Lower Limb Trauma Management: Ace Your Exams

Comprehensive Exam

00:00

Start Quiz

Question 1

A 45-year-old male presents to the emergency department after a high-speed motor vehicle collision. He is hypotensive (BP 80/50 mmHg) and tachycardic (HR 125 bpm). Physical examination reveals obvious instability of the pelvic ring with ecchymosis over the perineum and pubic symphysis. Initial resuscitation with 2 liters of crystalloid has failed to improve his hemodynamic status. Which of the following is the most appropriate next step in his immediate management?

Explanation

In a hemodynamically unstable patient with a suspected pelvic ring injury, the priority is hemorrhage control. A pelvic binder (or sheet) provides immediate temporary stabilization and reduction of the pelvic volume, which can tamponade bleeding. If the patient remains unstable after initial resuscitation and binder application, the next step is typically emergent surgical stabilization (e.g., external fixation) in the operating room or angiography for embolization, often dictated by local protocol and surgeon preference. While CT scan, Foley catheter insertion, and angiography are important diagnostic and therapeutic steps, immediate mechanical reduction via a binder and early surgical intervention for ongoing instability take precedence for life-threatening hemorrhage. Tranexamic acid and massive transfusion protocol are adjuncts but don't address the primary mechanical cause of bleeding.

Question 2

A 28-year-old male sustains a posterior hip dislocation after a dashboard injury in an MVC. On examination, his hip is internally rotated, adducted, and flexed. He has diminished sensation in the plantar aspect of his foot and weakness in ankle dorsiflexion and eversion. What is the most appropriate initial management step, considering the neurovascular status?

Explanation

Posterior hip dislocations are orthopedic emergencies due to the high risk of avascular necrosis (AVN) of the femoral head and associated sciatic nerve injury. The most critical factor is the time to reduction. A neurological deficit (like the described sciatic nerve palsy) does NOT contraindicate immediate closed reduction. In fact, prompt reduction may allow for neurological recovery. A CT scan is important AFTER successful closed reduction to assess for incarcerated fragments or occult fractures (e.g., femoral head impaction, posterior wall acetabular fracture), but it should not delay reduction. Open reduction is reserved for failed closed reduction or irreducible dislocations. MRI is not an acute management tool.

Question 3

A 35-year-old construction worker sustains an open tibial shaft fracture (Gustilo-Anderson Type IIIA) after being struck by heavy machinery. He arrives in the ED 1 hour after injury. What is the immediate priority in his management after ATLS resuscitation and basic wound coverage?

Explanation

For open fractures, particularly Gustilo-Anderson Type IIIA, emergent irrigation and debridement in the operating room is the most critical step to prevent infection and facilitate healing. While antibiotics are crucial, they are adjuncts to surgical debridement. The 'golden period' for debridement is traditionally considered within 6-8 hours, but earlier is better, especially for higher grades. CTA might be indicated if there's concern for vascular injury, but controlling contamination is paramount. Definitive fixation is performed after initial debridement, often at a later stage once the soft tissue envelope has been optimized. Compartment pressures would be measured if compartment syndrome is suspected, but initial management focuses on the open wound.

Question 4

A 22-year-old football player presents with severe pain in his right lower leg after a direct blow. He complains of paresthesia in his foot and pain on passive dorsiflexion of his toes. The calf is tense to palpation. What is the most reliable diagnostic finding for acute compartment syndrome?

Explanation

The most reliable diagnostic criterion for acute compartment syndrome is a 'delta pressure' (diastolic blood pressure minus intracompartmental pressure) less than 30 mmHg. While an absolute pressure of 30 mmHg or greater is often used as a threshold, it must be considered in relation to the patient's blood pressure, as a lower absolute pressure can still be significant in hypotensive patients. Pain out of proportion to injury, paresthesia, and a tense compartment are classic clinical signs, but they are subjective and can be unreliable in altered mental status or pediatric patients. A palpable distal pulse does not rule out compartment syndrome, as arterial inflow is typically preserved until very late stages. Elevated CK levels indicate muscle damage but are not diagnostic of acute compartment syndrome.

Question 5

A 30-year-old male sustains a high-energy knee injury with gross instability in all planes. Radiographs confirm a knee dislocation without associated fractures. Pulses are diminished in the dorsalis pedis and posterior tibial arteries. What is the most appropriate next step in management?

Explanation

Knee dislocation, especially with vascular compromise, is an orthopedic emergency. The immediate priority is reduction of the knee to restore blood flow and reduce tension on the popliteal artery. Closed reduction should be attempted immediately. After reduction, pulses must be meticulously reassessed. If pulses remain diminished or absent, or if there is any concern for popliteal artery injury (even with palpable pulses if the mechanism suggests high energy), an emergent CT angiogram (or arteriogram) is warranted. Delaying reduction for imaging significantly increases the risk of limb ischemia and potential amputation. Ligament repair and external fixation are important later steps, but re-establishing circulation is paramount.

Question 6

A 78-year-old female presents after a ground-level fall, complaining of right hip pain. Radiographs show a displaced, comminuted subtrochanteric femur fracture. She has multiple comorbidities including hypertension, diabetes, and atrial fibrillation. Which of the following is the most appropriate definitive management for this fracture?

Explanation

Subtrochanteric femur fractures are typically high-energy injuries in younger patients and low-energy in osteoporotic elderly patients. The standard of care for displaced subtrochanteric fractures, particularly comminuted ones, is intramedullary nailing (IMN) with a long cephalomedullary nail. This implant provides biomechanical stability, allows for early weight-bearing, and has better outcomes compared to plate fixation in this region, which is subject to high bending forces. DHS is primarily used for intertrochanteric fractures and is biomechanically less suitable for subtrochanteric fractures. Hemiarthroplasty or THR are used for femoral neck fractures or certain highly comminuted intertrochanteric fractures not amenable to IMN, but not typically for subtrochanteric fractures. Non-operative management with traction is associated with high mortality and morbidity in the elderly and is generally avoided.

Question 7

A 40-year-old male falls from a height, landing on his heels. He presents with bilateral heel pain. Radiographs show a displaced calcaneus fracture. Which associated injury should be specifically investigated?

Explanation

Calcaneus fractures, especially those resulting from a fall from a height, are associated with a significant incidence of lumbar spine compression fractures (10-15%). The axial loading mechanism transmits force up the kinetic chain. Therefore, it is critical to obtain imaging of the lumbar spine (lateral X-ray or CT) in all patients with calcaneus fractures from a fall from height. While other injuries can occur, a lumbar spine fracture is the most common and critical associated injury to specifically rule out due to potential neurological sequelae.

Question 8

A 55-year-old female presents with midfoot pain and inability to bear weight after stepping off a curb awkwardly. Radiographs show subtle widening between the first and second cuneiforms. What is the most sensitive imaging modality to confirm a Lisfranc injury and guide management?

Explanation

Lisfranc injuries (tarsometatarsal joint complex disruption) can be subtle on standard plain radiographs, especially non-displaced or purely ligamentous injuries. While weight-bearing and stress radiographs are crucial for initial assessment, a CT scan is considered the most sensitive imaging modality to definitively diagnose and characterize Lisfranc injuries. It provides detailed bony anatomy, identifies small avulsion fractures, and measures subtle diastasis not visible on plain films. This information is critical for surgical planning. MRI is excellent for soft tissue injuries (ligaments) but often follows a CT scan for bony detail. A bone scan is not used for acute diagnosis.

Question 9

A 60-year-old obese male sustains a high-energy fall onto his knee, resulting in a Schatzker Type VI tibial plateau fracture. He has multiple open wounds and significant soft tissue swelling. What is the most appropriate initial surgical approach for this injury?

Explanation

Schatzker Type VI tibial plateau fractures are complex, high-energy injuries often associated with severe soft tissue damage, swelling, and open wounds. Immediate definitive ORIF carries a high risk of wound complications, infection, and flap necrosis due to the compromised soft tissue envelope. The preferred initial management is often damage control orthopedics: emergent external fixation with provisional joint spanning (spanning ex-fix) to stabilize the fracture, protect the soft tissues, and allow swelling to subside. Definitive ORIF is then performed in a delayed fashion (typically 7-14 days) once the 'wrinkle sign' appears and the soft tissues are amenable to surgery. Closed reduction and casting are inadequate for displaced, unstable, or articular fractures. Arthroplasty is not an acute treatment for fractures. Arthroscopic assistance is primarily for less severe fractures.

Question 10

A 48-year-old female presents after a motor vehicle accident with a comminuted fracture of the distal tibia extending into the ankle joint (pilon fracture). There is significant soft tissue swelling and blistering. What is the primary goal of immediate non-operative management?

Explanation

Pilon fractures are challenging due to their articular involvement and often severe soft tissue injury. Significant soft tissue swelling and blistering indicate a compromised soft tissue envelope that is not ready for definitive surgical intervention. The primary goal of immediate non-operative management (often with a spanning external fixator for provisional stability) is to allow the soft tissues to recover, reduce swelling, and improve the skin condition. This 'waiting game' is crucial to minimize the high risk of wound complications (dehiscence, infection) associated with early surgery on inflamed tissues. Anatomical reduction is the ultimate goal, but it must be achieved when the soft tissues allow. Early weight-bearing is contraindicated. DVT prophylaxis is important but not the primary goal of local fracture management in this context.

Question 11

A 25-year-old male sustains an ankle injury while playing basketball. Radiographs show a transverse fracture of the distal fibula at the level of the syndesmosis and widening of the syndesmosis. The medial clear space is also increased. This injury pattern most closely corresponds to which Weber classification type?

Explanation

The Weber classification for ankle fractures describes the level of the fibular fracture relative to the syndesmosis. A Weber C fracture involves a fibular fracture PROXIMAL to the syndesmosis, often with syndesmotic disruption and medial injury (deltoid ligament tear or medial malleolus fracture). A transverse fibular fracture at the level of the syndesmosis combined with syndesmotic widening and increased medial clear space (indicating medial ligamentous injury or fracture) is the hallmark of a Weber C injury, specifically indicating syndesmotic instability. Weber A is distal to syndesmosis, Weber B is at the level. A Maisonneuve fracture is a specific type of Weber C where the fibular fracture is very high, near the fibular head.

Question 12

A 60-year-old male undergoes closed reduction of a posterior hip dislocation 8 hours after injury. Post-reduction radiographs show a concentric reduction. He complains of persistent pain and numbness in the lateral aspect of his calf and weakness in foot dorsiflexion. Which nerve is most likely injured?

