This image represents the end stage of an uncompensated rotator cuff tear.

Figure 59a is the CT image of an 86-year-old woman with acromiohumeral distance of less than 2 mm, night pain, and an inability to actively raise the affected arm above shoulder level.

What clinical scenario is most consistent with the MR image of the L4-L5 disk level shown in Figure 14? Review Topic

Left L4 nerve root radiculopathy

Hip pain of 1-month duration has developed in a 72-year-old man with a previous total hip arthroplasty.He underwent dental work 6 weeks ago. Aspiration shows a white blood cell count of more than 6,000 cells/μL (reference range 4,500 to 11,000 cells/

Poorer prognosis for eradication of infection than that associated with infection from sensitive organisms

A 12-year-old girl has had pain in her right knee for 1 month that started as activity-related and progressed to night pain. Radiographs are shown in Figures 16a and 16b, and a biopsy specimen is shown in Figure 16c. What is the recommended treatment

Preoperative chemotherapy followed by surgical resection of the lesion and postoperative chemotherapy

Orthopedic Review | Dr Hutaif General Orthopedics Revie -... | 100 Random Orthopedic MCQs

Question 1High Yield

The patient is treated by another physician and undergoes the procedure shown in Figures 40a and 40b. She currently cannot stand upright. Spinopelvic measurements reveal her pelvic incidence to be 85 degrees and pelvic tilt to be 40 degrees. Her lordosis from T12-S1 is 35 degrees. Which additional surgical procedure should be considered?
40A
B

Explanation

- Single-level pedicle subtraction osteotomy

Question 2High Yield

A 38-year-old man has winging of the ipsilateral scapula after undergoing a transaxillary resection of the first rib 3 weeks ago. What is the most likely cause of this finding?

Explanation

During transaxillary resection of the first rib, the long thoracic nerve is at risk as it passes either through or posterior to the middle scalene muscle. Injury to this nerve may occur as the result of overly aggressive retraction of the middle scalene during the procedure.
REFERENCES: Leffert RD: Thoracic outlet syndrome. J Am Acad Orthop Surg 1994;2:317-325.
Todd TW: The descent of the shoulder after birth: Its significance in the production of pressure-symptoms on the lowest brachial trunk. Anat Anz 1912;41:385-397.

Question 3High Yield

-Premature arrest following growth plate injury is attributed to what mechanism?

Explanation

No detailed explanation provided for this question.

Question 4High Yield

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal Lachman test finding. The injured structure is composed of an

Explanation

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used.
Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for _vascular injury._

Question 5High Yield

Figures 92a and 92b are the reconstruction radiographs of a 16-year-old boy with a high-grade conventional osteosarcoma of his right proximal tibia. He has completed neoadjuvant
chemotherapy. Wide resection, endoprosthetic proximal tibia replacement, a medial gastrocnemius flap, and a split-thickness skin graft were performed. The preferred postsurgical knee rehabilitation regimen is

Explanation

This patient underwent resection of the patellar tendon insertion onto the proximal tibia. The residual tendon is sutured to the prosthesis with augmentation of the repair by the medial gastrocnemius flap. Immobilization for 6 weeks in full extension is preferred to permit healing of the tendon repair and prevent patella alta with associated extensor lag. Cast, splint, or brace are all acceptable options for the initial immobilization. Risk for knee stiffness with such immobilization is low because all of the distal knee ligamentous and capsular attachments are transected with resection. Two weeks of immobilization may be adequate for flap and skin graft healing, but this amount of time is inadequate for patellar tendon healing. Continuous passive motion vs therapist-
directed range of motion has not been rigorously compared for proximal tibia replacement. Responses 1 and 2 include early motion.
RECOMMENDED READINGS
89. [Eckardt JJ, Matthews JG 2nd, Eilber FR. Endoprosthetic reconstruction after bone tumor resections of the proximal tibia. Orthop Clin North Am. 1991 Jan;22(1):149-60. PubMed PMID: 1992431. ](http://www.ncbi.nlm.nih.gov/pubmed/1992431)[View](http://www.ncbi.nlm.nih.gov/pubmed/1992431)[ ](http://www.ncbi.nlm.nih.gov/pubmed/1992431)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/1992431)
90. [Jentzsch T, Erschbamer M, Seeli F, Fuchs B. Extensor function after medial gastrocnemius flap reconstruction of the proximal tibia. Clin Orthop Relat Res. 2013 Jul;471(7):2333-9. doi: 10.1007/s11999-013-2851-8. Epub 2013 Feb 20. PubMed PMID: 23423620. ](http://www.ncbi.nlm.nih.gov/pubmed/23423620)[View Abstract at ](http://www.ncbi.nlm.nih.gov/pubmed/23423620)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23423620)
91. [Mavrogenis AF, Pala E, Angelini A, Ferraro A, Ruggieri P. Proximal tibial resections and reconstructions: clinical outcome of 225 patients. J Surg Oncol. 2013 Mar;107(4):335-42. doi: 10.1002/jso.23216. Epub 2012 Jul 17. PubMed PMID: 22806768. ](http://www.ncbi.nlm.nih.gov/pubmed/22806768)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22806768)

Question 6High Yield

Figure 59 is the MR image of a 17-year-old high school wrestler who has had multiple subluxation episodes of his right shoulder. Physical therapy has not controlled his symptoms, and he was unable to finish the wrestling season because of pain and instability. CT scanning is suggested. What is the advantage of a CT scan?

Explanation

Most studies suggest that bone loss is most accurately imaged with a CT scan. Soft-tissue damage is more difficult to assess. Although the Goutallier classification for fatty infiltration is based on CT and not MR imaging findings, this is not relevant here. Multidirectional instability is a clinical, not imaging, diagnosis. CT’s substantial radiation dose can be especially harmful to young people
who presumably could live long enough to develop radiation-induced malignancies. Cost differences are minimal, and faster acquisition times are not clinically relevant. Breast and thyroid tissue exposure poses increased risk for radiation exposure for shoulder CT.
RECOMMENDED READINGS
4. [Jahnke AH Jr, Petersen SA, Neumann C, Steinbach L, Morgan F. A prospective comparison of computerized arthrotomography and magnetic resonance imaging of the glenohumeral joint. Am J Sports Med. 1992 Nov-Dec;20(6):695-700; discussion 700-1. ](http://www.ncbi.nlm.nih.gov/pubmed/1456363)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/1456363)
5. [Orchard JJ, Orchard JW, Grenfell T, Mitchell A. Ionising radiation: three game-changing studies for imaging in sports medicine. Br J Sports Med. 2014 Apr;48(8):677-8. doi: 10.1136/bjsports-2013-092499. Epub 2013 Jun 1. PubMed PMID: 23729176. ](http://www.ncbi.nlm.nih.gov/pubmed/23729176)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23729176)
6. [What are the Radiation Risks from CT? ](http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm115329.htm)[http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-](http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm115329.htm)Rays/ucm115329.htm (Accessed August 25, 2016).
RESPONSES FOR QUESTIONS 60 THROUGH 66
1. Initial period of sling immobilization followed by physical therapy
2. Open reduction and internal fixation with or without bone grafting
3. Reverse total shoulder arthroplasty (rTSA)
4. Hemiarthroplasty
5. Unconstrained (TSA)
6. Closed reduction and Kirschner wire (K-wire) stabilization
Match the treatment listed above with the clinical scenario described below.

Question 7High Yield

Figure 58 is the CT scan of a 50-year-old man who has fallen from a height of 12 feet. He has a reported incomplete spinal cord injury. He is intubated and sedated prior to an examination. What are the likely neurological examination findings?

Explanation

This patient has sustained a fracture dislocation of his spine at T5. At this level of injury, the incident is unlikely to affect motor strength in the upper extremities, but it can affect motor function below T5. Sensation to the nipple line is typically at T4 and the umbilicus at T10. The absence of the bulbocavernosus reflex indicates spinal shock. Bulbocavernosus reflex refers to anal sphincter contraction in response to squeezing the glans penis or pulling on the Foley. Spinal shock usually resolves within 48 hours, and the return of the reflex signals termination of spinal shock. With this degree of fracture dislocation, it is unlikely that motor function is spared without sensation changes.
RECOMMENDED READINGS
5. [Ko HY, Ditunno JF Jr, Graziani V, Little JW. The pattern of reflex recovery during spinal shock. Spinal Cord. 1999 Jun;37(6):402-9. PubMed PMID: 10432259.](http://www.ncbi.nlm.nih.gov/pubmed/10432259)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10432259)
6. [Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, Johansen M, Jones L, Krassioukov A, Mulcahey MJ, Schmidt-Read M, Waring W. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med. 2011 Nov;34(6):535-46. doi: 10.1179/204577211X13207446293695. PubMed PMID: 22330108. ](http://www.ncbi.nlm.nih.gov/pubmed/22330108)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22330108)
7. American Spinal Injury Association Standards for neurological classification of spinal injured patients. Chicago, IL: ASIA; 1982.

Question 8High Yield

Which of the following soft tissue tumors may cause tumor-induced osteomalacia:

Explanation

Tumor-induced osteomalacia can be caused by a small tumor of bone or soft tissue (phosphaturic tumor). Small tumors may not be detected.
I. General Features
A. Presentation
1/. C hronic, vague symptoms - principally, bone pain
2/. Muscle weakness
3/. Fractures may occur
B. Metabolic profile
1/. Hypophosphatemia
2/. Low reabsorption of phosphate from the kidney
3/. 1,25 dihydroxy vitamin D - low or normal
4/. 25 hydroxy vitamin D, 24,25 dihydroxy vitamin D - normal
C . Tumor types
1/. Soft tissue
a. Hemangiopericytoma b. Sclerosing angioma
c. Benign angiofibroma d. Neurofibromatosis
D. Pathophysiology
1/. A molecule that wastes phosphorus - phosphatonin
E. Radiographic features
1/. Osteopenia
2/. Pseudofractures
3/. C oarsened trabeculae
4/. Soft tissue - a small, well-circumscribed soft tissue mass may be noted
F. Treatment
1/. Oral phosphate
2/. 1,25 dihydroxy vitamin D Correct Answer: Hemangiopericytoma

Question 9High Yield

**ONLINE ORTHOPEDIC MCQS FOOT0 9**
**1**. Figure 1 shows the radiograph of a 60-year-old woman who underwent a previous operation for great toe pain 20 years ago. She has had increasing pain over the past 5 years and now reports pain with any motion, swelling, and clicking. She also reports pain under the ball of foot. What is the most appropriate management to alleviate her metatarsalgia and great toe pain?

Explanation

The patient has a failed Silastic implant. Nonsurgical management will not work at this point. A Keller resection will only exacerbate her metatarsalgia. Implant removal with structural bone grafting and MTP fusion is the most appropriate choice because restoration of length is needed to alleviate the forefoot pain and bone grafting is required to fuse the MTP joint because there is an abundance of osteolysis. Total toe implants do not offer good long-term outcomes and are very difficult to fit into the large exploded-out cavity of the proximal phalanx.**
**

Scientific References

Question 10High Yield

Figure 6a through 6c

Explanation

Figure 2 depicts a typical unicameral bone cyst with a pathologic fracture. The decision to treat this lesion should be based on the amount of cortical thinning. If these lesions involve a pathologic fracture, many surgeons will treat them nonsurgically to see if the fracture stimulates healing of the cyst. If the cyst wall remains thin or the patient is symptomatic, then treatment is directed at decreasing cyst volume, increasing cortical thickness, and eliminating symptoms. This can be accomplished by curettage and grafting, injection with autogenous bone marrow, or grafting with 1 of the many available bone void fillers. In some cases, internal fixation may be required. This typically is accomplished with flexible intramedullary nails.
Figure 3 shows a typical nonossifying fibroma. These benign lesions are usually incidental findings on a radiograph and often resolve in adulthood. Treatment usually is not required, and these lesions typically do not produce symptoms.
Figure 4 shows an osteoid osteoma of the femoral neck. This is characterized by a central radiolucent nidus surrounded by reactive bone with increased radiodensity. These lesions are painful because of the large amount of prostaglandin they secrete. They temporarily respond to oral anti-inflammatory drugs. Treatment is directed at eliminating the nidus and can be done through curettage, but radiofrequency ablation, which allows for a minimally invasive approach, is often used today.
Figure 5 shows diskitis with vertebral osteomyelitis. The disease is characterized by fever and back pain. Movement is extremely uncomfortable for these children, and they may adopt unusual postures to alleviate pain. The MRI shows involvement of 1 vertebrae and an adjacent disk. Left untreated, this condition often spreads to involve multiple vertebrae and also can cause an epidural abscess. Treatment during the early stages is IV antibiotics. Many orthopaedic surgeons also use bracing to prevent late vertebral collapse.
Figures 6a through 6c show septic arthritis of the ankle with metaphyseal osteomyelitis. The recommended treatment is incision and drainage followed by IV antibiotics. MRI may be considered before surgery to assess for an associated osteomyelitis or abscess that may also necessitate surgical debridement. Increasingly, these scenarios are managed with a rapid transition to oral antibiotics.

Question 11High Yield

A 68-year-old man presents with chronic progressive right shoulder pain and loss of motion. He has active shoulder elevation of 120° and 5-/5 shoulder forward flexion strength limited by pain. He has exhausted nonsurgical management over the past year and is now interested in surgical intervention. Figure 1 is the preoperative axial CT scan of his shoulder. During surgical reconstruction, the surgeon should anticipate the location of maximal glenoid erosion to be
58

Explanation

In patients with primary osteo- arthritis of the shoulder, eccent- ric wear on the face of the glenoid is frequently combined with static subluxation of the humeral head. Current studies have clarified that patients with Walch B2 glenoid develop wear along the posterior inferior face of the glenoid and not directly posterior. At the time of shoulder arthroplasty, the eccentric center of rotation must be corrected by soft-tissue, bony, and/or implant
techniques to minimize the risk for poor outcomes. The surgeon should orient
his correction along the posterior inferior to anterior superior plane.

Question 12High Yield

Nerve conduction velocity is slowed by

Explanation

A number of factors affect nerve conduction velocity; for example, increased body temperature increases nerve conduction velocity. Nerve conduction velocity is slowed by advancing age, compression, decreased blood flow, and fibrosis (from large imprecise sutures used for nerve repair). There is no association between hand dominance and nerve conduction velocity.
RECOMMENDED READINGS
57. Dodds SD. Peripheral Nervous System. In Boyer MI, ed. AAOS Comprehensive Orthopaedic Review. Vol 1. 2nd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2014:113-126.
58. Freedman M, Helber G, Pothast J, Shahwan TG, Simon J, Sher L. Electrodiagnostic evaluation of compressive nerve injuries of the upper extremities. Orthop Clin North Am. 2012 Oct;43(4):409-16. doi:10.1016/j.ocl.2012.07.010. Epub 2012 Sep 10. Review. PubMed PMID: 23026456.
59. Lundborg G. A 25-year perspective of peripheral nerve surgery: evolving neuroscientific concepts and clinical significance. J Hand Surg Am. 2000 May;25(3):391-414. Review. PubMed PMID: 10811744.

Question 13High Yield

The mangled extremity severity score (MESS) utilizes all of the following variables EXCEPT:

Explanation

The MESS is a tool utilized to help predict limb salvage success versus primary amputation at the time of presentation. As a screening tool for amputation, this scoring system has a high specificity but low sensitivity, as scores lower than 7 may also ultimately need amputation. All of the variables except choice #5 are part of the scoring system.
The scoring system is as follows: 1. Skeletal / soft-tissue injury: Low energy = 1; Medium energy = 2; High energy = 3; very high energy = 4; 2. Limb ischemia: Pulse reduced or absent but perfusion normal = 1; Pulseless = 2; Cool, paralyzed, insensate = 3; 3. Shock: normotensive = 0; transient hypotension = 1; persistent hypotension = 2; 4. Age: < 30 = 0; 30-50 = 1;
>50 = 2. Limb category scores are doubled for ischemia > 6 hours. The system's original designers reported a cutoff of 7 as predicting amputation.
The referenced study by Ly et al found that the scoring system did not predict functional outcomes at 6 or 24 months. They also found that the Limb Salvage Index; the Predictive Salvage Index; the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score; and the Hannover Fracture Scale-98 all did not predict outcomes at 6 or 24 months.

Question 14High Yield

Figures 77a and 77b are the recent knee radiographs of a 53-year-old man whose history includes tobacco use and secondary polycythemia. He is now experiencing bilateral knee pain, knee swelling, and increasing discomfort with ambulation. All efforts at nonsurgical treatment have failed. What is the most reasonable next treatment option?

Explanation

The radiographs reveal bilateral bone infarcts with subchondral collapse. The images are diagnostic for bone infarct. Other hematological conditions are associated with multiple bone infarcts, including sickle-cell disease, hemophilia, aplastic anemia, thalassemia, and acute lymphoblastic leukemia. Postsurgical radiation therapy is considered for Paget disease, but the radiographic appearance is not consistent with that diagnosis.
RECOMMENDED READINGS
57. [Lotke PA, Ecker ML. Osteonecrosis of the knee. J Bone Joint Surg Am. 1988 Mar;70(3):470-3. Review. PubMed PMID: 3279040.](http://www.ncbi.nlm.nih.gov/pubmed/3279040)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/3279040)
58. [Sorich MM, Cherian JJ, McElroy MJ, Banerjee S, Jones LC, Minniti CP, Mont MA. Osteonecrosis of the Hip in Hematologic Disease: A Review of Conditions and Treatment Options. J Long Term Eff Med Implants. 2015;25(4):253-68. PubMed PMID: 26852634.](http://www.ncbi.nlm.nih.gov/pubmed/26852634)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26852634)
59. Karim AR, Cherian JJ, Jauregui JJ, Pierce T, Mont MA. Osteonecrosis of the knee: review. Ann Transl Med. 2015 Jan;3(1):6. doi: 10.3978/j.issn.2305-5839.2014.11.13. Review. PubMed PMID: 25705638.
[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25705638)
CLINICAL SITUATION FOR QUESTIONS 78 AND 79
Figures 78a through 78d are the radiograph, CT scans, and biopsy specimen of a 45-year-old man with a history of treatment for localized low-grade pelvic chondrosarcoma with limb salvage. He now has recurrent pain about his hip.

Question 15High Yield

An 18-year-old collegiate football player injures his right shoulder during a tackle. He reports pain and numbness in the shoulder and numbness radiating to his fingers. His symptoms improve within 15 minutes and he has no residual symptoms. This condition is best known as

Explanation

**
**
DISCUSSION: The condition described in this case is known as a stinger or burner. It is caused by stretching the upper trunk of the brachial plexus in the C5 and C6 nerve roots. The symptoms are temporary and last 15 to 20 minutes. There are no residual deficits, unless the patient has had multiple repetitive injuries. Once motor and sensory examination findings and reflexes have normalized, the athlete can return to play. Acute spinal cord injury may cause temporary complete paralysis in the upper and lower extremities with resolution of symptoms within 24 hours. Central cord syndrome affects the upper more than lower extermities and affects mostly elderly patients. Nerve root avulsions lead to permanent deficits and have a poor prognosis for return of function. Guillain-BarDe syndrome is an autoimmune disease that presents as an ascending paralysis with weakness in the legs that spreads to the upper limbs and the face along with complete loss of deep tendon reflexes.
REFERENCES: Safran MR: Nerve injury about the shoulder in athletes. Part 2: Long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med 2004;32:1063-1076. Aval SM, Durand P Jr, Shankwiler JA: Neurovascular injuries to the athlete’s shoulder: Part I. J Am Acad Orthop Surg 2007;15:249-256.

Question 16High Yield

Figure 20 shows the radiograph of a 21-year-old college basketball player who jammed his left index finger on the rim. He reports pain and tenderness over the dorsum of the distal interphalangeal (DIP) joint. Examination reveals that he is unable to actively extend the DIP joint; however, the skin is intact. Management should consist of

Explanation

Mallet fingers without DIP joint subluxation can be treated with extension splinting. Surgical fixation may be necessary in bony mallet injuries when the joint is subluxated. Size of the bony fragment, while often correlating with stability, is not always an indication for fixation. Buddy taping allows motion; therefore, the fragment will not heal in the appropriate position. Intermittent splinting with range-of-motion exercises also will not allow the fragment to heal in the appropriate position.
REFERENCES: Crawford GP: The molded polyethylene splint for mallet finger deformities.
J Hand Surg Am 1984;9:231-237.
Wehbe MA, Schneider LH: Mallet fractures. J Bone Joint Surg Am 1984;66:658-669.

Question 17High Yield

A 40-year-old male laborer with an acute left shoulder injury (Figures 94a and 94b).

Explanation

- Open reduction and internal fixation (ORIF)_

Question 18High Yield

Which of the following statements is true concerning atlanto-occipital dislocations in children:

Explanation

Pediatric atlanto-occipital dislocation is increasing in frequency due to improved emergency care. Although the injuries are sometimes fatal and are often accompanied by severe spinal cord injury, this is not always the case. Although the dens-basion distance should be less than 10 mm and the power ratio should be less than 1 in normals, these are not always abnormal in children with such injuries. C linical and radiographic correlation, with computer tomography or magnetic resonance imaging if needed, are called for to maximize diagnosis.

Question 19High Yield

..What is the best next step?

Explanation

- Posterior shoulder dislocation PREFERRED RESPONSE: 2- CT scan

Question 20High Yield

Which muscles cause the fracture displacement of the proximal fragment shown in figure A?

Explanation

The gluteus medius attaches to the greater trochanter, leading to abduction, while the iliopsoas attaches to the lesser trochanter, leading to flexion. French et al evaluated forty-five Russell-Taylor Type 1B subtrochanteric femoral fractures which were stabilized using an interlocked cephalomedullary nail. The intraoperative complication rate was 13.5%; and the most frequent complication was a varus malreduction. The primary reason for this was failure to counteract the muscle forces acting on the proximal fragment combined with the adducted position of the distal femur during portal creation. This problem can be avoided if the position of the proximal fragment is evaluated carefully and reduced before guidewire insertion.

Question 21High Yield

A 17-year-old football player is tackled with an opposing player's helmet hitting him hard in the abdomen. He is knocked backwards and suffers a diaphyseal femur fracture. He denies any loss of consciousness. Vital signs reveal a heart rate of 118, mean arterial pressure (MAP) of 68, and a respiration rate of 32 per minute. A FAST ultrasound study shows trace free fluid in the perisplenic space. A CBC taken prior to bolus IV fluids reveals a hematocrit of 48%, and a blood gas shows a lactate level of 1.8 and a base excess of -2.0. Which of the follow statements regarding the patient's hemodynamic status is correct?

Explanation

Normal lactate levels or base excess indicate adequate tissue perfusion.
Hypovolemic shock leads to poor tissue perfusion due to inadequate flow or oxygenation. If a patient is in compensated shock (i.e. normal vital signs), there may be ongoing inadequate perfusion of some end-organs. Elevated lactate or a base deficit are markers of poor end-organ perfusion, thus when normalized indicate appropriate end-organ perfusion even if vital sign derangements persist.
Rossaint et al. wrote a comprehensive review article in 2006 in which they discuss principles of fluid management, coagulopathy, hypothermia and tissue oxygenation in hypovolemic shock. In addition to prolonged elevated lactate levels correlating to mortality, lactate levels (or base deficits) can be used to evaluate for compensated shock in the setting of normal hemodynamic status.
Illustration A shows the classification of hypovolemic shock. Note the percent of blood loss required for vital sign abnormalities.
Incorrect Answers:
Answer 1: While an arterial line is often helpful in the setting of
uncompensated hemodynamic shock, it would not be as important as measures of adequate tissue perfusion for ruling out compensated shock. Answer 2: The hematocrit is expected to stay normal for a short time even in the setting of massive blood loss. The hematocrit only changes once the patient has physiologic or iatrogenic fluid shifts in response to the blood loss. Answer 3: Vital sign derangements indicate uncompensated shock, but do not directly measure tissue perfusion or end-organ damage
Answer 5: Though uncommon, bleeding from isolated femur fractures can lead to Class II shock (blood loss 15-30%)

Question 22High Yield

Figures 66a and 66b are the radiographs of a healthy 54-year-old right-hand-dominant man 3 months after he fell onto his outstretched left hand. He was initially treated with 8 weeks of closed reduction and casting. He reports ongoing ulnar-sided wrist pain, stiffness, and diminished function. An examination reveals a clinical sag deformity with a loss of radial length but no substantial swelling. The distal radius is nontender, and rotation is nearly full. Wrist motion is limited, with 55 degrees of flexion, 25 degrees of extension, and full digital motion. The most appropriate treatment is

Explanation

This patient has a substantial nascent malunion of his distal radius. Although a distal ulna excision would likely improve his ulnar-sided wrist pain, the Darrach procedure is more appropriate for older, somewhat less active individuals. In addition, the distal radius malunion is substantial, and it would be preferable to address the malunion given the major loss of radial length, inclination, and increased palmar tilt. The joint surface of the distal radius is uninvolved, and there is no evidence of arthrosis. It is preferable to osteotomize the distal radius sooner rather than later. Delayed osteotomy is often more difficult with more severe soft-tissue contractures, and improved results have been demonstrated following surgical treatment of nascent rather than mature distal radius malunions. Advantages include easier correction, no need for structural bone grafts, less overall total disability, and earlier return to work.
RECOMMENDED READINGS
30. Bilgin SS, Armangil M. Correction of nascent malunion of distal radius fractures. Acta Orthop Traumatol Turc. 2012;46(1):30-4. PubMed PMID: 22441449.
31. Jupiter JB, Ring D. A comparison of early and late reconstruction of malunited fractures of the distal end of the radius. J Bone Joint Surg Am. 1996 May;78(5):739-48. PubMed PMID: 8642031.

