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

Question 1

A 25-year-old male sustains a severe open tibia fracture with extensive soft tissue stripping (Gustilo-Anderson IIIB) after a motorcycle collision.

What is the most critical factor in reducing the risk of deep infection in this patient?

Explanation

The early administration of systemic antibiotics is the single most important factor in preventing infection in open fractures. Historically, the '6-hour rule' for operative debridement was considered paramount; however, recent large studies have debunked this, showing no significant difference in infection rates between debridement before or after 6 hours, provided antibiotics are given promptly.

Question 2

A 40-year-old male is brought to the trauma bay after a severe motor vehicle crash. He is hemodynamically unstable with a blood pressure of 80/50 mmHg. Radiographs show an anteroposterior compression (APC-III) pelvic ring injury.

A circumferential pelvic binder is indicated. What is the most appropriate anatomical landmark for the correct placement of the pelvic binder?

Explanation

A pelvic binder should be centered over the greater trochanters. Placement at the level of the greater trochanters provides the most effective mechanical advantage to close the pelvic ring, decrease pelvic volume, and promote tamponade of venous bleeding. Placement higher (e.g., iliac crests) can paradoxically widen the symphysis in some fracture patterns.

Question 3

A 28-year-old male sustains a vertically oriented (Pauwels type III) femoral neck fracture. What fixation construct provides the most biomechanically stable fixation to resist the high shear forces associated with this fracture pattern?

Explanation

Pauwels type III fractures are highly vertical and subjected to significant shear forces, leading to a high rate of displacement and nonunion when treated with multiple cancellous screws alone. A fixed-angle device, such as a sliding hip screw (SHS) combined with an anti-rotation (derotation) screw, provides superior biomechanical stability against shear stress in young patients requiring joint preservation.

Question 4

A 32-year-old male presents with a closed midshaft tibia fracture treated with closed reduction and casting. Twelve hours later, he complains of severe pain out of proportion to the injury. Which of the following is the most sensitive early clinical sign of acute compartment syndrome?

Explanation

Pain with passive stretch of the muscles in the affected compartment is typically the earliest and most sensitive clinical sign of acute compartment syndrome. Pulselessness, pallor, and paralysis are late signs indicating irreversible ischemia. A high index of suspicion is required to diagnose compartment syndrome before nerve and muscle necrosis occurs.

Question 5

A 55-year-old female sustains a volar Barton's fracture of the distal radius. Which of the following carpal bones is most likely to subluxate volarly along with the fracture fragment?

Explanation

In a volar Barton's fracture, the volar marginal fragment of the distal radius shears off. The strong short and long radiolunate ligaments remain attached to this fragment, causing the lunate (and the rest of the carpus) to subluxate volarly with the fractured radius margin. Therefore, the lunate strictly follows the volar fragment.

Question 6

A 45-year-old male sustains a coronal plane fracture of the lateral femoral condyle (Hoffa fracture) after a high-speed collision. Which of the following is true regarding the characteristics and management of this injury?

Explanation

A Hoffa fracture is a coronal shear fracture of the femoral condyle, usually involving the posterior aspect of the lateral condyle. It is an unstable, intra-articular fracture that requires open reduction and internal fixation (typically with lag screws) to restore the articular surface and prevent post-traumatic arthritis. It is often missed on AP radiographs and is best seen on lateral radiographs or CT scans.

Question 7

Which of the following scenarios is considered an absolute indication for the operative treatment of an acute midshaft clavicle fracture?

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, fractures with impending skin breakdown (tenting), and fractures associated with neurovascular injury (e.g., subclavian artery injury). Shortening > 2cm, 100% displacement, and severe comminution are considered relative indications where surgery may improve functional outcomes or decrease nonunion rates.

Question 8

A 22-year-old male falls on an outstretched hand and sustains a fracture of the proximal pole of the scaphoid.

He undergoes percutaneous fixation. What is the primary arterial supply to the proximal pole of the scaphoid that places it at high risk for avascular necrosis?

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery. These vessels enter the scaphoid at the dorsal ridge (near the waist) and supply the proximal pole in a retrograde fashion. Therefore, fractures at the waist or proximal pole disrupt this delicate retrograde supply, leading to a high rate of avascular necrosis and nonunion.

Question 9

A 60-year-old female sustains a Schatzker type II tibial plateau fracture. During surgical fixation, elevation of the depressed lateral articular fragment is performed, leaving a large metaphyseal void.

What is the most appropriate intraoperative step to address this void?