Explanation

The sciatic nerve is commonly injured in posterior hip dislocations. The sciatic nerve divides into the tibial and common peroneal nerves. The described symptoms (numbness in the lateral calf, weakness in foot dorsiflexion - ankle dorsiflexion and eversion) are classic signs of a common peroneal nerve palsy. The common peroneal nerve is more susceptible to injury than the tibial nerve due to its superficial course and tethering around the fibular neck. The femoral nerve would cause quadriceps weakness and anterior thigh sensory loss. The obturator nerve affects adduction. The gluteal nerves affect hip abduction or extension, respectively.

Question 13

A 32-year-old male involved in a motorcycle accident sustains multiple long bone fractures (bilateral femoral and tibial shaft fractures). Three days post-injury, he develops acute respiratory distress, petechial rash on his chest and axilla, and altered mental status. What is the most likely diagnosis?

Explanation

The classic triad of respiratory distress, neurological dysfunction (altered mental status), and petechial rash appearing 12-72 hours after long bone fractures is highly suggestive of Fat Embolism Syndrome (FES). While pulmonary embolism and ARDS are serious complications, the presence of the petechial rash and the specific timing post-multiple long bone fractures strongly point to FES. Pneumonia and cerebral infarct are less likely given the specific constellation of symptoms and the acute post-traumatic timeline. FES is a life-threatening complication, with management being primarily supportive.

Question 14

A 16-year-old male sustains a supracondylar femur fracture after a direct blow to the distal thigh. On presentation, he has a weak dorsalis pedis pulse compared to the contralateral side. What is the most appropriate initial diagnostic study to evaluate vascular status?

Explanation

Supracondylar femur fractures are notorious for their association with popliteal artery injury due to the proximity of the fracture fragments to the vessel. In any patient with suspected vascular compromise after a lower limb injury (diminished or absent pulse, pain, pallor, paresthesia, poikilothermia - the '5 Ps'), the initial screening tool is the Ankle-Brachial Index (ABI). An ABI less than 0.9 is highly suspicious for arterial injury. If the ABI is abnormal, or if there are clear hard signs of vascular injury, then a CTA or formal arteriogram is indicated. Immediate surgical exploration is reserved for definitive hard signs of vascular injury (e.g., expanding hematoma, pulsatile bleeding, absent pulse) without time for imaging, or after imaging confirms a repairable injury. Duplex ultrasound can be operator-dependent and MRA is not typically used acutely.

Question 15

A 38-year-old male presents after a rollover MVC. He is hypotensive and has a significantly widened pubic symphysis and disruption of the sacroiliac joints bilaterally on pelvic X-ray (APC III). His hemodynamic status is improving after initial fluid resuscitation and application of a pelvic binder. What is the most appropriate next step for definitive pelvic stabilization?

Explanation

An APC III (Anteroposterior Compression Type III, or 'open book' fracture with posterior disruption) involves both anterior and posterior pelvic ring instability. While a pelvic binder provides initial temporary stability and reduces the volume, definitive stabilization is required. Given the posterior instability (sacroiliac joint disruption), percutaneous iliosacral screw fixation is often the preferred method for stabilizing the posterior ring, which is crucial for overall pelvic stability. Anterior external fixation is important, but often used as a temporary measure or in conjunction with posterior fixation. Angiography is indicated for ongoing hemodynamic instability despite mechanical stabilization. ORIF of the pubic symphysis might be considered for isolated symphysis diastasis but not for APC III. Skeletal traction is generally not used for pelvic ring fractures.

Question 16

A 72-year-old female with a previous total hip arthroplasty (THA) for osteoarthritis falls and sustains a periprosthetic femur fracture. Radiographs show the fracture around the stem, with the stem itself appearing loose (Vancouver Type B3). What is the most appropriate management strategy?

Explanation

Vancouver B3 periprosthetic femur fractures are characterized by a fracture around or distal to the stem with a loose femoral stem or significant bone loss. Given the stem looseness, simply fixing the fracture around the existing stem (ORIF with plates/screws or cerclage wires) is insufficient. The unstable stem needs to be addressed. The definitive management is typically revision total hip arthroplasty with a longer, often proximally coated or extensively coated, stem that bypasses the fracture by at least two cortical diameters, sometimes combined with allograft struts or plates for bone grafting and stabilization. Non-operative management is reserved for very stable, non-displaced fractures. Girdlestone is a salvage procedure typically reserved for intractable infection or failed revisions in very low-demand patients.

Question 17

A 50-year-old male falls directly onto his patella, sustaining a comminuted patella fracture with 5mm displacement and articular incongruity. He is unable to perform a straight leg raise. What is the most appropriate management?

Explanation

Displaced patella fractures with disruption of the extensor mechanism (unable to perform a straight leg raise) require surgical fixation to restore extensor function and achieve articular congruity. For comminuted but salvageable patella fractures, tension band wiring (often combined with circumferential cerclage wiring for comminution) is the most common and effective technique. It converts the distraction forces into compression forces at the articular surface during knee flexion. Partial patellectomy is reserved for highly comminuted fragments that cannot be reconstructed. Total patellectomy leads to significant quadriceps weakness and is a salvage procedure. Non-operative management is only for non-displaced fractures with an intact extensor mechanism. Knee arthrodesis is an extreme salvage option for devastating knee injuries.

Question 18

A 65-year-old male slips and falls, experiencing a sudden 'pop' above his knee. He has significant swelling and pain above the patella and is unable to actively extend his knee. A palpable gap is noted superior to the patella. What is the most likely diagnosis?

Explanation

The patient's presentation (sudden 'pop' above the knee, inability to actively extend the knee, and a palpable gap superior to the patella) is classic for a quadriceps tendon rupture. A patellar tendon rupture would present with a palpable gap inferior to the patella and a high-riding patella (patella alta). A patella fracture would typically be diagnosed on X-ray and might or might not have a palpable gap depending on the comminution and displacement. Meniscal tears and ACL ruptures typically do not cause complete inability to actively extend the knee or a palpable gap in the extensor mechanism. Quadriceps tendon ruptures often occur in older individuals with underlying degenerative changes.

Question 19

According to the Gustilo-Anderson classification, which of the following describes a Type IIIB open fracture?

Explanation

The Gustilo-Anderson classification is crucial for guiding management and predicting outcomes in open fractures. Type IIIB is defined as an open fracture with extensive soft tissue damage, periosteal stripping, bone exposure, and massive contamination, requiring reconstructive soft tissue procedures (e.g., local or free flap) for coverage. Type I is a small wound (<1cm), minimal damage. Type II is a wound >1cm but <10cm, moderate damage. Type IIIA has extensive soft tissue damage, but adequate soft tissue coverage is usually possible. Type IIIC includes an associated arterial injury requiring repair, regardless of the soft tissue damage severity. A gunshot wound is not a standalone Gustilo type, but is classified based on wound size and soft tissue damage.

Question 20

A 20-year-old male sustains a severe crush injury to his leg. He has an open tibia fracture and a palpable but weak dorsalis pedis pulse. The ankle-brachial index (ABI) is 0.7. Which of the following 'hard signs' of vascular injury would necessitate immediate surgical exploration of the popliteal artery?

Explanation

Hard signs of vascular injury are clinical indicators that strongly suggest significant arterial disruption and typically mandate immediate surgical exploration without delay for imaging. These include: absent or rapidly diminishing pulse, expanding or pulsatile hematoma, pulsatile bleeding, thrill, and bruit. While a diminished pulse and ABI of 0.7 are 'soft signs' that warrant further investigation (e.g., CTA), an absent distal pulse is a hard sign indicating complete or near-complete occlusion and necessitates immediate surgical intervention to restore blood flow and prevent limb ischemia. Paresthesia and pain out of proportion are signs of ischemia or compartment syndrome, but not specific hard signs of arterial injury themselves.

Question 21

A 30-year-old male sustains a closed, displaced femoral shaft fracture in a motor vehicle accident. He is hemodynamically stable. What is the most appropriate definitive management for this injury?

Explanation

For closed, displaced adult femoral shaft fractures, intramedullary nailing (IMN) is considered the gold standard of care. It provides stable fixation, allows for early mobilization and weight-bearing, and has high union rates with low complication rates. Skeletal traction is a temporary measure or used in specific situations (e.g., damage control in polytrauma) but not a definitive treatment for adults. A hip spica cast is typically used for pediatric femoral shaft fractures. External fixation is generally reserved for open fractures, polytrauma patients in damage control, or cases where IMN is contraindicated. Dynamic compression plating is an option but generally has higher complication rates and longer healing times compared to IMN for femoral shaft fractures.

Question 22

A 40-year-old male falls from a roof, landing on his buttocks. He has severe sacral pain and a palpable step-off over the posterior superior iliac spine (PSIS). Neurological exam reveals decreased sensation in the perineum and diminished rectal tone. Which Denis classification zone of sacral fracture is most likely?

Explanation

The Denis classification categorizes sacral fractures based on their relationship to the sacral foramina and spinal canal, which correlates with neurological injury risk. Denis Zone III fractures involve the sacral spinal canal centrally (medial to the neural foramina). These fractures carry the highest risk of neurological injury, often affecting bowel, bladder, and sexual function, as well as perineal sensation and rectal tone, consistent with the patient's presentation. Denis Zone I fractures are lateral to the neural foramina (ala fractures) and typically have a lower risk of neurological injury. Denis Zone II fractures involve the neural foramina but spare the central canal. Coccyx fractures and isolated ala fractures do not typically cause these significant neurological deficits.

Question 23

A 25-year-old ballet dancer experiences sudden midfoot pain after an axial load with a rotational component while landing from a jump. Radiographs are equivocal, but there is significant tenderness over the tarsometatarsal joint complex, and a small fleck fracture is noted at the base of the second metatarsal. What is the pathognomonic radiological sign of a Lisfranc injury that should be specifically sought out?

Explanation

A Lisfranc injury involves disruption of the tarsometatarsal joint complex. The Lisfranc ligament connects the medial cuneiform to the base of the second metatarsal. The pathognomonic radiological sign for a Lisfranc injury is diastasis (widening) between the base of the first and second metatarsals, particularly on weight-bearing or stress views, or between the medial cuneiform and second metatarsal. A 'fleck sign' (avulsion fracture off the base of the second metatarsal) is also highly indicative. While other fractures can occur, the widening between the first and second metatarsal bases is key. The other options describe different foot injuries or less specific findings.