Question 23High Yield

A 56-year-old man sustained a nondisplaced extra-articular fracture of the proximal aspect of the third metatarsal after dropping a heavy object on his left foot. Management should consist of

Explanation

This injury pattern is one of a direct trauma to the mid aspect of the foot. Without additional forces involved, capsular ligamentous injury is not anticipated; therefore, the injury should be a stable pattern. Treatment should consist of protected weight bearing as tolerated in a walking boot or walking cast. Surgical intervention with open reduction and internal fixation, percutaneous pinning, or open reduction and internal fixation with primary tarsometatarsal joint fusion is not indicated with this pattern of injury. The use of external bone stimulation in this acute fracture setting is not indicated. With injuries to the midfoot area where the exact mechanism of injury is uncertain, there should be a high index of suspicion for an associated injury to the tarsometatarsal joint, and standing radiographs or stress radiographs should be obtained.
REFERENCES: Myerson MS: Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1265-1296.
Early JS: Fractures and dislocations of the midfoot and forefoot, in Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001,
pp 2181-2245.

Question 24High Yield

Figures 15a and 15b are the radiographs of an active 65-year-old woman who has a 3-year history of increasing foot pain and flattening of the left foot. Inversion strength is 5+ and does not reproduce her symptoms. Bracing and nonsteroidal anti-inflammatory drugs have failed to provide adequate relief. She has a supple hindfoot and normal heel cord flexibility. What is the most appropriate treatment?
---

Explanation

The patient has a calcaneal fracture malunion, with symptomatic subtalar arthritis and anterior ankle and lateral subfibular impingement. Distraction subtalar arthrodesis addresses subtalar arthritis and anterior impingement and lateral wall ostectomy relieves symptoms of lateral impingement.The other procedures do not address all facets of the patient’s symptoms.

Question 25High Yield

-Figure 81 is the radiograph of a healthy 72-year-old man who has a 3-month history of medial knee pain.He denies any specific trauma. Until 3 months ago when the pain began, he had been an avid runner for many years. Initial treatment should be oral anti-inflammatory medication

Explanation

No detailed explanation provided for this question.

Question 26High Yield

Tourniquet use has been associated with increased pain post-operatively.

A 24-year-old male sustains the isolated injuries shown in Figures A and B during a high-speed motor vehicle accident. On physical examination, the overlying skin is intact and there is no evidence of a Morel-Lavallée lesion. Which of the following surgical techniques is considered to have the highest rate of fracture malreduction with this combined injury?

Explanation

Based on the radiographs shown, the patient has a comminuted trans-olecranon fracture dislocation of the elbow. Stability will be optimized with internal fixation in the form of a plating construct.
Trans-olecranon fracture dislocations often occur in the young secondary to high energy mechanisms. Direct blows often lead to high levels of comminution; the distal humerus is driven into the proximal ulna and olecranon, thereby leading to a concomitant dislocation. In this setting, the optimal treatment is use of a plate and screw fixation construct to provide mechanical stability.
Veillette et al. review the epidemiology, pathophysiology and treatment options for olecranon fractures. They highlight that because olecranon injuries involve the articular surface, fixation constructs should allow anatomic restoration of the joint surface. Additionally, fixation constructs should allow for early mobilization in order to prevent stiffness of the elbow.
Mortazavi et al. retrospectively reviewed eight patients who sustained anterior trans-olecranon fracture dislocations of the elbow. Based on their experience, they recommend use of plate fixation to optimize stability of the elbow.
Additionally, they indicate that satisfactory results can be obtained if the greater sigmoid notch is appropriately reduced.
Figures A and B show the AP and lateral radiographs of a trans-olecranon fracture dislocation of the elbow. Severe comminution of the olecranon can be seen on the lateral radiograph in Figure B.
Incorrect Answers:
Answers 1, 2, 4: K-wires alone would not provide optimal stability and allow for early motion. A tension-band construct or IM screw fixation is contraindicated with this degree of comminution.

: Use of cast immobilization would lead to high levels of stiffness and is not indicated for this patient.

A 25-year-old male sustained an isolated injury to his right foot after a fall from height. On examination, he has moderate swelling and pain over the dorsum of the foot. The overlying skin is intact. Radiographs of the foot are seen in Figures A and B. A CT scan image is seen Figures C. When consenting the patient for open reduction and internal fixation of this injury, what would you document as the most common complication?
1) Symptomatic implants

2) Subtalar arthritis

3) Tibiotalar arthritis

4) Malunion

5) Wound dehiscence

This patient has sustained a displaced talar neck fracture. The most common complication associated with this injury is post-traumatic arthritis of the subtalar and tibiotalar joint.
Talar neck fractures are the most common fracture of the talus. They occur most frequently during forced dorsiflexion of the foot with axial load. Displaced fractures are best treated with anatomic reduction and stable internal fixation.
Complications of surgery include nonunion or malunion, post-traumatic arthritis, infection, osteonecrosis, and secondary surgery. The prevalence of post-traumatic subtalar arthritis has been shown to be approximately 50-100% with these injuries.
Lindvall et al. examined a retrospective cohort of twenty-six displaced talar neck fractures that had been treated with open reduction and stable internal fixation. They reported that 26/26 fractures developed post-traumatic arthritis and pain within 48 months of follow-up after fixation. They concluded that post-traumatic arthritis is a more common complication than osteonecrosis following operative treatment.
Vallier et al retrospectively reviewed the records of 39 fractures of the talar neck treated with open reduction and internal fixation. Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p
A 23-year-old man presents with the injury seen in Figure A after a motor vehicle collision. He undergoes the treatment seen in Figure B. Which of the following statements is most accurate when comparing his treatment with open reduction and internal fixation?
1) Higher rates of radial nerve injury

2) Higher total complication rate

3) Lower rates of nonunion

4) Lower rates of shoulder impingement

5) Lower rates of malunion

Antegrade intramedullary (IM) nailing of humeral shaft fractures has been found to be associated with increased complication rates when compared with open reduction and internal fixation (ORIF).
Operative treatment of humeral shaft fractures remains controversial, with prospective randomized studies demonstrating small differences between IM nailing and ORIF.
Heineman et al. (2010) conducted a meta-analysis of prospective randomized studies comparing IM nailing with ORIF for humeral shaft fractures. The authors found no significant difference between the two treatment modalities for either their primary outcome (complications) or any of the secondary outcomes (nonunion, infection, nerve palsy, re-operation)
Heineman et al. (2012) have recently conducted an update on their meta-analysis to include more recent randomized studies. With the inclusion of these newer studies the author found a statistically significant increase in total complication rate with the use of IM nailing compared with ORIF.
Figure A demonstrates a displaced, transverse humeral shaft fracture. Figure B demonstrates antegrade IM nailing of a humeral shaft fracture
Incorrect Answers:
Answer 1: Radial nerve injury has not been shown to be different between IM nailing and ORIF
Answer 3: No difference in union rates between the two modalities in prospective studies
Answer 4: Higher rates of shoulder impingement have been seen with IM nailing in some studies
Answer 5: No difference in rates of malunion between IM nailing and ORIF

Elevated interleukin 6 (IL-6) is most closely associated to which of the following clinical outcomes in orthopedic trauma patients?

1) Decreased mortality rates

2) Increased mortality rates

3) Decreased osteomyelitis infection rates

4) Increased rhabdomyolysis rates

5) Increased compartmental syndrome rates

Elevated levels of Interleukin 6 (IL-6) is most closely associated with higher injury severity scores and increased mortality rates in polytrauma orthopaedic patients.
Hyperstimulation of the inflammatory system by major trauma is considered to be the key element in the pathogenesis of severe inflammatory response syndrome and multi-organ dysfunction syndrome. IL-6 is a complex acute-reactant cytokinase that is expressed by cells in response to tissue injury. IL-6 levels are associated with injury severity, complications, and mortality.
Patients with the most severe injuries have the highest IL-6 serum levels.
Sears et al. reviewed the markers of inflammation in major trauma. They suggest that interleukin-6 and human leukocyte antigen-DR class II molecules appear to have the greatest potential for use in predicting the clinical course and outcome in trauma patients. Early identification of traumatic patients, based on inflammatory markers and genomic predisposition, could help to guide intervention and treatment.
Pape et al measured the perioperative concentrations of interleukin-6 in sixty-eight blunt trauma patients with non-life threatening pelvic fractures. Release of proinflammatory cytokines were higher in patients undergoing surgical procedures that cause increased blood loss. The release of markers seems to be related to the type and magnitude of surgery, rather than to the duration of the procedure.
Illustration A shows a diagram of the acute inflammatory response after major trauma
Incorrect Answers:
Answer 1: Mortality rates have shown to be increased with elevated levels of IL-6 in early trauma.
Answer 3: Osteomyelitis is a complication of open fracture trauma. Elevated levels of IL-6 and CRP are seen with this infection.
Answer 4: IL-6 is not commonly measured in rhabdomyolysis. Creatine kinase is commonly elevated with musculoskeletal injury.
Answer 5: Elevated IL-6 levels are not closely correlated with incidence incidence of compartmental syndrome.

A 26-year-old female sustained a closed femoral shaft fracture which was treated as shown in Figure A. She subsequently developed a painful oligotrophic nonunion and an exchange nailing was performed 6 months later. However, she has had persistent pain in the thigh since time of revision surgery seven months ago, but denies any fevers, chills, or night sweats. Current examination reveals a mildly tender right thigh with no obvious deformity. Laboratory studies for infectious markers are normal, but her radiograph in Figure B continues to show an oligotrophic nonunion. Which of the following factors has most likely contributed to her current presentation?
1) One pack of cigarettes per day for last 8 years

2) Positive intraoperative cultures for coagulase-negative Staphylococcus at the time of nail exchange

3) Iliac crest bone grafting at the time of nail exchange

4) Exchange nail was dynamically interlocked

5) A larger diameter nail was used in the exchange

The clinical presentation and radiographs are consisted with persistent oligotrophic non-union of the femur, after reamed nail exchange. Of the following factors, cigarette smoking has been shown to have the biggest effect on non-union in this population.
Reamed intramedullary nail exchange has become widely accepted as the treatment of choice for most diaphyseal femoral nonunions. The use of reamed exchange nailing are thought to allow for more biomechanical stability via larger diameter nails and improved biologics with bone reaming. These will help to generate bone healing and bridge fracture gaps. Smoking has been shown clinically and experimentally to affect union rate and fracture callus strength. Patients with femoral shaft non-unions should be forewarned of the its effect on fracture healing in nail exchange.
Hak et al retrospectively reviewed a cohort of 23 patients treated with reamed nail exchange for symptomatic femoral shaft non-unions. 15 of the patients were smokers and only 10 (66.7 percent) went on to heal after reamed nail exchange. This was in comparison to all 8 non-smoking patients who healed without complication after exchange reamed nailing. They suggest that smokers should be referred to an appropriate smoking cessation program before revision nail exchange is considered.
Figure A shows a proximal third femoral shaft fracture that was treated with intramedullary nailing. The oblique fracture line remains evident with a small callus response at the fracture site at 8 months post-operative. Figure B shows an radiograph of the exchange femoral nail 7 months after revision sugary.
There is increased fracture callus at fracture site, however the fracture line remains evident.
Incorrect Answers:
Answer 2: Intraoperative coagulase-negative staph. cultures are likely contaminant. The patient denies infectious symptoms and inflammatory markers for infection are negative. In addition, the radiographs do not suggest infection as there is no cortex irregularity, bone lysis, or implant loosening.
Answer 3: Bone grafting at the time of nail exchange has shown to increase bone union.
Answer 4: Dynamic interlocked screws were shown to increase bone union greater than static interlocked screws at the time nail exchange.
Answer 5: Bone grafting at the time of nail exchange has shown to increase bone union.

The sacrospinous and sacrotuberous ligaments are disrupted in which of the following injury patterns?

1) Ischial tuberosity avulsion fracture

2) Type I anterior-posterior compression pelvic ring injury

3) Type II lateral compression pelvic ring injury

4) Type II anterior-posterior compression pelvic ring injury

5) Both column acetabular fracture

Type II anterior-posterior compression (APC) pelvic ring injuries have disruption of the symphysis pubis, as well as disruption of the anterior SI ligaments, sacrotuberous ligament, and sacrospinous ligament. The alternative pattern of disruption of the pelvic floor ligaments is sometimes seen as an avulsion injury from the bony attachments of these structures (sacrum or ischium).
The progression of this pattern to involve the posterior SI joint ligaments creates a type III pattern, which is vertically and rotationally unstable.
Tile published a comprehensive review of pelvic ring injuries, focusing on the
anatomy and pathology of these injuries. He noted that the posterior SI complex is the most important to pelvic ring stability, which is the reason why these are generally classified by the grade of posterior injury. He also reminds the reader that these classification systems are not a substitute for individualized treatment decision making.
Illustration A shows an APC III pelvic ring injury, with significant symphyseal diastasis and SI joint widening. Illustration B shows the ligamentous anatomy of the pelvic ring.
Incorrect Answers:
Answer 1: These injuries are generally seen in sports-related trauma, with avulsion of the hamstring(s) from the ischium.
Answer 2: This injury pattern does not have any involvement of these two ligaments by definition.
Answer 3: This injury pattern involves inward rotation of the hemipelvis, thus protecting these structures. A type III LC injury may have a contralateral rupture of these ligaments, however.
Answer 5: This injury pattern typically does not involve rupture of these ligaments unless an ipsilateral pelvic ring injury is seen.

A 34-year-old man is involved in a motorcycle accident and sustains a closed tibia fracture and multiple rib fractures. A radiograph is provided in Figure A. During surgical treatment of this fracture, which of the following techniques will help facilitate a successful reduction and intramedullary fixation?
1) Hyperflexion to help prevent apex anterior angulation

2) A medial parapatellar incision to help prevent valgus angulation

3) Starting point just lateral to the medial tibial eminence to help prevent valgus angulation

4) A medially placed blocking screw to help prevent valgus angulation

5) Suprapatellar nailing technique to help prevent apex anterior angulation

The clinical scenario and radiograph demonstrate a proximal tibia fracture amenable to intramedullary nail fixation. The suprapatellar nailing technique helps prevent apex anterior or procurvatum deformity typical of these injuries.
Proximal third tibial shaft fractures are often difficult to reduce anatomically due to the tendency for both valgus and flexion deformity at the fracture site. Many different techniques have been devised to overcome the deforming forces. These include (1) Poller blocking screws posterior and lateral to the intramedullary nail (IMN), (2) utilizing a semi-extended knee position during IMN of proximal tibia fractures, (3) use of a suprapatellar approach for IMN,

Question 27High Yield

Lyme disease is caused by which of the following organisms or mechanisms:

Explanation

Lyme disease was initially thought to be an idiopathic autoimmune disorder; however, in the 1970s, researchers at Yale University identified Borrelia burgdorferi as the cause of the disease. The disease is transmitted by a deer tick known as Ixodes ricinusi.
Group A streptococcal pharyngitis may be followed by rheumatic fever, but not Lyme disease.
Vibrio vulnificus is the organism responsible for severe soft tissue infections in patients who are exposed to fresh-water shellfish. Group B Streptococcus is a common etiologic agent for necrotizing fasciitis.

Question 28High Yield

In obstetric brachial plexus injury, return of which of the following muscle by 3 months is considered an indicator of plexus recovery:

Explanation

Biceps recovery at 3 months is considered the single most important indicator of recovery in obstetric plexus palsy.

Question 29High Yield

Disruption of which anatomic structure is necessary for the second-toe pathology to occur?

Explanation

- Plantar plate

Question 30High Yield

A right-handed 24-year-old woman underwent an arthroscopic Bankart repair for recurrent anterior dislocations 9 months ago. Despite extensive physical therapy for 8 months, the patient has very limited range of motion (elevation to 130 degrees and external rotation to 10 degrees with the arm at the side). Shoulder radiographs are normal. The next step in management should consist of

Explanation

Arthroscopic capsular release is an effective means of treating stiffness that is the result of capsular contractures, such as in the case of a tight Bankart repair. Open release allows lengthening of a surgically shortened subscapularis, such as after a tight Putti-Platt repair. Additional physical therapy is unlikely to be effective because 8 months of treatment has failed to result in improvement. Accepting this degree of asymptomatic limited motion is not advisable because of the functional limitations for the patient and the increased risk of postoperative degenerative arthritis.
REFERENCES: Warner JJ, Allen AA, Marks PH, Wong P: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 1997;79:1151-1158.
Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic management of refractory shoulder stiffness. Arthroscopy 1997;13:133-147.

Question 31High Yield

A 45-year-old woman has severe anterior knee pain. Her radiographs indicate end-stage patellofemoral
compartment osteoarthritis. The tibiofemoral compartments are preserved. Extensive nonsurgical treatment has failed to provide relief, and she is offered patellofemoral arthroplasty (PFA). What is the most common long-term mode of failure for PFA using an implant with an onlay prosthesis design?

Explanation

Contemporary onlay-design trochlear prostheses in PFA replace the entire anterior trochlear surface. Previous inlay designs were inset within the native trochlea and carried a higher risk of catching and patellar instability, particularly in patients with trochlear dysplasia; they also generally have higher failure rates. The current most common mode of failure is progression of arthritis throughout the knee, in some series as high as 25% at 15 years. Aseptic loosening, particularly of cemented implants, is less common. Infection is an uncommon long-term complication. Patients considering PFA should be advised of the risk of arthritis progression. Many authors routinely obtain a preoperative MRI to assess the status of the tibiofemoral compartments.

Question 32High Yield

Which of the following drugs is a selective estrogen receptor modulator:

Explanation

A new class of selective estrogen receptor modulator acts as an antagonist in breast tissue and an agonist in bone. Raloxifene selectively stimulates estrogen receptors in bone and is an antagonist in breast tissue.
Progestin used in conjunction with estrogen opposes the action of estrogen and lowers the risk of endometrial cancer that might occur with estrogen therapy alone.
Aredia, Fosamax, and alendronate are biphosphonates that inhibit osteoclasts, thereby decreasing bone resorption.Correct
Answer: Evista (raloxifene, Eli Lilly and Company)

Question 33High Yield

In an obese patient undergoing unicondylar knee arthroplasty (UKA):

Explanation

The knee should have less than 15° of deformity in varus or valgus and less than 10° flexion contracture. Inflammatory or crystalline-induced arthritis, knee subluxation, gross ligamentous laxity, and obesity are relative contraindications to the procedure. Scott and colleagues found that increased body weight contributed to failure in UKA and suggested that the best candidates are less than 180 lb

Question 34High Yield

The patient fails nonsurgical treatment for this condition. What is the best next step?

Explanation

Osgood-Schlatter disease is an apophysitis of the tibial tubercle. This condition is present in males more than females and occurs prior to fusion of the tubercle to the epiphysis of the tibia. The apophysis is cartilaginous before 11 years of age and begins to ossify between 11 and 14 years of age. The apophysis fuses to the epiphysis between 14 and 18 years of age (females before males). Symptoms are pain and swelling, and pain is worse with jumping and running. Initial treatment should consist of activity limitation, ice, quadriceps and hamstring stretching, and possible bracing. NSAIDs may be used to control symptoms. When symptoms resolve, the athlete may return to activities. In fewer than 10% of cases, symptoms persist after skeletal maturity. For these patients, excision of the ossicle will usually resolve symptoms. The ossicle is usually not part of the tendon attachment and can be resected without detaching any of the patellar tendon.
RECOMMENDED READINGS
1. [Vergara-Amador E, Davalos Herrera D, Moreno LÁ. Radiographic features of the development of the anterior tibial tuberosity. Radiologia. 2016 Feb 22. pii: S0033-8338(16)00019-9. doi: 10.1016/j.rx.2016.01.005. [Epub ahead of print] English, Spanish. PubMed PMID: 26917430. ](http://www.ncbi.nlm.nih.gov/pubmed/26917430)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26917430)
2. [Frank JB, Jarit GJ, Bravman JT, Rosen JE. Lower extremity injuries in the skeletally immature athlete. J Am Acad Orthop Surg. 2007 Jun;15(6):356-66. Review. PubMed PMID: 17548885. ](http://www.ncbi.nlm.nih.gov/pubmed/17548885)[View Abstract](http://www.ncbi.nlm.nih.gov/pubmed/17548885)[ ](http://www.ncbi.nlm.nih.gov/pubmed/17548885)[at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17548885)

Question 35High Yield

A 10-year-old boy sustained an injury to the left knee. The radiographic findings shown in Figure 19 are most commonly associated with injury to which of the following structures?

Explanation

The radiograph shows a bony avulsion of the ACL attachment site on the tibial spine in this skeletally immature patient. In this age group, injury often results in failure of the bony attachment site rather than the substance of the ligament. Avulsion of the patellar tendon insertion site can occur, but this structure is located at the apophysis of the tibial tubercle. The attachment site of the PCL is much more posterior. In adults, bony avulsion is more commonly associated with PCL injuries than with ACL injuries. When a small bony avulsion of the lateral capsule from the lateral tibial plateau is seen on the AP view, this finding is considered pathognomonic of an ACL injury (Segond sign) in adults. The area of the pes anserinus is anterior and distal; avulsion would be unusual.
REFERENCES: Baxter MP, Wiley JJ: Fractures of the tibial spine in children: An evaluation of knee stability. J Bone Joint Surg Br 1988;70:228-230.
Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.
DeLee JC: Ligamentous injury of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 406-432.

Question 36High Yield

The second-toe deformity is most accurately described as

Explanation

- crossover toe.

Question 37High Yield

Figures 1 and 2 are the AP and lateral radiographs of a 5-year-old African-American boy who has a 1-month history of pain and swelling in his upper arm. His mother reports a medical history that includes sickle cell disease. Laboratory studies demonstrate elevated erythrocyte sedimentation rate and C-reactive protein level, and a white blood cell count of 17,000. What organism is most likely associated with this process in the patient?

Explanation

■
Although patients with sickle cell disease are at far higher risk of developing salmonella osteomyelitis than the general population, Staphylococcus aureus remains the most common organism causing osteomyelits in children of this age group.

Question 38High Yield

Which of the following is the only nonreversible effect of anabolic steroids?

Explanation

DISCUSSION: The loss of hair or alopecia, is the only nonreversible effect of anabolic steroid use.
Once anabolic steroids are stopped, muscle hypertrophy and training gains are quickly lost and the HDL/ LDL ratios return to their preexisting levels. Fortunately, the personality effects and the acute acne are reversible.
REFERENCES: Hartgens F, Kuipers H: Effects of androgenic-anabolic steroids in athletes. Sports Med 2004;34:513-554.
Evans NA: Current concepts in anabolic-androgenic steroids. Am J Sports Med 2004;32:534-542.