Explanation

When a depressed articular segment in a tibial plateau fracture is elevated to restore joint congruity, it creates a metaphyseal void. This void must be filled with bone graft (autograft, allograft) or a structural bone substitute (e.g., calcium phosphate cement) to mechanically support the elevated articular surface and prevent secondary subsidence before the bone heals.

Question 10

A 35-year-old male sustains a high-energy acetabular fracture.

Imaging reveals involvement of both the anterior and posterior columns. Crucially, no portion of the articular surface remains attached to the intact axial skeleton (ilium). What is the correct Judet-Letournel classification for this fracture pattern?

Explanation

A both-column acetabular fracture is uniquely defined by the entire articular surface being detached from the intact ilium (the intact axial skeleton). This is radiographically identified by the 'spur sign' on the obturator oblique view, which represents the intact portion of the ilium protruding above the displaced acetabular roof.

Question 11

A 29-year-old snowboarder sustains a Hawkins type III fracture of the talar neck.

On follow-up radiographs taken 6-8 weeks post-injury, a subchondral radiolucent band is noted in the talar dome (Hawkins sign). What does this radiographic finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucent band visible in the talar dome on AP or mortise views around 6-8 weeks after a talar neck fracture. It represents disuse osteopenia, which can only occur if the bone has an intact blood supply allowing for osteoclastic resorption. Thus, a positive Hawkins sign reliably rules out avascular necrosis of the talar body.

Question 12

A 40-year-old female falls from a height and sustains a 'terrible triad' injury of the elbow.

This complex injury pattern is associated with profound instability. Which of the following defines the three components of the terrible triad of the elbow?

Explanation

The terrible triad of the elbow describes a traumatic elbow dislocation accompanied by fractures of the radial head and the coronoid process. It typically involves disruption of the lateral collateral ligament (LCL) complex as the elbow dislocates posterolaterally. Restoring stability involves fixing or replacing the radial head, fixing the coronoid, and repairing the LCL.

Question 13

A 35-year-old male sustains a pronation-external rotation (Weber C) ankle fracture.

Intraoperatively, after rigid internal fixation of the fibula, the surgeon performs a 'Cotton test' by applying a lateral pull on the fibula using a bone hook. What ligamentous structure is primarily being assessed for integrity?

Explanation

The Cotton test (lateral stress test) is used intraoperatively to assess the integrity of the distal tibiofibular syndesmosis. After fixing the lateral malleolus, a lateral force is applied to the fibula. Widening of the tibiofibular clear space on fluoroscopy indicates syndesmotic instability, which requires stabilization (e.g., syndesmotic screws or suture button construct).

Question 14

A 45-year-old roofer falls 15 feet, landing on his heels, and sustains bilateral intra-articular calcaneus fractures.

Which of the following radiographic angles is characteristically decreased, flattened, or inverted in this injury pattern due to posterior facet collapse?

Explanation

Bohler's angle is formed by drawing a line from the highest point of the anterior process to the highest point of the posterior facet, and another line from the posterior facet to the superior edge of the calcaneal tuberosity. The normal angle is 20 to 40 degrees. In intra-articular fractures, depression of the posterior facet causes Bohler's angle to decrease, flatten, or become negative (inverted).

Question 15

A 50-year-old male presents with a high-energy closed pilon fracture. Clinical examination reveals severe soft tissue swelling and the presence of fracture blisters around the ankle.

What is the most appropriate initial management for this injury?

Explanation

High-energy pilon fractures are fraught with soft tissue complications if treated with early open surgery. The standard of care is a staged protocol: initial application of a joint-spanning external fixator (to restore length and alignment) and elevation. Definitive internal fixation is delayed until the soft tissue envelope recovers, usually indicated by the return of skin wrinkles ('wrinkle sign'), typically 10-21 days post-injury.

Question 16

A 25-year-old male is involved in a motor vehicle crash and sustains an isolated, closed midshaft femur fracture. He is resuscitated in the trauma bay and is hemodynamically stable.

What is the optimal timing for intramedullary nailing of his femur to minimize the risk of pulmonary complications (such as ARDS)?

Explanation

In a hemodynamically stable patient with an isolated femur fracture, early definitive fixation (Early Total Care, typically within 24 hours) is indicated. It significantly decreases the incidence of pulmonary complications, acute respiratory distress syndrome (ARDS), and overall mortality by mobilizing the patient early and reducing systemic inflammatory response.

Question 17

A 6-year-old boy falls off the monkey bars and sustains a widely displaced, extension-type supracondylar humerus fracture.