Question 24

A 20-year-old female elite runner reports insidious onset of increasing pain in her anterior shin that is worse with running and relieved by rest. Physical exam reveals localized tenderness over the anterior tibia. Radiographs are normal. What is the most appropriate next diagnostic step?

Explanation

The patient's symptoms (insidious onset, activity-related pain, localized tenderness, normal radiographs) are highly suggestive of a tibial stress fracture. While rest and NSAIDs are part of the initial management, confirmation of the diagnosis is crucial to prevent progression to a complete fracture, especially in an elite athlete. Plain radiographs are often normal in early stress fractures. A bone scan (showing increased uptake) or MRI (showing marrow edema) are the most sensitive imaging modalities to confirm the diagnosis of a stress fracture. Compartment pressure measurement would be for chronic exertional compartment syndrome, which presents with diffuse pain and cramping, not typically focal tenderness. Physical therapy and NSAIDs are treatment, not the next diagnostic step to confirm a stress fracture.

Question 25

A 45-year-old male sustains a direct blow to the lateral aspect of his knee, resulting in a fibular head fracture. He immediately develops foot drop and paresthesia over the dorsum of his foot. Which nerve is most likely injured?

Explanation

The common peroneal nerve courses superficially around the neck of the fibula, making it highly susceptible to injury with fibular head fractures or direct trauma to this area. Damage to the common peroneal nerve results in a 'foot drop' (weakness in ankle dorsiflexion and eversion) and sensory loss over the dorsum of the foot and lateral leg. The common peroneal nerve then divides into the superficial and deep peroneal nerves. The saphenous nerve is a sensory nerve of the medial leg. The tibial nerve supplies the posterior compartment of the leg and plantar sensation. While specific branches (superficial or deep peroneal) could be injured, the global presentation of foot drop points to the common peroneal nerve prior to its division.

Question 26

A 30-year-old female sustains a unimalleolar fracture of the medial malleolus with 3mm of displacement and no syndesmotic widening. What is the most appropriate definitive management for this injury?

Explanation

Medial malleolus fractures with greater than 2mm of displacement or any degree of rotation are generally considered unstable and typically require open reduction and internal fixation (ORIF) with screws (e.g., lag screws or tension band wiring). This ensures anatomical reduction of the articular surface and restores the integrity of the deltoid ligament attachment, preventing chronic instability and post-traumatic arthritis. Non-operative management with a cast is reserved for truly non-displaced, stable medial malleolus fractures. Immediate weight-bearing in an AFO is too aggressive for a displaced fracture. Below-knee amputation is not indicated.

Question 27

A 55-year-old male sustains a severe pilon fracture of the distal tibia with extensive articular comminution and significant soft tissue swelling. Which of the following is a common long-term complication of this specific type of fracture?

Explanation

Pilon fractures (distal tibial plafond fractures) are intra-articular fractures resulting from high-energy axial loading. Due to the significant articular cartilage damage and comminution, and the difficulty in achieving and maintaining anatomical reduction, post-traumatic ankle arthritis is a very common and often debilitating long-term complication, even with optimal surgical management. While nonunion and malunion can occur, and compartment syndrome is an acute risk, post-traumatic arthritis is the most prevalent and significant long-term sequela due to the direct damage to the joint surface. Popliteal artery injury is uncommon in pilon fractures but more common in knee dislocations or supracondylar femur fractures.

Question 28

A 35-year-old male sustains a closed, non-displaced spiral fracture of the middle third of the tibia shaft. The fibula is intact. What is the most appropriate initial treatment?

Explanation

For a closed, non-displaced spiral tibial shaft fracture with an intact fibula, non-operative management is often appropriate. A long leg cast is typically applied initially to control rotation and provide stability, followed by conversion to a patellar tendon-bearing (PTB) brace (functional brace) once acute pain and swelling subside, allowing for early weight-bearing and knee range of motion. The intact fibula provides some inherent stability, aiding non-operative treatment. IMN or plating would be overtreatment for a non-displaced fracture, typically reserved for displaced or unstable fractures. A short leg cast does not adequately control rotation for a tibial shaft fracture. External fixation is reserved for more complex open or unstable fractures.

Question 29

A 28-year-old male sustains an anterior hip dislocation after a motor vehicle accident. On physical examination, his hip is externally rotated, abducted, and slightly flexed. What associated nerve injury should be specifically assessed?

Explanation

Anterior hip dislocations are less common than posterior dislocations. The typical mechanism is forced abduction and external rotation. In this position, the femoral nerve is at risk of injury due to its proximity to the anterior capsule and femoral head. Injury to the femoral nerve would manifest as weakness in knee extension (quadriceps) and sensory loss over the anterior thigh and medial leg (via the saphenous nerve branch). Sciatic and common peroneal nerve injuries are characteristic of posterior hip dislocations. Superior gluteal nerve injuries are associated with pelvic fractures or iatrogenic damage. Lateral femoral cutaneous nerve injury causes meralgia paresthetica (lateral thigh numbness) and is less directly associated with hip dislocation.

Question 30

A 58-year-old male sustains a displaced femoral neck fracture. He has a history of chronic alcoholism and smoking. What is the most significant long-term complication associated with femoral neck fractures, especially in patients with predisposing factors?

Explanation

Displaced femoral neck fractures disrupt the blood supply to the femoral head, which predominantly comes from the medial and lateral circumflex arteries. This makes avascular necrosis (AVN) of the femoral head a particularly high-risk complication, occurring in 15-40% of displaced fractures, and is significantly higher in patients with compromised vascularity due to factors like smoking and alcoholism. Nonunion is also a common complication, but AVN is often more devastating, potentially leading to femoral head collapse and the need for arthroplasty. While DVT and infection are risks with any major orthopedic trauma, AVN is uniquely prevalent and devastating for femoral neck fractures due to the specific anatomy of blood supply.

Question 31

A 7-year-old child sustains a closed, displaced transverse fracture of the midshaft femur. He is otherwise healthy. What is the most appropriate definitive treatment?

Explanation

For pediatric femoral shaft fractures in the 6-12 year age group, flexible intramedullary nailing (TENs or Ender nails) is often the preferred treatment. It provides stable fixation, allows for early weight-bearing and mobilization, minimizes the risk of physeal injury, and preserves growth potential. While IMN is common in adults, reamed solid nails are generally avoided in younger children due to potential damage to the trochanteric apophysis and growth disturbance. A hip spica cast is suitable for younger children (typically <6 years) or minimally displaced fractures. Skeletal traction is usually a temporary measure or for very young children. Plate fixation is an option but associated with larger incisions and potential for refracture or growth disturbance.

Question 32

A 40-year-old male sustains a fall directly onto his knee, resulting in a significantly displaced, transverse patella fracture with 1 cm of diastasis. He cannot extend his knee against gravity. Which of the following is the most appropriate surgical technique to address this injury?

Explanation

For displaced patella fractures that compromise the extensor mechanism (inability to extend the knee), surgical fixation is required. The goal is to restore articular congruity and the extensor mechanism. Tension band wiring, often augmented with cerclage wiring for comminution, is the most common and effective technique for reconstructible patella fractures. It converts the distracting forces of the quadriceps and patellar tendons into compressive forces at the fracture site during knee flexion, promoting healing. Partial patellectomy or total patellectomy are salvage procedures for extensively comminuted or irredeemable fragments. Screw fixation alone may not withstand the strong tensile forces. Non-operative management is only for non-displaced fractures with an intact extensor mechanism.

Question 33

A 50-year-old male suffers a high-energy Schatzker Type VI tibial plateau fracture with significant soft tissue swelling and blistering. What is the primary indication for initial temporary spanning external fixation rather than immediate definitive internal fixation?

Explanation

High-energy tibial plateau fractures (like Schatzker Type VI) are frequently associated with severe soft tissue injury, swelling, and blistering. Attempting immediate definitive internal fixation (ORIF) in such a compromised soft tissue environment carries an unacceptably high risk of wound dehiscence, infection, and skin necrosis. Therefore, the primary indication for initial temporary spanning external fixation (damage control orthopedics) is to provide stability while allowing the soft tissues to recover and for swelling to subside. Definitive ORIF is then performed in a delayed fashion (typically 7-14 days) once the soft tissue 'wrinkle sign' is present and the skin is healthy enough for surgery. While it can improve comfort, that's not the primary reason for delaying definitive fixation.

Question 34

A 40-year-old male sustains a trimalleolar ankle fracture requiring open reduction internal fixation. Two years post-surgery, he presents with chronic ankle pain, stiffness, and crepitus. Radiographs show joint space narrowing and osteophytes. What is the most likely long-term complication?

Explanation

Trimalleolar fractures are intra-articular injuries that often involve significant disruption of the ankle joint congruity. Even with optimal surgical reduction and fixation, damage to the articular cartilage and alterations in joint mechanics predispose to the development of post-traumatic ankle arthritis. This is a very common long-term complication, characterized by chronic pain, stiffness, joint space narrowing, and osteophytes. While nonunion, infection, instability, and CRPS are possible complications, post-traumatic arthritis is arguably the most common and debilitating long-term sequela after severe intra-articular ankle fractures. It can eventually necessitate an ankle fusion or arthroplasty.

Question 35

A 30-year-old male sustains an open Gustilo Type IIIB tibial shaft fracture with a large soft tissue defect requiring a free flap for coverage. In addition to prompt debridement and stabilization, what is a crucial component of his long-term rehabilitation plan?

Explanation

Open tibial shaft fractures, especially Gustilo Type IIIB, are complex injuries involving bone, muscle, and skin. While bone healing and flap integration are paramount, aggressive and early range of motion exercises for adjacent joints (knee and ankle) are crucial to prevent stiffness and optimize functional outcome. Prolonged immobilization can lead to severe joint contractures, which are difficult to treat. Weight-bearing is typically initiated gradually after appropriate bone and soft tissue healing. Serial radiographs are important, but not a 'crucial component' of rehabilitation. Antibiotic prophylaxis duration is much shorter than 6 months. Preventing joint stiffness and restoring motion is key for functional recovery.

Question 36

A 40-year-old male develops acute compartment syndrome in his lower leg after a high-energy trauma. Which muscle compartment is most commonly affected in the lower leg and necessitates fasciotomy?

