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Orthopedic Trauma MCQs & Clinical Insights: Advanced Exam Preparation

Tackle a Complex Lower Limb Trauma Examination Question

23 Apr 2026 112 min read 104 Views
Illustration of examination question lower limb - Dr. Mohammed Hutaif

Key Takeaway

For anyone wondering about Tackle a Complex Lower Limb Trauma Examination Question, An examination question lower limb trauma scenario, such as a supracondylar femur and distal tibia fracture in an elderly patient, emphasizes cautious management. Prioritize early stabilization, considering the patient's limited reserves. For femoral fractures, a fixed-angle plate with a less invasive technique is often preferred. Distal tibia fractures with soft tissue compromise may benefit from a circular frame.

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Question 1

A 35-year-old male presents after a high-speed motor vehicle collision with an open Gustilo-Anderson IIIB comminuted tibia shaft fracture and an ipsilateral closed femoral shaft fracture. He is hemodynamically stable after initial resuscitation. What is the most appropriate initial management strategy for the lower extremity injuries?





Explanation

In a stable polytrauma patient with a 'floating knee' injury (ipsilateral femoral and tibial shaft fractures), initial management prioritizes damage control for open fractures and early stabilization of long bone fractures. Debridement and irrigation of the open tibia are paramount to prevent infection and should be performed within 6-8 hours. External fixation provides temporary stabilization of the open tibia. Definitive fixation of the femur (intramedullary nailing) is typically performed early in stable patients (often within 24-48 hours) to reduce systemic inflammatory response (reducing risk of ARDS, MOF) and improve patient mobilization. While both require attention, the open fracture debridement is time-sensitive, and femur fixation contributes significantly to patient stability and outcomes. Option A is too aggressive for an open fracture initially. Option B delays essential debridement for the open tibia. Option C is overly conservative for the femur in a stable patient and delays definitive care. Option D misprioritizes definitive fixation of the open tibia before femur stabilization.

Question 2

A 48-year-old male sustains a Schatzker VI tibial plateau fracture following a fall from height. Examination reveals a tense leg with pain out of proportion, especially on passive dorsiflexion of the toes. Distal pulses are palpable but weak. Which of the following is the most critical immediate concern in this patient?





Explanation

A Schatzker VI tibial plateau fracture, involving both condyles and often significant displacement, is a high-energy injury with a substantial risk of compartment syndrome due to soft tissue trauma, hemorrhage, and associated swelling. The clinical presentation of a 'tense leg with pain out of proportion' and pain on passive stretch (especially dorsiflexion) despite palpable pulses strongly suggests impending or established compartment syndrome. This is a surgical emergency requiring immediate fasciotomy to prevent irreversible muscle ischemia, nerve damage, and limb loss. While popliteal artery injury (E) is a serious concern with knee trauma, the constellation of signs points more directly and urgently to compartment syndrome. DVT prophylaxis (A) is important but not the most critical immediate concern. Ipsilateral fibular head fracture (B) is a common associated injury but not as acutely limb-threatening. Pre-operative templating (D) is a later step in surgical planning.

Question 3

A 28-year-old female presents after a motorcycle accident with a mechanically unstable pelvic ring injury classified as a Young-Burgess Lateral Compression Type III. Her blood pressure is 90/60 mmHg, and heart rate is 120 bpm, despite initial fluid resuscitation. What is the most appropriate next step in her management?





Explanation

A Young-Burgess LC-III injury indicates a significant pelvic disruption, typically involving a sacral fracture or sacroiliac joint disruption, leading to posterior instability and potential for severe retroperitoneal hemorrhage. In a hypotensive patient with a suspected pelvic hemorrhage, the immediate priority is to stabilize the pelvis and control bleeding. Application of a pelvic binder (or sheet) provides temporary external compression, reducing the pelvic volume and potentially tamponading venous bleeding, which accounts for the majority of hemorrhage in pelvic fractures. This should be combined with continued aggressive fluid resuscitation and transfusion. While angiography (B) may be required for ongoing arterial bleeding, it typically follows initial mechanical stabilization. Immediate external fixation (A) is often performed once the patient is more stable, or after initial binder application if the binder proves insufficient. CT scan (C) is for diagnosis but can be delayed until initial stabilization. Laparotomy (E) is primarily for intra-abdominal sources of bleeding, and while possible, pelvic hemorrhage is more likely the cause of hypotension in this specific scenario.

Question 4

A 62-year-old male falls from a ladder, sustaining a bimalleolar ankle fracture with medial comminution and lateral displacement. He has a history of poorly controlled diabetes and peripheral neuropathy. During surgery, excellent reduction and rigid internal fixation are achieved. Post-operatively, what is the most critical aspect of his immediate ankle rehabilitation protocol?





Explanation

This patient presents with several complicating factors: medial comminution (suggesting compromised medial soft tissues/bone quality), diabetes, and peripheral neuropathy. Diabetes can impair wound healing, increase infection risk, and lead to poor bone quality. Peripheral neuropathy further increases the risk of unrecognized skin breakdown and Charcot arthropathy. Strict non-weight-bearing is crucial to protect the repair from excessive stress, which could lead to hardware failure, loss of reduction, or soft tissue complications. Vigilant skin and wound care are paramount due to his diabetic status. Early range of motion (A) and aggressive weight-bearing (B) are contraindicated due to the unstable nature of the fracture and patient comorbidities. A functional brace (D) and immediate strengthening (E) would be premature and risk loss of fixation and healing complications.

Question 5

A 30-year-old female presents with a displaced femoral shaft fracture after a motor vehicle accident. She has significant chest trauma, requiring intubation and mechanical ventilation for pulmonary contusions. Her Injury Severity Score (ISS) is 25. What is the most appropriate timing for definitive fixation of her femoral fracture?





Explanation

This patient is a polytrauma patient with significant chest injuries and an ISS of 25. While early definitive fixation of long bone fractures is generally beneficial, patients with severe pulmonary compromise (e.g., severe pulmonary contusions requiring mechanical ventilation) are at higher risk of adverse outcomes, such as ARDS or fat embolism syndrome, with immediate total care. In such cases, a 'damage control orthopedics' approach is often preferred, where initial stabilization of the femur with an external fixator is performed, followed by definitive intramedullary nailing once the patient's pulmonary status and overall physiological reserve have improved, typically after 3-7 days. 'Early total care' (A, B) is aggressive for this patient profile. Option C (24-48 hours) might still be too early if significant pulmonary compromise persists. Option E (immediate external fixation with delayed conversion) is the essence of damage control orthopedics for this specific scenario.

