsanguination. This ratio most closely mimics whole blood and mitigates trauma-induced coagulopathy.

Question 46

A 35-year-old male arrives after a severe crush injury with a blood pressure of 75 mmHg and a heart rate of 135 bpm. Pelvic radiographs show a displaced vertical shear pelvic fracture. A pelvic binder is applied, and uncrossmatched blood is transfused, but his hemodynamics do not improve. The FAST exam is negative. What is the most appropriate next step?

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST (ruling out major intra-abdominal hemorrhage), the pelvic retroperitoneum is the primary source of bleeding. Emergent retroperitoneal pelvic packing or angiography with embolization is indicated.

Question 47

A 5-day-old infant presents with decreased movement of the left lower extremity following a difficult breech delivery. Radiographs reveal a displaced spiral fracture of the midshaft of the left femur. What is the most appropriate initial management?

Explanation

In neonates and infants less than 6 months of age, isolated diaphyseal femur fractures are excellently managed with a Pavlik harness. This provides sufficient stabilization, allows for diapering, and relies on the immense remodeling potential at this age.

Question 48

A 24-year-old male sustains a closed comminuted femur fracture. Thirty-six hours after admission, he develops acute respiratory distress, confusion, and a petechial rash over his axillae and conjunctivae. Which of the following describes the underlying pathophysiology of this syndrome?

Explanation

Fat Embolism Syndrome (FES) presents with a classic triad of hypoxemia, neurological abnormalities, and petechial rash. It is caused by marrow fat entering venous circulation, causing mechanical microvascular obstruction and a toxic biochemical cascade from free fatty acids.

Question 49

A newborn has a swollen, externally rotated, and shortened right lower extremity following a breech delivery. Radiographs show the right femoral shaft displaced superiorly and laterally, but the femoral head ossification center is absent. Ultrasound confirms the femoral head remains within the acetabulum. What is the most likely diagnosis?

Explanation

Transepiphyseal separation of the proximal femur in neonates often mimics hip dislocation on plain film because the proximal epiphysis is unossified. Ultrasound or an arthrogram is crucial to distinguish it from DDH by confirming the head is located in the acetabulum.

Question 50

A 30-year-old male sustains a low-velocity gunshot wound to the right leg. Radiographs reveal a non-displaced midshaft tibia fracture. There is a clean entrance wound, no exit wound, and the bullet is not intracapsular. The neurovascular examination is intact. What is the standard of care?

Explanation

Low-velocity gunshot wounds resulting in non-displaced fractures with minimal soft-tissue damage can generally be treated like closed fractures. Management includes local wound care, tetanus prophylaxis, a short course of oral antibiotics, and appropriate splinting.

Orthopedic Ob Trauma Review | Dr Hutaif Trauma & Fractu -...

Quick Medical Answer

Orthopedic Ob Trauma Review | Dr Hutaif Trauma & Fractu -...

Detailed Chapters & Topics

Humeral Shaft Throwing Fractures in Overhead Athletes: Advanced Epidemiology, Biomechanics, and Surgical Anatomy

Advanced Insights into Distal Radius Fractures: Epidemiology, Classification, Anatomy & Biomechanics

Proximal Humerus Fractures: Comprehensive Guide to Epidemiology, Classification, & Surgical Anatomy

Orthopedic Trauma Review | Dr Hutaif Trauma & Fractures -...

Orthopedic With Answer Trauma Review | Dr Hutaif Trauma -...

Orthopedic Ob Trauma B Review | Dr Hutaif Trauma & Frac -...

Orthopedic Ob Trauma A Review | Dr Hutaif Trauma & Frac -...

Orthopedic Ob Trauma C Review | Dr Hutaif Trauma & Frac -...

Orthopedic Ob Trauma D Review | Dr Hutaif Trauma & Frac -...

Orthopedic Trauma Review | Dr Hutaif Trauma & Fractures -...

Orthopedic Trauma Review | Dr Hutaif Trauma & Fractures -...

Orthopedic Ob Trauma D Review | Dr Hutaif Trauma & Frac -...

Orthopedic Ob Trauma A Review | Dr Hutaif Trauma & Frac -...

Orthopedic Ob Trauma B Review | Dr Hutaif Trauma & Frac -...

Guide Overview