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Orthopedic Board Prep: Interactive Viva Exam Practice for Trauma & Surgical Cases

Ace Your Ortho Exam: Lower Limb Trauma Structured Oral Examination Question

23 Apr 2026 85 min read 136 Views
Illustration of structured oral examination question - Dr. Mohammed Hutaif

Key Takeaway

For anyone wondering about Ace Your Ortho Exam: Lower Limb Trauma Structured Oral Examination Question, A structured oral examination question in orthopedics assesses a candidate's ability to diagnose and manage common injuries. For an intracapsular neck of femur fracture in an elderly, independent patient, candidates must identify the injury, evaluate patient comorbidities, and propose surgical management. The preferred approach often involves total hip arthroplasty over hemiarthroplasty for better functional outcomes and survivorship.

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Question 1

A 45-year-old male presents after a high-energy fall, sustaining a posterior wall acetabular fracture with a congruent reduction after closed hip dislocation. Post-reduction radiographs show no incarcerated fragments. Which of the following is the most appropriate management strategy?





Explanation

For isolated posterior wall acetabular fractures that are congruent and stable after closed reduction of a hip dislocation, non-operative management with protected weight-bearing and restricted range of motion is a recognized option. Instability is typically assessed with stress radiographs or dynamic fluoroscopy after reduction. If stable, close monitoring for secondary displacement or late instability is crucial. Surgical indications usually include persistent instability, incarcerated fragments, or significant displacement. Immediate ORIF is typically reserved for unstable fractures or those with incarcerated fragments. Skeletal traction is less commonly used for these stable fracture patterns. Hip arthroplasty is not indicated primarily for this injury pattern without pre-existing arthritis or severe head damage. A CT scan is usually performed initially to assess the fracture pattern and rule out incarcerated fragments, but repeating it in 24 hours without clinical change is not the primary management.

Question 2

A 28-year-old active male sustains a displaced transverse patella fracture. He undergoes tension band wiring. Which of the following post-operative instructions is most critical to prevent early failure of the construct?





Explanation

The tension band wiring technique converts the tensile forces on the patella during knee flexion and active extension into compression forces at the fracture site. Active knee extension against resistance, particularly against gravity (e.g., straight leg raises), places significant tensile stress across the anterior aspect of the patella and can lead to immediate failure of the tension band construct. Early motion, especially passive flexion, is often encouraged to prevent stiffness, but active extension needs to be limited or avoided in the early post-operative period. Weight bearing is usually determined by pain tolerance and often progresses from touch-down to full, but it's less critical for the construct integrity than active extension. Restricting flexion too much can lead to stiffness, and unrestricted CPM may also put undue stress on the repair if active extension is performed.

Question 3

A 68-year-old female with osteoporosis falls at home, sustaining a displaced intertrochanteric hip fracture. She is otherwise healthy. What is the most appropriate definitive management for this fracture?





Explanation

Displaced intertrochanteric hip fractures in elderly patients are typically managed surgically. A dynamic hip screw (DHS) is the gold standard for stable and reducible intertrochanteric fractures, providing controlled collapse at the fracture site which promotes impaction and healing. While intramedullary nailing (IMN) is often preferred for unstable intertrochanteric fractures (e.g., reverse obliquity, comminuted), a DHS remains a very viable option for many stable patterns, especially in the context of osteoporosis where load sharing is beneficial. Non-operative management is associated with high mortality and morbidity in this patient population. THA or hemiarthroplasty are generally reserved for displaced femoral neck fractures or failed previous fixation, not primarily for intertrochanteric fractures. External fixation is rarely used for these fractures due to high rates of complications and poor stability.

Question 4

A 32-year-old male sustains a Gustilo Type IIIB open tibia fracture with significant soft tissue loss and exposed bone. After initial debridement and stabilization, what is the most appropriate timing and method for definitive soft tissue coverage?





Explanation

Gustilo Type IIIB open tibia fractures involve extensive soft tissue damage and often require specialized soft tissue coverage. The 'golden period' for these injuries extends beyond primary closure, which is typically reserved for clean, smaller wounds without significant contamination or tissue loss. For Type IIIB injuries, early and definitive soft tissue coverage, usually within 72 hours of injury, is critical to reduce infection rates and promote fracture healing. This often involves local rotational flaps or free tissue transfer, depending on the size and location of the defect. Delayed primary closure is not appropriate for large defects with exposed bone. Split-thickness skin grafts require a well-vascularized bed and are usually insufficient to cover exposed bone or deep structures. Leaving the wound open for weeks increases infection risk and prolongs hospitalization.

Question 5

Which of the following Salter-Harris fracture types has the highest risk of growth arrest?