Question 39High Yield

Which of the following genes has been shown to stimulate proteoglycan synthesis for prevention of disk degeneration:

Explanation

Intervertebral disk degeneration has been associated with a progressive decrease in proteoglycan content of nucleus pulposus. The potential application of gene therapy for prevention of disk degeneration is to increase or maintain the proteoglycan content of nucleus pulposus. Thompson and colleagues reported that addition of TGF-Ã1 to canine disk tissue in culture stimulated in vitro proteoglycan synthesis

Question 40High Yield

Figures 38a and 38b

Explanation

Inversion of the ankle can cause various injuries about the foot and ankle, all via the same mechanism. Fifth metatarsal base avulsion (Figure 35) fractures can be treated with use of a walking boot until pain subsides. Jones fractures (Figure 36) can be treated with surgical or nonsurgical treatment, although young, active patients are perhaps better treated with ORIF, which can decrease disability time. Treatment of an anterior process calcaneus fracture (Figure 37) is similar to that for a fifth metatarsal base avulsion fracture. Figures 38a and 38b show a calcaneal fracture-dislocation, which necessitates ORIF.
RECOMMENDED READINGS
1. [View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23959223)
2. [Polzer H, Polzer S, Mutschler W, Prall WC. Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence. Injury. 2012 Oct;43(10):1626-32. doi: 10.1016/j.injury.2012.03.010. Epub 2012 Mar 30. Review. PubMed PMID: 22465516. ](http://www.ncbi.nlm.nih.gov/pubmed/22465516)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22465516)
3. [Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1307-15. doi: 10.1007/s00167-012-2138-8. Epub 2012 Sep 6. Review. PubMed PMID: 22956165. ](http://www.ncbi.nlm.nih.gov/pubmed/22956165)[View Abstract at](http://www.ncbi.nlm.nih.gov/pubmed/22956165)[ ](http://www.ncbi.nlm.nih.gov/pubmed/22956165)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22956165)
4. [Berkowitz MJ, Kim DH. Process and tubercle fractures of the hindfoot. J Am Acad Orthop Surg. 2005 Dec;13(8):492-502. Review. PubMed PMID: 16330511. ](http://www.ncbi.nlm.nih.gov/pubmed/16330511)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16330511)

Question 41High Yield

Which of the following statements best characterizes a Dega osteotomy as a distinct osteotomy from a Salter osteotomy:

Explanation

The Dega osteotomy, originally described in Poland in 1964, is an incomplete transiliac osteotomy. The medial pelvic cortex is largely preserved, and the osteotomy hinges upon this point. Both osteotomies are best performed in young children, before triradiate cartilage closure. The Salter osteotomy is stabilized by pins, so the Dega needs no internal fixation. The Salter osteotomy lengthens the limb because it is a complete osteotomy.

Question 42High Yield

A 5-year-old boy has had a limp for the past 4 weeks with intermittent pain at the foot. He remains normally active and has no history of trauma. He has no fevers, rashes, or swelling. Examination reveals tenderness at the mid-dorsum of the foot medially. Radiographs are seen in Figures la and lb. Treatment should include which of the following?

Explanation

DISCUSSION: Osteochondrosis of the tarsal navicular is most commonly identified between the ages of 2 and 9 years. The condition is benign and self limited in nature. In patients with severe pain, a period of casting may be warranted, but otherwise management usually consists of observation or a supportive orthotic.

REFERENCES: DiGiovanni CW, Patel A, Calfee R, et al: Osteonecrosis in the foot. J Am Acad Orthop Surg 2007;15:208-217.
Williams GA, Cowell HR: Kohler’s disease of the tarsal navicular. Clin Orthop Relat Res 1981 ;158:53- 58.

8 • American Academy of Orthopaedic Surgeons**

Figure 2

Question 43High Yield

A 24-year-old white man presents to the emergency department. He was bitten on his fist while fighting with another man. You notice teeth marks on the dorsum of the metacarpophalangeal (MC P) joint of the right middle finger. The bite does not appear to be deep because the joint is not exposed, and you can see the extensor tendon, which seems intact. The patient has active extension at the MC P joint. The wound is red and swollen, but there is no tenderness or redness on the volar aspect of the MC P joint. The patient has some limitation in range of motion. He is afebrile. Radiographs reveal air in the joint but no joint
dislocation or fracture, and there is no neurovascular deficit. All of the following are appropriate steps in the management of this patient except:

Explanation

Human bite wounds on the hand are typically found over the MP joint. The mechanism of injury is a clenched-fist blow to the mouth. Oral flora enters the wound, which often communicates with the joint. Eikenella corrodens is frequently cultured from human bite wounds, but the most common pathogen is staphylococcus aureus. Appropriate treatment includes the administration of tetanus toxoid, exploration if there is air in the joint or frank infection, observation, intravenous antibiotics, arm elevation, and splinting. All bites over joints should be assumed to penetrate and require formal incision and drainage.

Question 44High Yield

Second-impact syndrome following a concussion

Explanation

According to several consensus statements, no child or adolescent athlete with a concussion should be allowed to return to play on the same day, regardless of severity. Second-impact syndrome refers to a second traumatic head injury that occurs while an athlete is still experiencing symptoms from the first injury. Young athletes are particularly vulnerable to second-impact syndrome. The mechanism by which this syndrome occurs likely is disruption of cerebral autoregulation, which may result in cerebral vascular congestion, diffuse brain swelling, and death.

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6a

Figure 6b

Figure 6c
RESPONSES FOR QUESTIONS 2 THROUGH 6
1. Curettage and/or grafting
2. Radiofrequency ablation
3. Intravenous (IV) antibiotics
4. Incision, drainage, and IV antibiotics
5. Neoadjuvant chemotherapy followed by surgical reconstruction
6. Observation alone
For each clinical vignette seen in the figures, select the best initial treatment from the list above.

Question 45High Yield

Based on the injury shown on the axial MRI scan of the shoulder in Figure 1, what other pathology should be closely examined for during surgery?

Explanation

The axial MRI scan reveals a subluxated biceps tendon. In the study by Koh and associates, 85% of patients with a biceps subluxation on MRI were found to have a subscapularis tear at the time of arthroscopy. These are not always obvious on the MRI, and close inspection of the leading edge/upper border of the subscapularis tendon at the time of arthroscopy is necessary. Although supraspinatus tears, SLAP tears, and Bankart tears can all occur in conjunction with a biceps subluxation, none have been shown to be strongly correlated with this pathology, nor as specific to this pathology.
57

Question 46High Yield

A 15-year-old right-handed pitcher reports shoulder pain after throwing. His symptoms have been present for 3 months and have been getting progressively worse. Clinical examination shows no atrophy of the shoulder muscles, but he has pain with resisted motion of the shoulder, especially internal rotation. Radiographs are shown in Figures 73a and 73b. What is the next step in the evaluation and treatment of his shoulder pain?

Explanation

DISCUSSION: The patient has proximal humeral epiphyseolysis, otherwise known as “Little League shoulder.” This is an overuse injury of the shoulder in the skeletally immature overhead throwing athlete. Most frequently seen in pitchers, it usually develops after an increase in the amount or intensity of throwing activity. Initial treatment involves cessation of throwing activities so the proximal humeral growth plate injury can heal, followed by a gradual return to throwing.

REFERENCES: Chen FS, Diaz VA, Loebenberg M, et al: Shoulder and elbow injuries in the skeletally immature athlete. J Am Acad Orthop Surg 2005;13:172-185.
Keeley DW, Hackett T, Keims M, et al: A biomechanical analysis of youth pitching mechanics. J Pediatr Orthop 2008;28:452-459.
Sabick MB, Kim YK, Torry MR, et al: Biomechanics of the shoulder in youth baseball pitchers:
Implications for the development of proximal humeral epiphysiolysis and humeral retrotorsion. Am J Sports Med 2005;33:1716-1722.

Question 47High Yield

Figure 1 is the radiograph of a 49-year-old man who sustained a closed injury to his
left shoulder in a motor vehicle collision. He underwent uncomplicated ORIF (see Figure 2), but at his first post-operative visit he had persistent pain and deformity (see Figure 3). What is the primary factor contributing to this complication?
---

---

---

Explanation

The fixation construct most likely failed due to a lack of inferomedial calcar support. Biomechanical and clinical studies have emphasized the importance of medial calcar support in preventing varus collapse. This can be accomplished in a number of ways, including anatomic reduction of the medial calcar, long locking screws that engage the inferomedial humeral head, or medial cortical reconstruction with a fibular strut.
The working length of the construct is not excessively long, and the plate length is sufficient. Though there remains a gap at the fracture site, the overall reduction is satisfactory and not the primary cause for fixation failure.

Question 48High Yield

Which of the following statements is true regarding scoliosis in cerebral palsy (C P):

Explanation

C urves greater than 50Â° usually progress.
Scoliosis is most common in totally involved C P patients. Scoliosis is rare in patients with hemiplegia. Braces rarely halt curves in C P.
Surgery has no proven effect on prolonging life expectancy. The complication rate is higher in C P.

Question 49High Yield

What is the theoretical advantage of an open subpectoral technique of tenodesis of the long head of the biceps tendon compared to arthroscopic soft-tissue tenodesis techniques?

Explanation

DISCUSSION: A subpectoral biceps tenodesis requires an additional incision at the insertion of the pectoralis major tendon on the humerus. This can be difficult to do in the lateral decubitus position and certainly this technique does not decrease surgical time when compared to arthroscopic soft-tissue techniques. There have been no level I studies comparing the two techniques; however, the theoretical advantage of the open biceps subpectoral tenodesis is that the biceps tendon is removed from the bicipital groove, which may eliminate a source of pain in the biceps tendon.
REFERENCES: Mazzocca AD, Rios CG, Romeo AA, et al: Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy 2005;21:896.
Osbahr DC, Diamond AB, Speer KP: The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis. Arthroscopy 2002;18:483-487.

Figure 94

Question 50High Yield

The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.

A 24-year-old motorcyclist is brought in as a polytrauma after striking a tree at 65 mph. He is found to have injuries involving the chest, abdomen, pelvis, as well as a left open femoral shaft fracture. He undergoes resuscitation in the trauma bay. Which of the following parameters best supports proceeding with irrigation, debridement and external fixation as opposed to immediate reamed intramedullary nailing?

Explanation

This patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.
Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on interfragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.
Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation
was an effective treatment for displaced olecranon fractures, with good functional outcomes.
Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.
Incorrect answers:

. All displaced olecranon fractures should be considered for internal fixation. Displacement alone does not direct choice of implant.
Answer 2. Intra-articular extension is an indication for surgery to re-establish articular congruity but does not dictate implant selection.
Answer 3. Extension distal to the coronoid is an indication for plate fixation but there is no evidence of such extension on the radiograph shown
Answer 4. This fracture is comminuted, without a distinct fracture line.

A 35-year-old male was involved in a high speed motorcycle accident. He has a closed head injury, bilateral pulmonary contusions and splenic rupture. His orthopaedic injuries are shown in Figure A. He has a blood pressure of 90/50 mm Hg and a heart rate of 115, despite aggressive resuscitation. An arterial blood gas reveals that his blood lactate is 3.5 and base deficit is -6 mmol/L. Following successful closed reduction of the right hip in the operating room with a percutaneous inserted Schantz pin, what is the next most appropriate treatment for his orthopaedic injuries?
1) Bilateral open reduction and internal fixation

2) Open reduction internal fixation on the right, reamed intramedullary nailing on the left

3) Temporizing external fixation on the right, open reduction and internal fixation on the left

4) Bilateral reamed intramedullary nailing

5) Bilateral temporizing external fixation

This patient presents with features of hemodynamic instability and a high injury severity score. The next most appropriate treatment would be temporizing external fixation bilaterally. This patient meets the criteria for damage control orthopaedics.
Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology does not undergo further inflammatory insult. As a result, external fixation of femoral shaft fracture and pelvic stabilization is an effective treatment under this strategy. Other indications include vascular injury and severe open fracture.
Pallister et al. reviewed the effects of surgical fracture fixation on the systemic inflammatory response to major trauma. They show that early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure. However, early fracture surgery increases the post-traumatic inflammatory response, which
carries a higher complication rate compared to temporary fixation.
Tisherman et al. created clinical guidelines for the endpoints of resuscitation. Level I data found that standard hemodynamic parameters do not adequately quantify the degree of physiologic derangement in trauma patients. The initial base deficit, lactate level, or gastric pH should be used to stratify patients with regard to the need for ongoing fluid resuscitation.
Pape et al. retrospectively reviewed the impact of early total care vs. damage control orthopaedics in the treatment of femoral shaft fractures in polytrauma patients. They found a significantly higher incidence of acute respiratory distress syndrome (ARDS) with intramedullary nailing (15.1%) compared to external fixation (9.1%) when DCO subgroups were compared.
Figure A is a pelvic AP radiograph showing a right hip fracture-dislocation with an ipsilateral femoral shaft fracture. On the left side there is a displaced pertrochanteric hip fracture.
Incorrect Answers:
Answer 1-3: Open reduction internal fixation would not be indicated in damage control orthopaedics.
Answer 4: Bilateral reamed intramedullary nailing would be indicated in early total care of these injuries. As this patient is hemodynamically unstable, with a high injury severity score and bilateral lung contusions, damage control orthopaedics would be indicated.

Which of the following has been shown to be the greatest risk factor for refracture after implant removal from a radial shaft?

1) Removal of locking screws

2) Removal of small fragment plates

3) Removal of metaphyseal implants

4) Removal of implants less than 1 year after insertion

5) Removal of protective splinting from limb earlier than 10 weeks postoperatively

Removal of implants earlier than 1 year after insertion is a risk factor for refracture of the bone after implant removal.
The risk of refracture after hardware removal is multifactorial. Multiple
variables have been studied such as protective splinting for 6 weeks after hardware removal, waiting 12 months or more prior to hardware removal, and the location of the fracture. The variable that seems to correlate most with the risk of refracture is a diaphyseal location of the initial fracture. Large fragment plates (4.5 mm), when removed, are also at higher risk for refracture in the forearm.
Deluca et. al reported on a case series of patients who sustained a refracture of a forearm after implant removal. They noted that radiolucency at the site of the original fracture was seen in most refractured patients when the plate was removed. They also recommend delaying implant removal to two years after insertion to minimize risk.
Rumball et. al reported that the incidence of refracture after forearm implant removal is 6% in their series. They found that early removal, lack of postoperative immobilization, and plate size are the most critical risk factors for refracture.
Illustration A shows a forearm with evidence of refracture after implant removal.
Incorrect Answers:
Answer 1: Removal of locking screws does not increase the risk of refracture. Answer 2: Removal of large fragment plates (4.5mm) are at increased risk of refracture as compared to small fragment plates (3.5mm).
Answer 3: Metaphyseal implant removal has a decreased risk of refracture compared to diaphyseal implant removal.
Answer 5: Protective splinting for 6 weeks is all that is generally recommended for these patients.

A 23-year-old male arrives to the trauma bay after a motorcycle crash caused by a drive-by shooting. The patient is awake and alert and following commands. Vital signs include a blood pressure of 145/90 and a heart rate of 117bpm. Initial lactate is reported as 2.4 mmol/L. The patient has 2 rib fractures on the right with a clear chest radiograph. The patient is neurovascularly intact with a 4cm transverse wound over the medial ankle. Figures A, B and C exhibit his orthopaedic injuries. What is the most appropriate management?
1) Irrigation, debridement and placement external fixator right ankle, external fixation femur and intramedullary fixation tibia

2) Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and tibia

3) Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and external fixation tibia

4) Irrigation, debridement and placement external fixator right ankle, femur and tibia

5) Irrigation, debridement and external fixation right ankle and skeletal traction

The patient is relatively hemodynamically stable. In this case the femur and tibia should be definitively fixed while the open ankle fracture can be irrigated and debrided and placed in a spanning external fixator, temporizing for later definitive fixation.
Aside from an elevated heart rate and mildly elevated lactate (normal
Figure A is an anterior-posterior (AP) radiograph of a 27-year-old male who was a bicyclist struck by a motor vehicle. He was intubated in the field and unresponsive in the trauma slot. Ultrasound of his abdomen is positive for blood and he is brought to the operating room emergently for an exploratory laparotomy. He is found to have ischemic bowel and a grade 4 liver laceration. His lactate is 9.0 mg/dL. Which figure represents the next appropriate step in regard to his pelvic ring injury?
1) Figure B

2) Figure C

3) Figure D

4) Figure E

5) Figure F

The radiograph exhibits an elevated left hemipelvis with complete sacroiliac disruption, which can be temporized with placement in skeletal traction.
The patient is unstable, as indicated by an elevated lactate level. The most appropriate next step is temporizing skeletal traction to reduce the left hemipelvis.
Langford et al. review the initial diagnosis, evaluation and resuscitation in the management of pelvic fractures. Reduction of pelvic volume can be achieved with pelvic binders and temporizing external fixation for anterior posterior compression (APC) and/or lateral compression (LC) fracture patterns, while skeletal traction can help do the same in vertical shear patterns.
Matullo et al. review the uses of skeletal traction in orthopaedic trauma, where lower extremity skeletal traction can be an efficient, fast, easy way to help reduce pelvic volume in vertical shear injuries, especially when the patient is unstable and not cleared for definitive fixation.
Figure A exhibits an elevated left hemipelvis indicative of a vertical shear injury and complete SI disruption. Figure B is an example of a pelvic binder. Figure C is a pelvic reconstruction plate. Figure D is a schematic of an anterior pelvic external fixator. Figure E is a schematic drawing of a patient in lower extremity
skeletal traction. Figure F is a radiograph exhibiting S1 and S2 sacroiliac (SI) screws.
Incorrect answers:
Answer 1: A pelvic binder would not be helpful in this scenario and actually may worsen the deformity.
Answer 2: Definitive plate fixation of the anterior pelvis will be needed, but only when the patient is adequately resuscitated.
Answer 3: An anterior external fixator may actually do more harm than good as it may require more time than placing skeletal traction, and also have difficulty controlling the posterior pelvis from the front.
Answer 5: Percutaneous SI screws may be placed later, once the patient is resuscitated and stable.

A 38-year-old man is involved in a motor vehicle collision and suffers the grossly open injury shown in Figure A. He subsequently undergoes irrigation and debridement and placement of an external fixator. In Figure B, if the proximal pin is placed at the red circle as compared to the black circle, the patient is at increased risk for which of the following?
1) Foot drop

2) Injury to the anterior tibial artery

3) Septic arthritis

4) Flexion contracture of the knee

5) Patellar tendon rupture

The patient is at increased risk of septic arthritis when placing the proximal tibial pin too proximal due to penetration of the joint capsule. Pin site flora can track into the joint and lead to a septic knee.
Tibial external fixators can be used to temporize tibial shaft, pilon, and ankle fractures not ready for definitive management due to soft tissue concerns and/or practice of damage control orthopaedics. Intracapsular placement of fixator pins can lead to septic arthritis. The capsular reflection typically extends 14 mm distal to the subchondral line.
DeCoster et al. reported a cadaveric dissection study for safe placement of proximal tibia pins and determined that the capsule inserts 14 mm below the articular surface along the posteromedial and posterolateral surfaces. For fractures requiring extremely proximal pin placement, they recommend
anterior cortex penetration only at least 6 mm distal to articular surface.
Reid et al. investigated safe transtibial pin placement using MRI and cadaveric and volunteer knees. They found that pin placement 14 mm distal to subchondral bone will result in low likelihood of capsular penetration.
Figure A is an AP radiograph showing a segmental middle third tibia/fibula fracture. Figure B is a lateral diagram of the tibia showing potential sites of proximal pin placement.
Incorrect Answers:
Answer 1: Foot drop would occur secondary to common peroneal nerve injury, which is not at risk with very proximal pin placement.
Answer 2: The anterior tibial artery is not at risk with very proximal pin placement.
Answer 4: The knee is free to move and therefore should not develop a flexion contracture secondary to the external fixator.
Answer 5: Patellar tendon rupture is not complication of external fixator pin placement in the tibia.

Figures A and B are radiographs of a 43-year-old, right-hand dominant, male that injured his arm in a motor vehicle accident. What would be an absolute indication for surgical fixation of his injury?
1) Radial nerve palsy

2) Intra-articular extension

3) 2mm fracture distraction, 5 degrees of rotational malignment

4) Ipsilateral proximal both bone forearm fracture

5) Bilateral fracture

This patient has a humeral shaft fracture. An absolute indication for surgery would include a floating elbow, i.e. ipsilateral both bone forearm fracture.
The primary causes of humeral fractures include motor vehicle accidents, falls, or violent injury. Almost all cases are treated non-operatively with functional bracing. The absolute indications for surgical management include: ipsilateral vascular injury, severe soft-tissue injury, open fracture, compartment syndrome, and associated ipsilateral forearm fracture, ie, floating elbow. The relative indications for surgical management include: segmental fracture, intraarticular extension, significant fracture distraction, bilateral humeral fracture, inability to maintain acceptable alignment, and polytrauma.
Klenerman et al. reviewed non-operative treatment of humeral shaft fractures. They showed that acceptable results could be achieved even after 20° of
anterior bowing, 30° of varus angulation, 15° of malrotation, and 3 cm of shortening.
Carroll et al. reviewed the management of humeral shaft fractures. They state the indications for operative fixation to be polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical techniques include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing
Figure A and B shows a comminuted mid-shaft humeral fracture with intraarticular extension.
Incorrect Answers:
Answer 1,2,3,5: These associated injuries are NOT an absolute indication for surgery. An area of controversy is the occurrence of new-onset radial nerve injuries after closed manipulation. However, the current algorithm does not support early open nerve exploration and fixation.

Which of the following findings is a contraindication in retrograde nailing of a periprosthetic distal femur fracture around a total knee arthroplasty?

1) Posterior-stabilized total knee implant

2) Cruciate retaining total knee implant

3) Spiral fracture pattern

4) Distal femoral replacement

5) Knee flexion contracture of 15 degrees

A distal femoral replacement (TKA) implant will generally preclude placement of a retrograde nail due to the long stem on the femoral component.
Supracondylar femur fractures above a well-fixed TKA component are increasingly common. These fractures are often treated with a lateral locking plate, but can also be treated with a retrograde nail in certain circumstances. An important factor in determining if nailing is a viable option are knowing the TKA implant and it's design. In addition, if the TKA component is known, the maximum size of reamer head and nail can be determined preoperatively from the size of the femoral 'box'.
Schutz et al report on a prospective multicenter study of 112 patients who underwent fixation of a distal femur fracture with the LISS system. They report that 90% of fractures went on to union and they attribute all of the failures to either the high-energy nature of particular fractures or a lack of experience in applying the plate in an appropriate pattern. They also note that primary grafting of these fractures is not necessary.
Illustration A shows a periprosthetic femur fracture treated with a retrograde nail.
Incorrect Answers:
1: A posterior-stabilized implant can be treated with an intramedullary nail in many circumstances but can be technically challenging, depending on the components.
2: A cruciate retaining TKA is not a contraindication to use of a retrograde nail. 3: A spiral pattern periprosthetic supracondylar femur fracture can be treated with a femoral nail.
5: A knee flexion contracture will often provide the flexion necessary for access to the box of the femoral component. A knee extension contracture, however, can preclude access to this box for placement of a nail.