Question 6

A 40-year-old male sustains a high-energy Pilon fracture (AO/OTA 43-C3) following a fall from significant height. Initial radiographs show severe comminution and articular involvement. The skin is intact but severely swollen with fracture blisters. What is the most appropriate initial management strategy for this fracture?





Explanation

High-energy Pilon fractures (distal tibia articular fractures) are associated with severe soft tissue injury. Immediate ORIF (A) is contraindicated in the presence of severe soft tissue swelling and fracture blisters due to a very high risk of wound complications, infection, and skin necrosis. The most accepted initial management involves 'staged' treatment: initial stabilization with an ankle spanning external fixator, often combined with fibular fixation (if unstable), to restore length, alignment, and indirectly reduce the fracture fragments. This allows the severe soft tissue swelling to subside ('wrinkle sign'), typically over 7-14 days, before definitive ORIF of the articular surface. Skeletal traction (C) might be part of an external fixator setup but is not the sole initial management. Cast application (D) is insufficient for stability and does not address swelling. Amputation (E) is rarely an initial consideration unless there is unsalvageable limb injury.

Question 7

A 55-year-old construction worker presents with a calcaneal fracture after a fall from scaffolding. Plain radiographs show an intra-articular fracture with significant decrease in Böhler's angle. Which of the following associated injuries should be specifically ruled out during the initial workup?





Explanation

Calcaneal fractures, especially those resulting from falls from height, are high-energy injuries. A well-known association, occurring in approximately 10-15% of cases, is a lumbar spine compression fracture. The axial load transmitted through the body during a fall that causes a calcaneal fracture often also impacts the spine. Therefore, a thorough evaluation including a lateral lumbar spine radiograph is essential. While other injuries (A, B, D, E) are possible in polytrauma, the specific association with lumbar spine fractures is critical for calcaneal fracture patients.

Question 8

A 22-year-old collegiate athlete sustains a knee dislocation (tibiofemoral dislocation) during a football tackle. Initial assessment reveals a grossly deformed knee, but distal pulses are palpable and strong. After closed reduction in the emergency department, what is the most critical next step in management?





Explanation

Knee dislocations, even those that spontaneously reduce or are easily reduced in the ED and have palpable pulses, carry a high risk of popliteal artery injury (up to 40% in some series). The popliteal artery can be stretched, compressed, or intimaly damaged, leading to delayed thrombosis, pseudoaneurysm formation, or compartment syndrome. Therefore, close monitoring for vascular compromise is paramount. While a CT angiography (C) is a definitive diagnostic tool for vascular injury, observed serial ankle-brachial index (ABI) measurements (e.g., every hour for 24-48 hours) combined with clinical examination is the standard screening tool. An ABI < 0.9 or a drop in ABI warrants immediate further investigation (e.g., CTA). MRI (B) evaluates ligamentous injury but is not the immediate priority. Early bracing and physical therapy (A, B) would be inappropriate without clearing vascular status. Admission for neurovascular observation (E) is correct, but specifically highlighting serial ABI measurements makes option D more precise for the immediate critical step.

Question 9

A 40-year-old male sustains an open Schatzker III tibial plateau fracture. During initial debridement, he is noted to have significant devitalized muscle and a large skin defect that cannot be closed primarily. What is the most appropriate definitive soft tissue management for this injury?





Explanation

An open Schatzker III tibial plateau fracture with significant devitalized muscle and a large skin defect that cannot be closed primarily requires robust soft tissue coverage, especially when bone or hardware is exposed. Split-thickness skin grafts (B) are generally not sufficient for covering exposed bone or large defects over mobile joints, as they are thin and provide poor padding. Free tissue transfer (D) is an excellent option for very large or complex defects but is a more extensive procedure. Local rotational flaps (C) are often the workhorse for moderate-sized defects around the knee, providing vascularized tissue coverage and better padding than skin grafts. Delayed primary closure (A) is not possible given the initial defect. Daily wet-to-dry dressings (E) are a temporizing measure for wound bed preparation but not definitive soft tissue coverage for exposed bone.

Question 10

Which of the following is an absolute contraindication to intramedullary nailing of a femoral shaft fracture?





Explanation

The primary absolute contraindication to intramedullary nailing (IMN) of a femoral shaft fracture is an active infection in the operative field. An active systemic infection (e.g., sepsis) originating from a distant source (C) is a strong relative contraindication, as it increases the risk of hematogenous seeding and subsequent implant infection, making it the most correct answer among the choices. Option A (open Gustilo IIIB) is a complex scenario, but after thorough debridement, external fixation with planned delayed IMN is common, not an absolute contraindication. Ipsilateral severe knee ligamentous injury (B) is a concern for surgical approach and potential complications but not an absolute contraindication to IMN. Severely comminuted fracture patterns (D) are often managed well with IMN. Associated TBI (E) is a relative contraindication to immediate surgery due to potential hemodynamic instability or increased intracranial pressure, but not an absolute contraindication to IMN as a fixation method.

Question 11

A 70-year-old female presents with a displaced intra-articular calcaneal fracture. She has multiple comorbidities including severe osteoporosis. What is the most significant long-term complication unique to intra-articular calcaneal fractures, even with optimal surgical management?





Explanation

The most significant long-term complication unique to intra-articular calcaneal fractures, particularly after surgical management, is post-traumatic subtalar arthritis (B). Despite achieving anatomical reduction and stable fixation, the high-energy nature of the injury and damage to the articular cartilage often lead to degenerative changes in the subtalar joint. This can result in chronic pain, stiffness, and impaired gait, often necessitating a subtalar fusion as a salvage procedure. While DVT (A), wound infection (C), and CRPS (D) are all possible complications, they are not unique to intra-articular calcaneal fractures in the same way subtalar arthritis is. Nonunion (E) is rare in calcaneal fractures.

Question 12

A 25-year-old male sustains a posterior hip dislocation. After successful closed reduction, what is the most important imaging study to obtain and why?





Explanation

After closed reduction of a posterior hip dislocation, a CT scan of the hip (B) is essential. It serves two critical purposes: 1) to confirm concentric reduction of the femoral head within the acetabulum, and 2) to rule out incarcerated intra-articular fragments (e.g., osteochondral fragments from the femoral head or acetabulum) that would necessitate open reduction. Failure to identify and remove such fragments significantly increases the risk of post-traumatic arthritis and loss of reduction. Repeat plain radiographs (C) are usually obtained immediately after reduction but are insufficient to rule out small incarcerated fragments. MRI (A) and angiography (D) are typically not the immediate next step, and bone scan (E) is for delayed complications like AVN.

Question 13

Which of the following physical examination findings is most suggestive of an unstable lateral compression (LC-II) pelvic ring injury?