Explanation

The anterior compartment of the lower leg is the most commonly affected compartment in acute compartment syndrome. This is due to several factors: it is a relatively tight osteofascial compartment, it contains the tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles (which swell significantly with trauma), and it houses the deep peroneal nerve and anterior tibial artery. While all four compartments (anterior, lateral, superficial posterior, deep posterior) can be affected, the anterior compartment is most frequently involved, followed by the deep posterior compartment. Therefore, a release of at least the anterior and lateral compartments, and often also the superficial and deep posterior compartments, is performed during a fasciotomy.

Question 37

A 25-year-old male sustains a pelvic ring injury after being crushed between two vehicles. Radiographs show widening of the pubic symphysis (>2.5 cm) and disruption of the anterior sacroiliac ligaments with partial tearing of the posterior sacroiliac ligaments. His posterior structures remain intact. This injury pattern is classified as which Young-Burgess type?

Explanation

The Young-Burgess classification categorizes pelvic ring injuries by mechanism and pattern of instability. An Anteroposterior Compression (APC) mechanism results from forces applied from anterior to posterior. APC-II injuries are characterized by widening of the pubic symphysis (>2.5 cm) and disruption of the anterior sacroiliac ligaments, but with intact posterior sacroiliac ligaments, making them rotationally unstable but vertically stable. APC-I has only symphysis widening or pubic rami fractures without significant posterior disruption. APC-III involves complete disruption of both anterior and posterior sacroiliac ligaments, leading to both rotational and vertical instability. Lateral compression injuries involve forces from the side, and vertical shear involves superior/inferior forces.

Question 38

A 68-year-old male falls down stairs and sustains a subtrochanteric femur fracture. He has significant comminution and extension into the greater trochanter. What is the preferred surgical treatment for this fracture pattern?

Explanation

Subtrochanteric femur fractures are highly unstable and subject to significant deforming forces (pull of gluteus medius, iliopsoas, adductors). A long cephalomedullary nail is the implant of choice for most subtrochanteric fractures, particularly those with comminution or extension into the greater trochanter. It provides superior biomechanical stability compared to plates, controls rotation, and allows for earlier weight-bearing. Short intramedullary nails are generally only suitable for intertrochanteric fractures that do not extend into the subtrochanteric region. DHS is primarily for intertrochanteric fractures. Plating is an option but has a higher failure rate and longer healing for subtrochanteric fractures. Hemiarthroplasty is not indicated for subtrochanteric fractures unless there's severe pre-existing arthritis or non-reconstructible femoral head. The length of the nail is crucial to bypass the comminution adequately.

Question 39

A 35-year-old male presents with acute foot drop after a penetrating injury to the posterior aspect of his knee. Which nerve is most likely injured, and what specific muscle group would be affected?

Explanation

Foot drop is characterized by an inability to dorsiflex the ankle. This is primarily controlled by the muscles innervated by the deep peroneal nerve (tibialis anterior, extensor hallucis longus, extensor digitorum longus) and the muscles of eversion (peroneus longus and brevis) innervated by the superficial peroneal nerve. Both of these are branches of the common peroneal nerve. Therefore, injury to the common peroneal nerve (often at the level of the fibular neck or popliteal fossa) is the most likely cause of foot drop with associated weakness in ankle dorsiflexion and eversion. The tibial nerve affects plantarflexion. Sural nerve is purely sensory. Femoral nerve affects knee extension.

Question 40

A 25-year-old male falls from a height and sustains a displaced fracture of the talar neck. What is the most critical complication to counsel the patient about regarding this injury?

Explanation

Talus fractures, especially displaced talar neck fractures (Hawkins Type II, III, IV), carry a very high risk of avascular necrosis (AVN) of the talar body. The talus has a precarious blood supply, with arterial branches entering through the talar neck and sinus tarsi. Displaced fractures significantly disrupt this blood supply. The more displaced the fracture, the higher the risk of AVN. While nonunion, malunion, and post-traumatic subtalar arthritis are also common and significant complications, AVN is often the most feared due to its potential for talar collapse and devastating long-term consequences. Infection is a risk for open fractures but not inherent to the blood supply issue.

Question 41

A 28-year-old soccer player presents with acute onset lateral ankle pain after an inversion injury. He reports a 'snapping' sensation and tenderness posterior to the lateral malleolus. Swelling is noted in this area. Plain radiographs are normal. What specific clinical maneuver would best evaluate the suspected injury?

Explanation

The patient's symptoms (lateral ankle pain after inversion, 'snapping' sensation, tenderness posterior to the lateral malleolus) are highly suggestive of a peroneal tendon subluxation or dislocation. This occurs when the peroneal retinaculum is torn. The peroneal tendon subluxation test involves reproducing the injury mechanism: forced dorsiflexion and eversion of the foot against resistance. A palpable or visible subluxation/dislocation of the peroneal tendons from behind the lateral malleolus confirms the diagnosis. The other tests evaluate different structures: anterior drawer and talar tilt for lateral ligament sprains, squeeze test for syndesmosis, and Thompson test for Achilles rupture.

Question 42

A 35-year-old male sustains a posterior malleolus fracture as part of a trimalleolar ankle fracture. The fragment involves 30% of the articular surface of the distal tibia. What is the most appropriate management of the posterior malleolus fragment?

Explanation

Posterior malleolus fractures, when they involve a significant portion of the articular surface (typically >25-30% on lateral X-ray or CT scan) and are displaced (usually >2mm), contribute to ankle instability and increased risk of post-traumatic arthritis. In such cases, open reduction and internal fixation (ORIF) is indicated to restore articular congruity and stability. The preferred approach often involves a posterolateral or posteromedial incision. Smaller, non-displaced fragments can sometimes be managed non-operatively. Excision is generally avoided due to the disruption of the tibiofibular syndesmosis attachment. Closed reduction is rarely successful for displaced fragments of this size.

Question 43

A 45-year-old weekend warrior feels a sudden 'pop' in his heel during a game of tennis. He complains of severe pain and is unable to push off his foot. On examination, there is a palpable gap in the Achilles tendon, and he has a positive Thompson test. What is the most appropriate management for this injury?

Explanation

The patient's presentation (sudden 'pop', pain, inability to push off, palpable gap, positive Thompson test) is classic for an acute Achilles tendon rupture. While non-operative management can be considered for specific patient populations (sedentary, elderly) or very specific tear patterns, for active, middle-aged individuals, immediate surgical repair is generally recommended. Surgical repair provides a stronger repair, reduces the risk of rerupture, and allows for earlier functional rehabilitation compared to non-operative treatment, although both have their roles. Physical therapy would follow initial management. Corticosteroid injections are contraindicated for tendon ruptures due to weakening effects. Casting in dorsiflexion would lengthen the tendon and prevent healing.

Question 44

A 60-year-old female presents with forefoot pain, burning, and numbness that radiates into the third and fourth toes. Symptoms are worse with walking in tight shoes. On examination, a positive Mulder's click is elicited. What is the most likely diagnosis?

Explanation

The patient's symptoms (forefoot pain, burning, numbness radiating to the third and fourth toes, worse with tight shoes, and a positive Mulder's click) are pathognomonic for Morton's neuroma. This is a common compressive neuropathy of the interdigital nerve, most often between the third and fourth metatarsal heads. A metatarsal stress fracture would typically cause localized bony tenderness and pain with impact. Plantar fasciitis causes heel pain, especially first steps in the morning. Tarsal tunnel syndrome involves the posterior tibial nerve and affects the arch and toes (often sensory only). Hallux valgus is a deformity of the great toe, causing pain at the bunion.

Question 45

A 20-year-old male sustains a traumatic guillotine amputation of his left leg at the mid-tibial level in an industrial accident. He is hemodynamically stable. What is the immediate priority for limb care in the pre-hospital or emergency department setting for potential replantation?

Explanation

The proper handling of an amputated limb for potential replantation is critical to maximize viability. The amputated part should be gently cleaned of gross contamination, wrapped in saline-moistened sterile gauze, placed in a sealed plastic bag, and then placed in a second bag or container with ice water (not direct ice, which can cause frostbite). This 'cool ischemia' slows metabolic processes, extending the time window for successful replantation. Placing directly on ice can cause frostbite. Submerging in water can cause tissue maceration. Freezing destroys cells. Immediate wound closure of the stump is not the priority over preserving the amputated part and can compromise future replantation efforts.

Question 46

A 30-year-old male sustains a multi-ligamentous knee injury (dislocation equivalent) involving the ACL, PCL, and MCL. He has palpable but diminished distal pulses. What is the most appropriate imaging study to assess for vascular injury?

Explanation

Multi-ligamentous knee injuries, particularly those involving dislocation, have a high association with popliteal artery injury, even with palpable pulses. Given the diminished pulses (a 'soft sign' of vascular injury), a high-resolution imaging study is warranted to thoroughly evaluate the popliteal artery and its branches. Computed tomography angiography (CTA) has become the preferred imaging modality in this setting due to its rapid acquisition, high sensitivity, and ability to simultaneously assess for associated bony injuries or soft tissue hematomas. Duplex ultrasound can be useful but is highly operator-dependent. MRI is excellent for ligamentous and soft tissue detail but is not ideal for acute vascular assessment. Plain radiographs show only bony changes, and a venogram assesses veins, not arteries.

Question 47

A 22-year-old male is involved in a high-speed motorcycle accident, sustaining an open book pelvic fracture (APC III) with complete disruption of the pubic symphysis and both sacroiliac joints. He is hemodynamically unstable despite initial resuscitation and external pelvic binding. What is the most appropriate next step for urgent management of the posterior pelvic ring instability?

Explanation

In a patient with an APC III pelvic fracture, who is hemodynamically unstable despite initial resuscitation and pelvic binding, the primary bleeding is often venous from the sacral plexus, or arterial from sacral branches. While angiography for arterial bleeding is critical if instability persists, achieving mechanical stability of the posterior pelvic ring is paramount to tamponade venous bleeding and prevent ongoing hemorrhage. Percutaneous iliosacral screw fixation provides definitive stabilization of the posterior pelvic ring, significantly reducing pelvic volume and allowing for a more stable environment for clotting. This often precedes or is performed in conjunction with angiography if arterial bleed is suspected. A CT scan is useful but should not delay life-saving hemorrhage control. Skeletal traction is generally not used for pelvic fractures. ORIF of the symphysis only addresses the anterior ring, not the posterior instability.

Question 48

A 70-year-old female with severe osteoporosis sustains a displaced fracture of the greater trochanter after a fall. She is able to bear weight with pain, and the fracture is isolated with minimal comminution. What is the most appropriate management approach?