On examination, the hand is pink and capillary refill is normal, but the radial pulse is absent. What is the most appropriate next step in management?

Explanation

A 'pulseless, pink' hand in the setting of a displaced pediatric supracondylar humerus fracture indicates that collateral circulation is adequate despite kinking or spasm of the brachial artery. The most appropriate immediate step is urgent closed reduction and percutaneous pinning. The pulse typically returns once the fracture is anatomically reduced and the artery is unkinked.

Question 18

A 30-year-old male football player sustains a hyperplantarflexion injury to his midfoot. Radiographs demonstrate widening of the space between the medial cuneiform and the second metatarsal base.

This finding signifies a disruption of the Lisfranc ligament. The Lisfranc ligament anatomically connects which two osseous structures?

Explanation

The Lisfranc ligament is a crucial, strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. There is no ligamentous connection between the bases of the first and second metatarsals, making this area vulnerable to disruption.

Question 19

A 65-year-old female sustains a displaced 4-part proximal humerus fracture.

Recent anatomical studies (e.g., Hettrich et al.) have redefined the primary blood supply to the humeral head. Based on current evidence, which artery provides the predominant blood supply to the humeral head, placing it at risk for avascular necrosis?

Explanation

Classical teaching stated that the anterior humeral circumflex artery (via the arcuate artery) was the main blood supply. However, recent MRI and anatomical studies by Hettrich et al. demonstrated that the posterior humeral circumflex artery provides the predominant blood supply (up to 64%) to the humeral head. Disruption of these vessels in 4-part fractures leads to a high risk of avascular necrosis.

Question 20

A 50-year-old male is undergoing open reduction and internal fixation of an anterior column acetabular fracture via the ilioinguinal approach.

During dissection over the superior pubic ramus, the surgeon encounters significant bleeding. Which of the following vascular anastomoses (often termed the 'Corona Mortis') is classically located in this region and at risk of iatrogenic injury?

Explanation

The Corona Mortis ('crown of death') is a vascular anastomosis between the obturator vessels (which are part of the internal iliac system) and the external iliac or inferior epigastric vessels. It crosses the superior pubic ramus. Iatrogenic injury during the ilioinguinal or Stoppa approach can cause massive, difficult-to-control hemorrhage.

Question 21

A 28-year-old polytrauma patient presents with bilateral femoral shaft fractures and a severe pulmonary contusion. His admission lactate is 4.5 mmol/L, base deficit is 8 mEq/L, and he is hemodynamically transiently responsive to fluids. According to the principles of Damage Control Orthopedics (DCO), what is the most appropriate initial management of his femoral fractures?

Explanation

This patient is considered borderline/unstable based on elevated lactate, high base deficit, and severe chest injury. Damage Control Orthopedics (DCO) using temporary external fixation is indicated to minimize the "second hit" of systemic inflammation associated with intramedullary nailing.

Question 22

A 35-year-old construction worker falls from a scaffolding. Pelvic radiographs are obtained, and the obturator oblique view demonstrates a pathognomonic "spur sign." What acetabular fracture pattern does this sign indicate?

Explanation

The "spur sign" on the obturator oblique radiograph represents the intact portion of the ilium that remains attached to the axial skeleton. It is pathognomonic for an associated both-column acetabular fracture.

Question 23

A 24-year-old male undergoes reamed intramedullary nailing for a closed midshaft tibia fracture. Four hours postoperatively, he complains of escalating leg pain out of proportion to the injury. His blood pressure is 110/65 mmHg. Intracompartmental pressure testing reveals an anterior compartment pressure of 40 mmHg. What is the most appropriate next step in management?

Explanation

The diagnosis of acute compartment syndrome is largely clinical but is confirmed when the delta pressure (diastolic blood pressure minus compartment pressure) is less than 30 mmHg. Here, the delta pressure is 25 mmHg (65 - 40), mandating immediate four-compartment fasciotomy.

Question 24

A 45-year-old female sustains a high-energy supracondylar femur fracture. Computed tomography reveals a displaced coronal shear fracture of the lateral femoral condyle (Hoffa fragment).

What is the most biomechanically sound fixation strategy for this specific fragment?

Explanation

Hoffa fractures are coronal plane intra-articular shear injuries. They must be anatomically reduced and stabilized with independent AP or PA interfragmentary lag screws placed orthogonal to the fracture line prior to neutralization plating.