Explanation

A Young-Burgess Lateral Compression Type II (LC-II) pelvic ring injury is characterized by an internal rotation force causing an anterior injury (e.g., pubic rami fractures) and a posterior injury involving the ipsilateral sacroiliac joint or sacrum, often with a crescent fracture of the iliac wing. Rotational instability (E), often detected by gently compressing the iliac wings laterally (provocative stress test), is the key indicator of an unstable lateral compression injury. Sacral tenderness (A) is general for posterior injury. Blood at the urethral meatus (B) suggests urethral injury, which can be associated but isn't specific for LC-II mechanical instability. Faber test (C) is for hip pathology. Pain with internal rotation of the hip (D) is non-specific.

Question 14

A 40-year-old male presents with a Grade III open tibia shaft fracture sustained in a motor vehicle accident. He also has a severe closed head injury. The patient is intubated and sedated. During the initial debridement, you note a large segment of bone is missing (segmental bone loss). What is the most appropriate initial management strategy for the bone defect?





Explanation

In the setting of a Grade III open tibia fracture with significant bone loss in a polytrauma patient (severe head injury), the immediate priority is wound debridement, infection control, and temporary stabilization. An antibiotic cement spacer (C) is an excellent initial strategy for managing segmental bone loss in an open fracture. It helps maintain the bone defect space, delivers high local concentrations of antibiotics, and acts as a placeholder for future definitive bone reconstruction (e.g., bone grafting, bone transport). Immediate cancellous bone grafting (A) is generally contraindicated in an acute open wound due to high infection risk. Circular external fixators for bone transport (B) are for definitive management, not initial. Primary shortening (E) might be considered for very small defects but not for large segmental loss and can lead to leg length discrepancy. The strategy is damage control: debride, stabilize, prevent infection, and plan for reconstruction. Option D is close but 'delayed management of bone defect' can be more specific, and the antibiotic spacer is a recognized component of initial management for bone loss.

Question 15

Which of the following is the most sensitive and specific clinical finding for diagnosing acute compartment syndrome in an awake and alert patient with a tibia fracture?





Explanation

Pain out of proportion to the injury (C) and pain with passive stretch of the muscles in the affected compartment are the most sensitive and specific clinical signs of acute compartment syndrome in an awake and alert patient. While paresthesia (A) and weakness (B) are late signs of nerve ischemia and muscle necrosis, respectively, they indicate advanced compartment syndrome. Absence of distal pulses (D) is rare and a very late sign, indicating arterial occlusion, not typically compartment syndrome. Pallor (E) is also a late, less reliable sign. The key is recognizing the escalating pain, especially with passive stretch, which prompts compartment pressure measurements for definitive diagnosis.

Question 16

A 50-year-old male presents with a Lisfranc injury (tarsometatarsal fracture-dislocation) after a fall. Initial radiographs are equivocal, but there is significant midfoot pain and swelling. What is the most appropriate next imaging study to confirm the diagnosis?





Explanation

When plain radiographs are equivocal for a Lisfranc injury but clinical suspicion is high (midfoot pain, swelling, ecchymosis, especially plantar ecchymosis), a CT scan of the foot (C) is the gold standard for definitive diagnosis. It provides detailed bony anatomy, allowing visualization of subtle diastasis, avulsion fractures, and articular incongruity at the tarsometatarsal joints. Weight-bearing radiographs (A) might reveal subtle instability if the patient can tolerate them, but CT is superior for complex bony anatomy. MRI (B) is excellent for soft tissue (ligament) injury but less precise for subtle bony disruption than CT, and is typically reserved for assessing the integrity of the Lisfranc ligament if bony injury is unclear or for persistent pain after fixation. Bone scan (D) is not specific. Ultrasound (E) is not used for this diagnosis.

Question 17

A 30-year-old male sustains an acetabular fracture (posterior wall and column) with associated posterior hip dislocation. He undergoes successful closed reduction. Post-reduction, he reports numbness and tingling in his foot and weakness in ankle dorsiflexion. Which nerve is most likely injured?





Explanation

Posterior hip dislocations and associated acetabular fractures (especially posterior wall) are well-known to cause sciatic nerve injury (D). The sciatic nerve exits the pelvis through the greater sciatic notch, lying directly posterior to the hip joint. It can be stretched, compressed, or contused during dislocation or by fracture fragments. The symptoms of numbness/tingling in the foot and weakness in ankle dorsiflexion (foot drop) are classic signs of peroneal division injury of the sciatic nerve. The femoral nerve (A) innervates the anterior thigh and would cause quadriceps weakness. The obturator nerve (B) innervates the medial thigh. The superior gluteal nerve (C) innervates gluteus medius/minimus, affecting hip abduction. The peroneal nerve (E) is a branch of the sciatic, but the sciatic nerve itself is the structure injured proximally.

Question 18

In a patient with a closed intertrochanteric fracture of the femur, which factor is most crucial in deciding between intramedullary nailing and a sliding hip screw fixation?





Explanation

The integrity of the lateral femoral wall (C) is a critical factor in determining the stability and success of fixation for intertrochanteric fractures, particularly when considering a sliding hip screw (SHS). A compromised lateral wall (e.g., reverse obliquity, large posterolateral fragment) can lead to medial migration of the femoral shaft relative to the head-neck segment, leading to loss of reduction and cut-out with an SHS. In such unstable fractures, an intramedullary nail provides better biomechanical stability. Comminution of the lesser trochanter (B) is a sign of instability but less critical than the lateral wall for SHS specifically. Age (A), osteoporosis (D), and activity level (E) influence choice but are secondary to fracture pattern stability.

Question 19

A 68-year-old male with multiple comorbidities sustains an unstable intertrochanteric hip fracture. He is deemed a poor surgical candidate for general anesthesia for definitive fixation. What is the most appropriate non-operative management approach?





Explanation

For an elderly, unstable intertrochanteric hip fracture patient deemed too high risk for definitive surgical fixation, the goal of non-operative management shifts from achieving anatomical reduction and union to minimizing complications of prolonged immobility while providing comfort. Prolonged bed rest (D) and skeletal traction (A) lead to high rates of complications like pneumonia, DVT, pressure ulcers, and accelerated deconditioning. Hip spica cast (B) is poorly tolerated and ineffective in adults. Percutaneous pinning (E) still involves anesthesia risks and might not be stable enough for early mobilization. The most appropriate non-operative approach emphasizes pain control and progressive mobilization as tolerated, accepting a likely malunion or nonunion but prioritizing patient comfort and prevention of life-threatening complications related to immobility. It's a palliative approach. This option (D) is better than C, as early mobilization with non-weight-bearing is difficult and can lead to displacement.