Explanation

Isolated, displaced fractures of the greater trochanter are typically avulsion fractures due to the pull of the gluteus medius and minimus. If the patient is able to bear weight and the fracture is isolated without extension into the intertrochanteric region, and the fragment is not significantly retracted causing abductor insufficiency, non-operative management with protected weight-bearing (e.g., crutches or walker) and progressive rehabilitation is often successful. Surgical fixation is usually reserved for very large, displaced fragments (typically >2 cm displacement) leading to significant abductor weakness. Intramedullary nailing or arthroplasty would be overtreatment for an isolated greater trochanteric fracture.

Question 49

A 15-month-old toddler presents with a refusal to bear weight on his left leg after twisting it while playing. Radiographs of the tibia and fibula show a non-displaced spiral fracture of the distal tibia. The child denies direct trauma, and there are no other signs of injury or abuse. What is this fracture commonly referred to as?

Explanation

A 'toddler's fracture' is a common, non-displaced, spiral or oblique fracture of the distal tibia typically seen in children between 9 months and 3 years of age. It often results from a low-energy torsional force, such as twisting the leg, and the child may present with refusal to bear weight or limp. Radiographs can be subtle but usually show a faint spiral line. It's important to differentiate from child abuse, but in the absence of other signs, it's a common accidental injury. Greenstick fractures are incomplete fractures common in children but often involve bending forces. Bumper fractures are tibial plateau fractures. Triplane fractures are complex Salter-Harris Type IV distal tibia fractures. Segond fracture is an avulsion fracture of the lateral tibial plateau, associated with ACL tears.

Question 50

A 40-year-old male sustains a high-energy pelvic fracture (APC II) with significant pubic symphysis diastasis. He is hemodynamically stable. Which of the following is the most effective immediate measure to reduce pelvic volume and potentially control hemorrhage while awaiting definitive fixation?

Explanation

For an unstable pelvic fracture, particularly an 'open book' (APC II or III), the primary immediate goal is to reduce the pelvic volume. This mechanically compresses the bleeding venous plexus and small arterial branches, providing immediate hemorrhage control. A simple pelvic binder or a tightly wrapped sheet around the greater trochanters is a rapid and effective method to achieve this. While external fixation is a definitive mechanical stabilization, a binder is typically applied first, especially in the pre-hospital or immediate ED setting. Fluid resuscitation and blood products are crucial for managing hypovolemia, but they do not address the source of bleeding. Foley insertion is for bladder assessment and not volume reduction.

Question 51

A 35-year-old male presents with a painful swelling in his lower leg after a direct blow. He has paresthesia in the web space between his first and second toes and weakness in ankle dorsiflexion. The leg is tense, and pain is exacerbated by passive stretch of the toes. The compartment pressure in the anterior compartment is 45 mmHg, and his diastolic blood pressure is 70 mmHg. What is the delta pressure and what does it indicate?

Explanation

The delta pressure is calculated as Diastolic Blood Pressure - Intracompartmental Pressure. In this case, 70 mmHg (DBP) - 45 mmHg (ICP) = 25 mmHg. A delta pressure of less than 30 mmHg (some sources use 20 mmHg) is a strong indication for fasciotomy, even if the absolute compartment pressure is below 30 mmHg, especially when clinical signs are also present. A negative delta pressure means the compartment pressure is higher than the diastolic blood pressure, a clear and urgent indication for fasciotomy. The patient's symptoms (paresthesia, weakness, tense leg, pain on passive stretch) are classic clinical signs of acute compartment syndrome. Therefore, this indicates acute compartment syndrome requiring emergent fasciotomy. The absolute pressure of 45 mmHg alone is also an indication given the clinical signs.

Question 52

A 24-year-old male presents with a Salter-Harris Type IV fracture of the distal tibia following a twisting injury. The fracture line extends through the epiphysis, physis, and metaphysis. Which of the following is the most significant concern with this specific type of physeal injury?

Explanation

Salter-Harris Type IV fractures involve a fracture line extending through the epiphysis, physis, and metaphysis. These fractures are considered intra-articular and involve the growth plate. The most significant concern with Type IV (and Type V) physeal injuries is the high risk of growth arrest and subsequent angular deformity. This is because the fracture crosses the physis, potentially damaging the chondrocytes, and if not anatomically reduced, a bony bridge can form across the physis. While post-traumatic arthritis (due to articular involvement) and malunion are also risks, growth arrest is the unique and most feared complication of this specific physeal injury type. Nonunion is rare in pediatric fractures.

Question 53

A 50-year-old male sustains a comminuted, displaced intra-articular fracture of the calcaneus (Sanders Type III). What is the primary goal of surgical management for this fracture?

Explanation

Intra-articular calcaneus fractures are complex injuries. The primary goal of surgical management (typically open reduction internal fixation, ORIF) for displaced, intra-articular calcaneus fractures is the restoration of the anatomy of the posterior facet of the subtalar joint and the overall shape of the calcaneus. This includes restoring parameters like Böhler's angle and Gissane's angle, which are indicators of the calcaneal height and posterior facet reduction. Correcting these angles helps to restore the mechanics of the hindfoot and subtalar joint. Early full weight-bearing is usually contraindicated. Excision of fragments is not appropriate for comminuted fractures. Primary subtalar fusion is a salvage procedure for severe comminution or failed ORIF, not the primary goal. Amputation is a last resort.

Question 54

A 65-year-old male presents with severe pain in his left thigh after a ground-level fall. Radiographs show a displaced, comminuted intertrochanteric hip fracture. He has a history of severe Parkinson's disease, making him a high fall risk and non-compliant with weight-bearing restrictions. What is the most appropriate surgical management to allow for early weight-bearing and mobilization?

Explanation

For unstable (comminuted) intertrochanteric hip fractures, especially in elderly patients with comorbidities or those at high risk for non-compliance with weight-bearing, a short cephalomedullary nail (intramedullary hip screw) is generally preferred over a dynamic hip screw (DHS). IM nails provide greater biomechanical stability, particularly against medial collapse and rotation, allowing for earlier and more confident weight-bearing. While DHS is a good option for stable intertrochanteric fractures, it is less stable for comminuted patterns. Arthroplasty might be considered for very specific, highly comminuted patterns in active patients, but the IM nail is typically the go-to. Skeletal traction is outdated for definitive management. ORIF with plates is rarely used for intertrochanteric fractures.

Question 55

A 30-year-old male sustains a high-energy trauma to his ankle, resulting in a lateral malleolus fracture, a small posterior malleolus fracture, and complete disruption of the syndesmosis. What is the most important component of surgical fixation for stability in this injury?

Explanation

This injury pattern (lateral malleolus fracture + posterior malleolus fracture + syndesmotic disruption) describes a severe rotational ankle fracture with syndesmotic instability. While fixation of the malleoli is important, the most crucial component for restoring ankle stability and preventing long-term complications is addressing the syndesmotic disruption. This is typically achieved with syndesmotic screw fixation or a suture-button construct. Without stable syndesmotic fixation, the mortise remains widened, leading to chronic pain and arthritis. Lag screw fixation of the lateral malleolus is standard but not sufficient for syndesmotic disruption. The posterior malleolus fixation depends on its size. Deltoid ligament repair is rarely performed directly, as medial stability is usually restored with fibular and syndesmotic reduction and fixation.

Question 56

A 25-year-old male presents with severe knee pain and swelling after a forced valgus injury. Physical examination reveals tenderness over the medial femoral condyle, but radiographs are normal. What is the most likely acute soft tissue injury?

Explanation

A forced valgus injury (force applied to the lateral side of the knee, pushing the knee inwards) primarily stresses the medial collateral ligament (MCL). This typically results in an MCL tear, which causes pain and tenderness over the medial aspect of the knee. While ACL and meniscal tears can also occur with valgus injuries, an isolated MCL tear is very common and would present with localized medial tenderness and instability to valgus stress. LCL tears result from varus stress. PCL tears are often from dashboard injuries or hyperflexion. Patellar tendon rupture presents with inability to extend the knee and a high-riding patella.

Question 57

A 55-year-old female presents with acute pain and swelling in the region of the second metatarsal head. She describes a feeling of 'walking on a pebble' and tenderness on palpation of the plantar aspect of the second metatarsal head. Radiographs are normal. What is the most likely diagnosis?

Explanation

The symptoms (pain and swelling in the second metatarsal head region, 'walking on a pebble' sensation, tenderness on the plantar aspect, normal radiographs) are classic for a plantar plate rupture or attenuation. The plantar plate is a fibrocartilaginous structure that supports the metatarsophalangeal joint. Rupture often leads to instability of the joint, hammer toe deformity (often of the second toe), and subluxation of the toe. While Freiberg's infraction (osteochondrosis of the metatarsal head) and stress fracture can cause metatarsal head pain, they would typically involve the bone itself. Morton's neuroma affects the interdigital nerve. Sesamoiditis affects the hallux. The 'walking on a pebble' and tenderness directly on the plantar plate are key.

Question 58

A 28-year-old male sustains a spiral fracture of the middle third of the femur. He is hemodynamically stable. Which of the following is an absolute indication for emergent intramedullary nailing (IMN) rather than delayed or staged fixation?

Explanation

For an isolated femoral shaft fracture in a stable patient, IMN is the treatment of choice, but the timing (urgent vs. delayed) can vary. However, in the setting of polytrauma, particularly with associated chest injuries (e.g., flail chest, pulmonary contusion), early total care (ETC) with emergent intramedullary nailing of long bone fractures is an absolute indication. This 'fix and stabilize' approach helps prevent complications like fat embolism, improves pulmonary mechanics (reducing atelectasis and pneumonia), and facilitates patient mobilization and nursing care. While open fractures are also treated urgently, this scenario specifically points to the benefits of early fixation in polytrauma. Extensive swelling is a relative contraindication to immediate definitive fixation, often requiring staged management (damage control orthopedics).

Question 59

A 40-year-old male falls from a ladder and sustains an open, comminuted distal tibia fracture with significant soft tissue loss and bone exposure (Gustilo-Anderson Type IIIB). Which of the following principles guides the initial surgical management of the soft tissue defect?

Explanation

For a Gustilo-Anderson Type IIIB open fracture, the initial surgical priority after ATLS and temporary stabilization is copious irrigation and thorough debridement of all devitalized tissue (skin, muscle, bone). This is critical to minimize the risk of infection. Following debridement, the wound is typically left open and managed with serial debridements and wound care. Primary closure is contraindicated due to the high risk of infection in contaminated, high-energy wounds. A vacuum-assisted closure (VAC) device can be used after debridement, but not in place of it. Bone grafting is performed later, once the soft tissue envelope is stable and infection-free. Bulky compression dressing alone is insufficient.