Question 25

A 32-year-old male is involved in a severe motor vehicle accident and sustains a displaced fracture of the talar neck with subtalar and tibiotalar dislocation (Hawkins Type III). Which of the following vessels provides the predominant blood supply to the talar body and is at greatest risk in this injury?

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the majority of the blood supply to the talar body. Displaced talar neck fractures carry a high risk of osteonecrosis due to the disruption of this retrograde blood supply.

Question 26

A 22-year-old motorcyclist is thrown from his bike. He presents with massive swelling over the left shoulder, an absent radial pulse, and complete paralysis of the left upper extremity. Chest radiograph demonstrates a widely displaced clavicle fracture with severe lateral displacement of the scapula. What is the most appropriate next step after stabilizing his airway and breathing?

Explanation

This clinical picture represents scapulothoracic dissociation, a devastating injury highly associated with subclavian or axillary vascular disruption and brachial plexus avulsion. Urgent vascular assessment with CT angiography (or immediate surgical exploration if actively exsanguinating) is critical.

Question 27

A 50-year-old male sustains a Gustilo-Anderson IIIB open fracture of the proximal third of the tibia. After aggressive serial debridements, a 6 cm x 4 cm anterior soft tissue defect exposes the bare bone and the proximal tibial plate. What is the most appropriate soft tissue coverage option?

Explanation

Soft tissue defects in the proximal third of the tibia are classically best covered with a pedicled medial (or lateral) gastrocnemius muscle rotational flap. The soleus flap is preferred for the middle third, while the distal third typically requires free tissue transfer.

Question 28

An 82-year-old female presents with a displaced intertrochanteric femur fracture. She has a history of coronary stents placed 2 years ago and takes clopidogrel (Plavix) daily. According to current AAOS guidelines, what is the safest and most effective approach regarding the timing of her surgery?

Explanation

Current AAOS guidelines strongly recommend operative fixation of geriatric hip fractures within 48 hours to decrease mortality and complications. Delaying surgery for clopidogrel washout is not indicated and increases overall morbidity.

Question 29

A 40-year-old male arrives in the trauma bay hypotensive and tachycardic. Radiographs confirm an anteroposterior compression type III (APC-III) pelvic ring injury. After application of a circumferential pelvic binder and transfusion of 2 units of packed red blood cells, his blood pressure remains 75/40 mmHg. A FAST examination is negative. What is the most appropriate next step in management?

Explanation

In a hemodynamically unstable patient with an unstable pelvic ring injury and a negative FAST scan, the source of bleeding is primarily presumed to be retroperitoneal/pelvic (venous plexus or arterial). The gold standard interventions are preperitoneal pelvic packing and/or angiography for embolization.

Question 30

A 35-year-old female falls onto a fully extended knee. Radiographs reveal a depressed, split fracture of the medial tibial plateau.

What is the classic mechanism of injury for this Schatzker IV fracture, and what surgical approach is typically required?

Explanation

A Schatzker IV fracture involves the medial tibial plateau and is typically caused by a high-energy varus force combined with axial loading. It requires a medial or posteromedial approach to apply an anti-glide buttress plate to prevent varus collapse.

Question 31

A 26-year-old male presents with a closed, transverse fracture of the middle third of the humeral shaft following an arm wrestling match. Physical examination reveals an inability to extend the wrist and fingers, with numbness in the first dorsal web space, which was present immediately after the injury. What is the most appropriate initial management of this neurologic deficit?

Explanation

Immediate complete radial nerve palsy in the setting of a closed humeral shaft fracture is mostly a neuropraxia or axonotmesis. Standard of care is functional bracing and observation, as over 70% will spontaneously recover within 3 to 4 months.

Question 32

A 30-year-old football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs show widening between the first and second metatarsals, and a small bony avulsion is noted in the intercuneiform space (the "fleck sign"). The Lisfranc ligament, responsible for this sign, connects which two anatomical structures?

Explanation

The Lisfranc ligament is a strong interosseous ligament that attaches the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. The "fleck sign" represents a bony avulsion of this ligament and is pathognomonic for a Lisfranc injury.

Question 33

A 14-month-old non-ambulatory child is brought to the emergency department crying with a swollen right thigh. Radiographs demonstrate a displaced spiral fracture of the femoral shaft. The parents state the child caught his leg in the crib slats. What is the most appropriate next step in management?

Explanation

Femoral shaft fractures (particularly spiral patterns) in non-ambulatory children are highly suspicious for non-accidental trauma (NAT) due to the torsional force required. Mandatory steps include admitting the child, consulting child protection services, and obtaining a full skeletal survey.