Question 20

A 20-year-old male presents with a high-energy distal tibia (Pilon) fracture with significant articular comminution. He is initially managed with external fixation. After 10 days, the soft tissue swelling has subsided ('wrinkle sign'). What is the ideal surgical approach for definitive open reduction and internal fixation of this fracture?





Explanation

The anterolateral approach (D) is often favored for definitive ORIF of Pilon fractures, especially those involving the anterior or lateral plafond. It provides excellent visualization of the distal tibia articular surface, allows for reduction of impacted fragments, and offers a safe interval between the tibialis anterior and peroneal tendons. The anteromedial approach (A) is also used but can be limited in visualizing the entire articular surface. The direct anterior approach (C) risks injury to neurovascular structures. Posterolateral (B) and medial (E) approaches are typically reserved for specific fracture patterns or associated posterior malleolar fractures.

Question 21

A 45-year-old male sustains a traumatic amputation of the right leg just proximal to the ankle joint. The decision is made for replantation. What is the most critical time limit for successful replantation of a lower extremity, particularly regarding warm ischemia time?





Explanation

For lower extremity replantation, the critical warm ischemia time is typically considered to be 6 hours (C). Beyond this, muscle viability significantly decreases, leading to higher rates of complications such as rhabdomyolysis, compartment syndrome, infection, and ultimately, replantation failure. While cold ischemia can extend this window (up to 12-24 hours if the limb is properly cooled and preserved), the question specifically asks about warm ischemia. Compared to upper extremities (especially digits), lower extremities have a larger muscle mass, making them more susceptible to ischemic damage.

Question 22

Which of the following describes a 'Maisononneuve fracture'?





Explanation

A Maisonneuve fracture (B) is a specific type of ankle injury characterized by a fracture of the proximal fibula (near the fibular neck), often associated with an unstable syndesmosis (disruption of the tibiofibular ligaments) and a medial injury (either a deltoid ligament rupture or a medial malleolar fracture). This injury results from external rotation and pronation forces transmitted up the interosseous membrane. It is crucial to diagnose because the proximal fibular fracture indicates instability at the ankle, requiring syndesmotic fixation even if the ankle joint itself appears less obviously displaced on plain radiographs.

Question 23

A 38-year-old male presents with a Gustilo-Anderson IIIA open tibia shaft fracture. After initial debridement and external fixation, the wound is clean but cannot be closed primarily. What is the most appropriate next step in soft tissue management within the first week?





Explanation

For a Gustilo-Anderson IIIA open tibia fracture where primary closure is not possible and the wound is clean after debridement, vacuum-assisted closure (VAC) therapy (D) is an excellent temporizing measure. It promotes wound bed preparation, reduces edema, and encourages granulation tissue formation. This makes the wound more amenable to definitive closure or coverage (e.g., skin graft, local flap) within the first 7-10 days. Delayed primary closure (A) is for wounds that can be closed but are left open initially. Skin grafts (B) are generally not appropriate over exposed bone or tendon. Local flaps (C) and free tissue transfer (E) are definitive coverage options, but VAC prepares the wound for these, and it's less common to jump straight to these within the first week without wound bed optimization.

Question 24

What is the primary risk factor for avascular necrosis (AVN) of the femoral head following a femoral neck fracture?





Explanation

The degree of fracture displacement (B) is the most significant risk factor for avascular necrosis (AVN) of the femoral head following a femoral neck fracture. Displaced femoral neck fractures disrupt the blood supply to the femoral head (medial circumflex femoral artery predominantly), leading to ischemia and subsequent AVN. The greater the displacement, the higher the likelihood of complete vascular disruption. While age (A) and osteoporosis influence fracture risk and healing, displacement is the direct cause of vascular compromise. Other options (C, D, E) are not primary risk factors for AVN.

Question 25

A 75-year-old female presents with a displaced femoral neck fracture. She is functionally independent with no significant comorbidities. What is the most appropriate definitive surgical management?





Explanation

For an active, independent elderly patient (typically >65 years) with a displaced femoral neck fracture and no significant pre-existing hip pathology, total hip arthroplasty (THA) (C) is increasingly considered the most appropriate definitive surgical management. Compared to hemiarthroplasty, THA offers better functional outcomes, reduced rates of re-operation, and lower rates of revision for acetabular erosion in active patients. Bipolar hemiarthroplasty (B) is a common alternative, often favored for less active or sicker elderly patients. Cannulated screw fixation (A) is typically reserved for non-displaced or impacted femoral neck fractures due to high failure rates in displaced fractures. DHS fixation (D) is for intertrochanteric fractures. Excision arthroplasty (E) is a salvage procedure for failed arthroplasty or severe infection.

Question 26

Which of the following is the most important factor to consider when deciding on the timing of definitive surgical fixation for an acetabular fracture in a stable patient?





Explanation

For acetabular fractures, the 'window of opportunity' for optimal surgical fixation is generally considered to be within 7-10 days, provided the soft tissue envelope allows. However, the most critical factor influencing timing is the condition of the soft tissue envelope (E). Excessive swelling, fracture blisters, or open wounds necessitate delay to allow soft tissue recovery, as immediate surgery in these conditions significantly increases the risk of wound complications and infection. While fracture pattern (B) and marginal impaction (C) dictate surgical approach and technique, and patient age (A) can influence recovery, soft tissue condition is the primary determinant of when surgery can safely proceed. Quality of reduction with traction (D) is good for temporary stabilization, but not definitive for timing.

Question 27

A 25-year-old male sustains a spiral fracture of the distal tibia and fibula. Radiographs suggest an unstable ankle fracture. Which imaging view is most crucial for assessing syndesmotic integrity?





Explanation

The mortise view of the ankle (C) is the most crucial standard plain radiographic view for assessing syndesmotic integrity. It is an AP view with the foot internally rotated 15-20 degrees to open up the ankle mortise. This view allows for evaluation of the tibiofibular clear space, tibiofibular overlap, and medial clear space. Widening of these parameters suggests syndesmotic disruption. While stress radiographs (E) can be used to dynamically assess syndesmotic stability, the mortise view is the standard static image. AP (A) and lateral (B) views provide additional information but are less specific for syndesmotic assessment. Oblique (D) is less commonly used for syndesmosis.

Question 28

Which of the following is an indication for operative management of an acute Achilles tendon rupture?