A patient falls and sustains the isolated injury seen in Figures A and B. The surgical plan includes open reduction and internal fixation with a small mini-fragment plate using a direct lateral approach. During the approach, the forearm was placed in a fully pronated position. What would be the correct position of the forearm during plate application?
1) Full pronation

2) 25 degrees pronation

3) Neutral

4) 25 degrees supination

5) Full supination

Using the lateral approach (Kocher or Kaplan), the correct placement of the arm should be in a neutral position so that the plate can be placed on the bare area of the proximal radius.
Displaced radial head fractures with less than 3 fragments can be amendable to open reduction internal fixation. The methods of fixation include buried or headless screws, if placed at the articular surface, or posterolateral plating, if placed in the bare area. The safe zone for plating is located at a 90-110 arc from the radial styloid to Lister's tubercle with the arm in neutral rotation. This position helps to avoid impingement of ulna against the plate with forearm rotation. It should be noted that during the approach, that the forearm should be fully pronated to avoid injury to the posterior interosseous nerve.
Mathew et al. reviewed the concepts of terrible triad injuries of the elbow. Radial head fractures are treated conservatively when there is an isolated minimally displaced (less than 2mm) fracture with no mechanical block to motion. Open reduction internal fixation is used for Mason II or III fractures with
A 38-year-old male is involved in a high speed motor vehicle collision. He has a Glasgow Coma Scale of 13 and receives 2 liters of fluid en route to the emergency department. Upon evaluation in the emergency department, he is found to have a bilateral femoral shaft fractures, a right ankle fracture, and a left both bone forearm fracture. He also has 2 left sided rib fracture and a grade II liver laceration. His heart rate is 130 and blood pressure is 85/50. All of the following
would be indications to practice damage control orthopaedics in this patient except:

1) Bilateral femur fractures

2) Rib fractures

3) Lactate of 5.2

4) Urine output of 20 cc/hr

5) Heart rate and blood pressure

Rib fractures without evidence of further thoracic trauma would not be an indication to practice damage control orthopaedics. This patient is underresuscitated based on his lactate level, urine output, and vital signs and definitive management should be delayed.
Damage control orthopaedics is the practice of delaying definitive management of fractures and utilizing temporary stabilization (such as an external fixator) until a patient has recovered from the initial physiologic insult of trauma.
Patients are at increased risk for perioperative complications such as ARDS and multi-system organ failure during the acute period after polytrauma. In addition to underresuscitation, other indications to practice damage control orthopaedics include: injury severity score>40 (or >20 with thoracic trauma), bilateral femoral fractures, hypothermia below 35 degrees Celsius, and pulmonary contusions.
Pape et al. (2007) studied the incidence of acute lung injuries in polytrauma patients undergoing either intramedullary nailing or external fixation and later definitive fixation of femoral shaft fractures. They found that patients undergoing immediate intramedullary nailing were nearly 6.7 times more likely to have acute lung injury
The Canadian Orthopedic Trauma Society studied the effect of reamed versus unreamed femoral nailing on incidence of ARDS for femoral shaft fractures in trauma patients using a randomized controlled study. They found no difference between the groups.
Pape et al. also examined the pathophysiological cascades that accompany soft tissue injuries of the extremities, abdomen, and pelvis and recommend a more comprehensive for evaluation of patients with these injuries.
Incorrect Answers:
Answer 1: Bilateral femur fractures are an indication to practice damage control orthopaedics and delay definitive fixation
Answers 3,4,5: All of these answers suggest that the patient is underresuscitated. Definitive fixation should be delayed

The anterior intrapelvic (modified Stoppa) approach is most appropriate for which of the following fractures?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

The anterior intrapelvic (AIP) or modified Stoppa approach provides access to the quadrilateral plate, which is a common location for fracture displacement in associated both column acetabulum fractures as seen in Figure D.
Compared to the traditional ilioinguinal approach, the modified Stoppa with a lateral window can offer comparable access to the quadrilateral plate, which can allow for its use in associated both column fracture patterns.
de Peretti et al. prospectively followed 25 patients with both column fractures
treated via an iliofemoral approach. Results led the authors to not recommend the extensile approach for both column fractures due to lack of efficiency and high complication rates.
Alonso et al. compared the extensile iliofemoral and triradiate approaches, and both reported acceptable results. However, concerning were the relatively high rates of heterotopic ossification, despite prophylaxis.
Bible al. performed a cadaver study to quantify the amount of access provided by the modified Stoppa approach. This approach provides access to approximately 80% of both the inner pelvis, and the quadrilateral plate, however, comparison to the ilioinguinal approach was not performed.
Shazar et al., in a cohort comparison between the ilioguinal and Stoppa approaches, noted better visualization and potential improve fracture reduction via the Stoppa approach for both column fractures. However, this study was limited in its retrospective and relative observer bias.
Figure A depicts a posterior wall fracture dislocation with concomitant femoral neck fracture. Figure B is an iliac oblique view which depicts a posterior column fracture. Figure C exhibits a posterior column + posterior wall fracture. Figure D depicts acetabular fracture with protrusio. Figure E exhibits a posterior wall fracture.
Incorrect answers:
Answers 1,2,3, and 5: Posterior sided injuries, especially for these injuries, would probably be best approached via the Kocher-Langenback approach. Surgical dislocation with a trochanteric slide may help visualization in answer 1.

Figure A is a radiograph of a 75-year-old woman that fell onto her non-dominant shoulder from a standing height. She was treated nonoperatively for 9 months but continues to complain of pain when she elevates her arm. In patients with this type of fracture pattern, what factor has the greatest impact on fracture healing?
1) Hand dominance

2) Angulation of fracture

3) Smoking

4) Early physical therapy

5) Diet

This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with non-operative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to
impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than non-smokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:
Answers 1,2,4: These factors do not have a significant influence on bone healing.
Answer 5: Diet has shown to improve bone healing but this does not have the greatest impact.

A 26-year-old male epileptic patients presents with right shoulder pain and deformity after a grand mal seizure. After medical stabilization, he denies previous injury to his shoulder. Pre-reduction and post-reduction radiographs of the shoulder are shown in Figures A-C, respectively; physical examination reveals a normal upper extremity neurovascular examination. After shoulder immobilization, what would be the next most appropriate step in management of this patient?
1) Abduction brace for three weeks, followed by therapy

2) Right shoulder MR arthrogram

3) Open reduction and internal fixation

4) Hemiarthroplasty

5) Early range of motion

This patient has presented with a fracture dislocation of the right shoulder. After urgent closed reduction, this patient requires open reduction internal fixation of the proximal humerus, and greater tuberosity fracture fragment in particular.
Isolated greater tuberosity fractures may be associated with shoulder dislocations. Careful review of imaging is critical to identify fracture lines that may extend into the humeral neck and head. If these extensions go undetected, catastrophic propagating fractures may occur during closed reduction maneuvers. Treatment is usually with open reduction internal fixation (ORIF). Young patients with proximal humerus fractures should be treated more aggressively with ORIF as compared to elderly patients. Another example would be a severely impacted valgus proximal humeral fracture in a young patient.
Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).
Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results can be achieved with fixation methods.
Figure A shows an anterior fracture-dislocation of the right shoulder. Figure B and C show post-reduction radiographs with a congruent glenohumeral joint. Displacement of the greater tuberosity (GT) fragment is greater than 5mm.
Incorrect Answers:
Answer 1: The GT fragment is displaced more than 5-10mm which would warrant surgical reduction and stabilization of the fracture.
Answer 2: MR arthrogram may be indicated to rule out an intra-capsular soft-tissue injury. However, this would not be warranted prior to fixation of the fracture.
Answer 4: Hemiarthroplasty would be indicated in some 4-part proximal humerus fractures or elderly patients. Considering this patient's age and valgus impaction of the fracture, ORIF would be most appropriate.
Answer 5: Early range of motion would be warranted AFTER fixation of the fracture.

Pelvic packing can be performed to temporarily treat a hemodynamically unstable patient with a pelvic ring fracture. Which of the following is the preferred location of the skin incision to perform pelvic packing?

1) Right anterior superior iliac spine (ASIS) to mid-symphysis, left lateral window incision

2) Left ASIS to mid-symphysis, right lateral window incision

3) Subumbilical incision

4) ASIS to ASIS bilaterally

5) Pararectus incision

The preferred skin incision location is a subumbilical incision, 6-8cm extending upwards from the pubic symphysis towards the umbilicus; this allows access to all of the appropriate areas for pelvic packing.
Following skin incision, the rectus fascia is then divided in the midline which allows for access to both sides of the bladder for packing deep in the pelvic
brim. On each side, 3 lap pads are placed from sacroiliac joint to the retropubic space, all placed below the level of the pelvic brim.
Hak et al. review the options for emergent treatment in life threatening hemorrhage secondary to pelvic fractures. The authors offer several options for emergent treatment, which includes the use of pelvic binders, the placement of external fixators, pelvic packing and interventional angiography. Goals include reduction of pelvic volume and stopping rapid hemorrhage to save a patient's life. Pelvic packing, properly performed, is done through a subumbilical incision, as described above.
Osborn et al. retrospectively reviewed and compared emergent pelvic packing to angiography in hemorrhagic pelvic fracture clinical scenarios. The authors noted comparable results in mortality with a noted decrease in need for post-procedure transfusions in the pelvic packing group.
Cothren et al. reported their outcomes following an institutional algorithmic change from pelvic ex-fix/angiography to pelvic packing and ex-fix. Since their institutional change, the authors noted a significant decrease in transfusions, need for angiography and mortality.
Incorrect answers:
Answers 1,2: While these approaches may give access to the pelvic brim, each only give access to one side; one needs to circumferentially access and pack the pelvis.
Answer 4: An ASIS to ASIS skin incision is an unnecessary dissection with too many important structures that lie very close to the skin, including the femoral vessels.
Answer 5: A pararectus incision is an alternative approach to access the quadrilateral plate for acetabular fractures and does not play a role in pelvic packing.

A 28-year-old man is brought by ambulance to the emergency department after falling from the roof of his home four hours ago. Upon initial evaluation, he has visible deformities of his bilateral lower extremities and a positive FAST exam. Heart rate is 135, blood pressure 85/58, and urine output is 40 cc over 3 hours. According to ATLS guidelines, what percentage of his blood volume has this patient likely lost?
1/.
1) 30-40%

2) 40-50%

3) >50%

This patient has likely lost 30-40% of his blood volume and is likely in stage III hemorrhagic shock on the basis of his heart rate, blood pressure, and urine output.
Initial assessment of a trauma patient should involve evaluation of airway, breathing and circulation. An average adult has approximately 5 L of circulating blood volume. Class III and IV hemorrhagic shock, approximated by loss of greater than 30% of blood volume, typically requires resuscitation with fluids and blood products. Lactate level (normal 100 and diminished urine output
4, 5: Blood loss of greater than >40% typically leads to heart rate >140, decreased blood pressure and negligible urine output.

Which of the following fracture patterns would be most appropriately treated with open reduction and internal fixation with posteromedial and lateral plates via dual incisions?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

The patient in Figure D has a bicondylar tibial plateau fracture with a posteromedial fracture fragment, which is an indication for lateral and posteromedial plating via dual incisions.
Bicondylar tibial plateau fractures are typically treated with open reduction internal fixation. Studies have shown that the posteromedial fragment is common in bicondylar tibial plateau fractures. Standard lateral implants do not gain adequate screw purchase in posteromedial bone. Posteromedial incisions using the interval between the semimembranosus and medial head of the gastrocnemius can be used to gain access to the fragment and provide exposure to place a posteromedial plate.
Barei et al. reviewed 57 OTA C-type bicondylar tibial plateau fractures, and found the presence of a posteromedial fragment in 74% of cases. They suggest
the use of alternate methods of fixation for the posteromedial fragment rather than lateral fixed-angle plates alone.
Higgins et al. reviewed 111 patients with bicondylar tibial plateaus that underwent CT scan evaluation. They found the incidence of a posteromedial fragment in 59% of the patients and on average accounted for 25% of the articular surface.
Barei et al. reviewed 83 patients treated with dual incisions for fixation of bicondylar tibial plateau fractures. They found deep infections in 8.4% of patients. Satisfactory articular reduction was found in 62% of patients, satisfactory coronal alignment in 91% of patients, satisfactory sagittal alignment in 72%, and satisfactory condylar width in 98%.
Figure A shows an AP and lateral radiograph of a split/depressed lateral tibial plateau fracture. Figure B shows an AP and lateral radiograph of a proximal third tibial shaft fracture with a proximal fibula fracture. Figure C shows an AP and lateral radiograph of a medial plateau fracture with articular depression. Figure D shows an AP and lateral radiograph of a bicondylar tibial plateau fracture. Figure E shows an AP and lateral radiograph of a tibial tubercle fracture in a tibia with open physes.
Incorrect Answers:
Answer 1: Schatzker II tibial plateau fractures can be treated with a single lateral plate.
Answer 2: Proximal third tibial shaft fractures can be treated with an intramedullary nail or percutaneous plating
Answer 3: Schatzker IV tibial plateau fractures can be treated with a single medial or posteromedial plate.
Answer 5: Tibial tubercle fractures in children can be treated with anterior to posterior screws.

Figure A shows the radiographs of a 87-year-old patient after a fall from standing. He lives in a nursing home and uses a walker to transfer from bed to chair. His past medical history includes recurrent urinary tract infections, congestive heart failure, angina and diabetes. Which of the following factors is associated with the best postoperative outcome in this patient?
1) Immediate surgical intervention

2) Postoperative epidural analgesia

3) Postoperative antibiotics

4) Pre-operative medical optimization

5) Choosing total hip arthroplasty instead of hemiarthroplasty

Geriatric patient with hip fractures tends to have a number of coexisting medical conditions that impact surgical risk. A successful pre-operative medical evaluation has the greatest impact on surgical outcomes in this patient population.
Patients with complex past medical histories are at great risk of complications with surgery. This helped to drive the formation of the ASA classification system as a way to score patients out of 5 based on their anesthetic and surgical risks. Patients with significant systemic disease (ASA III and IV) have shown to demonstrate poorer outcomes as compared to patients with less severe medical comorbidities (ASA I and II).
Egol et al. looked at factors that impact the outcomes of hip fractures in geriatric patients. They showed that cardiac and pulmonary complications were most frequent complications post-operatively. It was stated that early mobilization and pre-operative evaluations have the greatest impact on outcomes.
Parvizi et al. looked at the thirty-day mortality following hip arthroplasty for acute fracture. They reviewed a database of 7774 consecutive patients that underwent hip arthroplasty for the treatment of an acute fractures. The overall mortality was 2.4%. Risk factors were found to be cemented implants, female patients, elderly patients, and patients with cardiorespiratory comorbidities.
Roberts et al reviewed the 2015 AAOS Clinical Practice Guideline: Management of Hip Fractures in the Elderly. Although pre-operative medial optimization was not mentioned in this review, there is strong evidence to support an interdisciplinary care program for patients with hip fractures.
Figure A shows a displaced left femoral neck fracture. Incorrect Answers:
Answer 1: Most studies have shown an association between operative delay of
more than 24-48 hours and a higher 1-year mortality rate. However, In patients with with more than 3 medical comorbidities, medical optimization has a greater impact on post-operative outcomes than time to surgery.
Answer 2: Post-operative epidural anaesthesia has shown to decrease postoperative delirium but does not affect 30-day mortality.
Answer 3: Postoperative antibiotics have not shown to reduce the 30-day mortality.
Answer 5: Total hip arthroplasty has shown to improved functional outcomes at 1 year compared with hemiarthroplasty. However, there has been no change in mortality.

A 36-year-old male sustains severe injuries as a result of a motor vehicle collision. After 5 days, the patient is stabilized and transferred to your facility for continued management. After obtaining appropriate imaging, including the images shown in Figures A, B and C the patient should be given which of the following mobility restrictions?
1) Touch-down weight bearing on the left lower extremity, non-weightbearing on the right lower extremity

2) Weight bearing as tolerated on the left lower extremity, non-weightbearing on the right lower extremity

3) Non-weight bearing on the left lower extremity, non-weightbearing on the right lower extremity

4) Touch-down weight bearing on the left lower extremity, weight bearing as tolerated on the right lower extremity

5) Weight bearing as tolerated on the left lower extremity, weight bearing as tolerated on the right lower extremity

Figures B and C shows a stable, impacted lateral compression (LC) type I injury, which can be treated with immediate mobilization without restrictions. The right lower extremity has a pilon fracture, which should be treated with non-weight bearing.
LC-I injuries are stable patterns, as they involve an impaction injury to the anterior sacrum, which has some inherent stability. In addition, the posterior sacro-iliac (SI) soft tissue structures remain intact, which provides critical stability during immediate mobilization.
The reference by Tile is a review article on the principles of management of these injuries, and he reviews how the Tile classification system is important to help determine surgical need and where the stabilization is required. For the stable LC-1 type injury, no fixation is required.
Incorrect Answers:
Answer 1: A patient cannot do touch-down weight bearing on one side and non-weightbearing on the other side simultaneously.
Answer 3: The LC-I injury pattern is stable and can undergo immediate weightbearing as tolerated.
Answer 4: The LC-I pattern is stable and would allow immediate weightbearing, and the right pilon fracture would require non-weightbearing. Answer 5: The right pilon fracture would require non-weightbearing at this time.

A 24-year-old male sustains the fracture dislocation shown in Figure A. How is this fracture pattern best classified?
1) Moore I

2) Moore II

3) Schatzker III

4) Schatzker V

5) OTA type 41B3

Figure A shows a Moore Type II fracture. Moore type II fractures consist of fractures involving the entire tibial condyle, where the fracture line begins in the opposite compartment and extends across the tibial eminence.
A number of classification systems are used to describe tibial plateau fractures. The main classification systems that are widely used include Schatzker, AO/OTA, Hohl and Moore. The Moore classification describes high energy fracture-subluxation injuries of the knee. This is thought to have clinical implications as the type of fracture pattern can indicate an associated soft-
tissue injury.
Moore retrospectively reviewed over a 1000 proximal tibia fractures to devise a classification systems based on the characteristic of five types of tibia plateau fracture patterns. He believed this system helped to better understand knee instability and concomitant soft-tissue injury. For example, Moore Type III fractures (rim avulsion) are associated with a high rate of neurovascular injury.
Figure A shows a fracture involving the entire tibial condyle. Illustration A shows a schematic diagram of the Moore classification (I - V). Illustration B shows a table that describes the Moore classification (I - V).
Incorrect Answers:
Answer 1: Moore Type I is a coronal split fracture of the medial tibia plateau which displaces distally. It does not cross over to the contralateral side of the eminence.
Answer 3: Schatzker Type III is a pure lateral plateau depression.
Answer 4: Schatzker Type V is a bicondylar fracture where the metaphysis and diaphysis remain intact.
Answer 5: OTA type 41B3 is a partial articular fracture with a split-depression of the unilateral plateau.

A 19-year-old male football player plants and twists his right lower extremity sustaining a spiral fracture of his distal third tibial shaft. Of the following images, which is most commonly associated with distal third spiral tibial shaft fractures.
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

The patient has a spiral distal tibial shaft fracture. Spiral distal tibial shaft fractures are commonly associated with intraarticular fracture extension, usually in the form of a posterior malleolus fracture.
Spiral distal third tibial shaft fractures need to be evaluated for intraarticular extension prior to operative management. As this can be missed on x-rays, a CT scan of the ankle is recommended to identify this associated injury. This is important when intramedullary fixation is used for definitive management, as nail insertion can displace a previously non displaced intraarticular fracture.
Anteroposterior screw fixation prior to nailing may be useful in these cases.
Boraiah et al. found that in 62 patients with spiral distal tibial fractures, 39% (24 patients) had a posterior malleolus fracture. They recommended CT evaluation of the ankle to prevent missed intraarticular fractures.
Hou et al. found a posterior malleolus fracture in 9.7% (28 out of 288 cases) of patients with tibial shaft fractures. They recommended CT or MRI evaluation of the ankle prior to surgery.
Figure A shows an axial CT scan of a right ankle with a posterior malleolus
fracture. Figure B shows an AP radiograph of a right ankle with a vertical medial malleolus fracture. Figure C shows a coronal CT scan of a right ankle with a Tillaux fracture. Figure D shows a sagittal CT scan of a right ankle with a comminuted talus fracture. Figure E shows a lateral radiograph of a right knee showing a knee dislocation. Illustration A shows an AP radiograph of a left distal third spiral/oblique tibial shaft fracture. Illustration B shows a lateral radiograph of a left distal third spiral/oblique tibial shaft fracture. Illustration C shows a sagittal CT of a distal third spiral/oblique tibial shaft fracture with a posterior malleolus fracture.
Incorrect Answers:
Answer 2: Vertical medial malleolar fractures are not typically associated with distal third tibial shaft fractures.
Answer 3: Juvenile Tillaux fractures occur typically in patients with open physes. They do not occur in patients with closed physes, and are not associated with tibial shaft fractures.
Answer 4: Spiral/oblique tibial shaft fractures are not associated with talus fractures.
Answer 5: Knee dislocations are considered high energy injuries, and are not associated with tibial shaft fractures.

What would be the most appropriate treatment for this patient at this time?
1) Observation only

2) Referral to physiotherapy

3) MRI spine and hip

4) Total hip arthroplasty

5) Intramedullary femoral nail

This osteoporotic female patient is presenting with subtrochanteric lateral cortical thickening and hip pain. This is consistent with an insufficiency fracture of the femur secondary to use of bisphosphonate medication for treatment of osteoporosis. The most appropriate treatment would be intramedullary femoral nail fixation.
Bisphosphonate medications have been shown to be associated with atypical (subtrochanteric) femur fractures. These patients often have prodromal hip pain and lateral cortical thickening on radiographs prior to fracture. In addition, there has shown to be a significantly increased risk of fracture in the presence of the “dreaded black line” that occurs at the site of thickening.
Lenart et al. examined a case series of patients using bisphosphonates for the treatment of osteoporosis. They identified 15 postmenopausal women who had
been receiving alendronate for a mean (±SD) of 5.4±2.7 years and who presented with atypical low-energy fractures. Cortical thickening was present in the contralateral femur in all the patients with this pattern.
Goh et al. retrospectively reviewed patients who had presented with a low-energy subtrochanteric fractures. They identified 13 women of whom nine were on long-term alendronate therapy. Five of these nine patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.
Figure A shows a right hip radiograph with subtrochanteric lateral cortical thickening. There is mild arthritic changes in the hip. Illustration A shows a bone scan and radiographs of subtrochanteric lateral cortical thickening that resulted in fracture.
Incorrect Answers
Answer 1: Symptomatic lateral femoral cortical stress fractures, known as "dreaded black lines", should be treated with early stabilization to prevent subtrochanteric fracture.
Answer 2: Referral to physiotherapy would not be indicated.
Answer 3: Symptoms are related to a subtrochanteric stress fracture, which has been identified on radiograph. MRI would not be indicated.
Answer 4: This patient has mild arthritis. Treatment with a long bridging femoral stem may stabilize the fracture, However, the gold standard treatment would be intramedullary nailing.

A right-hand dominant female sustains a right proximal humerus fracture. The patient is provided a sling, and is recommended pendulum exercises with elbow range of motion to begin in 1 to 2
weeks. Which of the following would be an indication for surgical management?
1) Age greater than 70 years.

2) Fracture pattern in Figure A

3) Significant medical comorbidities.

4) Fracture pattern in Figure B

5) Fracture pattern in Figure C

The patient has been treated with non-operative management for her proximal humerus fracture. Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced.
Head splitting proximal humerus fractures should be treated with operative management. Open reduction internal fixation versus hemiarthroplasty are used to treat this type of fracture. Surgical management is also considered in proximal humerus fractures in young patients, in fractures where the greater tuberosity is displaced >5 mm, and in proximal humerus fractures associated with humeral shaft fractures.
Koval et al. studied 104 patients with one-part proximal humerus fractures treated non-operatively, and found 80% with good or excellent results. They also found that 90% of patients treated non-operatively had either no or mild pain about the shoulder at follow-up.
Lefevre-Colau et al. performed a randomized prospective study on 74 patients with an impacted proximal humerus fracture. One group was treated with early mobilization of the shoulder (within 3 days after the fracture) while the other group was immobilized for 3 weeks followed by physiotherapy. They concluded that early mobilization was safe and allowed for quicker return to functional use of the affected limb.
Figure A shows an AP radiograph of a right minimally displaced greater tuberosity proximal humerus fracture. Figure B shows AP and axillary radiographs of a right head split proximal humerus fracture that is posteriorly dislocated. Figure C shows an AP radiograph of a right minimally displaced Salter Harris II proximal humerus fracture. Illustration A shows an AP radiograph of a left valgus impacted proximal humerus fracture with a greater tuberosity fragment displaced >5mm treated with ORIF.
Incorrect Answers:
Answers 1, 2, 3, and 5 are all factors that would favor non-operative management for a proximal humerus fracture.

A 37-year-old male arrives to the trauma slot following a high-speed motorcycle crash. His Glasgow Coma score is 14 and his only orthopaedic injury is exhibited in Figure A. His current vital signs are a BP of 90/60, HR 120, and a lactate of 2.5 mMol/L. Other findings include a grade 1 splenic laceration and bilateral pulmonary contusions seen on chest radiograph. Which of the following has been suggested as an indication to perform damage control orthopedic care?
1) HR >110

2) Bilateral pulmonary contusions seen on chest radiograph

3) SBP = 90mmHg

4) Unilateral femur fracture

5) Lactate = 2.5 mMol/L

Pulmonary contusion severe enough to be diagnosed on chest radiograph alone is an indicator that the patient may benefit from damage control orthopaedics (DCO).
Despite the patient's overall stable nature, suffering pulmonary injury severe enough to be seen on x-ray alone suggests that temporary stabilization with staged definitive fixation may avoid potential morbidity.
Pape et al. review the evolution and balance of early total care (ETC) and DCO. Summarizing the literature, the authors report several standalone indicators that would justify DCO regardless of stable status. This includes: Injury Severity Score of greater than 40, Injury Severity Score of greater than 20 with chest trauma, multiple injuries with severe pelvic/abdominal trauma/ hemorrhagic shock, bilateral femoral fractures, pulmonary contusion noted on radiographs alone, hypothermia of less than 35 degrees C), and a head injury with an Abbreviated Injury Score of 3 or greater.
Figure A exhibits a right femoral shaft fracture. Illustration A exhibits a summarized table stating the criterion used to determine the condition of a polytrauma patient. (Table from Pape et al, PMID: 19726738)
Incorrect answers:
Answer 1: Heart rate alone (even elevated severely) is not an indicator to
implement DCO.
Answer 3: A systolic BP of 90 mmHg is not an indicator to implement DCO. A SBP of 70mmHg or lower may indicate a patient in extremis (along with other parameters) indicating the benefits of DCO.
Answer 4: A unilateral femur fracture alone in a stable patient is not an indicator of DCO; a patient with bilateral femur fractures, however, may benefit from DCO.
Answer 5:A lactate of 2.5 mMol/L, while slightly elevated, does not warrant DCO. A lactate value of greater than 6 alone would indicate the need for DCO.