Question 60

A 70-year-old female sustains a ground-level fall, resulting in an undisplaced femoral neck fracture (Garden Type I). She is otherwise healthy and active. What is the most appropriate surgical management for this fracture?

Explanation

For an undisplaced (Garden Type I or II) femoral neck fracture in an active, healthy elderly patient, the preferred treatment is usually cannulated screw fixation (percutaneous pinning). This preserves the femoral head, minimizes surgical invasiveness, and aims to achieve fracture union. The risk of avascular necrosis and nonunion is lower than in displaced fractures. Hemiarthroplasty or total hip arthroplasty are typically reserved for displaced femoral neck fractures (Garden Type III or IV) or for patients with pre-existing severe hip arthritis. Skeletal traction and bed rest are outdated and associated with high morbidity/mortality in the elderly.

Question 61

A 28-year-old male sustains a high-energy patella fracture, disrupting the extensor mechanism. He undergoes tension band wiring and cerclage fixation. Postoperatively, what is the most critical early rehabilitation goal to prevent long-term complications?

Explanation

After surgical fixation of a patella fracture that restores the extensor mechanism, the most critical early rehabilitation goal is protected range of motion (ROM) exercises for the knee. This helps prevent arthrofibrosis (severe stiffness) of the knee, which is a common and debilitating complication of patella fractures and prolonged immobilization. Full weight-bearing is usually delayed, and quadriceps strengthening is initiated cautiously. Achieving full flexion is a long-term goal. Complete immobilization, while necessary acutely for some injuries, is generally avoided for patella fractures after stable fixation to prevent stiffness. The key is protected motion to balance healing with mobility.

Question 62

A 30-year-old male sustains an open Gustilo Type IIIA distal tibial shaft fracture with a small zone of exposed bone. After urgent irrigation and debridement, the wound remains open. What is the next most appropriate step in soft tissue management?

Explanation

For an open Gustilo Type IIIA fracture with a soft tissue defect after debridement, immediate primary closure is contraindicated due to the risk of infection and potential for wound breakdown. Leaving the wound open with standard dressings allows for granulation tissue formation, but a vacuum-assisted closure (VAC) device is highly beneficial. VAC therapy promotes granulation tissue formation, reduces edema, removes exudate, and prepares the wound bed for delayed definitive soft tissue coverage (e.g., skin graft or flap, depending on the extent of the defect) in a controlled manner. Skin grafting directly over exposed bone is unlikely to take. High-dose antibiotics are part of treatment but don't address the soft tissue defect directly.

Question 63

A 60-year-old female with diabetes and peripheral neuropathy sustains a comminuted fracture of the cuboid bone in her midfoot. The fracture is displaced, but she has palpable pulses and intact motor function. What is the most critical concern regarding wound healing and infection in her management?

Explanation

Patients with diabetes, especially those with peripheral neuropathy, are at significantly increased risk for developing diabetic foot ulcers, delayed wound healing, and subsequent osteomyelitis following any foot trauma or surgery. Impaired sensation, poor circulation, and compromised immune function create a high-risk environment. Therefore, careful wound management, diligent glycemic control, and vigilance for signs of infection are paramount. While AVN, compartment syndrome, DVT, and CRPS are potential complications, the combination of diabetes and foot trauma makes ulcers and osteomyelitis a very pressing and common concern. This requires a multidisciplinary approach.

Question 64

A 25-year-old male sustains a direct blow to the lateral aspect of his knee, resulting in a knee dislocation. After emergent closed reduction, he has palpable pulses, but an ABI of 0.8 on the affected side. What is the most appropriate next step in management?

Explanation

Even after successful reduction of a knee dislocation, a multi-ligamentous injury puts the popliteal artery at high risk. An ABI of 0.8 is a 'soft sign' of vascular injury (ABI < 0.9 is abnormal) and mandates further investigation. While observation and serial exams might be considered in some scenarios, an abnormal ABI following knee dislocation requires definitive vascular imaging to rule out an intimal tear or spasm that could lead to delayed thrombosis and limb loss. An emergent CT angiogram (CTA) is the gold standard for this assessment. Discharging the patient or proceeding directly to ligament repair without clearing the vascular status would be negligent. A long leg cast would prevent regular vascular assessment.

Question 65

A 30-year-old male presents with a closed, displaced transverse fracture of the proximal third of the tibia shaft. The fracture is unstable. He has no neurovascular deficits. What is the optimal definitive surgical management for this fracture?

Explanation

For displaced and unstable tibial shaft fractures, particularly in the proximal or middle third, intramedullary nailing (IMN) is generally considered the gold standard. IMN offers excellent biomechanical stability, allows for early weight-bearing, has high union rates, and provides good soft tissue preservation. While ORIF with plates and screws is an option, it requires more extensive soft tissue dissection and can be associated with higher rates of infection and wound complications, especially in the proximal tibia where soft tissue coverage is poorer. External fixation is usually reserved for open fractures, highly contaminated wounds, or as a temporary measure. Cast immobilization is typically only for non-displaced or very stable fractures. Skeletal traction is not a definitive treatment.

Question 66

A 45-year-old male sustains a crush injury to his foot, resulting in a displaced fracture-dislocation of the naviculocuneiform joints. Which of the following associated injuries should be specifically sought out due to shared mechanism and potential for long-term morbidity?

Explanation

Naviculocuneiform fracture-dislocations involve the midfoot, similar to Lisfranc injuries (tarsometatarsal joint complex). Both result from high-energy axial loading or twisting forces and can be difficult to diagnose. Given the proximity and shared mechanism, it's crucial to thoroughly evaluate for concomitant Lisfranc injuries. Missing a Lisfranc injury can lead to significant long-term pain, deformity, and arthritis due to instability of the midfoot. While other injuries can occur, a Lisfranc injury is the most critical associated injury in this anatomical region due to its functional implications. Metatarsal stress fractures are chronic, Achilles rupture is a distinct injury, and ankle sprains are more distal.

Question 67

A 68-year-old male undergoes open reduction and internal fixation of a distal femur fracture. Postoperatively, he develops sudden onset dyspnea, pleuritic chest pain, and hypoxemia. What is the most important initial diagnostic test to confirm the suspected diagnosis?

Explanation

The patient's symptoms (sudden dyspnea, pleuritic chest pain, hypoxemia) following a major lower limb orthopedic surgery are highly suggestive of a pulmonary embolism (PE). The most important initial diagnostic test to confirm a PE is a computed tomography pulmonary angiogram (CTPA). This imaging modality directly visualizes emboli in the pulmonary arteries. While D-dimer assay is a good screening test, a positive result requires further imaging for confirmation, especially in high-risk patients. ECG and chest X-ray might show non-specific changes but are not diagnostic for PE. Lower extremity venous duplex ultrasound can identify the source DVT but does not confirm the PE itself.

Question 68

A 25-year-old male presents with a painful, swollen ankle after an inversion injury. Radiographs show no fracture. On examination, there is significant swelling and tenderness over the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). The anterior drawer test is positive, but the talar tilt test is stable. Which grade of ankle sprain does this most likely represent?

Explanation

Ankle sprains are graded based on the severity of ligamentous injury. Grade I is a stretch of the ligament without macroscopic tearing, resulting in minimal instability. Grade II involves a partial tear of the ligament, leading to some instability (often a positive anterior drawer test indicating ATFL laxity), but with a firm endpoint and stable talar tilt (CFL usually intact or minimally stretched). Grade III is a complete rupture of one or more ligaments (typically ATFL and CFL), resulting in gross instability (positive anterior drawer and talar tilt with no firm endpoint). A positive anterior drawer with a stable talar tilt indicates a partial tear, typically Grade II. A high ankle sprain involves the syndesmotic ligaments.

Question 69

A 75-year-old female presents with a non-displaced fracture of the lateral condyle of the tibia (Schatzker Type I) after a low-energy fall. She has significant medical comorbidities, including heart failure and chronic kidney disease. What is the most appropriate management approach?

Explanation

A Schatzker Type I tibial plateau fracture is a split fracture of the lateral tibial plateau that is typically non-displaced and involves minimal articular depression. In elderly patients with significant medical comorbidities, non-operative management with protected weight-bearing (initially non-weight-bearing, then toe-touch or partial weight-bearing as tolerated) and early range of motion is often the preferred approach. This avoids the risks of surgery in a medically fragile patient, while still allowing for fracture healing. ORIF is typically reserved for displaced or unstable fractures. External fixation is more for open or highly comminuted fractures. TKA is for end-stage arthritis. Skeletal traction is outdated.

Question 70

A 22-year-old male sustains a motorcycle accident resulting in a comminuted open distal femur fracture (Gustilo Type IIIA). He has diminished pulses in the foot. After emergent irrigation and debridement, and closed reduction, pulses remain diminished. What is the most appropriate next step?

Explanation

In the setting of an open distal femur fracture with diminished pulses after initial reduction, there is a high suspicion for vascular injury (popliteal artery). While the wound needs debridement and fracture needs stabilization, the vascular status is critical. An ABI should be immediately performed. If the ABI is abnormal (<0.9), a CT angiogram is the next diagnostic step to localize and characterize the vascular injury. Surgical exploration is reserved for hard signs of vascular injury (absent pulses, expanding hematoma, pulsatile bleeding) or after imaging confirms a repairable injury. Repeating reduction attempts can worsen vascular injury. External fixation is often used for damage control but doesn't address the vascular issue. Skeletal traction is not definitive.

Question 71

A 50-year-old obese male suffers a low-energy fall, sustaining an unstable intertrochanteric hip fracture. He has multiple medical comorbidities. What is the primary benefit of early surgical fixation (within 24-48 hours) for this patient?

Explanation

For elderly patients with hip fractures, early surgical fixation (ideally within 24-48 hours, 'hip fracture in 24-48') is crucial. The primary benefit is a significantly decreased time to ambulation and reduced incidence of medical complications such as pneumonia, pressure ulcers, DVT/PE, and overall mortality. Prolonged bed rest in this population leads to increased morbidity and mortality. While surgical fixation does improve union rates, the immediate benefit for an unstable intertrochanteric fracture is the ability to mobilize the patient. AVN is not a primary concern with intertrochanteric fractures, unlike femoral neck fractures. DVT prophylaxis is still needed. Cosmetic outcome is not a primary driver for urgency.