Question 34

A 55-year-old female was treated non-operatively with a cast for a non-displaced Colles fracture. Six weeks post-injury, she returns to the clinic reporting a sudden, painless inability to extend the interphalangeal joint of her thumb. What is the most likely etiology of her new deficit?

Explanation

Extensor pollicis longus (EPL) tendon rupture is a well-known complication of non-displaced distal radius fractures. It occurs due to attritional wear against the fracture callus at Lister's tubercle or vascular compromise within the intact third extensor compartment.

Question 35

A 68-year-old female on alendronate for 12 years presents with a low-energy transverse subtrochanteric fracture of the right femur with lateral cortical "beaking." She complains of 3 months of aching pain in her left thigh as well. Radiographs of the left femur show lateral cortical thickening but no complete fracture. What is the recommended management for the left femur?

Explanation

This patient has an atypical femur fracture associated with long-term bisphosphonate use. The presence of prodromal pain and radiographic lateral cortical thickening on the contralateral side indicates an impending fracture, necessitating prophylactic intramedullary nailing.

Question 36

A 45-year-old male sustains a displaced intra-articular calcaneus fracture (Sanders type III). Surgical fixation via an extensile lateral approach is planned. Which of the following patient factors is the most significant independent predictor for postoperative wound necrosis and deep infection?

Explanation

Active smoking is the most significant risk factor for wound edge necrosis, dehiscence, and deep infection following the extensile lateral approach to the calcaneus. The risk of wound complications is significantly magnified due to nicotine-induced microvascular vasoconstriction.

Question 37

A 38-year-old male presents with a severely displaced, comminuted distal tibia fracture (pilon fracture) extending into the tibiotalar joint. The ankle is massively swollen with multiple hemorrhagic fracture blisters. What is the most appropriate initial surgical management?

Explanation

High-energy pilon fractures with severe soft tissue injury (fracture blisters, massive swelling) mandate a staged protocol. A spanning external fixator restores length and alignment while allowing the soft tissue envelope to heal (usually 1-3 weeks) prior to definitive ORIF.

Question 38

A 25-year-old hemodynamically stable male sustains an ipsilateral midshaft femur and midshaft tibia fracture ("floating knee") in a motorcycle collision. Assuming both fractures are amenable to intramedullary nailing, what is the most widely accepted sequence of operative fixation?

Explanation

In a hemodynamically stable patient with a floating knee, it is standard practice to fix the femur first. Stabilizing the femur eliminates the larger lever arm, prevents further soft tissue injury, and facilitates positioning of the leg for the subsequent tibial nailing.

Question 39

A 75-year-old female presents with a periprosthetic femur fracture around a cemented, polished taper-slip femoral stem sustained after a mechanical fall. Radiographs demonstrate that the fracture extends distal to the lesser trochanter but remains proximal to the tip of the stem. The stem is radiographically loose. According to the Vancouver classification, what is the most appropriate definitive management?

Explanation

This is a Vancouver B2 periprosthetic fracture (fracture around a loose stem with adequate bone stock). The gold standard treatment is revision arthroplasty using a long, fully porous-coated or modular fluted tapered stem that bypasses the fracture by at least two cortical diameters.

Question 40

A 45-year-old male is struck by a vehicle and sustains the injury shown in the reference radiograph.

The imaging confirms a highly depressed, isolated medial tibial plateau fracture (Schatzker IV) with a varus deformity. Which of the following surgical approaches and fixation strategies is most appropriate?

Explanation

Schatzker IV fractures involving the medial plateau typically feature a posteromedial shear fragment. A posteromedial approach allows for the application of an anti-glide buttress plate to directly counteract the deforming varus shear forces.

Question 41

A 24-year-old male falls onto an outstretched hand, sustaining a proximal pole scaphoid fracture. The high risk of avascular necrosis (AVN) in this fracture pattern is directly related to the retrograde blood supply of the scaphoid. The primary arterial supply to the proximal pole enters at which of the following anatomical locations?

Explanation

The primary blood supply to the scaphoid is derived from the dorsal carpal branch of the radial artery, which enters at the dorsal ridge near the waist and flows in a retrograde fashion to supply the proximal pole.

Question 42

A 68-year-old female sustains a 4-part proximal humerus fracture. Recent quantitative anatomic studies regarding the arterial supply to the humeral head indicate that which vessel is responsible for providing the majority of the blood supply to the articular segment?