A 24-year-old patient presents after a fall from the balcony of a third story building in which he landed on his feet. He reports lumbar back pain and numbness in his perineum region. Radiographs of his hips and pelvis are seen in Figure A, while CT images are shown in Figures B and C. How is this fracture pattern best classified?
1) Young-Burgess APC Type II

2) Young-Burgess LC Type I

3) "U" Type Spinopelvic Dissociation

4) Denis Zone-I

5) Denis Zone-II

This patient has a Denis zone-III "U" Type Spinopelvic Dissociation of the sacrum.
The Denis classification system for sacral fractures is based on anatomical fracture zones. Zone-III fractures involve the spinal canal and have a high rate of associated neurologic injury. It is important to recognize bilateral sacral
fractures with a transverse component, as this often causes spinopelvic discontinuity and possible cauda equina. The lack of mechanical continuity between the spine and pelvis will most likely require reduction and fixation for initial stability. There may also be a need for sacral decompression with fixation mechanisms given the onset of neurologic symptoms.
Mehta et al. reviewed sacral fractures. They report that patients with a transverse sacral fracture involving more proximal sacral segments (S1, S2, or S3) tend to have a higher prevalence of bladder dysfunction than do those involving distal sacral segments (S4 or S5).
Schildhauer et al. report the best way to visualize Denis zone-III "U" type fractures is to obtain a lateral view of the sacrum or sagittal reformatted images with a CT scan. Standard pelvic radiographs often miss this injury.
Figure A shows an AP pelvis with suggestion of sacral irregularities. No fracture pattern can be indentified. Figures B and C show CT scan images showing a "U" Type fracture pattern with angulation and translational displacement of the cephalad and caudad parts of the sacrum. Illustration A shows examples of complex sacral Denis zone-III fractures.
Incorrect Answers:
Answer 1: APC Type II fractures do not classify fracture extensions into the sacral canal. The posterior SI ligaments are considered intact. There is usually disruption of sacrospinous and sacrotuberous ligaments.
Answer 2: LC Type I is an oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture.
Answer 4,5: Figures A-C demonstrate a "U" type fracture of the sacrum.

A 55-year-old male presents with the radiographs seen in Figures A and B after falling off his bike. Physical examination reveals an isolated, closed elbow injury. His limb is neurovascularly intact. Which complication would be most likely with surgical fixation of this injury?
1) Ulnar neuropathy

2) Posterior interosseous nerve injury

3) Early loss of fixation

4) Elbow flexion contracture

5) Avascular necrosis

This patient is presenting with a comminuted capitellar and trochlear fracture. If treated with open reduction internal fixation, the most likely post-operative complication would be elbow stiffness or contracture.
An axial compression force transmitted by the radial head to the capitellum with the elbow in a semiflexed position can result in a shear fracture of the anterior portion of the capitellum. AP, lateral, and radiocapitellar radiographs are recommended to identify these injuries. The lateral X-ray may reveal the “double arc” sign, which represents extension of the capitellum fracture into the trochlea. Extension of the fracture into the trochlea has important implications into the surgical approach to these injuries.
Ruchelsman et al. retrospectively reviewed the outcomes of sixteen patients with capitellar fractures treated with open reduction internal fixation. They found the presence of greater flexion contractures at the time of follow-up in elbows with Type-IV capitellar fractures. All fractures healed, and no elbows had instability or weakness with fixation.
Ring et al. retrospectively reviewed the outcomes of twenty one distal humerus articular fractures that were reduced and stabilized with implants buried beneath the articular surface. Ten patients required a second operation: (6) release of an elbow contracture; (2) treatment of ulnar neuropathy; (1) removal of hardware; (1) early loss of fixation.
Figures A and B show AP and lateral radiographs of the elbow with a comminuted fracture of the capitellum and trochlea. Note the “double arc” sign on the lateral view. Illustrations A and B show open reduction internal fixation of the fracture. Note fixation with multiple interfragmentary screws.
Incorrect Answers:
Answers 1,2,3,5: All of these may be complications with this surgery. These complications are not as common as elbow contracture or stiffness.

Figure A shows a radiograph of a 30-year-old male who underwent fixation of a left leg injury just over two years ago. He presents with persistent pain and drainage from the distal wound despite 4 months of oral antibiotics. He has no systemic symptoms. He has a past medical history of Grave's disease and Irritable Bowel Syndrome. What would be the best management at this stage?
1) Chronic suppressive, culture-directed, antibiotic therapy

2) Above knee amputation

3) Endocrine consultation, irrigation and debridement, removal of hardware and negative-pressure wound therapy

4) Irrigation and debridement, removal of hardware, over-reaming medullary canal, external fixation and culture-directed antibiotics

5) Irrigation and debridement, retention of hardware, acute bone grafting and culture-directed antibiotics

This is a case of fracture nonunion in the setting of chronic osteomyelitis and infected hardware. The best treatment option available would be irrigation and debridement, removal of hardware, ring external fixator and culture directed antibiotics.
The management of infected nonunion in the setting of chronic osteomyelitis is technically demanding. The aims of treatment are to eradicate the infection and obtain bone union. Non-surgical options are largely unsuccessful in patients with draining chronic osteomyeltis in the setting of infected hardware and nonunion. Surgical options involve incision and debridement of necrotic tissue followed by reconstruction of bone and possible soft tissue (to provide
healthy viable coverage). The most common techniques are ringed fixator/circular frames, staged intramedullary device with or without external fixator, free tissue transfer, or radical debridement, bone grafting, and fixation.
Motsitsi et al. reviewed the management of infected nonunion of long bones. They suggest that the Ilizarov technique is regarded as a standard treatment in infected nonunion of the tibia. When there is bone defect after debridement, the bone can be shortened or treated with bone transport.
Egol et al look at a series of patients with chronic osteomyelitis. Limb salvage should be attempted in all patients. The presence of a chronic draining sinus requires surgical debridement and culture directed antibiotics. Infected hardware should be removed. A two-stage strategy is the best and well-proven treatment option.
Figure A shows a intramedullary nail in the left tibia. There is a moderate amount of bone loss at the fracture site with mixed sclerotic bone suggestive of osteomyelitis.
Incorrect Answers:
Answer 1: Chronic suppressive therapy would be considered in a patient that is unable to undergo surgical intervention
Answer 2: Amputation is a primary option for patients unable to undergo lengthy or multiple surgical interventions.
Answer 3: After removing the hardware, the fracture non-union will need to be stabilized.
Answer 5: This patients has a chronic infection that requires radical bone debridement and local infection control. The use of acute bone grafting in a single stage procedure in the distal 1/3 tibia (poor blood supply) is less ideal, especially in the setting of infection.

A 32-year-old male sustained the injury seen in Figure A after a motor vehicle accident. Which of the following factors is most predictive of mortality with this type of injury?
1) Fracture classification

2) Number of blood transfusions in the first 24 hours

3) Gender

4) Time to operative fixation

5) Use of pelvic binders

The best predictors of mortality with pelvic ring fractures include older age and hemodynamic shock at presentation. The amount of blood transfused indicates the severity of hemodynamic instability.
Pelvic ring fractures are typically high energy, blunt injuries. The leading cause of mortality with these injuries is hemorrhage and hemodynamic instability.
The most common source of hemorrhage include venous injury (80%), which is usually caused by a shearing injury of posterior thin walled venous plexus and bleeding cancellous bone. Other sources of hemorrhage include arterial injury (10-20%) from the superior gluteal artery (posterior ring injury, anterior posterior compression [APC] pattern), internal pudendal artery (anterior ring injury, lateral compression [LC] pattern) and obturator artery.
Smith et al. found fracture pattern and angiography/embolization were not predictive of mortality in patients with unstable pelvic injuries. The three factors they found to be predictive were: increased blood transfusions in the first 24 hours, age >60 years, and increased Injury Severity Scores (ISS) scores. Deaths were most commonly from exsanguination (24 hours).
Starr et al. demonstrated that age and shock on presentation were most predictive of mortality after pelvic ring injury.
Figure A shows a APC III pelvic fracture. Illustration A shows a table describing the Young-Burgress classification of pelvic ring fractures.
Incorrect Answers:
Answers 1,3-5: Gender, fracture pattern, time to operative fixation or use of pelvic blinders do not correlate directly with mortality.

Figure A shows intraoperative radiographs of a 45-year-old patient with a left elbow injury. What would be the next most appropriate step in this patients care?
1) Early range of motion

2) Hinged elbow brace for 4 weeks

3) Repair lateral collateral ligament

4) Remove and upsize implant

5) Remove and downsize implant

The intraoperative images are consistent with overstuffing of the ulnohumeral joint during a radial head replacement. The most appropriate next step would be removing and downsizing the implant.
Overstuffing the radiohumeral joint by >2.5 mm can significantly alter elbow kinematics. It has also shown to lead to pain and early joint disease. The most sensitive method to assess for overstuffing of the joint is by direct visualisation intra-operatively. This can be performed by visualising the lateral aspect of the ulnohumeral joint when the radial head is resected and comparing this to when the trial radial head is reduced in place. In comparison, radiographic asymmetry of the medial ulnohumeral joint has been shown to be less sensitive. Radiographic findings of incongruity of ulnohumeral joint only occurs when significant overlengthening of the radius occurs.
Frank et al. examined the effect of radial head thickness in seven cadaver specimens. They found that incongruity of the medial ulnohumeral joint would only become apparent radiographically after overlengthening of the radius by
>or=6 mm.
Doornberg et al. examined seventeen computed tomography scans of the elbow to investigate the height of the radial head relative to the lateral edge and central ridge of the coronoid process. They found that the radial head was on average only 0.9 mm more proximal than the lateral edge of the coronoid process.
Figure A shows intraoperative radiographs of a patient that has undergone a radial head arthroplasty. There is significant widening of the medial ulnohumeral joint on an AP radiograph as well as widening of the ulnohumeral joint on the lateral radiograph,
Incorrect Answers:
Answer 1: Early range of motion is supported after radial head arthroplasty. However, the next most appropriate step in this scenario would be the intraoperative assessment for radiohumeral joint overstuffing.
Answer 2: Hinged braces may be used in the post operative period. However, overstuffing the radiohumeral joint is of first priority.
Answer 3: There is no indication in this question for lateral collateral ligament repair
Answer 4: Removing the implant and upsizing the radial head would be the opposite of what is needed in this scenario.

Aside from improving the intramedullary nail starting point in Figure A, the use of blocking screws could have been used at the time of fixation to prevent this post-operative deformity. What would have been the correct orientation of these screw(s) in the proximal fragment?
1) Medial only

2) Lateral only

3) Anterior and medial

4) Posterior and medial

5) Posterior and lateral

The clinical presentation is consistent with a malunion of a proximal one-third tibia fracture with a valgus and procurvatum deformity. The correct orientation of Poller blocking screws to help prevent this malalignment would be in the posterior and lateral aspects of the metaphyseal fragment.
Insertion of the blocking screw lateral to the nail prevents valgus deformity, and insertion of the blocking screw posterior to the nail prevents apex anterior deformity. A more lateral starting point for nail insertion can also help to
prevent valgus deformity. The semiextended position of the knee for nail insertion also helps to eliminate the tendency for the fracture to flex, due to the avoidance of excessive knee flexion during the reduction.
Stedtfeld et al. describes the mechanical model for blocking screws. They state that two or more blocking screws can be placed in each plane (AP and lateral) alongside the nail to create a narrow canal for the nail. This allows for multiple points of fixation and realignment of the bone as the nail is passed.
Lindvall et al looked at a series of 56 extra-articular proximal tibial fractures treated with intramedullary nailing or percutaneous locked plating. Neither nailing or plating these fractures showed a distinct advantage in the overall outcomes. Apex anterior malreduction however was the most prevalent form of malreduction in both groups.
Lang et al. looked at a series of proximal third tibia fracture treated with intramedullary nailing. They reported that posterior tibial comminution will also contribute to apex anterior angulation. They states this occurs when the fracture hinges on the intact cortex anteriorly during nail insertion.
Figure A shows a proximal one third tibia fracture treated with an intramedullary nail. There is malreduction of the fracture with valgus and procurvatum deformity.
Incorrect Answers:
Answer 1: would prevent varus malalignment Answer 2: would prevent valgus malalignment alone
Answer 3: would prevent varus and recurvatum malalignment Answer 4: would prevent varus and procurvatum malalignment

When evaluating a fracture dislocation of the elbow, a varus and posteromedial rotation mechanism of injury typically results in what injury pattern?

1) A fracture of the radial head requiring ORIF

2) A highly comminuted radial head fracture requiring radial head arthroplasty or resection

3) An MCL injury requiring repair

4) A type I avulsion fracture of the coronoid

5) An anteromedial coronoid fracture

A varus and posteromedial rotation mechanism of injury typically results in a fracture of the anteromedial facet of the coronoid which frequently requires reduction and fixation to restore stability.
A varus and posteromedial mechanism of injury about the elbow presents with an injury pattern distinctly different from other injury patterns. A key part of treating this injury pattern is recognizing a fracture of the anteromedial facet of the coronoid, which often requires reduction and fixation to restore stability about the elbow. It is important to recognize this during preoperative planning since this injury typically requires a medial approach.
Steinman presents a review article describing coronoid fracture patterns and their mechanisms of injury.
Doornberg and Ring present a level 4 review showing that coronoid fracture patterns and their required treatments are predictable based on mechanism of injury. Varus and posteromedial mechanisms were found to reliably create a fracture of the anteromedial facet of the coronoid, and were associated with sparing of the MCL and radial head.
Doornberg and Ring also presented a Level 3 review of anteromedial facet cornoid fractures. They found that they could not be adequately visualized and treated from a lateral approach, and that they typically required reduction and fixation to restore adequate stability to the elbow. This stresses the importance of recognizing this injury pattern during preoperative planning.
Illustrations A and B are AP and lateral radiographs of an elbow following a varus/posteromedial injury with an anteromedial coronoid facet fracture.
Illustration C is a diagram demonstrating fracture lines that create an anteromedial facet fracture fragment. This fracture can be subclassified into three subtypes [anteromedial rim (a), rim plus tip (b), and rim and tip plus the sublime tubercle (c)]
Incorrect answers:
Answers 1, 2, 3: Radial head fractures, and MCL injuries are not seen in varus/posteromedial mechanisms. They are seen in terrible triad elbow injuries which are due to valgus and posterolateral rotatory forces.
Answer 4: The coronoid fracture seen in these injuries is an anteromedial facet fracture, and not an avulsion fracture of the tip of the coronoid.

A 26-year-old female presented to the emergency department with the injury seen in Figure A after an awkward fall while intoxicated. She undergoes closed reduction and repeat radiographs are seen in Figure B. After a normal physical examination, including ranging the hip from 0-90 degrees, which of the following options would be the next most appropriate step in management?
1) Femoral skeletal traction

2) CT scan

3) Hip spica cast application

4) Observation only

5) Serial neurovascular examinations

This patient has presented with a posterior left hip dislocation. The next most appropriate step would be performing a post-reduction CT scan to assess for joint reduction and congruity, associated fractures, or loose bodies.
Hip dislocations occur most commonly in young patients with high energy trauma. They are usually classified as simple or complex, with complex dislocations being those with associated fractures of the acetabulum or proximal femur. Urgent close reduction should occur within 6 hours from the time of injury. Post reduction CT scans must be performed for all traumatic hip dislocations to look for fractures or impacted areas of the femoral head or acetabulum, as well as incongruent reductions and free intra-articular joint fragments.
Calkins et al. looked at measurements of the posterior acetabulum on CT scans (the Acetabular Fracture Index) after hip dislocations to evaluate for hip stability. Hips were found to be unstable if less than 34% of the remaining posterior acetabulum was present after dislocation. Hips with greater than 55% were stable. In between 34 and 55% were indeterminate.
Moed et al. found that posterior wall fractures involving less than 20% of the posterior wall were considered stable. Fractures involving more than 40%-50% were unstable, leaving a wide range of posterior wall fractures classified as indeterminate.
Figure A shows a left posterior hip dislocation. Figure B shows a reduced left hip with no obvious fracture. Illustration A shows an axial CT scan image of the left hip. There is no acetabular fracture identified.
Incorrect Answers:
Answer 1: Femoral skeletal traction would be considered if there was an associated acetabular fracture or loose body.
Answer 3: Hip spica casts are not used with these injuries.
Answer 4: Observation would be considered after the CT scan is performed. Answer 5: There was no mention of neurovascular injury. This patient has a normal neurovascular examination. There is no fracture or risk of hematoma formation. This would not be necessary.

A 40-year-old male sustained the injury seen in Figure A, and subsequently underwent the procedure shown in Figure B. One hour post-operatively he starts to complain of pain in the operative leg, and the pain is unchanged with active or passive stretch. The external dressing is released with little resolution of symptoms. His blood pressure is 115/78 mm Hg with compartment pressures in the leg measuring 31 to 35 mm Hg. His ABI index is 1.1 in the leg. What would be the next step in management?
1) MRI angiography of leg

2) Four-compartment fasciotomy

3) Follow-up examination the following day

4) Continued monitoring and serial examinations

5) EMG study

The patient is at risk for developing compartment syndrome of the leg. The next most appropriate step would be to support his systemic blood pressure and monitor compartment pressures.
A clinical assessment is the diagnostic cornerstone of acute compartment syndrome. However, the intracompartmental pressure measurement has been advocated to help confirm the diagnosis in patients where there remains uncertainty after clinical exam. An absolute compartment pressure >30 mm Hg or a difference in diastolic pressure and compartments pressure (delta p) 30 mm Hg after tibial fracture do not have a greater incidence of complications than those with low pressures, so long that Delta P
A 10-year-old girl suffers a displaced tibia fracture. Initial numbness over the dorsum of the the foot resolved following an anatomic closed reduction and placement in a long leg cast performed in the emergency room. The cast was placed with the the ankle dorsiflexed just above neutral to prevent equinus contracture and then the cast and padding was adequately bivalved. Overnight, the patient began experiencing recurrent numbness and paresthesias in her exposed toes and a slight increase in her pain at the fracture site. Your next best step would be:

1) Repeat closed reduction under conscious sedation

2) Selective compartment fasciotomies

3) External fixation and compartment monitoring

4) 4-compartment fasciotomies with fracture fixation done emergently

5) Modify the cast to reposition the ankle into slight plantarflexion

Circumferential casting with the ankle dorsiflexed can cause increased intracompartmental pressures in the leg. However, this patient's cast has been adequately bivalved during initial cast placement. Therefore, the next best step is cast modification to allow the ankle to assume an angle between neutral and 30 degrees of plantar flexion and further reducing the compartment pressure.
Tibia fractures are one of many common underlying etiologies for the development of compartment syndrome in the leg. Fracture reduction as well as eliminating circumferential dressings are important early preventative steps to take. Bivalving casts - including splitting the cast padding - is often indicated in fractures of long bones that are treated with initial casting. While casting patients in a plantigrade or dorsiflexed position reduces the risk of equinus contractures and holds the ankle mortise reduced, dorsiflexing the ankle has been shown to increase the intracompartmental pressures throughout the leg compartments.
Weiner et al. placed pressure monitors into the anterior and deep posterior compartments in healthy volunteers to measure the effects of casting on compartment pressures. They found that the intramuscular pressures were lowest with the ankle positioned between plantigrade and a resting plantar flexion position (0-37 degrees), and that bivalving the cast reduced the pressures 33-47%.
Illustration A shows the needle trajectories for compartment pressure monitoring in the leg. This should be performed within 5 cm of the fracture to get accurate peak pressures.
Incorrect Answers:
Answers 1, 3: The stem does not suggest that the reduction was lost, so neither repeating a closed reduction or placement of an external fixator is indicated at this time.
Answers 2, 4: While suspicion should remain elevated for the development of compartment syndrome, simple conservative measures such as cast modification are ideal first steps to avoid onset of compartment syndrome. The clinical vignette given does not portray clinical compartment syndrome requiring emergent fasciotomy. It would be reasonable to maintain a high level of suspicion given the injury, but non-invasive cast modification is a simple, safe and quick first step.

A 35-year-old male horseback rider was bucked into the air and then landed forcefully with his perineum on the saddlehorn of the saddle. At a one year follow-up, the only long term sequela of his injuries is erectile dysfunction. Which radiographic injury seen in Figures A-E is most commonly associated with this complication?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

This patient has sustained a saddle-horn injury to the pelvis. An anterior posterior compression (APC) injury is the most common pelvic injury associated with this mechanism.
Saddle-horn injury to the pelvis occurs when a horseback rider is bucked into the air and then lands forcefully with his or her perineum on the saddlehorn of the saddle. The bony injury to the pelvis usually consists of a diastasis of the pubic symphysis with/without subsequent widening of the sacroiliac joints. The
majority of patients are able to return close to their pre-injury level of employment and activity after these injuries. However, sexual dysfunction is a common complication with this injury. Sexual dysfunction can be due to urethral, vascular, neurologic, and psychogenic injuries.
Collinge et al. looked at a series of male patients with injuries to the perineum after coming into contact with the saddle or saddle horn on a horse. Eighteen of the twenty patients were found to have sexual dysfunction at the time of the latest follow-up. A multi-disciplinary approach to these patients is needed when treating pelvic injuries.
Cannada et al. surveyed 71 women of childbearing age who had a pelvic fracture. She found that half the patients reported physical genitourinary complaints with 38 percent of women noting new onset pain with intercourse. In terms of psychological impact, they showed that 45 percent of patients answered affirmatively to decreased interest in intercourse and decreased orgasm frequency after the injury.
van Nieuwenhoven et al. describe three equestrians who suffered from straddle injuries with symphysis diastasis and rupture of sacroiliac ligaments after falls or kicks from horses. They show that these presumed low-energy injuries can cause extremely severe injuries to the pelvis itself and to the adjacent organs.
Figure A shows a Burgess APC Type II pelvic fracture. Figure B shows left ASIS avulsion fracture. Figure C shows a left hip dislocation. No pelvic fracture is identified. Figure D shows a subacute superior/inferior pubic rami fracture.
Figure E shows a right femoral neck fracture.
Incorrect Answers:
Answers 2,3,4,5: Any pelvic or lower limb fracture can cause a disruption in a patients activities of daily living. This may include sexual dysfunction, for both men and women. The injury pattern that has the greatest potential for sexual dysfunction are APC type pelvic injuries.

A 31-year-old male driver was involved in a high-speed motor vehicle accident. His injuries include a left subdural hematoma (Abbreviated Injury Score [AIS]=4), left segmental femur fracture (AIS=3), ruptured spleen (AIS=4), nasal fracture (AIS=2), fractured left ribs 4 to 7 (AIS=2), and a closed pelvic ring fracture (AIS=3). What is his Injury Severity Score (ISS)?
1/. 18

1) 25

2) 33

3) 41

4) 48

This patients Injury Severity Score (ISS) is 41. In this patient, the highest AIS scores were from the head (AIS=4), abdomen (AIS=4) and pelvis (AIS=3).
Therefore, the calculation for the ISS score was 4^2 + 4^2 + 3^2 = 41.
The ISS score is calculated as the sum of the square values from the highest Abbreviated Injury Score [AIS] scores in the three most severely injured ISS body regions. ISS scores range from 1 to 75. A single score of 6 on any AIS region results in automatic score of 75. ISS scores > 15 are associated with mortality of 10%.
Poole et al. found that the AIS and ISS appropriately reflect the impact of extraskeletal injuries in patients with femur fractures, but they do not adequately reflect the increased morbidity associated with multiple lower extremity fractures.
Balogh et al. aimed to compare the scoring efficacy of the injury severity score (ISS) and the new injury severity score (NISS) in predicting post-injury outcomes. They found that multiple orthopaedic injuries, as used in the NISS system, had a significantly greater impact on reported poor post-injury outcomes. They suggest that NISS should replace the traditional ISS when grading trauma related outcomes.
Illustration A shows a table of the various ways to score injury severity in trauma patients.
Incorrect Answers:
Answers 1,2,3,5: ISS = A^2 + B^2 + C^2, where A, B, C are the AIS scores of the three most severely injured ISS body regions. The only correct answer is ISS=41.