Explanation

Salter-Harris Type V fractures, which involve a crush injury to the growth plate, have the highest risk of growth arrest due to direct damage to the germinal cells. While relatively rare, the prognosis for future growth is poor. Type IV fractures (fracture through metaphysis, physis, and epiphysis) also carry a high risk if not anatomically reduced, as a cartilaginous bridge can form across the physis. Type I (separation of physis) and Type II (physis and metaphysis) generally have good prognoses if reduced. Type III (physis and epiphysis) have a better prognosis than Type IV or V but still require anatomical reduction, especially if intra-articular.

Question 6

A 72-year-old male with a history of hypertension and diabetes presents with a displaced comminuted subtrochanteric femur fracture. He is hemodynamically stable. What is the preferred surgical treatment for this fracture pattern?





Explanation

Subtrochanteric femur fractures are highly load-bearing and are subject to significant deforming forces (pull of gluteus medius/minimus on the proximal fragment, adductors on the distal fragment). Intramedullary nailing (IMN) is considered the gold standard for subtrochanteric femur fractures due to its load-sharing nature, biomechanical advantages, and typically less soft tissue stripping compared to plating. A DHS is primarily designed for intertrochanteric fractures and is less stable for subtrochanteric patterns, particularly comminuted ones. Plating can be an option but often requires more extensive exposure and is more prone to failure in comminuted or osteoporotic bone. Non-operative management is generally associated with poor outcomes. Hemiarthroplasty is not indicated for subtrochanteric fractures unless there's a concomitant femoral neck fracture or pre-existing hip pathology requiring replacement.

Question 7

A 35-year-old male sustains a high-energy rotational injury to his ankle, resulting in a Maisonneuve fracture. What is the key to appropriate diagnosis and management of this injury?





Explanation

A Maisonneuve fracture is a specific type of ankle injury characterized by a fracture of the proximal fibula, rupture of the syndesmosis (anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, interosseous membrane), and often a deltoid ligament rupture or medial malleolus fracture. The key to diagnosis is recognizing the proximal fibula fracture in the context of an ankle injury, which often appears innocuous on standard ankle views. The critical aspect for management is assessing and restoring syndesmotic integrity, as disruption of the syndesmosis leads to ankle instability. Fixation of the medial malleolus is only done if it is fractured and significantly displaced. Calcaneal fractures are not directly associated. Vascular injury is rare unless there's a significant open injury or dislocation. Non-weight bearing cast immobilization alone is insufficient if the syndesmosis is unstable, which it typically is.

Question 8

Which of the following findings is most concerning for impending compartment syndrome in a patient with a closed tibial shaft fracture?





Explanation

While all listed options are potential signs of compartment syndrome, 'pain with passive stretching of the toes' (for the deep posterior and anterior compartments) and 'severe pain unresponsive to increasing doses of opioids' (pain out of proportion to injury) are considered the most sensitive and earliest signs of evolving compartment syndrome. Paresthesia can be an early sign but may also indicate nerve injury unrelated to compartment syndrome. Diminished pulses and pallor are late signs, often indicating irreversible muscle ischemia and nerve damage, and are less reliable early indicators because compartment pressure often exceeds venous pressure long before arterial flow is compromised.

Question 9

A 6-year-old child sustains a Salter-Harris Type II fracture of the distal tibia. The fracture is displaced. What is the optimal management strategy?





Explanation

Salter-Harris Type II fractures involve the physis and metaphysis, sparing the epiphysis and joint surface, and generally have a good prognosis. For displaced fractures, closed reduction is the preferred treatment to avoid surgical disruption of the physis. Once reduced, a long leg cast provides stable immobilization. Open reduction and internal fixation, particularly with screws across the physis, carries a significant risk of growth arrest. Percutaneous pinning can be used in unstable reductions, but pins should ideally avoid crossing the physis or, if necessary, be smooth and removed early. Observation is for minimally displaced or undisplaced fractures. Growth plate ablation is not indicated.

Question 10

Which ankle fracture classification system is based on the mechanism of injury and describes predictable patterns of ligamentous and osseous injury?





Explanation

The Lauge-Hansen classification system categorizes ankle fractures based on the position of the foot at the time of injury and the deforming force applied. It describes a sequential pattern of injury to ligaments and bones, which can help predict the extent of damage and guide reduction. The Danis-Weber classification is based on the level of the fibular fracture relative to the syndesmosis. The Gustilo-Anderson classification is for open fractures. The AO classification is a comprehensive alphanumeric system for all fractures. The Salter-Harris classification is for physeal injuries in children.

Question 11

A 55-year-old male with a history of alcohol abuse presents with a displaced calcaneal fracture after falling from a ladder. He has significant hindfoot swelling and ecchymosis. What is the most important initial assessment prior to definitive management?





Explanation

Calcaneal fractures, especially those resulting from falls from height, are often associated with other injuries, particularly spine (lumbar compression fractures) and contralateral lower extremity fractures. Therefore, a thorough secondary survey to rule out these associated injuries is paramount. While liver function tests and imaging (CT is usually preferred over MRI for bony detail) are part of a comprehensive workup, and surgical consultation will be necessary, the immediate priority is to ensure there are no other life- or limb-threatening injuries or associated fractures that might be missed.