Explanation

A palpable gap in the tendon (>1 cm) (D) after an acute Achilles tendon rupture is a strong indication for operative management, as it suggests significant retraction and difficulty achieving good apposition with non-operative treatment, leading to higher rates of re-rupture. Operative repair typically leads to a lower re-rupture rate and better functional outcomes, especially in active individuals. Elderly patients with low demands (A) and patients with significant comorbidities (B) might be better managed non-operatively. Partial tears (C) are often managed conservatively if the functional deficit is minimal. Non-compliant patients (E) are often poor candidates for surgical repair due to the demanding post-operative rehabilitation.

Question 29

A 40-year-old male presents with a high-energy tibial shaft fracture with significant comminution. He underwent intramedullary nailing. Six months post-operatively, he has persistent pain, swelling, and purulent discharge from the surgical site. Cultures are positive for Staphylococcus aureus. What is the most appropriate management strategy?





Explanation

This patient has a chronic post-operative osteomyelitis around the intramedullary nail (IMN). In the presence of purulent discharge and positive cultures, hardware removal, thorough irrigation and debridement, and targeted intravenous antibiotics (D) are generally required to eradicate the infection. Re-fixation (e.g., with an external fixator or a new IMN after a 'washout' period) is often necessary to maintain stability and promote healing, depending on the fracture stability. Long-term oral antibiotics (A) or suppressive antibiotics with implant retention (B) are usually insufficient for active hardware-associated infection. Irrigation and debridement with hardware retention (C) may be considered for acute infections or early post-op but not typically for chronic purulent infections around an IMN. External fixation with IMN removal and observation (E) may provide stability, but the focus needs to be on eradicating the infection.

Question 30

What is the most common cause of malunion following a surgically treated distal tibia fracture?





Explanation

Rotational malalignment (C) is a common and functionally significant cause of malunion following surgically treated distal tibia (shaft or pilon) fractures. Even small degrees of internal or external rotation can lead to significant gait abnormalities, knee or ankle pain, and increased stresses on adjacent joints. While other factors (A, B, D, E) can contribute to complications, rotational malalignment is often a subtle yet critical parameter that, if not addressed during surgery, leads to functional impairment. Inadequate debridement (A) is for open fractures. Premature weight-bearing (B) can lead to loss of reduction or hardware failure. Insufficient fixation (D) can cause nonunion or displacement. Infection (E) can cause nonunion.

Question 31

A 30-year-old male presents with a closed femoral shaft fracture following a motorcycle accident. He also has a mid-shaft radius fracture on the ipsilateral arm. He is hemodynamically stable. What is the preferred method of definitive fixation for his femoral shaft fracture?





Explanation

Reamed intramedullary nailing (D) is generally considered the gold standard for definitive fixation of most adult femoral shaft fractures. Reaming allows for a larger diameter nail, which provides greater biomechanical strength and stability, and improves cortical contact for faster healing. While unreamed nailing (E) can be used in certain situations (e.g., severe polytrauma with pulmonary compromise, open fractures to minimize emboli), reamed nailing is preferred for stable, closed fractures in otherwise healthy individuals. Plate fixation (A) is typically reserved for nonunion, peri-prosthetic fractures, or fractures with extensive soft tissue damage where IMN is not feasible. External fixation (B) is usually temporary. Flexible nailing (C) is primarily for pediatric femur fractures.

Question 32

Which type of knee dislocation is most commonly associated with a popliteal artery injury?





Explanation

Anterior knee dislocations (A) are most commonly associated with popliteal artery injury. This occurs when the tibia is forced anteriorly on the femur, causing the distal femoral condyles to hyperextend and tear or stretch the popliteal artery, which is tethered by its branches proximally and distally. While all knee dislocations carry a risk, the mechanism of anterior dislocation places the most direct stress on the artery.

Question 33

A 28-year-old male sustains an open Gustilo-Anderson IIIC proximal tibia fracture with an associated popliteal artery injury. After vascular repair, what is the most appropriate method for initial skeletal stabilization?





Explanation

A Gustilo-Anderson IIIC proximal tibia fracture means severe soft tissue damage, significant contamination, and an associated vascular injury. After vascular repair, skeletal stabilization is crucial. A circular external fixator (e.g., Ilizarov or Taylor Spatial Frame) (D) is often the preferred method for initial stabilization of such complex proximal tibia fractures. It allows for definitive stabilization, helps protect the vascular repair, permits easy wound access for debridement and soft tissue management, and can be used for bone transport or deformity correction if bone loss or malunion occurs. Plates (A) and intramedullary nailing (B) are generally contraindicated due to the severe soft tissue damage, high infection risk, and the need for ongoing wound care. An ankle-spanning external fixator (C) provides temporary stability but is not ideal for proximal tibia fractures and is not a definitive fixation. Skeletal traction (E) is a temporary measure and inadequate for definitive stabilization.

Question 34

Which of the following describes the 'floating knee' injury?





Explanation

A 'floating knee' injury (C) refers to an ipsilateral fracture of the femoral shaft and the tibia shaft. It is a high-energy injury often associated with significant soft tissue damage, increased risk of complications (e.g., compartment syndrome, vascular injury, nerve injury), and often occurs in polytrauma patients. While option B describes fractures around the knee joint, the classic definition of a floating knee refers to the shaft fractures, effectively 'disconnecting' the knee joint from both proximal and distal segments.

Question 35

A 33-year-old male presents with a closed mid-shaft tibia fracture. He is hemodynamically stable, and there is no evidence of compartment syndrome. What is the most appropriate definitive management strategy?





Explanation

For most adult, closed, diaphyseal tibia fractures, reamed intramedullary nailing (D) is the gold standard for definitive management. It provides rigid fixation, allows for early weight-bearing and mobilization, has high union rates, and minimizes soft tissue stripping. While casting (A) or bracing (B) can be used for very stable, non-displaced fractures, IMN is preferred for most mid-shaft fractures. Plate and screw fixation (C) is generally reserved for fractures with articular extension, severe comminution precluding nailing, or nonunions. External fixation (E) is usually temporary, especially in closed fractures, due to pin tract infection risk and patient discomfort.

Question 36

What is the most common mechanism of injury for a posterior wall acetabular fracture?





Explanation

A posterior wall acetabular fracture (C) typically results from a 'dashboard injury' in a motor vehicle accident. This mechanism involves a direct axial load to the flexed, adducted, and internally rotated hip, driving the femoral head posteriorly into the posterior column and wall of the acetabulum. This often causes an associated posterior hip dislocation. Direct blow to the greater trochanter (A) would typically cause a lateral wall or column fracture. Falls onto outstretched hand (B) cause upper extremity injuries. Lateral compression to the pelvis (E) causes pelvic ring injuries.