A 60-year-old otherwise healthy female sustains the fracture in Figure A. Immediate surgical treatment would most likely prevent which of the following complications?
1) Malunion.

2) Regional osteopenia.

3) Skin necrosis.

4) Posttraumatic arthritis.

5) Refracture.

The patient has a calcaneal tuberosity fracture. The Achilles tendon is attached to the displaced fragment, which can cause soft tissue compromise and skin necrosis if not treated promptly.
Displaced calcaneal tuberosity and tongue-type calcaneus fractures have a high incidence of wound complications if not treated urgently. Recommended management includes surgical fixation often performed percutaneously. Lag screws are typically directed from the posterior superior tuberosity inferiorly and distal. In cases of skin sloughing and skin necrosis, flaps may be needed.
Gardner et al. reviewed 139 tongue-type calcaneus fractures, and found that 21% had some degree of posterior skin compromise. Additionally, there was a statistically significant increase in posterior skin compromise with delayed presentations.
Hess et al. reviewed 3 cases of calcaneal tuberosity avulsion fractures that let to skin necrosis because of a delay in treatment.
Tornetta reviewed the indications for percutenaous treatment of calcaneus fractures, and found it was successful and most useful in tongue-type calcaneus fractures.
Figure A shows a lateral radiograph of a R ankle showing a calcaneal tuberosity fracture. Illustration A shows an AP radiograph of a R ankle following percutaneous reduction and internal fixation of the calcaneus fracture with two cannulated screws. Illustration B shows a lateral radiograph of a R ankle showing interval reduction and fixation of the calcaneus fracture. Illustration C shows a clinical photograph of posterior skin compromise associated with a calcaneal tuberosity fracture.
Incorrect Answers:
Malunion, regional osteopenia, posttraumatic arthritis, and refracture risk would not be significantly altered with immediate surgical intervention as opposed to operative management within a reasonable time frame.

When elevating the joint surface in the injury pattern seen in Figure A, what material has the highest compressive strength when filling the metaphyseal void?
1) Calcium phosphate

2) Tricalcium phosphate

3) Cancellous autograft

4) Cancellous allograft

5) rhBMP-7

Figure A illustrates a depressed lateral tibial plateau. One of the key components of fixing a depressed articular segment is maintaining the reduction.
Trenholm et al reviewed an experimental study where a split depression (Schatzker II) fracture was created in a cadaveric model. The stiffness of the elevated fragment in cadavers using calcium phosphate cement versus cancellous bone graft as support showed no difference, but calcium phosphate cement was found to have greater compressive strength than cancellous bone alone.
The review article by Hak reviews the composition, advantages, and disadvantages of commerically available bone graft substitutes.
Incorrect answers:
2: Tricalcium phosphate is a bone graft substitute that is osteoconductive, but has less compressive strength.
3-4: Cancellous bone has less compressive strength than calcium phosphate. 5: rhBMP-7 is not used as a bone filling agent in this instance, as it is typically provided on a easily compressible collagen sponge.

A 42-year-old male sustains multiple abdominal injuries along with the fractures shown in Figures A and B. Which of the following factors is most useful to determine the patient's resuscitation and ability to undergo early definitive fixation of these two fractures?
1) Pulse pressure

2) Respiratory rate

3) Urine output

4) Platelet count

5) Base deficit

The base deficit, or lactate level, has been shown to best reflect the resuscitation status and survival after trauma.
Normalization of hemodynamic parameters does not accurately reflect the resuscitation status and a patient can be in compensated shock (occult tissue hypoperfusion) despite normalization of the heart rate and blood pressure. The use of temporizing measures with delayed definitive fracture treatment has been shown to decrease systemic complications in these patients with occult hypoperfusion.
Crowl et al. performed a retrospective study of 127 patients with femoral shaft fractures undergoing intramedullary nailing, assessing for occult hypoperfusion. Patients with occult hypoperfusion preoperatively had a twofold increase in postoperative complications and significant increase in postoperative infections.
Tisherman et al. present a review of hemodynamic parameters and their use in assessment of resuscitation. They report that hyperlactatemia is common among critically ill patients, and lactate levels and their trend may be reliable markers of illness severity and mortality. Therefore, measurement of blood lactate is recommended to stratify patients based on the need for fluid resuscitation and the risks of multiple organ dysfunction syndrome and death. They conclude that lactate is a reliable indicator of sepsis severity and a marker of resuscitation; however, it is an unreliable quantitative marker of tissue hypoxia/hypoperfusion.
Pallister et al. present a review of the effect of early stabilization of long bone fractures. They note that early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure, both of which are caused by activation of the systemic inflammatory response. This activation results in tissue recruitment of and injury by circulating polymorphonuclear leukocytes.
Figure A is a radiograph showing a femoral shaft fracture, while Figure B shows an open tibial shaft fracture.
Incorrect Answers:
Answers 1-4: Normalization of these factors does not always predict adequate resuscitation.

Interleukin-6 levels have been shown to be a reliable measure of which of the following?

1) Osteoporosis

2) Severity of injury

3) Sarcomatous tumor burden

4) Bone turnover

5) Hyperparathyroidism

Interleukin-6 (IL-6) is a proinflammatory cytokine that is increased according to the level of injury sustained and acts to activate the host immune system. In addition, new literature exists to indicate its high sensitivity and specificity for detecting infection in total joint arthroplasty.
Overactivation of the immune system and cytokines can lead to systemic inflammatory response syndrome (SIRS), which results in end-organ damage, including small-vessel vascular damage; this would lead to parenchymal cell death from hypoxic insult.
Keel et al. report that immediate and early trauma deaths are determined by brain injuries or significant blood loss, while late mortality is caused by secondary brain injuries and host defense failure. The secondary effects are characterized by local and systemic release of pro-inflammatory cytokines, arachidonic acid metabolites, proteins of the contact phase and coagulation systems, complement factors and acute phase proteins, as well as hormonal mediators.
Pape et al. investigated the effect of surgeries as a "second-hit" phenomenon. They found that surgery on days 2-4 was associated with a greater amount of postoperative organ dysfunction than if the secondary surgery was done on days 5-8. They also found a significant association between IL-6 values above 500pg/dL at the time of surgery and development of multiple organ failure.
Sears et al. review the effect of the inflammatory response to trauma and the development of complications (death, multiple organ failure). They report that IL-6 and the HLA-DR2 molecules currently appear to have the most potential for use in predicting outcomes in trauma patients.
Illustration A is a diagram that shows some of the effects of IL-6 production.
Incorrect Answers:
1,3-5: IL-6 levels are not known to be reliably altered by these factors.

A 31-year-old male sustained a displaced proximal humerus fracture after a motor vehicle accident. Which of the following factors has the lowest association with humeral head ischemia in these injuries?

1) Four-part fracture

2) Head-splitting fracture

3) Neck fracture with a long calcar segment

4) Disrupted medial periosteal hinge

5) AO type C3 fracture

A long calcar fracture segment, also known as the posteromedial metaphyseal head extension, is a good prognostic sign against the development of osteonecrosis in displaced proximal humerus fractures.
The humeral head is directly supplied by the anterior and posterior humeral circumflex arteries. Disruption of these vessels can result in humeral head osteonecrosis. Fracture patterns with long medial metaphyseal segments (greater than 8 mm) have not shown to critically disrupt the vascular supply to the humeral head causing osteonecrosis. Other factors shown to be protective against osteonecrosis after trauma include an intact medial hinge and simple fracture patterns.
Hertel et al. examined the factors predictive of osteonecrosis of the humeral
head after fracture. These include four-part fragments, angular displacement
>45 degrees of the head, displacement of the tuberosities greater than 10 mm, glenohumeral fracture-dislocation, and head-splitting fractures.
In Hertel's second paper and follow up study they noted that the initial post-fracture humeral head ischemia does not predict development of necrosis.
Illustration A shows an example of a long and short calcar fracture segment. Illustration B shows the AO classification of proximal humerus fractures.
Incorrect Answers:
Answers 1,2,4,5: All these factors are predictive of osteonecrosis.

A 50-year-old female has been diagnosed with osteomyelitis of her left tibia. The infection is isolated to the meduallary canal of the bone, and her past medical history is significant for heavy smoking and chronic venous stasis. Based on the clinical staging of osteomyelitis, what would be her Cierney-Mader classification?

1) Stage 2A

2) Stage 1B

3) Stage 1C

4) Stage 3B

5) Stage 4C

The Cierny-Mader classification is a clinical classification based on clinical and anatomic features. This patient's Cierny-Mader classification is Stage 1B.
The Cierney-Mader classification system characterizes osteomyelitis in one of four anatomic stages. Stage 1 is confined to the medullary cavity of the bone. Stage 2 involves only cortical bone. Stage 3 is a localized infection to cortical and medullary bone. However, the bone remains stable. Stage 4 involves the entire thickness of the bone, with loss of bone stability. The Cierny-Mader system also sub-characterizes patients as A, B, or C. The [A} patients have no systemic or local immune compromising factors. The [B] patients have one or more systemic or local compromising factors. The [C] patients are severely immunocompromised and treatment will lead to greater morbidity than the infection.
Mader et al. described the treatment algorithm of osteomyelitis using the Cierny-Mader classification. Treatment involves both antibiotic and surgical debridement. For type 1 infection, thorough intramedullary reaming and unroofing is usually performed.
Illustration A shows a table for the Cierny-Mader classification. Illustration B shows a schematic illustration of the anatomical involvement of osteomyelitis using the Cierny-Mader classification.
Incorrect Answers:
Answer 1: This would be a cortical infection only in a healthy patient. Answer 3: This would be a medullary cavity infection only in a severely compromised patient.
Answer 4: This would be a localized infection to cortical and medullary bone in a patient with one or more systemic or local compromising factors.
Answer 5: This would be a diffuse infection involving the entire bone in a severely compromised patient.

A 68-year-old female sustains a fall to her dominant arm and sustains the fracture seen in Figure A. She undergoes uneventful open reduction internal fixation with a locked plate and screw construct. Which of the following radiographs (Figures B, C, D, E, or F) show the most common complication associated with this treatment modality?
1) Figure B

2) Figure C

3) Figure D

4) Figure E

5) Figure F

Figure B shows screw penetration of the articular surface, which is the most common complication following locked plate and screw fixation.
Inadequate fixation, typically in the humeral head, subsequently fails leading to varus deformity and screw penetration. This most commonly occurs in fixation for 3 and 4 part fractures, but can also occur following fixation for 2 part fractures.
Egol et al. retrospectively reviewed 51 patients following locked plating of 3-and 4-part proximal humerus fractures, they found 16% had screw penetration. The authors recommended ensuring appropriate number and length of the screws placed to prevent cut-out.
Brunner et al. reviewed 158 proximal humerus fractures. They found at 1 year follow-up noted 14% screw penetration rate. They recommended close followup to monitor for cut-out.
Figure A shows a 3-part proximal humerus fracture. Figure B exhibits varus cut-out and screw penetration. Figure C exhibits non-union and fixation failure. Figure D exhibits avascular necrosis and complete head collapse. Figure E (arrow) exhibits changes consistent with heterotopic ossification.
Figure F exhibits non-union and fixation failure at the level of the shaft.
Incorrect answers:
Answer choice 2/5 (figure C/F): Non-union and fixation failure can also occur, but at a relatively low rate.
Answer choice 3 (Figure D): Avascular necrosis also occurs, but at a lower rate than screw penetration.
Answer choice 4 (Figure E): Heterotopic ossification (arrow) can occur but is rare.

Figure A shows an acute, isolated and closed, left knee injury in a 40-year-old male struck by a motor vehicle. What would be the most
appropriate surgical fixation for this injury?
1) Definitive external fixation

2) Temporary external fixation then lateral percutaneous screws

3) Lateral nonlocking plate +/- bone graft substitutes

4) Medial and lateral locking plate +/- bone graft substitutes

5) Lateral percutaneous screws with assisted arthroscopy

This patient has sustained a Schatzker 2 (AO/OTA Type B) fracture of the lateral tibial plateau. The most appropriate treatment of this fracture would be fixation with a lateral nonlocking plate +/- bone graft substitute.
Displaced, widened and depressed tibia plateau fractures are an indication for operative intervention. The aim of surgery is to restore anatomic articular congruity, length, alignment and rotation of the proximal tibia. This is best achieved by (1) direct reduction of the articular surface, and (2) fixation of the interfragmentary piece with a plate and screw construct, which provides subarticular support, interfragmentary compression, and prevents shearing of the fracture. In patients with good bone quality, this is best achieved with an undercontoured lateral nonlocking plate in buttress mode.
Karunakar et al. showed that there was no significant difference between split depression tibial plateau fractures (Shatzker II) fixed with either (1) buttress plate with rafting screws versus (2) periarticular plate with built in rafting screw hole options.
Gardner et al. examined 62 consecutive Schatzker type II fractures with radiographs and MRIs preoperatively. They found that joint depression greater than 6mm and widening of greater than 5mm was associated with a lateral meniscal injury over 80% of the time.
Figure A provided a sequence of coronal CT scan images of a left knee. There is a lateral split depression tibial plateau fracture with significant joint
depression, articular impaction and condylar widening.
Incorrect Answers:
Answer 1: Definitive external fixation of tibial plateau fractures may be considered in patients who are unable to tolerate definitive surgery, severe open fractures, infections, or significant bone loss.
Answer 2: Temporary external fixation would be considered in patients with significant soft tissue injury.
Answer 4: Locking plates do not provide buttress effect when used in pure locking mode. In addition, locking plates add significant incremental cost to the procedure. Medial plating would support a bicondylar fracture.
Answer 5: Screws alone are unlikely to be adequately stable in this patient. Although not commonly employed, knee arthroscopy is considered by some surgeons to be a valuable method to assist in obtaining the best articular surface reduction during surgery.

An otherwise healthy young adult male sustains a transverse radial shaft and ulna fracture. He undergoes definitive surgical fixation with two non-locking compression plates (LCPs) as shown in Figure A. What is the principle of this fixation technique on bone healing?
1) Absolute stability with direct healing by callus formation

2) Relative stability with indirect healing by callus formation

3) Absolute stability with direct healing by internal remodeling

4) Relative stability with indirect healing by internal remodeling

5) Absolute stability with endochondral bone formation

Definitive surgical fixation for a simple transverse both bone forearm fracture would include open reduction and internal fixation with absolute stability with direct healing by internal remodelling (i.e., primary bone healing). The radius is fixed with a 7-hole 3.5mm LC-DCP plate in compression mode. The ulna was fixed with a 8-hole 3.5mm LC-DCP neutralization plate with (2) lag screws.
Restoration of the radial bow, length, and alignment in conjunction with primary bone healing would optimize the restoration of pronation/supination in the forearm. Compression plating and anatomic reduction of articular fractures are examples of absolute stability. Casting, bridge plating, external fixation, and intramedullary nailing provide relative stability, with secondary bone healing resulting.
Moed et al. reviewed 56 patients with open diaphyseal forearm fractures treated with immediate internal fixation. The complications included deep infection in 2 patients and non-union in 6. This study indicated immediate stable plate fixation was a beneficial method of treatment for open diaphyseal forearm fractures.
Jones et al. discussed current literature on treating adult diaphyseal forearm fractures with open reduction internal fixation versus intramedullary nailing, and concluded a randomized prospective study is needed. They stated current literature is inconclusive.
Figure A shows a both bone forearm fracture fixed with absolute stability. The radius is fixed with a 7-hole 3.5mm LC-DCP plate in compression mode. The ulna was fixed with a 8-hole 3.5mm LC-DCP neutralization plate with (2) lag screws.
Incorrect Answers:
Answers 1-2, 4-5: Absolute stability is a biological process of osteonal bone remodelling. This is predominantly intramembranous ossification. Enchondral bone formation occurs in non-rigid fracture healing (secondary bone healing).

A 27-year-old man sustains a tibial plateau fracture as pictured in Figure A-D. Which combination of fixation constructs and stability
would optimize his outcome?
1) Intramedullary nailing for a relative stability construct

2) Posteromedial buttress plating for an absolute stability construct

3) Locked lateral plating an absolute stability construct

4) Medial antiglide plating for a relative stability construct

5) Spanning external fixation for an absolute stability construct

Intraarticular tibial plateau fractures require absolute stability constructs to maintain anatomic joint reductions without callus formation. This condylar split fracture is ideally treated with buttress fixation at the apex of the fracture to avoid the high likelihood of shear failure with a laterally placed fixed-angle construct.
Tibial plateau fractures in young adults are high energy injuries, and the condylar split components of the fractures occur due to shear failure. The mechanism of failure - axial loading combined with a varus or valgus moment with the knee extended or flexed - dictates the orientation of the condylar split fracture line(s). There are multiple fracture classification schemes that assist with surgical decision making, particularly with placement of buttress plate fixation to resist shear failure. Articular impaction and joint depression must also be addressed.
Bai et al. performed a biomechanical study on fresh cadavers to simulate residual articular step-offs after fixation. With a >5 mm step-off, contact pressures increased over 200%.
AO guidelines of tibial plateau fracture management are discussed in depth in AO Principles of Fracture Management, and up-to-date principles can be found on the AO surgery reference. Anatomic reduction and absolute stability are important elements of all intraarticular proximal tibia fractures.
Figures A and B are injury films of a tibial plateau fracture with a large posterior split of the medial condyle. Figure C shows an axial CT cut displaying the same fracture. Illustrations A-C show how the injury was treated. Through a posterior incision, an under-contoured anti-glide plate was used to reduce the fracture at the apex. Subsequently, a pre-contoured posteromedial buttress plate was placed to maintain the reduction. The articular reduction was finalized with rafting screws outside of the plating construct to optimize the angle of subchondral support.
Incorrect Answers:
Answers 1, 4: Relative stability is inappropriate for intraarticular fractures that require anatomic reductions
Answer 3: Laterally-based locked plating for a medial condyle fracture creates large moments about the screw-plate interface, and the construct is apt to fail in shear
Answer 5: Spanning external fixation is most commonly used for temporizing tibial plateau fractures when significant soft tissue is present - in the absence of additional fixation for a hybrid construct, it would provide relative stability

Surgical fixation with absolute stability would be most appropriate for which of the following fracture patterns?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

Anatomic reduction and fixation with absolute stability is appropriate for articular fractures, such as posterior malleolar ankle fractures with significant joint involvement.
Compression plating and anatomic reduction of periarticular fractures yield absolute stability. Fractures treated with absolute stability achieve primary bone healing. Posterior malleolar ankle fractures comprising greater than 25% of the joint and non-comminuted lateral malleolar ankle fractures are typically treated with internal fixation to achieve absolute stability. Casting, bridge plating, external fixation, and intramedullary nailing provide relative stability, with secondary bone healing resulting. In fractures with significant comminution and in lower extremity diaphyseal long bone fractures, relative stability is employed.
Gardner et al. surveyed members of the Orthopaedic Trauma Association (OTA) and American Orthopaedic Foot and Ankle Society (AOFAS) regarding treatment of posterior malleolus ankle fractures. They found that size influenced decision making, with 97% electing to treat those posterior malleolus fractures that comprised 50% of the joint. The most common used
approach was the posterolateral approach, which utilizes the interval between the flexor hallucis longus and peroneals.
Forsberger et al. reviewed 45 consecutive patients treated with surgical fixation of the posterior malleolus through the posterolateral approach. This approach allowed excellent exposure with few soft tissue complications.
De Vries et al. reviewed 45 patients with ankle fractures that had a posterior malleolar component. Those patients that had the posterior malleolar fragment fixed did not have statistically better functional scores than those who did not have the fragment fixed. They concluded that those patients with fragment sizes less than 25% did not require fixation and had good functional outcomes at 13 year follow-up.
Figure A shows an AP and lateral radiograph of a right comminuted distal third radial shaft fracture. Figure B shows an AP and lateral radiograph of a lateral and posterior malleolar ankle fracture in addition to a deltoid rupture. Figure C shows an AP and lateral radiograph of a comminuted middle third tibial shaft fracture. Figure D shows an AP radiograph of a minimally displaced greater trochanter fracture. Figure E shows an AP and lateral radiograph of a pediatric distal radial metaphyseal fracture. Illustration A shows an AP, mortise, and lateral radiograph of a posterior and lateral malleolus ankle fracture treated with open reduction and internal fixation.
Incorrect answers:
Answer 1: Significant comminuted radial shaft fractures are treated with bridge plating, which would achieve relative stability.
Answer 3: Diaphyseal tibial fractures are treated with intramedullary nailing, which achieves relative stability.
Answer 4: Minimally displaced greater trochanter fractures are treated nonoperatively.
Answer 5: Pediatric distal radius fractures are typically treated with closed reduction and casting, which achieves relative stability.

Figures A and B are radiographs of a 72-year-old male who presented to hospital 3 days after an unwitnessed fall. He presents with pain and the inability to mobilize since the fall. The patient lives independently and has no significant past medical history. Physical examination reveals an alert and oriented patient. This is an isolated injury with no other focal or systemic deficits. What would be the most important investigation to be obtained before taking this patient to the operating room?
1) Pelvic inlet and outlet views

2) CT head

3) Duplex ultrasound of both lower extremities

4) CT hip and pelvis

5) MRI hip and pelvis

The most appropriate investigation to order in this patient would be a duplex ultrasound of both lower extremities.
Immobilized elderly patients with a delay of more than two days from the fracture to presentation at the hospital are at a higher risk of deep-vein thrombosis (DVT). The risk can be higher in patients with factors that predispose to clot formation, such as malignancy. Patients with a delayed presentation to hospital should be investigated for DVT. The most common screening modality is duplex ultrasound of both lower extremities.
Hefley et al. looked at the effect of delayed admission to the hospital on the preoperative prevalence of DVT associated with hip fractures. They found that 6 out of 11 patients with a delay of more than two days between the fracture and admission to the hospital had evidence of thrombosis. They conclude all patients with delayed admission, after a hip fracture, should be evaluated for DVT preoperatively.
Figure A and B are AP and lateral radiographs that show a displaced left subcapital hip fracture.
Incorrect Answers:
Answer 1: There is no indication of pelvic inlet and out views. Generally speaking, pelvic inlet and outlet views assess the pelvic ring and pelvic bone stock, which are normal in this patient.
Answer 2: CT head would be indicated after an unwitnessed fall if the patient admitted to head injury, had neurological symptoms or acute focal/systemic deficits on exam. None of these are present in this patient.
Answer 4 and 5: A CT or MRI of the hip and pelvis are not indicated in a displaced fracture, but may be useful in diagnosing nondisplaced fractures.

A 67-year-old female sustains the injury shown in Figure A after a trip and fall. When discussing the outcomes of surgery with the patient, which of the following statements is true?
1) Post-surgical mortality rates are significantly lower after total hip arthroplasty compared to hemiarthroplasty

2) Internal fixation shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to arthroplasty

3) Bipolar hemiarthroplasty shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to unipolar hemiarthroplasty

4) A delay in surgery greater than 48 hours is acceptable if the patient has multiple medical comorbiditiesm which are not fully optimized

5) Dislocation rates are equivalent between total hip arthroplasty and hemiarthroplasty

Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. However, patients with significant medical comorbidity should be fully optimized before surgery.
Although several studies have shown a benefit to surgery within 48 hours, no definitive time frame has been elucidated. The majority of literature has shown improved outcomes in regards to pain, complications, and length of stay with early surgery. Patients with significant medical comorbidities have been shown to have the highest mortality rates.
Moran et al. aimed to determine whether a delay in surgery for hip fractures had an affect on postoperative mortality among elderly patients. In an observational study of 2660 patients, they showed that mortality following hip fracture surgery was 9% at 30-days, 19% at 90-days, and 30% at 12-months.
Patients with medical comorbidities had 2.5 times the risk of death within 30-days of surgery. In addition, individuals who had surgery delayed beyond 4 days had increased mortality at 90-days and 12-months.
Papakostidis et al. examined the timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. They showed no benefit of early surgery on incidence of AVN. However, delay of internal fixation of more than 24 hours showed increased rates of non-union.
Figure A shows a displaced right femoral neck fracture. Incorrect Answers:
Answer 1: Patients treated with hemiarthroplasty or total hip arthroplasty
demonstrated no statistically significant difference in mortality.
Answer 2: Arthroplasty consistently has better outcomes compared to internal fixation for the treatment of unstable/displaced (Garden III and IV) femoral neck fractures in elderly patients.
Answer 3: Outcomes of unipolar and bipolar hemiarthroplasty for unstable femoral neck fractures are similar.
Answer 5: Dislocation rates are higher with total hip arthroplasty compared to hemiarthroplasty.