Question 12

What is the primary goal of surgical fixation for a displaced Schatzker Type VI tibial plateau fracture?





Explanation

Schatzker Type VI tibial plateau fractures are complex bicondylar fractures with disassociation of the metaphysis from the diaphysis. The primary goals of surgical management are anatomical reduction of the articular surface to prevent post-traumatic arthritis and stable fixation to allow early range of motion. Restoration of overall limb alignment is also critical, but articulating surfaces take precedence for long-term joint health. Early weight bearing is generally not recommended for complex plateau fractures. Avascular necrosis is less common in the tibial condyle. While minimizing incision size is desirable, it should not compromise adequate visualization and reduction.

Question 13

A 40-year-old male sustains a Lisfranc injury after a fall with his foot plantarflexed and axially loaded. Which of the following is the most reliable radiographic sign of a Lisfranc injury?





Explanation

The Lisfranc ligament connects the medial cuneiform to the base of the second metatarsal. Diastasis (widening) between the base of the first and second metatarsals on weight-bearing AP radiographs is the most reliable radiographic sign of a Lisfranc injury, indicating disruption of the Lisfranc ligament complex and instability of the midfoot. A fleck sign (small avulsion fracture off the base of the second metatarsal or medial cuneiform) is also highly indicative. Fractures of the 5th metatarsal base or navicular/cuboid can occur but are not primary indicators of a Lisfranc injury. Talonavicular subluxation indicates a different midfoot or hindfoot pathology.

Question 14

What is the primary indication for surgical intervention in an acute Achilles tendon rupture?





Explanation

While there's ongoing debate regarding operative vs. non-operative management of Achilles tendon ruptures, surgical intervention is generally favored for high-demand athletes due to potentially lower re-rupture rates and better functional outcomes. However, a large gap between the tendon ends (>3 cm) often makes non-operative management less successful in achieving apposition and healing, thus making surgery a stronger consideration for anatomical repair. Patient age over 60 is often a relative contraindication for surgery. Complete rupture itself does not always mandate surgery, as many can be treated non-operatively, especially with early functional rehabilitation. Haglund's deformity is a pre-existing condition and not an acute indication for rupture repair.

Question 15

A 10-year-old male falls and sustains a femoral shaft fracture. He is hemodynamically stable. Which of the following is the most appropriate treatment?





Explanation

The optimal treatment for pediatric femoral shaft fractures varies with age, weight, and fracture pattern. For children aged 6-16, flexible intramedullary nailing (FIN) is often preferred for stable fractures due to its minimally invasive nature and allows earlier mobilization. Spica casting is an option for younger children (typically <6 years or <50 lbs) or those with less complex fractures. Plate and screw fixation is reserved for specific indications (e.g., polytrauma, head injury, open fractures, or failed IMN). External fixation is often used for open fractures, polytrauma, or severe soft tissue injuries. Bryant's traction is for very young children (typically <2 years).

Question 16

What is the most common serious complication following posterior hip dislocation, even after successful reduction?





Explanation

Avascular necrosis (AVN) of the femoral head is the most common serious long-term complication following posterior hip dislocation, with incidence increasing with prolonged dislocation time. Sciatic nerve injury is common acutely but usually resolves partially or completely. Post-traumatic osteoarthritis is also a long-term sequela but AVN is more directly linked to the initial insult. Heterotopic ossification can occur but is less common and less debilitating than AVN or severe osteoarthritis. Recurrent dislocation is rare after a single, well-reduced dislocation without associated bony injury.

Question 17

A 60-year-old male falls from a height and sustains a Pilon fracture (distal tibial plafond fracture). He presents with significant swelling and skin blistering. What is the most appropriate initial management strategy?





Explanation

Pilon fractures are high-energy injuries often associated with severe soft tissue damage. Significant swelling and blistering indicate compromised soft tissue envelope, making immediate ORIF risky due to high rates of wound complications and infection. The preferred initial management is to apply a spanning external fixator across the ankle to restore length, alignment, and indirectly reduce the fracture, which allows the soft tissues to recover. Definitive ORIF is then performed in a delayed fashion (often 7-14 days) once the swelling has subsided, and the skin wrinkles ('wrinkle sign'). A cast is insufficient to stabilize such a complex fracture. Percutaneous screws alone are usually inadequate. Amputation is a last resort.

Question 18

In the management of a stress fracture of the femoral neck, which of the following is an absolute indication for surgical fixation?