Question 37

A 20-year-old male sustains a Lisfranc injury. Intraoperatively, a significant gap between the medial cuneiform and the base of the second metatarsal is noted after reduction. What is the most appropriate method of fixation across the Lisfranc joint?





Explanation

For a Lisfranc injury with a significant diastasis after reduction, particularly involving the Lisfranc ligament complex, a suture button fixation system (e.g., TightRope) (D) has become increasingly popular. It provides dynamic stabilization, restores the normal biomechanics of the midfoot by allowing micro-motion, and reduces the need for hardware removal compared to traditional transarticular screws. While transarticular screws (A) from the medial cuneiform to the second metatarsal base were historically the gold standard, they create a rigid construct and are often removed. K-wires (B) are temporary and not strong enough. Plate and screw fixation (C) is typically for comminuted fractures. Fixation of only the first TMT joint (E) is insufficient for a significant injury.

Question 38

What is the most serious long-term complication of a neglected or inadequately treated Lisfranc injury?





Explanation

The most serious and debilitating long-term complication of a neglected or inadequately treated Lisfranc injury is post-traumatic midfoot arthritis (D). Persistent instability, malreduction, or articular damage at the tarsometatarsal joints leads to progressive degenerative changes, chronic pain, and significant functional disability. This often necessitates reconstructive surgery, such as midfoot fusion. Chronic ankle instability (A) is not a direct consequence. DVT (B) is an acute complication. Foot drop (C) is related to nerve injury, not typically Lisfranc. Calcaneal spur (E) is not related.

Question 39

A 70-year-old male sustains an open Schatzker V tibial plateau fracture (bicondylar). He is a smoker with peripheral vascular disease. What is the most appropriate initial management for this complex injury?





Explanation

This patient has a complex, high-energy open tibial plateau fracture (Schatzker V/bicondylar) complicated by significant comorbidities (smoking, PVD), which impair wound healing and increase infection risk. Immediate definitive ORIF (A) is contraindicated in open fractures with soft tissue compromise due to high infection and wound complication rates. The principles of damage control orthopedics apply: thorough debridement, temporary external fixation to stabilize the knee and allow soft tissues to recover, followed by delayed definitive ORIF (C) once the soft tissue envelope is favorable. External fixation across the knee (B) is a temporary measure, but the emphasis on debridement is critical. Skeletal traction (D) is largely historical for these types of fractures and carries its own risks. Amputation (E) is not an initial consideration unless there is unsalvageable limb injury (e.g., complete neurovascular disruption).

Question 40

A 25-year-old female presents with a transverse femoral shaft fracture. During reamed intramedullary nailing, she experiences sudden hypoxia, hypotension, and petechial rash. What is the most likely diagnosis?





Explanation

The triad of sudden hypoxia, hypotension, and a petechial rash, occurring during or shortly after intramedullary nailing of a long bone fracture (especially femoral shaft), is highly suggestive of Fat Embolism Syndrome (FES) (D). Reaming and nail insertion increase intramedullary pressure, forcing fat globules into the venous circulation, which can then travel to the lungs and brain, causing systemic inflammatory response. Pulmonary embolism (A) would typically present with hypoxia and hypotension but usually without the classic petechial rash. Myocardial infarction (B), anaphylaxis (C), and sepsis (E) would have different clinical presentations.

Question 41

What is the most appropriate imaging modality to evaluate for a missed acetabular fracture in a patient who previously sustained a posterior hip dislocation and now complains of persistent hip pain?





Explanation

Following a posterior hip dislocation, a CT scan of the pelvis with 3D reconstructions (C) is the most appropriate and sensitive imaging modality to evaluate for a missed acetabular fracture or incarcerated osteochondral fragments. Plain radiographs (A) can miss subtle fractures. Dynamic stress radiographs (B) are not used for acetabular fractures. MRI (D) is excellent for soft tissue injuries (labrum, cartilage) but less sensitive for acute bony details. Bone scan (E) indicates metabolic activity but is not specific for acute fracture morphology.

Question 42

A 55-year-old male with chronic alcoholism and poor nutrition sustains a Grade II open tibia shaft fracture. He is planned for definitive intramedullary nailing. What is the most important pre-operative intervention to reduce the risk of nonunion and infection?





Explanation

Chronic alcoholism and poor nutrition significantly compromise wound healing, immune function, and bone quality, substantially increasing the risk of nonunion and infection in open fractures. Nutritional optimization (e.g., protein, vitamins) and smoking cessation counseling (B) are critical pre-operative interventions that can improve patient physiology and wound healing potential. While prophylactic fasciotomy (C) can prevent compartment syndrome, it's not a primary intervention for reducing nonunion/infection risk directly. Higher dose antibiotics (D) are important but secondary to systemic health. Choice of reamed vs. unreamed nail (E) depends on fracture specifics and surgeon preference but doesn't override systemic health issues. Aggressive physical therapy (A) is premature.

Question 43

Which of the following describes the mechanism of injury for a 'reverse obliquity' intertrochanteric hip fracture?





Explanation

A 'reverse obliquity' intertrochanteric hip fracture (D) is characterized by a fracture line that runs from superomedial to inferolateral. This pattern is inherently unstable and often caused by high-energy adduction forces. It is particularly problematic for fixation with a sliding hip screw (DHS) because the oblique fracture line tends to convert shear forces into compressive forces, leading to medialization of the distal fragment and cut-out of the screw from the femoral head. Intramedullary nailing is generally the preferred fixation for these unstable fractures. Option A, B, C, D (medial impaction) are typically associated with more common intertrochanteric fracture patterns.

Question 44

In a patient with an open Gustilo-Anderson IIIB tibia fracture, after initial debridement and external fixation, which imaging modality is most useful for assessing the extent of soft tissue and periosteal stripping before definitive coverage?





Explanation

MRI (C) is the most useful imaging modality for assessing the extent of soft tissue and periosteal stripping in an open Gustilo-Anderson IIIB tibia fracture. It provides excellent soft tissue contrast, allowing visualization of muscle damage, fascial integrity, and periosteal disruption, which are crucial for planning definitive soft tissue coverage and predicting healing potential. Plain radiographs (A) show bone only. CT scan (B) shows bony detail better than MRI, but less soft tissue detail. Angiography (D) is for vascular assessment. Ultrasound (E) can assess superficial soft tissues but has limitations in deep structures.

Question 45

What is the most common classification system used for intra-articular calcaneal fractures?





Explanation

The Sanders classification (E) is the most commonly used system for intra-articular calcaneal fractures. It is based on coronal CT images and divides fractures into types I-IV based on the number and location of articular fragments in the posterior facet. This classification helps guide surgical management and prognosis. Gustilo-Anderson (A) is for open fractures. AO/OTA (B) is a general long bone classification. Schatzker (C) is for tibial plateau fractures. Essex-Lopresti (D) describes a specific forearm injury (radial head fracture with DRUJ dissociation).