An 87-year-old female sustains the injury shown in Figure A after a fall from standing. At baseline, she ambulates with a walker in her home and lives with a 24-hour home health aide. She has a past medical history of stroke and mild dementia. Following medical optimization, what is the most appropriate treatment modality?
1) Intramedullary nail

2) Hemiarthroplasty

3) Closed reduction percutaneous pinning

4) Total hip arthroplasty

5) Sliding hip screw

At baseline, with minimal ambulatory status and dependence on a 24-hour home health aide, the best treatment choice is hemiarthroplasty.
Arthroplasty is the gold standard for displaced femoral neck fractures in the elderly. In community ambulators with relative independent lives, total hip arthroplasty (THA) is recommended. For minimal ambulator, hemiarthroplasty is recommended.
van den Bekerom et al. randomized 252 patients over 70-years-old to either THA or hemiarthroplasty for displaced femoral neck fractures. With increased blood loss, operative time and dislocation risk, they did not recommend THA unless there was good preoperative ambulatory status, and/or pre-existing osteoarthritis or rheumatoid arthritis.
Figure A exhibits a displaced femoral neck fracture
Incorrect answers:
Answers 1, 3, 5 are not the treatment standards for displaced femoral neck fractures in the elderly.
Answer 4 is incorrect because the patient is minimally ambulatory at baseline with little independence.

A 20-year-old female arrives to the trauma bay following a motor vehicle accident. She was a restrained driver and has bilateral chest tubes placed in the trauma slot. Initial laboratory values are significant for a hematocrit of 45.5 g/dL and a lactate of 7 mmol/L. Both lower extremities exhibit grossly open wounds. Radiographs are shown in Figure A and B. What is the best initial management of her orthopaedic injuries?
1) Irrigation and debridement of left femur and right tibia with bilateral external fixator placement

2) Irrigation and debridement of left femur and right tibia with left external fixator placement and right tibial intramedullary nail placement

3) Irrigation and debridement of left femur and right tibia with left femoral and right tibial intramedullary nail placement

4) Irrigation and debridement of left femur and right tibia with left femur open reduction and internal fixation and right tibial intramedullary nail placement

5) Irrigation and debridement of left femur and right tibia with bilateral long leg splint placement

Presenting as an unstable patient, damage control orthopaedics (DCO) should be performed by placing bilateral external fixators following irrigation and debridement.
Signs of clinical instability include an elevated lactate level as well as injuries to both lungs, necessitating bilateral chest tubes. Furthermore, while the patient is young and her hematocrit reflects a 'normal' number, more likely is a hypovolemic state due to bilateral open long bone injuries. Resuscitation is required and early total care (ETC) should be avoided.
Pape et al. review the early data regarding DCO and ETC. Identification of patients in extremis, borderline, unstable or stable patients is critical to determining appropriate management. Adequate resuscitation, by tracking lactate, as well as full evaluation of the multiply injured patient is crucial in determining application of DCO versus ETC. DCO is necessary as a temporizing stage to improve mortality in critically injured patients.
Renaldo and Egol revisit the evolution of trauma care where early, acute treatment evolved to ETC, and again to the development and implementation of DCO and staged fixation. Reviewing the initial post-traumatic inflammatory response, the authors review literature that supports the implementation of DCO in the unstable patient, especially the role of the 'second hit' phenomenon and the spike in inflammatory cascade that occurs between days 2-5 following injury.
Figure A is a lateral x-ray of a comminuted, displaced, open distal femur fracture. Figure B is an anteroposterior radiograph of a spiral, oblique, open tibia fracture.
Incorrect Answers:
Answers 2-4: Due to the elevated lactate levels and unstable nature of the patient, DCO should be applied via placement of external fixators. Definitive fixation at this time could worsen the patient's acute condition and subsequent
morbidity and mortality.
Answer 5: This patient, while unstable, is not in extremis, therefore temporary skeletal stabilization should be placed with external fixators.

Figure A is a radiograph of a 31-year-old male cyclist who was struck by a vehicle. Physical examination revealed a 2 cm opening in the skin over the anteromedial leg. He was treated operatively with an unreamed intramedullary nail. What outcome can be expected using this operative modality when compared with reamed intramedullary nailing?
1) Higher rates of nonunion

2) Higher rates of malunion

3) Higher rates of infection

4) Lower rates of infection

5) No difference

The best definitive surgical fixation option for an open fracture of the tibia would be either a reamed or unreamed intrameduallary nail.
Treatment of open tibia fractures require immediate antibiotics and early
irrigation and debridement. Surgical fixation options are vast, but largely based on the severity of injuries both locally or systemically. External fixation devices are mainly used for provisional fixation in polytrauma patients or definitively in proximal or distal metaphyseal fractures. Plating may be used in a staged fashion after a period of external fixation. The most common fixation method is intramedullary nailing. The use of a reamed or unreamed nail technique does not affect union rates, infection rates, or need for additional surgeries in open tibia fractures.
Bhandari et al conducted a multicenter, blinded randomized trial of 1319 adults in whom a tibial shaft fracture was treated with either reamed or unreamed intramedullary nailing. When comparing outcomes in open and closed injuries at twelve months, they found a benefit for reamed intramedullary nailing in patients with closed fractures, but found no difference between approaches in patients with open fractures.
Finkenmeier et al conducted a randomized controlled study of reamed vs. unreamed nails in open and closed tibia fractures (excluding Grades IIIB and IIIC). They found that the use of reamed insertion of IM nails for the treatment of closed tibia fractures lead to an earlier time to union without increased complications. The authors reported no differences in infection rate, compartment syndrome rate, or percent needing additional surgeries to obtain union. More secondary procedures were needed with unreamed nails in closed fractures only.
Figure A shows a mid-shaft tibia fracture. Incorrect Answers:
Answers 1, 2, 3, 4: All prospective studies show no difference in the rates of
non-union, malunion, or infection when using a reamed or unreamed nails to treat open tibia fractures.

A 27-year-old male presented to the trauma bay following a motor vehicle crash and was diagnosed with a comminuted open tibia fracture. He was subsequently treated with an irrigation and debridement, and un-reamed intramedullary nail. At 4 months followup, despite some signs of healing, the fracture is not fully united. Which of the following is true?

1) Patient should be scheduled for exchange nailing.

2) Use of an un-reamed nail increased this patients risk of infection.

3) Use of an un-reamed nail increased this patient's risk of non-union.

4) Patient should continue to be observed without intervention.

5) Use of an un-reamed nail decreased this patient's risk of infection.

Tibia fractures, open or closed, when treated with an intramedullary nail can take 6 months or longer to achieve clinical and radiographic healing, and should be observed for at least 6 months before secondary intervention is considered.
Open tibia fractures should be managed with debridement and irrigation initially. The choice of definitive fixation between reamed and unreamed nailing remains controversial. Recent randomized controlled studies have examined the outcomes of reamed and unreamed nailing for both closed and open tibia shaft fractures.
Bhandari et al. present a prospective randomized study of patients with tibia fractures randomized to reamed or un-reamed tibial nails. Surgeons participating in the study were mandated to delay intervention for delayed union/nonunion until 6 months after the initial procedure. The authors found that many tibia fractures in both the reamed and unreamed nailing groups progressed to union without secondary intervention with this 6 month delay.
Finkemeier et al. present a prospective randomized trial of tibia fractures treated with reamed or un-reamed intramedullary nails. For closed fractures they found a higher rate of union at 4 months in the reamed group, but no difference at 6 or 12 months. There was no difference in union rates for open fractures at any time point. They found no differences in other variables such as infection or compartment syndrome.
Incorrect answers:
Answer 1: This fracture has signs of healing at 4 months, and should continue to be observed until at least 6 months before a secondary operation is considered.
Answers 2 and 5: There is no difference in infection risk between reamed and un-reamed nails for open tibia fractures
Answer 3: There is no difference in rate of eventual union between reamed and un-reamed nails for open tibia fractures.

A 27-year-old male sustains a type I open both bone forearm fracture as seen in Figure A. During irrigation and debridement a 1 cm of cortex is removed leaving a segmental gap. Which of the following adjuvants is recommended to supplement your internal fixation?
1) Bone grafting

2) Tricalcium phosphate

3) Calcium phosphate

4) Calcium sulphate

5) BMP-3

Bone grafting in the primary fixation of fractures is typically limited to those with segmental defects. While the increased surface area of a comminuted fracture may aid in the healing potential, the segmental defect is a limiting factor to fracture healing. Calcium sulphate, tricalcium phosphate, BMP-3, and calcium phosphate are not indicated in this clinical picture. BMP-2,4,6, and 7 all have osteoinductive activity but BMP-3 does not demonstrate osteoinductive activity.
In their retrospective review of 198 fracture, Wright et. al found BG was not indicated for comminuted open fracture, and only recommend BG when there is a segmental bone defect.
Wei et. al also performed a retrospective review of 64 fractures in 49 patients and found BG was not indicated for comminuted open fracture, and only recommend BG when there is a segmental defect.
Finally, Schemitsch and Richards determined that optimal outcome post forearm fracture depends on restoration of the radial bow.

A 30-year-old female falls onto her outstretched arm and sustains the injury shown in Figures A and B. After intra-articular lidocaine injection, her elbow range of motion is 30°-95° extension/flexion, 45° supination, 65° pronation. There is no wrist tenderness and the radius pull test is symmetric to the contralateral forearm. What is the most appropriate treatment?
1) Fragment excision via the extensor carpi ulnaris / anconeus approach

2) Internal fixation with headless compression screws via the brachialis / pronator teres approach

3) Internal fixation with a periarticular plate via the extensor carpi ulnaris /
anconeus approach

4) Radial head arthroplasty via the brachialis / pronator teres approach

5) Sling and early elbow range of motion

This patient has a Mason type III radial head fracture composed of two articular fragments with a mechanical block to motion and should be treated with open reduction internal fixation (ORIF) using a lateral approach to the radial head.
Treatment of radial head fractures depends on fracture anatomy, elbow/forearm motion and ipsilateral forearm injury. Minimally displaced fractures with no mechanical block to motion (Type I; see Illustration C) are most common and are treated with a sling and early motion. Displaced fractures with one fragment (Type II) and block to motion are often managed with ORIF. Fragments less than ~30% of the articular surface may be excised, provided there is no concern for ipsilateral forearm instability. Displaced multi-fragmentary fractures (Type III) are usually managed with radial head arthroplasty, but may be treated with ORIF in young patients with less than three fragments.
Ring et al. performed a retrospective study of 56 patients who underwent radial head ORIF. Patients with more than three articular fragments had significantly poorer patient outcome scores, loss of forearm rotation and required more secondary procedures to ultimately resect the radial head. The authors concluded that ORIF is effective for fractures with less than three articular fragments and that fractures with three or more fragments are better managed with prosthetic replacement.
Ruchelsman et al. reviewed radial head and neck fractures. Choice of treatment is impacted by fragment number, size (percentage of articular disc), comminution and stability, as well as radiocapitellar alignment and block to motion. When feasible, ORIF allows restoration of anatomic congruity and initiation of early motion. Radial head arthroplasty is preferred for radial head fractures with multiple fragments or if stable fixation cannot be ensured.
Figures A and B are the AP and lateral radiographs of the left elbow showing a displaced complete articular radial head fracture with two articular fragments [Ruchelsman et al.]. Illustrations A and B are fluoroscopic images showing subsequent fixation of the fracture with a periarticular plate [Ruchelsman et al.]. Illustration C is the Mason classification of radial head fractures.
Illustration D is an intraoperative photograph showing exposure of the radial head fracture via the Kocher approach (extensor carpi ulnaris / anconeus
interval).
Incorrect Answers:
Answer 1: While the patient has no evidence of ipsilateral distal radioulnar joint or interosseous membrane injury (no wrist tenderness, normal radius pull test), fragment excision is reserved for partial articular fractures involving less than 30% of the articular surface. Complete radial head resection can lead to long-term elbow dysfunction and should be reserved for elderly, low-demand patients.
Answer 2: Using the medial approach to the elbow for an isolated radial head procedure is not appropriate. ORIF can be performed with either headless compression screws or periarticular plates. Use of headless compression screws has been associated with improved postoperative ROM compared to plates.
Answer 4: Using the medial approach to the elbow for an isolated radial head procedure is not appropriate. Radial head arthroplasty should be reserved for older patients and fractures with three or more articular fragments.
Answer 5: Nonoperative treatment is not appropriate for this patient with a displaced fracture and mechanical block to motion.

What nerve is most at risk when applying the external fixator shown in Figure A using a minimally invasive fluoroscopic technique of pin insertion?
1) Ilioinguinal nerve

2) Obturator nerve

3) First branch of the femoral nerve

4) Lateral femoral cutaneous nerve

5) Superior gluteal nerve

Pelvic external fixation with supraacetabular pins through the AIIS can be utilized to stabilize a pelvic fracture. While using this technique, care must be taken not to injure the lateral femoral cutaneous nerve (LFCN). Gardner et al describe the technique for placement of supraacetabular external fixation pins and state that pins in this location are more stable biomechanically compared to other locations in the iliac crest. Grothaus et al performed a cadaveric study to determine the anatomic detail and variation of the LFCN and the distances it traveled from various landmarks.The found the nerve to potentially be at risk as far as 7.3 cm medial to the anterior superior iliac spine along the inguinal ligament and as much as 11.3 cm distal on the sartorius muscle from the anterior superior iliac spine. Riina et al performed a cadaveric study to define the neurovascular structures at risk with the placement of anterior-posterior locking screws in the proximal femur. They found that risks to the neurovascular structures during anterior-posterior locking in the proximal femur are diminished if locking is performed above the level of the lesser trochanter.

A patient sustains a comminuted calcaneus fracture. Three months after the injury the patient complains of shoewear problems secondary to clawing of the lesser toes. What is the most likely explanation for this deformity?

1) Sural nerve injury

2) Tethering of the flexor hallucis longus by fracture fragments

3) Medial plantar nerve neuropathy

4) Weakness of the tibialis posterior

5) Unrecognized foot compartment syndrome

Contracture of the intrinsic flexor muscles of the foot can be the result of unrecognized foot compartment syndrome. Foot compartment syndrome is a known complication of calcaneus fractures.
Myerson reported 3/43 patients in his series below had chronic foot compartment syndrome. There are 9 compartments in the foot: (1) medial, (2) superficial, (3) lateral, (4) adductor, (5-8) four interossei, and (9) calcaneal.
The plantar fascia limits the space available for hematoma and swelling, causing damage to the intrinsic flexors of the foot (particularly the lumbricals and interossei), resulting in clawtoes.

A 25-year-old male sustains a closed elbow dislocation after falling during a soccer game. Two months later, the patient continues to complain of pain and instability. Radiographs and physical exam are concerning for posteromedial instability. Which of the following fracture patterns is most consistent with this diagnosis?

1) Coronoid tip

2) Coronoid anteromedial facet

3) Radial head

4) Olecranon

5) Capitellar impaction injury

of coronoid fractures, they indicate that identification of anteromedial facet injuries is often difficult and that treatment should be instituted promptly to limit persistent instability and subsequent arthritis.
Illustration A shows an AP radiograph of the affected elbow. An event of posteromedial instability is evidenced by the fracture through the anteromedial facet of the coronoid. Illustrations B and C show the AP and lateral radiographs of a patient who developed significant arthrosis after inadequate treatment of varus posteromedial rotatory instability.
Incorrect answers
Answers 1, 3, 5: These injuries may be seen as the sequlae of posterolateral rotatory instability.
Answer 4: Large coronoid fractures are seen in olecranon fracture-dislocations around the elbow.

A 7-year old boy presents to the emergency room following a ATV accident with complaints of left pelvic pain. In the emergency room he is alert and oriented and is hemodynamically stable. On physical exam he is unable to bear weight on his left lower extremity. There is no tenderness to palpation at the posterior pelvis. A radiograph is performed and shown in Figure A and CT examination shows the posterior ring is stable and age-appropriate. What is the most appropriate treatment for this injury pattern?
1) Nonoperative management with weight bearing as tolerated

2) Percutaneous sacroiliac screw

3) Pelvic external fixation

4) Anterior pelvic ring plating

5) Anterior and posterior pelvic ring plating

The clinical presentation is consistent for a mildly displaced parasymphyseal fracture in a pediatric patient with an open triradiate cartilage. Weight bearing as tolerated is the most appropriate treatment.
In skeletally immature pelvic ring fractures, the majority of cases can be treated nonoperatively. Open reduction and internal fixation is required for acetabular fractures with >2 mm of fracture displacement and for any intraarticular or triradiate cartilage fracture displacement >2 mm. External fixation is necessary for pelvic ring displacement of >2 cm to prevent limb-length discrepancies.
Holden et al. emphasize that children with open triradiate cartilage have
different fracture patterns than do children whose triradiate cartilage has closed. They report because of the immaturity of the pelvis, the iliac wing is weaker than the elastic pelvic ligaments, resulting in bone failure before pelvic ring disruption has a chance to occur. For this reason fractures usually involve the pubic rami and iliac wings and rarely require surgical treatment.
Spiguel et al. reviewed 2850 pediatric trauma admissions at their institution and reviewed cases with a pelvic ring fracture. They found that although pelvic fractures are an uncommon injury in pediatric trauma patients, the morbidity associated with these injuries is significant. They report while the majority of pelvic fractures in children are treated nonoperatively, more than one-half of these patients have concomitant injuries requiring operative management.
Figure A shows an inferior rami fracture in a pediatric patient with an open triradiate cartilage.
Incorrect Answers:
Answers 1,3,4,5: These treatment options are not appropriate in a stable pelvic ring fracture in a child with open triradiate cartilage.

A 75-year-old-male presents after being struck by a vehicle while crossing the street. He complains of right leg pain, and physical exam reveals no evidence of an open fracture. Initial radiographs are shown in Figures A and B, and intramedullary nailing of the fracture is planned. What is the proper blocking screw technique to prevent apex anterior and valgus deformity of the fracture?
1) Insertion of blocking screws lateral and posterior to the nail

2) Insertion of blocking screws medial and posterior to the nail

3) Insertion of blocking screws lateral and anterior to the nail

4) Insertion of blocking screws medial and anterior to the nail

5) Insertion of blocking screws medial, lateral, and posterior to the nail

Apex anterior and valgus deformity of the proximal tibia fracture can be prevented by inserting blocking screws lateral and posterior to the nail in the proximal segment.
Blocking screws may be used to prevent deformity when performing intramedullary fixation of proximal tibia fractures. Insertion of the blocking screw lateral to the nail prevents valgus deformity, and insertion of the blocking screw posterior to the nail prevents apex anterior deformity. A more lateral starting point for nail insertion can also help to prevent valgus deformity. Stability screws can be placed prior to insertion of the nail to prevent deformity during nail passage, or after nail insertion to prevent postoperative deformity from developing.
Ricci et al. describe the technique and results of using blocking screws and intramedullary nails to treat patients with fractures of the proximal third of the tibial shaft. Post-operatively, all patients in their series had less than 5 degrees
of angular deformity in the planes in which blocking screws were used to control alignment. At 6 months follow-up, 10/11 patients maintained this alignment.
Figures A and B demonstrate a segmental tibial shaft fracture. Illustration A shows an intraoperative fluoroscopic image demonstrating insertion of the blocking screws intraoperatively. Illustrations B and C show post-operative radiographs demonstrating placement of the blocking screws and adequate alignment of the proximal segment.

A 36-year-old man sustains blunt chest trauma, an open right femur fracture, and a closed left tibia fracture following a high-speed MVC. Upon presentation to the emergency room, blood pressure is 80/40, HR 135, and urine output is .4 cc/kg/hr. Fluids and blood products are administered, and the patient is transferred to the ICU for further care. As an alternative to lactate and base deficit measurements, which of the following would best indicate adequate resuscitation has been achieved?

1) Systolic blood pressure > 120

2) Heart rate between 60-100

3) Urine output equals 0.4 cc/kg/hr

4) Gastric intramucosal pH of 7.4

5) Potassium between 3.5-4.5

Of the following variables, only a normal gastric mucosal pH (>7.3) is associated with restoration of tissue oxygenation.
Shock is an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. This leads to anaerobic metabolism
with the development of lactic acidosis and oxygen debt. Shock is either classified as compensated or uncompensated. Compensated shock exists when there is evidence of ongoing inadequate tissue perfusion despite the normalization of blood pressure, heart rate, and urine output. Uncompensated shock occurs when there is inadequate tissue perfusion and abnormal blood pressure, heart rate, and urine output. Thus, a patient may have normal vital signs but still be in a state of compensated shock that requires additional resuscitation.
Porter et al. review the optimal end points of resuscitation in trauma patients. They conclude that using traditional end points such as blood pressure, urine output and heart rate, may leave up to 85% of patients in "compensated" shock. They urge the use of lactate, base deficit, and gastric intramucosal pH as appropriate end points of resuscitation.
Roberts et al. discuss various aspects of damage control orthopaedics in the multiply injured trauma patient. Although they do not discuss the end points for resuscitation, they note that they presence of shock is a clinical parameter associated with adverse outcomes in the trauma patient.
Incorrect answers:
Answers 1-3: A patient may have normalized blood pressure, heart rate, and urine output but may still be in a state of compensated shock requiring further resuscitation.
Answer 5: Potassium levels do not assess adequate resuscitation

A 32-year-old man sustains the knee injury seen in Figure A after falling from a ladder. Which of the following options is the most biomechanically stable and appropriate definitive surgical treatment?
1) Spanning knee external fixation

2) Lateral plateau locking plate

3) Posteromedial locking plate

4) Lateral plateau percutaneous lag screws and posteromedial plate

5) Lateral plateau and posteromedial plating

The above clinical scenario is consistent with a bicondylar tibial plateau fracture. Bicondylar tibial plateau fractures are best definitively treated with dual incision technique using separate lateral plateau and posteromedial plates.
Yoo et al perfored a biomechanical study comparing locking and nonlocking single and dual plating constructs in maintaining posteromedial fragment reduction in a bicondylar tibial plateau fractures. They found that the posteromedial fracture fragment tolerated higher loads with a posteromedial conventional plate construct. The superiority of this dual plating construct may be caused by unreliable penetration of the posteromedial fragment by the lateral locking screws alone.
Zeng et al also performed a biomechanical study comparing the biomechanical strength of four different fixation methods for the posteromedial tibial plateau split fracture. The four following constructs: anteroposterior lag-screws, an anteromedial limited contact dynamic compression plate (LC-DCP), a lateral locking plate, or a posterior T-shaped buttress plate were studied. They found that the posterior-based buttress plating technique was the most biomechanically stable fixation method allowing the least amount of fracture subsidence for posteromedial split tibial plateau fractures.
Figure A shows an AP radiograph of a bicondylar tibial plateau. Illustration A shows a post-operative radiograph following the dual-plating technique for bicondylar tibial plateau fractures.
Incorrect answers:
Answer 1: External fixation is not the most appropriate definitive care for bicondylar tibial plateau fractures.
Answers 2-4: Not as biomechanically stable as dual plating technique for bicondylar tibial plateau fractures.

A 35-year-old male sustains a closed tibial shaft fracture after falling from 12 feet. Which of the following measurements would be concerning for an evolving compartment syndrome?