Explanation

Tension-side stress fractures of the femoral neck (typically posterior-medial) are inherently unstable and have a high risk of progression to complete fracture and displacement, and a higher risk of avascular necrosis. Therefore, they are considered an absolute indication for surgical fixation (e.g., with cannulated screws). Compression-side fractures (anterior-superior) are generally more stable and can often be managed non-operatively with activity modification and protected weight-bearing, unless displacement occurs. While military recruits and athletes may benefit from surgical fixation to expedite return to activity, it's not an absolute indication for all stress fractures unless instability or displacement is present. Minimally displaced fractures would fall under the category of compression or tension-side and the management depends on that distinction.

Question 19

Which type of knee dislocation (based on displacement direction) is most commonly associated with a popliteal artery injury?





Explanation

Anterior knee dislocations are most commonly associated with popliteal artery injury. This occurs when the tibia is forced anteriorly on the femur, stretching and potentially lacerating the popliteal artery as it is tethered posteriorly by its branches. While all knee dislocations carry a risk of vascular injury, anterior dislocations have the highest incidence (up to 40%). Posterior dislocations also carry a significant risk, but anterior is statistically higher.

Question 20

A 22-year-old male sustains a traumatic, open patella fracture. After initial debridement, what is the preferred method of internal fixation for a transverse, displaced patella fracture in a young, active patient?





Explanation

For most displaced transverse patella fractures, tension band wiring is the gold standard technique. It converts the tensile forces during knee flexion into compressive forces across the fracture site, promoting healing and allowing early range of motion. Cerclage wiring alone is usually insufficient. Excision of the patella (total patellectomy) or partial patellectomy are considered salvage procedures for highly comminuted fractures not amenable to fixation, as they lead to significant quadriceps weakness and extensor lag. Plate and screw fixation is generally reserved for highly comminuted fractures or specific fracture patterns not amenable to tension band.

Question 21

What is the most common nerve injury associated with proximal fibula fractures, particularly those involving the fibular head?





Explanation

The common peroneal nerve courses around the neck of the fibula, making it highly susceptible to injury with fractures of the fibular head or neck. Injury to the common peroneal nerve typically results in a 'foot drop' due to paralysis of the ankle dorsiflexors and evertors, along with sensory loss over the dorsum of the foot and lateral leg. The superficial and deep peroneal nerves are branches of the common peroneal nerve, so an injury to the common peroneal nerve would affect both. Sciatic and femoral nerves are anatomically more proximal.

Question 22

A 48-year-old construction worker presents with chronic knee pain and instability after a previous knee dislocation treated non-operatively. Examination reveals a positive Lachman test and pivot shift. What is the most appropriate management at this stage?





Explanation

A positive Lachman test and pivot shift are clinical signs highly suggestive of anterior cruciate ligament (ACL) deficiency. Given the history of knee dislocation, significant ligamentous injury, including ACL rupture, is highly likely. For a relatively young, active patient with symptomatic instability, ACL reconstruction is the definitive treatment to restore stability and prevent further meniscal and articular cartilage damage. Quadriceps strengthening can help but won't address the mechanical instability. Arthroscopic debridement or partial meniscectomy address specific intra-articular pathologies but not primary instability. Total knee arthroplasty is reserved for end-stage arthritis.

Question 23

In an elderly patient with a displaced femoral neck fracture, which type of fracture is generally best treated with a hemiarthroplasty rather than internal fixation?





Explanation

Displaced femoral neck fractures (Garden III or IV) in elderly patients, particularly those with pre-existing arthritis or significant medical comorbidities, have a high rate of complications (nonunion, avascular necrosis) when treated with internal fixation. Hemiarthroplasty (or total hip arthroplasty in more active patients) is generally preferred as it provides immediate stability, allows early weight bearing, and has more predictable outcomes. Impacted valgus (Garden I) and non-displaced (Garden II) fractures, and Pauwel's Type I (low angle of obliquity) can often be successfully treated with internal fixation, especially in younger, healthier patients.

Question 24

What is the primary role of the fibula in lower leg stability and function?





Explanation

While the fibula bears a small percentage of axial load, its primary anatomical and biomechanical role is to form the lateral wall of the ankle mortise, providing critical stability to the ankle joint by articulation with the talus and serving as an attachment site for numerous ligaments (e.g., lateral collateral ligaments of the ankle, syndesmotic ligaments). The tibia is the primary weight-bearing bone. The fibula provides origin for some lower leg muscles but not major knee extensors. The posterior neurovascular bundle is protected by the deeper muscles and fascia, not primarily the fibula itself.

Question 25

A 30-year-old patient with a transverse fracture of the tibial shaft presents with severe pain, swelling, and tense compartments in the lower leg. Compartment pressures are elevated. What is the most appropriate immediate intervention?





Explanation

Elevated compartment pressures in the setting of severe pain, swelling, and tense compartments indicate acute compartment syndrome, which is a surgical emergency. The definitive treatment is an emergency fasciotomy to decompress the involved compartments and prevent irreversible muscle and nerve ischemia. Delay can lead to permanent disability (Volkmann's contracture), nerve damage, and even limb loss. All other options are inappropriate or cause critical delays.