Question 46

A 40-year-old male presents with a Grade II open pilon fracture. The initial debridement is performed, and an external fixator is applied. Two weeks later, the soft tissues have 'wrinkled', and the skin appears healthy. The articular surface is comminuted. What is the most appropriate next step for definitive management?





Explanation

For a comminuted open pilon fracture, even after initial debridement and temporary external fixation, severe articular comminution may preclude safe and stable fixation with traditional plates and screws, especially if there is significant bone loss or soft tissue compromise. In such cases, a circular external fixator (D) (e.g., Ilizarov or Taylor Spatial Frame) can be a powerful tool for definitive management. It allows for gradual reduction, compression, distraction, and potential bone transport, while providing rigid stability and access for wound care. Limited ORIF (B) is common for less comminuted Pilon fractures. Intramedullary nailing (A) is generally contraindicated for articular Pilon fractures. Cast immobilization (C) is insufficient for stability. Observation (E) is not definitive.

Question 47

Which complication is unique to a Type III fibular collateral ligament (FCL) avulsion fracture of the fibular head (Segond-like lesion) associated with posterolateral corner injury?





Explanation

A Type III fibular collateral ligament (FCL) avulsion fracture of the fibular head (often indicative of a posterolateral corner injury) is uniquely associated with common peroneal nerve injury (A). The common peroneal nerve courses directly around the fibular neck, making it highly susceptible to stretch, contusion, or laceration during injuries to this region. Popliteal artery injury (B) is associated with knee dislocations, but less specifically with isolated FCL avulsions. DVT (C), compartment syndrome (D), and osteoarthritis (E) are more general complications or sequelae of knee trauma.

Question 48

A 28-year-old male presents with a posterior wall acetabular fracture with a stable hip joint after closed reduction. There is a 4 mm step-off on the post-reduction CT scan. The patient is otherwise healthy. What is the most appropriate management?





Explanation

For an acetabular fracture with even a minimal articular step-off or gap (typically >1-2 mm) following reduction, open reduction and internal fixation (ORIF) (C) is generally indicated in a young, healthy patient. Unreduced articular incongruity significantly increases the risk of post-traumatic osteoarthritis. A 4 mm step-off is considered an absolute indication for surgical correction. Non-weight-bearing (A) or skeletal traction (B) are insufficient to address articular incongruity. Percutaneous screw fixation (D) is typically for certain types of pelvic ring injuries or very simple acetabular fractures, not displaced posterior wall fractures. Delayed total hip arthroplasty (E) is a salvage procedure for established arthritis.

Question 49

Which of the following is an absolute indication for immediate operative exploration in a patient with a lower extremity trauma?





Explanation

An absent distal pulse combined with an expanding hematoma (A) is an absolute indication for immediate operative exploration (fasciotomy and vascular repair). This suggests an acute arterial injury, which, if not promptly addressed, will lead to limb ischemia and loss. While open fracture with gross contamination (C) requires urgent debridement, it's not 'immediate exploration' in the same sense as a vascular emergency. Pain out of proportion (D) suggests compartment syndrome, requiring pressure measurement and potentially fasciotomy, but not necessarily immediate exploration without definitive diagnosis. Decreased sensation (B) is a sign of nerve injury but not an immediate limb-threatening emergency. Minor laceration (E) indicates a Grade I open fracture needing debridement but not immediate exploration in this context.

Question 50

A 60-year-old obese female with diabetes sustains a comminuted ipsilateral femoral neck and shaft fracture. What is the most appropriate management for this 'floating hip' injury?





Explanation

For ipsilateral femoral neck and shaft fractures (a 'floating hip'), a long cephalomedullary nail (D) is often the most appropriate and biomechanically sound fixation method. This single implant can stabilize both the femoral neck and shaft fractures, providing a stable construct that allows for early mobilization. It avoids the need for two separate implants and associated stress risers or complex plating. Hemiarthroplasty (B) or THA (C) for the neck with separate shaft fixation would be more invasive and complex. Cannulated screws (A) are generally not adequate for displaced neck fractures in this age group, and plate fixation for the shaft is often less preferred than nailing. External fixation (E) is typically temporary.

Question 51

What is the most common nerve injured in association with a fracture of the fibular neck?





Explanation

The common peroneal nerve (D) courses directly around the fibular neck, making it highly susceptible to injury (stretch, compression, or direct trauma) in fractures of the fibular neck. Injury to this nerve typically results in foot drop (weakness of ankle dorsiflexion and eversion) and sensory loss in the dorsum of the foot. The tibial nerve (A) and posterior tibial nerve (E) are located medially and deep, while the sural (B) and saphenous (C) nerves are sensory only and less commonly injured in this specific fracture.

Question 52

A 32-year-old male sustains a high-energy posterior hip dislocation. After successful closed reduction, a post-reduction CT scan shows a small, non-displaced articular impaction of the femoral head. What is the most appropriate management?





Explanation

Following a posterior hip dislocation, even small articular impaction fractures of the femoral head (Pipkin type I or II) should be managed with strict non-weight-bearing for 6-8 weeks, combined with protected range of motion (C) to prevent further damage to the articular cartilage and allow for healing. Weight-bearing (A) or skeletal traction (B) are inappropriate. Open reduction (D) is typically reserved for larger, displaced Pipkin fractures or incarcerated fragments. Total hip arthroplasty (E) is a salvage procedure for established post-traumatic arthritis or severe femoral head damage.

Question 53

What is the most crucial consideration in preventing deep infection in a Grade IIIB open tibia fracture?





Explanation

Adequate and timely surgical debridement of devitalized tissue (C) is unequivocally the most crucial factor in preventing deep infection in open fractures, especially Gustilo-Anderson IIIB injuries. Devitalized tissue (skin, muscle, bone) serves as a nidus for bacterial growth, hindering the body's immune response and antibiotic penetration. While antibiotics (A) are essential, they are adjunctive to debridement. Anatomical reduction (B) is important for function but secondary to infection control. External fixation (D) provides stability but doesn't address the biological environment. Early weight-bearing (E) is post-operative and doesn't directly prevent infection.

Question 54

A 25-year-old male sustains a spiral fracture of the distal tibia extending into the ankle joint (Pilon fracture). The fracture is closed, but the ankle is severely swollen. What is the most appropriate immediate definitive fixation strategy?