Question 72

A 35-year-old male sustains a midshaft tibia and fibula fracture in a motor vehicle accident. He presents to the ED with severe pain and a tense anterior compartment of his lower leg. What is the most appropriate initial management step to assess for potential compartment syndrome?

Explanation

Given the clinical suspicion for acute compartment syndrome (severe pain, tense compartment, and a mechanism that suggests high energy), the most appropriate initial management step to confirm the diagnosis is to perform intracompartmental pressure measurements. While clinical signs (the '6 Ps': pain, paresthesia, pallor, paralysis, pulselessness, poikilothermia) are crucial, direct pressure measurement is the objective and most reliable diagnostic tool. Aggressive pain medication might mask symptoms. A tight compression bandage is contraindicated as it can worsen the pressure. Doppler ultrasound checks pulses, which are typically intact until late stages. CT scans are not used for diagnosing compartment syndrome directly.

Question 73

Which of the following describes the most appropriate method for reducing a posterior hip dislocation?

Explanation

Several techniques exist for closed reduction of a posterior hip dislocation, but the Stimson maneuver is widely taught and effective. In this maneuver, the patient is prone with the affected hip and knee flexed to 90 degrees, and downward axial pressure is applied to the knee while an assistant stabilizes the pelvis. The Allis maneuver (axial traction with internal/external rotation while the patient is supine) is also common. The Bigelow maneuver involves circumduction. The Captain Morgan technique involves placing the operator's knee under the patient's knee for leverage. All these maneuvers aim to apply traction and then gently rotate the femoral head into the acetabulum. Immediate open reduction is reserved for failed closed reduction or irreducible dislocations.

Question 74

A 60-year-old female sustains a distal fibula fracture with no medial tenderness or widening of the medial clear space on stress views. The fracture is located 4 cm above the ankle joint, but radiographs show no syndesmotic widening. Which Weber classification best describes this injury?

Patellar tendon rupture.
Quadriceps tendon rupture.
Patella fracture.
Meniscal tear.
Anterior cruciate ligament (ACL) rupture.

Correct Answer: Quadriceps tendon rupture.

Explanation:

Question 19:

According to the Gustilo-Anderson classification, which of the following describes a Type IIIB open fracture?

Options:

An open fracture with a wound less than 1 cm, minimal soft tissue damage, and simple fracture pattern.
An open fracture with a wound greater than 1 cm but less than 10 cm, moderate soft tissue damage, and minimal periosteal stripping.
An open fracture with extensive soft tissue damage, periosteal stripping, bone exposure, and massive contamination, requiring soft tissue coverage.
An open fracture with extensive skin and soft tissue damage, typically with vascular injury requiring repair.
An open fracture with a gunshot wound entrance and exit wound.

Correct Answer: An open fracture with extensive soft tissue damage, periosteal stripping, bone exposure, and massive contamination, requiring soft tissue coverage.

Explanation:

Question 20:

Options:

Absent distal pulse.
Non-pulsatile hematoma.
Paresthesia.
Diminished pulse with an ABI of 0.7.
Pain out of proportion.

Correct Answer: Absent distal pulse.

Explanation:

Question 21:

A 30-year-old male sustains a closed, displaced femoral shaft fracture in a motor vehicle accident. He is hemodynamically stable. What is the most appropriate definitive management for this injury?

Options:

Skeletal traction for 6-8 weeks.
Application of a hip spica cast.
External fixation.
Intramedullary nailing (IMN).
Dynamic compression plating.

Correct Answer: Intramedullary nailing (IMN).

Explanation:

Question 22:

Options:

Denis Zone I
Denis Zone II
Denis Zone III
Isolated sacral ala fracture
Coccyx fracture

Correct Answer: Denis Zone III

Explanation:

Question 23:

Options:

Loss of the normal foot arch.
Presence of a nutcracker fracture of the cuboid.
Diastasis between the first and second metatarsal bases.
Anterior dislocation of the navicular bone.
Fracture of the lateral cuneiform.

Correct Answer: Diastasis between the first and second metatarsal bases.

Explanation:

Question 24:

Options:

Referral for physical therapy.
Continue rest and NSAIDs for 2 weeks.
Order a bone scan or MRI of the tibia.
Consider a compartment pressure measurement.
Prescribe a short course of oral corticosteroids.

Correct Answer: Order a bone scan or MRI of the tibia.

Explanation:

Question 25:

Options:

Saphenous nerve.
Tibial nerve.
Common peroneal nerve.
Superficial peroneal nerve.
Deep peroneal nerve.

Correct Answer: Common peroneal nerve.

Explanation:

Question 26:

A 30-year-old female sustains a unimalleolar fracture of the medial malleolus with 3mm of displacement and no syndesmotic widening. What is the most appropriate definitive management for this injury?

Options:

Non-weight-bearing cast immobilization for 6 weeks.
Open reduction internal fixation (ORIF) with screws.
Close reduction and short leg cast for 4 weeks.
Application of an ankle-foot orthosis (AFO) with immediate weight-bearing.
Below-knee amputation.

Correct Answer: Open reduction internal fixation (ORIF) with screws.

Explanation:

Question 27:

Options:

Nonunion.
Malunion.
Post-traumatic ankle arthritis.
Compartment syndrome.
Popliteal artery injury.

Correct Answer: Post-traumatic ankle arthritis.

Explanation:

Question 28:

A 35-year-old male sustains a closed, non-displaced spiral fracture of the middle third of the tibia shaft. The fibula is intact. What is the most appropriate initial treatment?

Options:

Immediate intramedullary nailing (IMN).
Surgical plating of the tibia.
Short leg cast, non-weight bearing.
Long leg cast, non-weight bearing, followed by functional brace.
External fixation.

Correct Answer: Long leg cast, non-weight bearing, followed by functional brace.

Explanation:

Question 29:

Options:

Sciatic nerve.
Femoral nerve.
Common peroneal nerve.
Superior gluteal nerve.
Lateral femoral cutaneous nerve.

Correct Answer: Femoral nerve.

Explanation:

Question 30:

Options:

Nonunion.
Malunion.
Deep vein thrombosis (DVT).
Avascular necrosis (AVN) of the femoral head.
Infection.

Correct Answer: Avascular necrosis (AVN) of the femoral head.

Explanation:

Question 31:

A 7-year-old child sustains a closed, displaced transverse fracture of the midshaft femur. He is otherwise healthy. What is the most appropriate definitive treatment?

Options:

Immediate intramedullary nailing (IMN).
Flexible intramedullary nailing.
Open reduction and internal fixation with a plate.
Hip spica cast.
Skeletal traction.

Correct Answer: Flexible intramedullary nailing.

Explanation:

Question 32:

Options:

Partial patellectomy.
Total patellectomy.
Tension band wiring with cerclage.
Screw fixation without wiring.
Non-operative management with a cast.

Correct Answer: Tension band wiring with cerclage.

Explanation:

Question 33:

Options:

To allow for early rehabilitation and range of motion.
To facilitate definitive hardware removal at a later date.
To improve patient comfort and reduce pain.
To allow the compromised soft tissue envelope to recover and swell to subside.
To prevent compartment syndrome.

Correct Answer: To allow the compromised soft tissue envelope to recover and swell to subside.

Explanation:

Question 34:

Options:

Nonunion of the malleoli.
Infection of the hardware.
Recurrent ankle instability.
Post-traumatic ankle arthritis.
Chronic regional pain syndrome (CRPS).

Correct Answer: Post-traumatic ankle arthritis.

Explanation:

Question 35:

Options:

Early full weight-bearing on the affected limb.
Strict immobilization of the ankle and knee for 3 months.
Serial radiographs every week until union.
Aggressive range of motion exercises for the knee and ankle.
Antibiotic prophylaxis for 6 months.

Correct Answer: Aggressive range of motion exercises for the knee and ankle.

Explanation:

Question 36:

A 40-year-old male develops acute compartment syndrome in his lower leg after a high-energy trauma. Which muscle compartment is most commonly affected in the lower leg and necessitates fasciotomy?

Options:

Superficial posterior compartment.
Deep posterior compartment.
Lateral compartment.
Anterior compartment.
Peroneal compartment.

Correct Answer: Anterior compartment.

Explanation:

Question 37:

Options:

Lateral Compression Type I (LC-I).
Lateral Compression Type II (LC-II).
Anteroposterior Compression Type I (APC-I).
Anteroposterior Compression Type II (APC-II).
Vertical Shear (VS).

Correct Answer: Anteroposterior Compression Type II (APC-II).

Explanation:

Question 38:

Options:

Dynamic hip screw (DHS) with an antirotation screw.
Open reduction internal fixation (ORIF) with a locking plate.
Long cephalomedullary nail.
Hemiarthroplasty.
Short intramedullary nail.

Correct Answer: Long cephalomedullary nail.

Explanation:

Question 39:

A 35-year-old male presents with acute foot drop after a penetrating injury to the posterior aspect of his knee. Which nerve is most likely injured, and what specific muscle group would be affected?

Options:

Tibial nerve, leading to weakness in ankle dorsiflexion.
Common peroneal nerve, leading to weakness in ankle plantarflexion.
Sural nerve, leading to weakness in toe extension.
Common peroneal nerve, leading to weakness in ankle dorsiflexion and eversion.
Femoral nerve, leading to weakness in knee extension.

Correct Answer: Common peroneal nerve, leading to weakness in ankle dorsiflexion and eversion.

Explanation:

Question 40:

A 25-year-old male falls from a height and sustains a displaced fracture of the talar neck. What is the most critical complication to counsel the patient about regarding this injury?

Options:

Nonunion.
Malunion.
Infection.
Avascular necrosis (AVN) of the talar body.
Post-traumatic subtalar arthritis.

Correct Answer: Avascular necrosis (AVN) of the talar body.

Explanation:

Question 41:

Options:

Anterior drawer test for ATFL instability.
Talar tilt test for calcaneofibular ligament instability.
Squeeze test for syndesmotic injury.
Peroneal tendon subluxation test (forced dorsiflexion and eversion).
Thompson test for Achilles tendon rupture.

Correct Answer: Peroneal tendon subluxation test (forced dorsiflexion and eversion).

Explanation:

Question 42:

Options:

Non-operative management as it is likely insignificant.
Excision of the fragment to prevent impingement.
Open reduction and internal fixation (ORIF) if displaced and significant size.
Closed reduction and casting.
Arthroscopic debridement.

Correct Answer: Open reduction and internal fixation (ORIF) if displaced and significant size.