Question 26

Which of the following is considered a relative contraindication to intramedullary nailing of a femoral shaft fracture?





Explanation

Pre-existing osteomyelitis of the femur is a relative contraindication to intramedullary nailing, as placing a foreign implant (the nail) directly through an infected bone can exacerbate the infection and lead to chronic osteomyelitis. In such cases, external fixation or staged procedures might be considered. Open fractures (especially Gustilo Type I and II) are often treated successfully with IMN after appropriate debridement. Polytrauma patients often benefit from IMN for early stabilization. Segmental fractures are well-suited for IMN. Obesity can make surgical access challenging but is not a contraindication.

Question 27

What is the primary concern for a missed or delayed diagnosis of a pediatric femoral neck fracture?





Explanation

Pediatric femoral neck fractures have a high complication rate, and avascular necrosis (AVN) of the femoral head is the most devastating. The risk of AVN is directly related to the initial displacement and the time to reduction, making prompt diagnosis and anatomical reduction crucial. Missed or delayed diagnosis significantly increases the risk of AVN, which can lead to premature degenerative arthritis, nonunion, and malunion. While nonunion and malunion can occur, AVN is the most unique and severe complication directly linked to the blood supply disruption.

Question 28

A 25-year-old male sustains a high-energy tibial shaft fracture, resulting in an 8 cm bone defect after debridement. The skin envelope is intact. What is the most appropriate reconstructive option for this defect?





Explanation

For large bone defects (typically >4-6 cm, or critical size defects), distraction osteogenesis (e.g., using an Ilizarov frame or similar external fixator) is a highly effective method. It allows for bone transport to fill the defect while maintaining limb length. Bone graft alone would be insufficient for an 8 cm defect. Vascularized fibular graft is an option but is more complex and has higher donor site morbidity. Segmental bone resection and primary shortening results in unacceptable leg length discrepancy for an 8cm defect. Non-weight bearing will not induce healing of such a large defect.

Question 29

Which of the following describes a 'terrible triad' injury of the knee?





Explanation

The 'terrible triad' of the knee classically refers to a combined injury involving the Anterior Cruciate Ligament (ACL), Medial Collateral Ligament (MCL), and medial meniscus. This injury typically results from a valgus stress with external rotation to a flexed knee. While other combinations of injuries can occur, this specific combination is historically known as the 'terrible triad' due to its prevalence and complexity.

Question 30

What is the most common mechanism of injury for a posterior cruciate ligament (PCL) rupture?





Explanation

The most common mechanism for a PCL rupture is a direct blow to the anterior tibia when the knee is flexed, often referred to as a 'dashboard injury' in motor vehicle accidents, or a fall onto a flexed knee. This forces the tibia posteriorly relative to the femur, stressing the PCL. Hyperextension can also injure the PCL but is less common. Twisting injuries, valgus, and varus stresses typically injure the ACL, MCL, or LCL, respectively.

Question 31

What is the primary biomechanical advantage of reamed intramedullary nailing over unreamed nailing for tibia fractures?





Explanation

Reamed intramedullary nailing involves reaming the medullary canal to a larger diameter, allowing for a larger diameter nail. This results in increased implant-bone contact, providing greater construct stiffness and biomechanical stability, which can improve healing rates. However, reaming generates heat and can increase intramedullary pressure, potentially increasing the risk of fat embolism and, in compromised soft tissue, compartment syndrome. Unreamed nails are often smaller in diameter and may be preferred in cases with tenuous soft tissues or open fractures to minimize further compromise.

Question 32

A 75-year-old female presents with a non-displaced fracture of the talar neck. What is the most critical complication to monitor for in this fracture?





Explanation

Talar neck fractures, even non-displaced ones, carry a significant risk of avascular necrosis (AVN) of the talar body. The talus has a precarious blood supply, primarily from small vessels entering the neck and body, with no direct muscular attachments. A fracture of the talar neck often disrupts this blood supply, leading to ischemia of the talar body. The risk of AVN increases with displacement and comminution. Nonunion and malunion are also concerns, as is post-traumatic subtalar arthritis, but AVN is the most common and devastating complication related to the unique vascular anatomy of the talus. Tarsal tunnel syndrome is less common as a primary complication.

Question 33

Which of the following characteristics of a tibial shaft fracture indicates increased risk for nonunion?





Explanation

Open fractures, particularly Gustilo Type IIIB with extensive soft tissue damage and periosteal stripping, have a significantly higher risk of nonunion due to compromised blood supply to the fracture site and increased risk of infection. Transverse fractures generally heal slower than spiral fractures but are not as high a risk as Type IIIB open fractures. The junction of the middle and distal thirds of the tibia is considered a 'watershed' area with poorer blood supply, increasing risk. Minimal soft tissue injury implies a better prognosis.

Question 34

A 14-year-old male sustains a Salter-Harris Type III fracture of the distal tibia. Which of the following is true regarding its management?