1) Intraoperative anterior compartment measurement of 29, with preoperative diastolic pressure 58

2) Preoperative anterior compartment measurement of 25, with preoperative diastolic pressure of 60

3) Intraoperative anterior compartment measurement of 25, with intraoperative diastolic pressure of 54

4) Intraoperative anterior compartment measurement of 28, with intraoperative diastolic pressure of 72

5) Preoperative anterior compartment measurement of 22, with mean arterial pressure of 70

A delta P (diastolic blood pressure minus compartment pressure measurement)of
A 44-year-old male is involved in a motorcycle collision and presents with the radiographs shown in Figure A. A CT scan is obtained which shows intra-articular extension of the fracture, and lateral locked plating with intercondylar lag screw fixation is planned. Which of the following is important intra-operatively to ensure that the
intercondylar screws are contained within the bone and are of appropriate length?
1) AP fluoroscopic imaging with the leg in 30 degrees of internal rotation

2) AP fluoroscopic imaging with the leg in 30 degrees of external rotation

3) AP fluoroscopic imaging with the knee in full extension

4) Lateral fluoroscopic imaging with the knee in 30 degrees of internal rotation

5) Lateral fluoroscopic imaging with the knee in 15 degrees of flexion

Figure A illustrates a comminuted distal femur fracture. AP fluoroscopic imaging with the leg in 30 degrees of internal rotation is important to prevent intercondylar screw prominence.
Hardware irritation is a common post-operative complication of distal femoral plate fixation. Two common sites of pain are laterally where the iliotibial band is in contact with the plate, and medially where intercondylar screws may penetrate the cortex if they are of inappropriate length. Iliotibial irritation most commonly presents with activities requiring knee flexion and extension. It is important to remember that the lateral metaphysis of the distal femur is angulated 10 degrees from the sagittal plane, and the medial metaphysis is angulated 25 degrees from the sagittal plane. Therefore, if a straight AP view is obtained, a distal screw can appear to be inside the bone even if it is too long. In order to assess the exact length of the screw, one must obtain an AP view with 30° internal rotation of the lower extremity.
Gwathmey et al discuss distal femoral fractures in their review article. They state that the goal of surgical management is to promote early knee motion while restoring the articular surface, maintaining limb length and alignment,
and preserving the soft-tissue envelope with a durable fixation that allows functional recovery during bone healing. They describe a variety of surgical exposures, techniques, and implants developed to treat these injuries, including intramedullary nailing, screw fixation, and periarticular locked plating, possibly augmented with bone fillers.
Illustration A demonstrates the sagittal plane angulation of the medial and lateral cortex of the distal femur. Illustration B shows a knee in external rotation, with the intercondylar screw appearing to be of appropriate length. Illustration C shows the knee in internal rotation, which indicates that the screw is penetrating the medial cortex.

A 68-year-old male falls onto his outstretched hand and suffers the injury shown in Figures A and B. He undergoes operative treatment of his fracture, and immediate post-op radiographs are shown in Figure C. Two weeks later he presents with significantly increased pain and deformity. He denies any new trauma, and has followed all postoperative activity restrictions. Current radiographs are shown in Figure D and a clinical photograph of the affected wrist is shown in Figure E. Which of the following is the most likely cause for failure of fixation in this patient?
1) Failure to support the lunate facet with fragment specific fixation

2) Use of a non-locking plate

3) Lack of volar tilt restoration

4) Lack of radial styloid column plating

5) Use of only three bicortical screws in the intact radial shaft proximally

The failure of this patient's fixation post-operatively is caused by failure to support the lunate-facet fragment noted on the injury radiographs.
The stability of comminuted fractures of the distal part of the radius with volar fragmentation is determined not only by the reduction of the major fragments but also by the reduction of the small volar lunate fragment. The distal volar lunate fragment is the site of origin of the strong volar radiolunate ligaments which insert onto the lunate, and so displacement of this small piece volarly will allow the lunate and the rest of the carpus to subluxate volarly. The unique anatomy of this fragment may prevent standard fixation devices for distal radial fractures from supporting the entire volar surface effectively, as a standard volar plate cannot capture this small distal piece without risking injury to the flexor tendons. Fragment specific fixation of the volar lunate facet fragment with commercially available small plates, or with a tension-band construct or augmentation with K-wires may be required to reduce and stabilize this fragment.
Harness et al. reported on a cohort of 7 patients with a volar shearing fracture of the distal radius who lost fixation of a volar lunate facet fragment with subsequent carpal displacement after open reduction and internal fixation. Five patients underwent revision surgery with adequate results. The authors concluded that with regards to lunate facet fracture fragments, it is preferable to recognize the complexity of the injury prior to the initial surgical intervention and to plan accordingly to prevent early post-operative failure.
Taylor et al. compared the biomechanical stability of a fixed-angle volar plate versus a fragment specific fixation system in the treatment of an intraarticular, dorsally comminuted distal radius fracture model. They found that both fixed-angle volar plate and fragment-specific fixation systems performed comparably in a simulated early postoperative motion protocol. Fragment-specific fixation had improved stiffness characteristics only with respect to the smaller ulnar-sided fragment.
Figures A and B show a shearing radiocarpal-fracture subluxation with small lunate-facet fracture. Figure C shows an immediate post-operative radiograph. Figure D shows subluxation of the radiocarpal joint caused by failure to support lunate-facet fragment. Figure E shows the clinical appearance of a volarly subluxated wrist.
Incorrect Answers:
Answer 2: The use of a non-locking plate in this situation did not directly lead to the failure of fixation, and applying a similar construct with locking fixation
would not have prevented volar subluxation of the lunate facet fragment. Answer 3: Volar tilt was grossly restored post-operatively.
Answer 4: Radial styloid plating would not have prevented volar subluxation of the lunate facet fragment.
Answer 5: Three bicortical screws in the intact radial shaft proximally is adequate fixation.

Which of the following is most commonly associated with both simple and complex elbow dislocations?

1) radial head fracture

2) radial neck fracture

3) loss of terminal extension

4) repeat dislocation

5) coronoid base fracture

Elbow dislocations are classified as either simple (no associated fracture) or complex (associated fracture). The goal of treatment is a stable joint that tolerates early motion. The initial range of motion is the stable arc found on postreduction examination. Studies have demonstrated a better outcome when simple elbow dislocations are treated non-surgically rather than with surgical repair. Simple elbow dislocations usually have an excellent outcome (return of functional range of motion with normal strength). A loss of terminal extension is the most common sequelae.
Ross et al. reported on 20 patients with simple closed posterior elbow dislocations who were treated with immediate active ROM under close supervision. They found a final arc of motion of -4 to 139 degrees, with final motion reached a mean of 19 days after dislocation. Only 1 patient had recurrent instability.

A 36-year-old female sustains a knee injury after falling from a ladder onto her flexed knee; she cannot do a straight leg raise after a lidocaine injection into her knee. A radiograph is shown in Figure A. Which of the following treatment options has been shown to have the best outcomes with this injury?
1) Long leg cast

2) Hinged knee brace use with functional rehabilitation protocol

3) Open treatment with internal fixation or excision with patellar tendon advancement

4) Distal patellar resection and allograft reconstruction

5) Placement of a cerclage wire from patella to proximal tibia

The clinical presentation is consistent with and inferior pole patella fracture. Open reduction and internal fixation or excision with patellar tendon advancement is the most appropriate treatment of this injury pattern.
Whenever possible, salvage of the inferior pole through open reduction internal fixation is favored over simple excision and patellar tendon advancement, as this has been shown to be associated with improved outcomes. This is not always possible, however, and pole resection can be performed if the inferior comminution precludes fixation. Inferior outcomes of the partial distal patellectomy and patellar tendon advancement are (aside from the possible resulting patella baja) probably not directly related to the patellofemoral articulation. On the undersurface, the proximal 75% of the patella is covered with articular cartilage; however, the distal 25% is not, and does not articulate with the femoral trochlea.
Kastelec et al. performed a retrospective review of ORIF v. pole resection followed over 4.6 years postoperatively. There was a significant increase (better) in patellofemoral score with ORIF; significant differences in knee pain,
tolerated activity levels, and ROM were also noted. Patella baja was frequently noted with pole resection and correlated with worse functional outcomes.
Matejcic et al. performed a retrospective review of ORIF v. pole resection followed over 5.3 years postoperatively. Results were excellent/good in 90.1% of the ORIF and only 73.1% of the pole resection patients. In addition, significant differences between the groups were noted with regard to knee pain, swelling, level activity, compression pain, range of motion, muscular atrophy, muscular strength, and final patellofemoral score (all better with ORIF).
Figure A is a lateral knee radiograph showing an inferior pole patella fracture.

Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively?

1) Sling immobilization

2) Displacement and comminution

3) Age less than 40 years old

4) Immediate motion exercises

5) Male

Robinson et al have shown that lack of cortical apposition, comminution, female gender, and advancing age are the 4 factors that contribute to nonunion.
The Canadian Orthopaedic Trauma Society in a randomized, prospective study showed that for midshaft fracture in adults with 100% displacement, ORIF results in improved DASH and Constant scores (p = 0.001 and p
A 34-year-old male presents after falling off a roof at his job. He has an obvious deformity of his left lower extremity, and injury radiographs are shown in Figures A and B. He has no other injuries. Which of the following definitive treatment algorithms will most likely lead to the best outcomes in this patient?
1) Closed reduction and percutaneous screw fixation of the femoral neck, followed by reamed antegrade nailing of the femur fracture

2) Reamed antegrade nailing of the femoral shaft fracture, followed by open reduction and percutaneous screw fixation of the femoral neck fracture

3) Reamed retrograde nailing of the femoral shaft fracture, followed by closed
reduction and percutaneous screw fixation of the femoral neck

4) Open reduction and screw fixation of the femoral neck, followed by reamed retrograde nailing of the femoral shaft fracture

5) Open reduction and screw fixation of the femoral neck, followed by plating of the femoral shaft fracture

The clinical presentation is consistent with a femoral shaft fracture with an ipsilateral femoral neck fracture. Of the options presented, the most appropriate treatment is open reduction and lag screw fixation of the femoral neck fracture followed by reamed retrograde nailing of the femoral shaft fracture.
Ipsilateral femoral neck/shaft fractures are an uncommon injury estimated to occur in 2-6% of all femoral shaft fractures. It is generally agreed upon that due to the potentially devastating complications of the femoral neck fracture in young patients, the neck fracture should be treated first and the shaft fracture second. Anatomic reduction of the femoral neck fracture is paramount in obtaining successful healing, and therefore open reduction is recommended in the setting of fracture displacement. Provisional reduction of the femoral neck fracture, followed by antegrade nailing with subsequent addition of definitive fixation of the femoral neck is also acceptable.
Peljovich et al. present a review article on ipsilateral femoral neck and shaft fractures. The treatment algorithm they propose consists of first treating the femoral neck fracture, and then addressing the femoral shaft fracture with retrograde nailing. They also highlight the risk and benefits of each treatment approach.
Watson et al. reviewed 13 patients who had healing complications after undergoing surgical fixation of their ipsilateral femoral neck and shaft fractures. They found that lag screw fixation of the femoral neck fracture and reamed intramedullary nailing for shaft fracture stabilization were associated with the fewest complications. Therefore, this approach was recommended as the treatment of choice.
Figures A and B demonstrate an ipsilateral comminuted femoral shaft fracture, and a displaced femoral neck fracture. Illustrations A-C show an example of a femoral shaft fracture with an ipsilateral femoral neck fracture treated with lag screws of the femoral neck fx and retrograde nailing.
Incorrect Answers:
Answer 1: Open reduction of the femoral neck fracture with anatomic
alignment is preferred to closed reduction in this case.
Answer 2,3: The femoral neck fracture should be addressed first.
Answer 5: Nailing of the femoral shaft fracture would be preferred initially in this case to prevent disruption of the biology and fracture healing around the comminuted segments.

During surgical treatment of the most common variation of distal femoral "Hoffa" fractures, which of the following orientations for screw fixation should be used?

1) Medial to lateral screw placement across lateral femoral condyle

2) Anterior to posterior screw placement across medial femoral condyle

3) Medial to lateral screw placement across medial femoral condle

4) Anterior to posterior screw placement across lateral femoral condyle

5) Anterior to posterior screw placement across intercondylar notch

The most common variation of a Hoffa fracture is a coronal fracture of the lateral femoral condyle. The most appropriate screw placement of the above answer choices in the treatment of the most common Hoffa fracture variant would be anterior to posterior screws across the lateral condyle for fixation.
Hoffa fractures are coronally oriented fractures of the femoral condyles, with most occurring in the lateral condyle. They are commonly associated with high-energy fractures of the distal femur and can often be overlooked during the assessment and treatment of distal femur fractures. Hoffa fractures are best evaluated using CT scans.
Nork et al. studied the association of supracondylar-intercondylar distal femoral fractures and coronal plane fractures. Of 202 supracondylar-intercondylar distal femoral fractures, they found coronal plane fractures were diagnosed in 38%. A coronal fracture of the lateral femoral condyle was involved more frequently than the medial condyle. Eighty-five percent of these coronal fractures involved a single lateral femoral condyle.
Holmes et al. looked at five cases of coronal fractures of the femoral condyle. All cases received open reduction and internal fixation with lag screws through a formal parapatellar approach. They reported good results with all fractures healing within 12 weeks without complications with final range of motion at least 0 degrees to 115 degrees.
Illustration A shows sagittal and axial CT scan cuts showing a Hoffa fracture of the lateral femoral condyle. Illustration B shows multiple anterior to posterior, and posterior to anterior oriented screws for ORIF of the Hoffa fracture.

A 26-year-old right hand dominant male is involved in a motor vehicle collision and sustains the left humerus injury demonstrated in Figure A. The brachial artery is disrupted and requires urgent attention in the operating room. The patient's preoperative nerve evaluation demonstrates that the patient is unable to initiate extensor carpi radialis longus, extensor carpi radialis brevis, extensor pollicis brevis, extensor digitorum, extensor indicis proprius, and extensor pollicis longus motor activity. What is the most likely etiology for this observed neurologic examination?
1) Neurapraxia of the median nerve

2) Axonotmesis of the radial nerve

3) Neurotmesis of the ulnar nerve

4) Neurotmesis of the radial nerve

5) Axonotmesis of the ulnar nerve

The most likely cause of the radial nerve palsy in a high energy open humerus fracture is laceration or complete disruption of the radial nerve (Neurotmesis).
Neurotmesis is complete disruption of nerve and is associated witn no spontaneous recovery without intervention. Axonotmesis constitutes axon disruption, but the surrounding neural connective tissue is intact and nerve regeneration can occur(Wallerian or antegrade degeneration). Neurapraxias occur often by compression and the axon maintains continuity but local demyelination and ischemia occur.
Ring et al. present a Level 4 study of 24 patients that had radial nerve palsy associated with a humerus fracture. All 6 patients with a transected radial nerve had an open humerus fracture also. The results of primary nerve repair in this circumstance found that there was no recovery in any of the patients.
Foster et al. authored a Level 4 review of 14 patients had a radial nerve palsy and an associated open humerus fracture. 64% of the 14 patients had a radial nerve that was either lacerated or interposed between the fracture fragments. They recommend exploration of the radial nerve in the setting of a radial nerve palsy and concomitant open humerus fracture in contrast to observation of a radial nerve palsy in closed humerus fractures.
Figure A demonstrates an open left humerus fracture.
Incorrect Answers:
Answer 1,3,5: The radial nerve provides distal motor activity to the ECRL, ECRB, EPB, EIP, and EPL.
Answer 2: Axonotmesis of the radial nerve is not the most common form of injury associated with closed or open humerus fractures.

Which of the following is true regarding the center of rotation of angulation (CORA) as it refers to tibial diaphyseal angular deformity?

1) It is the point at which the proximal mechanical axis and distal mechanical axis meet

2) It is the point at which the proximal anatomical axis and proximal mechanical axis meet

3) It is always the point on the cortex at the most concave portion of the deformity

4) It is the point at which the distal anatomical axis and distal mechanical axis meet

5) It is always the point on the cortex at the most convex portion of the deformity

The center of rotation of angulation(CORA) in diaphyseal tibial deformity is defined as the intersection of the proximal mechanical(PMA) or anatomical axis(PAA), and the distal mechanical(DMA) or anatomical axis(DAA).
Angular deformity of the femur or tibia involves angulation not only of the bone but also of its axes. When a bone is divided and angulated, the mechanical and anatomic axis of the bone are also divided into proximal and distal segments.
The pairs of proximal and distal axis lines intersect to form an angle. The point at which the proximal and distal axis lines intersect is called the CORA.
The axis line of the proximal bone segment is called the PMA or PAA, and axis line of the distal segment is called the DMA or DAA. In the tibia, because the mechanical and anatomical axes are almost the same, the PMA and PAA lines overlap, as do the DMA and DAA lines.
Illustration A shows the CORA as it relates to the axes of an angulated tibia.
Incorrect Answers:
2-5:These do not describe the CORA or any other specific anatomical points as they related to long bone deformity.

At long term follow-up, a male who sustains multiple traumatic injuries compared with a premenopausal female, who sustained similar polytrauma, is most likely to have which of the following?

1) Higher quality-of-life scores than females

2) Increased rates of complex regional pain syndrome

3) Require more psychiatric counseling and pharmacologic management than females

4) Take more absentee days at work as a result of illness than females

5) Decreased incidence of lower extremity amputation

Ten or more years after severe polytrauma, premenopausal women, compared to men, demonstrate a higher incidence of posttraumatic stress disorder (PTSD) and take more sick leave time from work.
Depression following polytrauma should be screened for by treating orthopaedic surgeons. Depression commonly arises from a protracted injury and can compound the disability by increasing the perception of more physical illness.
Probst et al. present a Level 4 review of over 600 polytrauma patients. They found that quality-of-life was significantly lower in women (Short form-12 psychologic F = 48.6 +/- 10.8 vs. M = 50.8 +/- 9.4; p = 0.02), but the same rate of women (75.3%) and men (75.4%; p = 0.995) felt well rehabilitated.
Holbrook et al. report a Level 4 study of 1,048 polytrauma patients. They found that females had lower quality-of-life scores and were significantly more likely to develop early combined depression.
Incorrect Answers:
Answer 4: Females take more absentee days at work.
Answers 2, 3, 5: There is no data supporting these answer options.

A 29-year-old healthy Caucasian female presents to the emergency department with her boyfriend with a left anterior shoulder dislocation and several facial abrasions after tripping in the shower approximately three hours prior to arrival. She is 5’7’’ and weights 120 lbs (BMI 18.8). The patient notes that she has not had a menstrual period in three months and that she is training for a long-distance triathlon. Physical examination reveals no other obvious injuries. Basic serum laboratory values are unremarkable. A urine pregnancy test is positive. In addition to treating her shoulder dislocation, the orthopaedic surgeon should

1) Perform a skeletal survey to evaluate for other fractures or dislocations

2) Question the patient in private about the specific details of this injury and her sense of safety in the home

3) Refer the patient to a nutritionist given the patient’s BMI of 18.8

4) Obtain additional laboratory studies and admit the patient to the hospital for treatment of anorexia nervosa

5) Obtain advanced imaging of the shoulder to evaluate for underlying pathologic lesions

for her current injury, it is imperative for health care providers to inquire into the safety of the home environment in potential cases of intimate partner violence (IPV).
Risk factors for female victims IPV include being in the 2nd or 3rd decade of life, current pregnancy, having 1 or more prior children, and low socioeconomic status. Reporting requirements for adult abuse are not standardized amongst most states and physicians must understand the importance of identification and documentation in cases of suspected IPV.
Bhandari et al. state that musculoskeletal injuries are the second most common form of IPV (28%) after head and neck injuries (40%).
Musculoskeletal injuries can be variable, including sprains, fractures, dislocations, and foot injuries.
Della Rocca et al. conducted a survey and found orthopaedic surgeons have several misconceptions regarding victims of IPV and further, nearly half of their survey respondents reported identifying a victim of IPV while only 4% reported that they currently screen their injured female patients for IPV.
Zillmer presents a review of the issues surrounding IPV including proper identification, documentation, appropriate questioning and how to involve community services.
Illustration A shows some basic facts regarding IPV during pregnancy as reported by the CDC. Additional information can be found at the following link.
[htt](http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/index.htm)[p](http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/index.htm)[://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/index.htm](http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/index.htm)
Incorrect Answers:
Answer 1. There is no indication for a skeletal survey and it would be inappropriate to subject this pregnant patient to additional radiation.
Answer 3. There is no need to refer a patient to a nutritionist for a normal BMI Answer 4. There is no indication for admission or other laboratory studies in this otherwise healthy patient.
Answer 5. There is no need for advanced imaging in the emergency department in the case of an isolated traumatic shoulder dislocation

A 19-year-old military recruit complains of 7 weeks of right heel pain. He notes the pain is worse with jumping and long distance running. He has completed a course of plantar fascia and Achilles tendon stretching with no significant improvement in his symptoms. He denies constitutional symptoms. On examination, his body mass index is 22, he has a normal foot posture and can perform a single leg heel rise without difficulty. There is no pain with palpation of the lateral border of the foot or with external rotation stress to the midfoot. There is tenderness with medial and lateral compression of the hindfoot and there is a negative syndesmosis squeeze test. There is a negative Tinel's sign at the tibial nerve. Axial and lateral radiographs are shown in Figures A and B. What is the most appropriate next step in management?
1) Heel pad cortisone injection

2) Platelet rich plasma injection and 6 weeks of physical therapy

3) Restricted weight bearing and magnetic resonance imaging of the foot

4) Release of the first branch of the lateral plantar nerve

5) ASTYM or Graston physical therapy techniques to the achilles and plantar fascia

Restricted weight bearing and magnetic resonance imaging of the foot is indicated in this military recruit with a positive heel compression test and suspicion for calcaneal stress fracture.
Calcaneal stress fractures occur as a result of repetitive loading and are more common in females with the female athlete triad (anorexia athletica) of disordered eating, amenorrhea, and osteoporosis. On exam tenderness is obtained with medial and lateral compression of the calcaneus.
Sormaala et al. performed a Level 4 review over 8 years of the Finnish military. They found 34 calcaneal stress fractures with 19 occurring in the posterior part of the calcaneus. Only 15% of the patients had the stress fracture visualized on plain radiography. They conclude that MRI is warranted if plain radiography does not show abnormalities in a physically active patient with exercise-induced pain in the ankle or heel. A nuclear medicine bone scan is also appropriate for diagnosis but MRI may give greater detail.
Gehrmann et al. present a Level 5 review of foot stress fractures. They report that with calcaneal stress fractures the fracture lines are oriented vertically or obliquely in the tuberosity of the calcaneus.
Figures A and B show some sclerosis in the central calcaneus with no evidence of overt fracture and an enthesophyte at the Achilles tendon insertion.
Illustration A and B are T2 sagittal and coronal images demonstrating a stress fracture in the superior calcaneal tuberosity with surrounding edema.
Incorrect Answers:
Answer 1: Heel pad cortisone injections are typically avoided due to risk of fat pad atrophy and are not indicated in calcaneal stress fractures.
Answer 2: Platelet rich plasma is not indicated in calcaneal stress fractures. Answer 4: The patient presents with a negative Tinel's at the tibial nerve and presentation is not consistent with first branch of the lateral plantar nerve entrapment.
Answer 5: ASTYM and Graston physical therapies are not indicated for calcaneal stress fractures.

A 35-year old male is involved in a fall from height and present with the isolated injury shown in Figures A and B. The body of the talus is extruded medially through a large linear open wound. Along with irrigation and debridement, what is the most appropriate definitive management of this injury?
1) Reimplantation of the talar body followed by cast immobilization

2) Reduction of talar body, fracture fixation with smooth Steinman pins, and spanning fixator placement

3) Talar body allograft with internal fixation to native talar head

4) Fragment removal, antibiotic spacer placement and external fixation

5) Reduction of native talar body and ORIF of talar neck fracture

The patient is presenting with a displaced talar neck fracture with extrusion of the talar body. Reimplantation of the talar body and ORIF of the talar neck fracture is the most appropriate treatment.
Talar extrusions are rare injuries and are caused by high energy mechanisms. Complete dislocation without a concomitant fracture is extremely rare. The talus is prone to dislocation as there are no muscular attachments. These injuries need to be treated with anatomic reduction and internal fixation to prevent avascular necrosis and post-traumatic arthritis.
Smith et al. investigated the clinical results and functional outcome after reimplantation of the extruded talus. They concluded that salvage and reimplantation of the talus is a relatively safe procedure with only 2 of the 27 patients developing an infection. No association was found between outcome and associated talar fracture.
Van Opstal et al. reported on two cases of talar extrusions following high energy injuries and reviewed the associated literature. Both cases were treated with wound I&D, reduction and external fixation. After 1 year they had pain free ROM with no signs of AVN or arthritis. Review of the literature showed that anterolateral dislocations are more common than anteromedial. Total talar dislocation is thought to be the endpoint of maximum pronation or supination injuries.
Figures A and B show an extruded talar body in the setting of a Hawkins III talar neck fracture. Illustration A shows a clinical photo of an extruded talus.
Incorrect Answers:
Answer 1: Displaced talar neck fractures should not be treated in a cast, especially open fractures
Answer 2: Definitive treatment of this injury is most effectively accomplished with formal ORIF. Steinman pin fixation is not adequate, even in the presence of an external fixator.
Answer 3: There is no data supporting removal of fragment and use of allograft overuse of native talar body
Answer 4: There is no data supporting removal of the fragment. The associated

Updated Orthopedic Review | Dr Hutaif General Orthopedi -...

Orthopedic Review | Dr Hutaif General Orthopedics Revie -...

Key Takeaway

Scientific References

Scientific References

You Might Also Like

Orthopedic Board Review MCQs (2026 Edition) - Part 4

Orthopedic Board Review MCQs (2026 Edition) - Part 3

Chapter Index