Explanation

For a closed Pilon fracture with severe soft tissue swelling, a staged approach is generally preferred. The initial step is to stabilize the joint and reduce swelling with a spanning external fixator (B), often with fibular fixation. This allows the soft tissue envelope to recover ('wrinkle sign') before definitive open reduction and internal fixation (ORIF). Immediate ORIF (A) in the presence of severe swelling carries a high risk of wound complications and infection. Intramedullary nailing (C) is generally not suitable for articular fractures. Long leg cast (D) does not provide adequate stability or allow for soft tissue monitoring. Percutaneous screws (E) are insufficient for complex articular fractures.

Question 55

Which of the following is an accepted indication for acute knee arthroscopy in the setting of an acute tibial plateau fracture?





Explanation

Acute knee arthroscopy can be a valuable adjunct in the management of tibial plateau fractures. It allows for direct visualization and evaluation of articular cartilage integrity (A), repair of associated meniscal tears (B) (which are common), removal of incarcerated intra-articular fragments (C), and assessment of associated ligamentous injuries (D). Therefore, 'All of the above' (E) is the most accurate answer, highlighting the utility of arthroscopy in these complex injuries.

Question 56

A 72-year-old male with a history of Parkinson's disease sustains a comminuted, displaced intertrochanteric hip fracture. What is the most critical consideration for his post-operative management?





Explanation

For an elderly patient with significant comorbidities like Parkinson's disease and an intertrochanteric hip fracture, preventing complications of immobility is paramount. These patients are at high risk for pneumonia, pressure ulcers, DVT/PE, and delirium due to prolonged bed rest and anesthesia. Therefore, aggressive mobilization, despite the fracture, and vigilant nursing care focusing on respiratory hygiene, skin integrity, and early ambulation (within the limits of fixation) are critical (C). Early full weight-bearing (A) may not be possible depending on fracture stability and fixation. Aggressive range of motion (B) is not the immediate priority for hip fractures. Pain control (D) is important but is a means to allow mobilization. Referral to rehab (E) is a later step.

Question 57

What is the most common complication following surgical repair of a high-energy Lisfranc injury?





Explanation

The most common and debilitating complication following surgical repair of a high-energy Lisfranc injury is post-traumatic arthritis (D). Despite meticulous anatomical reduction and stable fixation, the initial severe cartilage damage and persistent subtle incongruity can lead to degenerative changes, chronic pain, and functional limitations, often requiring a fusion procedure. While hardware failure (B) and nonunion (A) can occur, post-traumatic arthritis is far more prevalent as a long-term sequela. Infection (C) and nerve injury (E) are less common.

Question 58

A 20-year-old male presents with a Grade II open femoral shaft fracture. He is hemodynamically stable. After initial debridement and external fixation, what is the ideal timing for conversion to intramedullary nailing?





Explanation

For a Gustilo-Anderson Grade II open femoral shaft fracture, after thorough initial debridement and external fixation, the ideal timing for conversion to intramedullary nailing is typically when the wound is clean, healthy, and showing signs of granulation, usually within 7-14 days (D). This staged approach minimizes the risk of infection associated with early definitive fixation in an open wound while providing stability and promoting healing. Converting too early (A, B, C) increases infection risk. Waiting too long (E) can lead to difficulties with reduction and nonunion.

Question 59

Which of the following is the hallmark radiological sign of an acute Lisfranc injury on a weight-bearing AP view of the foot?





Explanation

The hallmark radiological sign of an acute Lisfranc injury on a weight-bearing AP view of the foot is an increased space (diastasis) between the medial cuneiform and the base of the second metatarsal (C). This widening indicates disruption of the Lisfranc ligament complex, which connects these two bones and is crucial for midfoot stability. Options A and B describe other potential midfoot disruptions but are not the primary diagnostic sign for the Lisfranc joint itself. Loss of arch height (D) can be a general sign but is less specific. Navicular fracture (E) is a separate injury.

Question 60

A 65-year-old female sustains a comminuted distal femur fracture (AO/OTA 33-C3). She has severe osteoporosis. What is the most appropriate definitive surgical management?





Explanation

For a comminuted distal femur fracture, especially in an osteoporotic patient, open reduction and internal fixation with a locking plate (D) is generally the preferred definitive surgical management. Locking plates provide angular stability, which is crucial in osteoporotic bone, allowing for fixation of comminuted fragments without relying on screw purchase in poor bone stock. While intramedullary nailing (B, C) can be used for some distal femur fractures, they are less suitable for highly comminuted articular fractures where anatomical reduction and stability of the condyles are paramount. Skeletal traction (A) is not definitive. Total knee arthroplasty (E) is a salvage procedure for severe articular destruction, not typically an acute fracture fixation.

Question 61

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





Explanation

The primary goal of surgical management for an intra-articular calcaneal fracture is to achieve anatomical reduction of the posterior subtalar facet (C). Restoration of this articular surface is critical to minimize the risk of post-traumatic subtalar arthritis, which is the most common long-term complication. While restoring Böhler's and Gissane's angles (B) are important indicators of overall calcaneal morphology, they are secondary to the articular reduction. Rigid fixation (A) is a means to achieve the goal, not the goal itself. Decompressing peroneal tendons (D) might be an associated step but not the primary goal. Preventing DVT (E) is a general post-operative concern.

Question 62

Which of the following is considered an absolute contraindication to closed reduction of a knee dislocation?





Explanation

An open knee dislocation (C) is an absolute contraindication to closed reduction due to the risk of introducing bacteria into the joint and deep tissues, potentially leading to severe infection. Open dislocations require immediate surgical debridement and reduction in the operating room. While associated popliteal artery injury (B) is a critical concern, it does not contraindicate closed reduction; instead, reduction should be performed as quickly as possible to restore perfusion, followed by vascular assessment/repair. Age (A), obesity (D), and multiple ligament ruptures (E) are not contraindications to reduction.

Question 63

A 40-year-old male sustains a traumatic posterior hip dislocation. Which of the following conditions mandates open reduction, even after an attempt at closed reduction has failed?





Explanation

If closed reduction of a traumatic hip dislocation is unsuccessful or if post-reduction imaging (CT scan) reveals incarcerated intra-articular fragments (B), then open reduction is mandated. Incarcerated fragments prevent concentric reduction and significantly increase the risk of post-traumatic arthritis and re-dislocation. They must be removed. A concomitant femoral shaft fracture (A) is a 'floating hip' but doesn't necessarily contraindicate successful closed reduction of the hip. Avulsion fracture of the greater trochanter (C) is usually managed differently. Sciatic nerve palsy (D) is a complication, not an indication for open reduction itself. Obesity (E) makes reduction difficult but doesn't mandate open reduction on its own.

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