Explanation

A Salter-Harris Type III fracture involves the epiphysis and physis, meaning it extends into the joint. Therefore, it is an intra-articular fracture, and anatomical reduction (often requiring open reduction and internal fixation with screws parallel to the physis) is crucial to restore joint congruity and prevent premature degenerative arthritis. While growth arrest can occur, post-traumatic arthritis is a major concern. Non-operative management is only for truly non-displaced fractures. Percutaneous pinning should avoid crossing the physis if possible, or use smooth pins to minimize physeal damage.

Question 35

What is the appropriate management for an undisplaced, stable avulsion fracture of the base of the fifth metatarsal (Jones fracture zone 1)?





Explanation

Avulsion fractures of the base of the fifth metatarsal (often referred to as 'pseudo-Jones' fractures or in Zone 1) are typically caused by inversion injuries and traction from the peroneus brevis tendon. These fractures generally have an excellent blood supply and heal well with conservative management. Non-weight bearing in a short leg walking boot for 4-6 weeks is appropriate. Surgical fixation is rarely needed unless displacement is significant or nonunion occurs. Full weight bearing in a regular shoe is too early and carries a risk of nonunion or displacement. Excision is not a primary treatment.

Question 36

Which of the following factors is most strongly associated with an increased risk of DVT/PE in a patient with a lower extremity fracture?





Explanation

Prolonged immobilization, especially of the lower extremity, is a well-established major risk factor for deep vein thrombosis (DVT) and pulmonary embolism (PE) due to venous stasis. Other risk factors include advanced age, malignancy, obesity, history of DVT/PE, and specific fracture types (pelvis, hip). While traumatic brain injury can be associated with hypercoagulability, prolonged immobilization is a more direct and significant factor for DVT/PE in lower extremity trauma. Early ambulation is protective. Epidural catheters do not directly increase DVT/PE risk. Younger age is generally protective.

Question 37

A 6-month-old infant presents with a spiral fracture of the tibia, with no history of significant trauma provided by the parents. What is the most critical next step in evaluation?





Explanation

A spiral fracture of the tibia in a non-ambulatory infant with an inconsistent or absent history of trauma should raise strong suspicion for non-accidental trauma (child abuse), also known as a 'toddler's fracture' when walking, but concerning in an infant. The most critical next step is to obtain a skeletal survey (babygram) to look for other occult fractures of varying ages, which would confirm a diagnosis of child abuse. While the fracture needs stabilization, ruling out child abuse takes precedence. Antibiotics and immediate surgery are not indicated based on the initial presentation. A bone scan is not for initial diagnosis of abuse.

Question 38

What is the primary objective of a two-stage approach (external fixation followed by ORIF) for open tibial plateau fractures with significant soft tissue injury?





Explanation

For complex periarticular fractures like tibial plateau fractures, especially with significant soft tissue injury (open fractures, severe swelling, blistering), a two-stage approach is often employed. The first stage involves temporary stabilization with an external fixator to restore alignment, debride open wounds, and allow the acute soft tissue swelling to resolve. The primary objective is to 'optimize the soft tissue envelope' so that definitive internal fixation can be performed safely at a later date (typically 7-14 days) when the tissues are less inflamed, reducing the risk of wound complications and infection. Early weight-bearing is not the goal, and it doesn't primarily minimize blood loss or reduce DVT risk, nor does it prevent compartment syndrome (which may still require fasciotomy).

Question 39

Which of the following is a recognized complication of prolonged skeletal traction for a femoral shaft fracture?





Explanation

Prolonged skeletal traction, historically used for femoral shaft fractures, requires the patient to remain in bed for extended periods. This immobility significantly increases the risk of pressure sores (decubitus ulcers) at points of contact or pressure, as well as pneumonia, DVT, and joint stiffness. While nonunion can occur with any fracture, it's not a specific complication of traction itself. Compartment syndrome is an acute post-injury complication, and osteomyelitis is typically related to open fractures or surgical procedures. Fat embolism can occur with the initial trauma or reaming for IMN but is not a complication of prolonged traction specifically.

Question 40

What is the critical step in managing a dislocated knee that should always be performed, regardless of the presence of palpable pulses?





Explanation

The most critical immediate step in managing any dislocated knee (assuming the patient is hemodynamically stable) is prompt reduction of the dislocation. This is a limb-saving maneuver as it can restore vascular flow if compressed by the dislocation and reduces tension on neurovascular structures. Even if pulses are palpable, a vascular injury can still exist (intimal tear, spasm), but reduction is paramount before extensive workup. Arteriography or CT angiography is indicated after reduction (or if pulses remain absent/diminished post-reduction). Operative exploration is only for confirmed vascular injury or non-reducible dislocations. ABI measurement is part of the vascular assessment but follows reduction.