Explanation:

Question 43:

Options:

Non-operative management with a cast in plantarflexion.
Immediate surgical repair of the Achilles tendon.
Physical therapy focusing on stretching and strengthening.
Corticosteroid injection into the tendon.
Casting in dorsiflexion to stretch the tendon.

Correct Answer: Immediate surgical repair of the Achilles tendon.

Explanation:

Question 44:

Options:

Metatarsal stress fracture.
Plantar fasciitis.
Tarsal tunnel syndrome.
Morton's neuroma.
Hallux valgus.

Correct Answer: Morton's neuroma.

Explanation:

Question 45:

Options:

Place the amputated part directly on ice.
Wrap the amputated part in a saline-moistened gauze, seal in a plastic bag, and place on ice.
Submerge the amputated part in sterile water.
Freeze the amputated part to preserve tissues.
Perform immediate wound closure of the stump.

Correct Answer: Wrap the amputated part in a saline-moistened gauze, seal in a plastic bag, and place on ice.

Explanation:

Question 46:

Options:

Plain radiographs of the knee.
Magnetic resonance imaging (MRI) of the knee.
Computed tomography angiography (CTA) of the lower extremity.
Duplex ultrasound of the popliteal artery.
Venogram.

Correct Answer: Computed tomography angiography (CTA) of the lower extremity.

Explanation:

Question 47:

Options:

Immediate CT scan of the pelvis with contrast.
Percutaneous iliosacral screw fixation.
Skeletal traction through the distal femur.
Open reduction and internal fixation of the pubic symphysis.
Angiography and embolization of identified arterial bleeding.

Correct Answer: Percutaneous iliosacral screw fixation.

Explanation:

Question 48:

Options:

Open reduction internal fixation (ORIF) with a plate.
Intramedullary nailing (IMN).
Non-operative management with protected weight-bearing.
Hemiarthroplasty.
Total hip arthroplasty (THA).

Correct Answer: Non-operative management with protected weight-bearing.

Explanation:

Question 49:

Options:

Greenstick fracture.
Toddler's fracture.
Bumper fracture.
Triplane fracture.
Segond fracture.

Correct Answer: Toddler's fracture.

Explanation:

Question 50:

Options:

Application of an external fixator to the anterior pelvic ring.
Placement of a pelvic binder or sheet.
Insertion of a Foley catheter.
Fluid resuscitation with crystalloids.
Transfusion of packed red blood cells.

Correct Answer: Placement of a pelvic binder or sheet.

Explanation:

Question 51:

Options:

Delta pressure = 115 mmHg; indicates no compartment syndrome.
Delta pressure = 25 mmHg; indicates acute compartment syndrome requiring fasciotomy.
Delta pressure = -25 mmHg; indicates acute compartment syndrome requiring fasciotomy.
Delta pressure = 45 mmHg; indicates borderline compartment syndrome.
Delta pressure = 70 mmHg; indicates vascular compromise.

Correct Answer: Delta pressure = -25 mmHg; indicates acute compartment syndrome requiring fasciotomy.

Explanation:

Question 52:

Options:

Nonunion.
Malunion.
Post-traumatic arthritis.
Growth arrest or angular deformity.
Compartment syndrome.

Correct Answer: Growth arrest or angular deformity.

Explanation:

Question 53:

A 50-year-old male sustains a comminuted, displaced intra-articular fracture of the calcaneus (Sanders Type III). What is the primary goal of surgical management for this fracture?

Options:

Excision of all comminuted fragments.
Restoration of Böhler's angle and Gissane's angle.
Early full weight-bearing.
Primary subtalar fusion.
Amputation.

Correct Answer: Restoration of Böhler's angle and Gissane's angle.

Explanation:

Question 54:

Options:

Dynamic hip screw (DHS).
Short cephalomedullary nail.
Arthroplasty (hemi or total).
Skeletal traction.
Open reduction and internal fixation (ORIF) with plate and screws.

Correct Answer: Short cephalomedullary nail.

Explanation:

Question 55:

Options:

Lag screw fixation of the lateral malleolus.
Tension band wiring of the posterior malleolus.
Suture button or screw fixation across the syndesmosis.
Excision of the posterior malleolus fragment.
Fixation of the deltoid ligament.

Correct Answer: Suture button or screw fixation across the syndesmosis.

Explanation:

Question 56:

Options:

Lateral collateral ligament (LCL) tear.
Anterior cruciate ligament (ACL) tear.
Posterior cruciate ligament (PCL) tear.
Medial collateral ligament (MCL) tear.
Patellar tendon rupture.

Correct Answer: Medial collateral ligament (MCL) tear.

Explanation:

Question 57:

Options:

Morton's neuroma.
Freiberg's infraction.
Sesamoiditis.
Plantar plate rupture.
Metatarsal stress fracture.

Correct Answer: Plantar plate rupture.

Explanation:

Question 58:

Options:

Open fracture (Gustilo-Anderson Type I).
Polytrauma patient with chest injury (flail chest).
Associated nerve injury.
Extensive soft tissue swelling and blistering.
Isolated femoral shaft fracture.

Correct Answer: Polytrauma patient with chest injury (flail chest).

Explanation:

Question 59:

Options:

Immediate primary closure of the wound over the fracture.
Copious irrigation and debridement, followed by planned delayed primary closure or flap coverage.
Application of a vacuum-assisted closure (VAC) device without debridement.
Immediate bone grafting of the defect.
Placement of a bulky compression dressing only.

Correct Answer: Copious irrigation and debridement, followed by planned delayed primary closure or flap coverage.

Explanation:

Question 60:

Options:

Hemiarthroplasty.
Total hip arthroplasty (THA).
Cannulated screw fixation (percutaneous pinning).
Skeletal traction.
Non-operative management with bed rest.

Correct Answer: Cannulated screw fixation (percutaneous pinning).

Explanation:

Question 61:

Options:

Immediate full weight-bearing on the affected leg.
Achieving full knee flexion (140 degrees).
Early protected range of motion exercises for the knee.
Strengthening the quadriceps against heavy resistance.
Complete immobilization of the knee for 8-12 weeks.

Correct Answer: Early protected range of motion exercises for the knee.

Explanation:

Question 62:

Options:

Immediate primary closure over the exposed bone.
Leave the wound open and apply a standard dressing for delayed secondary intention healing.
Application of a vacuum-assisted closure (VAC) device with planned delayed soft tissue coverage.
Immediate skin grafting of the exposed bone.
High-dose intravenous antibiotics for 6 weeks.

Correct Answer: Application of a vacuum-assisted closure (VAC) device with planned delayed soft tissue coverage.

Explanation:

Question 63:

Options:

Avascular necrosis of the cuboid.
Compartment syndrome.
Deep vein thrombosis (DVT).
Diabetic foot ulcers and osteomyelitis.
Complex regional pain syndrome (CRPS).

Correct Answer: Diabetic foot ulcers and osteomyelitis.

Explanation:

Question 64:

Options:

Discharge with knee immobilizer and close follow-up.
Immediate surgical repair of the knee ligaments.
Admission for observation and serial vascular exams.
Emergent CT angiogram (CTA) of the lower extremity.
Application of a long leg cast.

Correct Answer: Emergent CT angiogram (CTA) of the lower extremity.

Explanation:

Question 65:

Options:

External fixation.
Intramedullary nailing (IMN).
Open reduction internal fixation (ORIF) with plate and screws.
Cast immobilization.
Skeletal traction.

Correct Answer: Intramedullary nailing (IMN).

Explanation:

Question 66:

Options:

Metatarsal stress fracture.
Achilles tendon rupture.
Lisfranc (tarsometatarsal) injury.
Ankle sprain.
Calcaneus fracture.

Correct Answer: Lisfranc (tarsometatarsal) injury.

Explanation:

Question 67:

Options:

Electrocardiogram (ECG).
Chest X-ray.
D-dimer assay.
Computed tomography pulmonary angiogram (CTPA).
Lower extremity venous duplex ultrasound.

Correct Answer: Computed tomography pulmonary angiogram (CTPA).

Explanation:

Question 68:

Options:

Grade I.
Grade II.
Grade III.
High ankle sprain (syndesmotic).
Subtalar sprain.

Correct Answer: Grade II.

Explanation:

Question 69:

Options:

Open reduction internal fixation (ORIF) with plate and screws.
External fixation.
Non-operative management with protected weight-bearing and early range of motion.
Total knee arthroplasty (TKA).
Skeletal traction.

Correct Answer: Non-operative management with protected weight-bearing and early range of motion.

Explanation:

Question 70:

Options:

Immediate external fixation and observation.
Repeat closed reduction attempts.
Perform an Ankle-Brachial Index (ABI) and if abnormal, a CT angiogram.
Proceed directly to open surgical exploration of the popliteal artery.
Apply skeletal traction.

Correct Answer: Perform an Ankle-Brachial Index (ABI) and if abnormal, a CT angiogram.

Explanation:

Question 71:

Options:

Reduced risk of avascular necrosis of the femoral head.
Reduced incidence of nonunion.
Decreased time to ambulation and reduced medical complications.
Elimination of the need for DVT prophylaxis.
Improved cosmetic outcome.

Correct Answer: Decreased time to ambulation and reduced medical complications.

Explanation:

Question 72:

Options:

Obtain an immediate CT scan of the lower leg.
Administer aggressive pain medication and observe.
Perform intracompartmental pressure measurements.
Apply a tight compression bandage to the leg.
Order a Doppler ultrasound to check distal pulses.

Correct Answer: Perform intracompartmental pressure measurements.

Explanation:

Question 73:

Which of the following describes the most appropriate method for reducing a posterior hip dislocation?

Options:

Stimson maneuver (patient prone, hip flexed 90 degrees, downward force on knee).
Allis maneuver (patient supine, hip flexed 90 degrees, axial traction, internal/external rotation).
Bigelow maneuver (patient supine, hip flexed 90 degrees, abduction, external rotation).
Captain Morgan technique (patient supine, hip flexed 90 degrees, foot on gurney, hip extension).
Immediate open reduction without attempting closed reduction.

Correct Answer: Stimson maneuver (patient prone, hip flexed 90 degrees, downward force on knee).

Explanation:

Question 74:

Options:

Weber A.
Weber B.
Weber C.
Maisonneuve fracture.
Pilon fracture.

Correct Answer: Weber C.

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

Lower Limb Trauma: Master Urgent Management & Ace Your Exams

Key Takeaway

Chapter Index