Question 41

A 68-year-old female presents with a displaced femoral neck fracture. Her past medical history includes severe dementia, rendering her non-ambulatory prior to the fall. What is the most appropriate treatment option?





Explanation

For frail, non-ambulatory elderly patients with severe dementia and a displaced femoral neck fracture, surgical intervention may not improve their functional status and carries significant risks of complications (delirium, infection, cardiac events). In such cases, non-operative management focusing on comfort, pain control, and early mobilization out of bed (e.g., to a wheelchair) is often the most humane and appropriate approach. While this results in nonunion, the goal is palliation rather than functional recovery. Hemiarthroplasty or THA would be too extensive given her pre-morbid state. ORIF has high failure rates in this group. External fixation is not used for femoral neck fractures.

Question 42

Which classification system is used to assess the severity of soft tissue damage in open fractures?





Explanation

The Gustilo-Anderson classification system is specifically designed to classify open fractures based on the extent of soft tissue damage, wound size, contamination, and associated comminution. This classification guides management, particularly regarding debridement, antibiotic use, and definitive soft tissue coverage. Danis-Weber classifies ankle fractures. AO classifies all fractures. Salter-Harris classifies physeal injuries. Schatzker classifies tibial plateau fractures.

Question 43

What is the most appropriate management for an undisplaced, stable fracture of the lateral malleolus (Weber A)?





Explanation

Weber A fractures (fracture of the fibula distal to the syndesmosis) are typically stable injuries because the syndesmosis and deltoid ligament are intact. For undisplaced and stable fractures, functional bracing or a walking boot with early weight-bearing as tolerated is the most appropriate management. This allows for earlier return to function and typically good outcomes. Surgical fixation is not indicated for stable, undisplaced fractures. Non-weight bearing in a cast is overly conservative for this stable pattern. Skeletal traction is not relevant.

Question 44

Which of the following is a strong indication for surgical fixation of a tibia shaft fracture in an adult?





Explanation

Segmental tibia fractures involve fracture lines at two or more levels, leading to an unstable segment. These fractures are inherently unstable and have a high risk of nonunion or malunion with non-operative management, making surgical fixation (typically intramedullary nailing) strongly indicated. Undisplaced hairline fractures, closed fractures with minimal displacement and angulation (within acceptable limits), and concomitant fibula fractures (unless part of a complex ankle injury like Maisonneuve) are often amenable to non-operative treatment or are not specific indications for surgery. Diabetes affects healing but is not an indication itself.

Question 45

In a patient with a suspected femoral shaft fracture, what is the most important initial management step in the emergency department setting after primary survey?





Explanation

After the primary survey (ABCDEs) and resuscitation, the immediate management of a suspected femoral shaft fracture (closed or open) involves the application of a traction splint (e.g., Sager or Hare traction splint). This helps to reduce pain, control bleeding (a femur can bleed significantly), prevent further soft tissue damage, and temporarily stabilize the limb, especially during transport or while awaiting definitive fixation. Antibiotics are for open fractures. CT angiography and operating room preparation are later steps. A long leg cast is insufficient for a femoral shaft fracture.

Question 46

What is the characteristic clinical presentation of a patient with a ruptured patellar tendon?





Explanation

A ruptured patellar tendon results in a loss of continuity of the extensor mechanism of the knee. Clinically, this manifests as a palpable defect below the patella, and due to the unopposed pull of the quadriceps, the patella will appear high-riding (patella alta). Crucially, the patient will be unable to actively extend the knee against gravity. A ruptured quadriceps tendon, in contrast, would result in a defect above the patella and a low-riding patella (patella baja).

Question 47

What is the most sensitive imaging modality for diagnosing osteomyelitis following an open fracture?





Explanation

While MRI with contrast is highly sensitive for soft tissue and bone marrow edema, making it excellent for early osteomyelitis, an Indium-111 labeled leukocyte scan (or combined WBC/bone scan) is often considered the most specific and sensitive imaging modality for diagnosing active infection (osteomyelitis), especially in the presence of hardware or previous surgery, as it specifically targets actively inflamed leukocytes. Plain radiographs are insensitive in early stages. CT is good for bony detail but less for early infection. Bone scans are sensitive but not very specific for infection in the presence of other bone pathology like fractures or hardware.

Question 48

What is the primary goal of surgical management for a displaced intra-articular calcaneal fracture?





Explanation

Displaced intra-articular calcaneal fractures often involve the subtalar joint. The primary goal of surgical management is to achieve anatomical reduction of the posterior facet (the articular surface between the talus and calcaneus) and restore the overall height, width, and alignment of the hindfoot. This is crucial for preventing post-traumatic subtalar arthritis, which is a common and debilitating complication. Restoration of Böhler's angle is a radiographic indicator of calcaneal height restoration. While tarsal tunnel syndrome can be a complication, decompression is not the primary goal of the fracture fixation. Early weight-bearing is usually contraindicated, and subtalar fusion is a salvage procedure for symptomatic arthritis, not the primary treatment for the acute fracture.

Question 49

A 2-year-old child presents with a 'toddler's fracture' (spiral fracture of the distal tibia) with no displacement. What is the most appropriate management?





Explanation

A toddler's fracture is a common, non-displaced spiral or oblique fracture of the distal tibia in young children (typically 9 months to 3 years old) due to low-energy rotational forces. These fractures are stable and heal reliably with conservative management. A long leg cast (or sometimes a short leg cast) for 3-4 weeks is the standard treatment, followed by gradual return to activity. Surgical intervention is rarely needed. Observation only is insufficient, and immediate full weight bearing is not advisable initially.

Question 50

Which of the following is true regarding a Pilon fracture (distal tibial plafond fracture)?





Explanation

Pilon fractures are high-energy intra-articular fractures of the distal tibia, typically resulting from axial loading with associated rotation. They are characterized by significant soft tissue injury and comminution. A CT scan is absolutely essential for comprehensive assessment of the fracture pattern, articular surface involvement, and comminution, which is critical for surgical planning. Non-operative management is reserved for truly non-displaced or low-demand patients, but most require surgery. Ankle arthrodesis is a salvage procedure for post-traumatic arthritis, not the primary treatment for the acute fracture.

Question 51

A 35-year-old male sustains an open tibia fracture, Gustilo Type II. After debridement and IMN, what is the recommended duration of intravenous antibiotic therapy?





Explanation

For Gustilo Type II open fractures, the recommended intravenous antibiotic regimen is a first-generation cephalosporin (e.g., Cefazolin) for 72 hours. For Type III fractures, an aminoglycoside (e.g., Gentamicin) is added to cover gram-negative organisms. Penicillin is added for farmyard injuries (Clostridial coverage). Prophylactic antibiotics for open fractures are typically given for no more than 72 hours, not 24 hours, and not for prolonged periods like 5 days or 6 weeks unless there is a confirmed infection. Metronidazole is for anaerobic coverage and not typically first-line for Type II. The question refers to prophylactic antibiotic duration, not treatment for established infection.

Question 52

Which of the following is a recognized complication of posterior screw fixation for a medial malleolus fracture?





Explanation

Posterior screw fixation of the medial malleolus (often used for vertical fractures or to avoid anterior hardware) requires careful technique due to the proximity of the posterior tibial neurovascular bundle (posterior tibial artery, posterior tibial nerve) to the posterior aspect of the tibia. Screws that are too long or improperly angled can injure these structures. The saphenous nerve is more anterior-medial. Peroneal tendons are lateral. Syndesmotic malreduction is related to fibular fixation. Achilles tendon is posterior but superficial to these structures.

Question 53

What is the most appropriate initial management for an unstable pelvic ring injury in a hemodynamically unstable patient?





Explanation

For hemodynamically unstable patients with unstable pelvic ring injuries, the most critical immediate intervention after primary survey and resuscitation is to stabilize the pelvic ring to reduce the pelvic volume and tamponade venous bleeding. This is achieved quickly and effectively with a pelvic binder, sheet wrap, or C-clamp. While angioembolization may be needed for arterial bleeding, and external fixation or ORIF for definitive stabilization, these are subsequent steps after initial hemorrhage control. Traction is not for pelvic ring stabilization.

Question 54

A 38-year-old male sustains a comminuted fracture of the distal femur extending into the knee joint (supracondylar-intercondylar fracture). What is the primary concern regarding long-term outcome after surgical fixation?





Explanation

Supracondylar-intercondylar femoral fractures (AO/OTA 33-C type) involve the articular surface of the knee. Despite achieving stable fixation, the primary long-term concern is the development of post-traumatic osteoarthritis due to residual articular incongruity, cartilage damage at the time of injury, and altered joint mechanics. While nonunion, AVN (less common here), and DVT can occur, osteoarthritis is the most common and often debilitating long-term sequela for complex intra-articular fractures. Leg length discrepancy is a concern for shaft fractures but less so for distal femur unless malunion is significant.

Question 55

In the management of a displaced subtrochanteric femur fracture, why is intramedullary nailing generally preferred over plate and screw fixation?





Explanation

Intramedullary nails are load-sharing devices, meaning they share the axial load with the bone, which helps to reduce stress shielding and promote physiological healing. Plates, conversely, are load-bearing, taking most of the load themselves, which can lead to stress risers at the plate ends and increase the risk of implant fatigue or refracture after removal. For subtrochanteric fractures, which are subject to high bending and rotational forces, load-sharing IMN offers superior biomechanical advantages and generally better healing rates compared to plates. While IMN can provide good stability, torsional stability depends on locking screws. AVN is not a primary concern for subtrochanteric fractures. Early weight bearing depends on fracture stability and patient factors. Infection rates are generally comparable when performed appropriately.

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Dr. Mohammed Hutaif
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