Explanation

Historically, the anterior humeral circumflex artery was thought to be the main blood supply. However, recent studies (e.g., Hettrich et al.) demonstrate that the posterior humeral circumflex artery supplies 64% of the humeral head, providing the most significant portion of its perfusion.

Question 43

A 32-year-old gymnast falls from a height and sustains a 'terrible triad' injury of the elbow. Operative intervention is planned. To properly restore elbow stability in a step-wise fashion, what is the accepted standard sequence of surgical repair?

Explanation

The standard surgical algorithm for a terrible triad injury follows an 'inside-out' approach. The deep anterior structures (coronoid) are repaired first, followed by the radial head, and finally the lateral collateral ligament (LCL) complex.

Question 44

A 22-year-old male undergoes open reduction and intramedullary nailing for a closed tibial shaft fracture. In the recovery room, he complains of unremitting leg pain out of proportion to the injury. Which of the following defines the critical 'Delta P' threshold used to diagnose acute compartment syndrome?

Explanation

The Delta P is calculated as the patient's diastolic blood pressure minus the intracompartmental pressure. A Delta P of less than 30 mmHg is the accepted threshold indicating inadequate perfusion and the need for emergent fasciotomies.

Question 45

A 40-year-old male sustains a severe subtrochanteric femur fracture. Preoperative radiographs demonstrate the classic deformity of the proximal fracture fragment, which is flexed, abducted, and externally rotated. Which muscle is primarily responsible for the flexion deformity of the proximal segment?

Explanation

In a subtrochanteric fracture, the proximal fragment is acted upon by the iliopsoas (causing flexion), the gluteus medius and minimus (causing abduction), and the short external rotators (causing external rotation).

Question 46

A 35-year-old female is diagnosed with a displaced transverse acetabular fracture after a rollover motor vehicle collision. On physical examination, a large, fluctuant, ecchymotic mass is palpated over the ipsilateral greater trochanter. What is the most appropriate management of this soft tissue lesion in the context of planned surgical fixation?

Explanation

A Morel-Lavallée lesion is a closed degloving injury that harbors a high risk of bacterial colonization and deep infection. It requires thorough drainage, debridement, and dead space management (often via percutaneous methods or limited incisions) prior to or simultaneously with underlying fracture fixation.

Question 47

A patient with a talar neck fracture demonstrates a subchondral radiolucent band in the talar dome on a radiograph at 6 weeks (Hawkins sign). What does this finding indicate?

Explanation

The Hawkins sign represents subchondral osteopenia due to hyperemia from intact vascularity. Its presence is highly predictive that avascular necrosis of the talar body will not occur.

Question 48

A 45-year-old female presents with an acetabular fracture after a motor vehicle collision. Computed tomography imaging reveals a fracture extending through the anterior column and the posterior hemitransverse. What is the classic surgical approach for this specific Letournel pattern?

Explanation

Anterior column and posterior hemitransverse fractures are typically addressed via an anterior approach (Ilioinguinal or Stoppa). The primary displacement is anterior, and the posterior component can usually be manipulated indirectly from the anterior window.

Question 49

A 28-year-old male with multiple injuries has a severely comminuted femur fracture, bilateral pulmonary contusions, and a lactate of 4.5 mmol/L. What is the most appropriate initial management of the femur fracture?

Explanation

This patient is physiologically unstable with a high lactate and pulmonary contusions. Damage control orthopedics (DCO) with external fixation is indicated to minimize the second-hit phenomenon associated with intramedullary nailing.

Question 50

A 35-year-old male sustains a closed tibial plateau fracture. Six hours later, he develops severe pain out of proportion to the injury. Which of the following is the most sensitive early clinical finding of acute compartment syndrome?

Explanation

Pain with passive stretch of the muscles within the affected compartment is the most sensitive and earliest clinical sign of acute compartment syndrome. Pulselessness and paralysis are late, often irreversible signs.

Question 51

A 40-year-old male sustains a high-energy trauma resulting in a coronal plane fracture of the lateral femoral condyle (Hoffa fracture). According to biomechanical studies, what is the optimal trajectory for screw fixation to achieve maximum stability?

Explanation

Biomechanical studies demonstrate that posterior-to-anterior screw trajectory provides superior fixation strength for Hoffa fractures. This orientation is more perpendicular to the fracture plane compared to the traditional anterior-to-posterior technique.

Question 52

A 22-year-old cyclist falls onto his shoulder, sustaining a completely displaced, shortened (>2 cm) midshaft clavicle fracture. Compared to nonoperative management, what is the primary advantage of open reduction and internal fixation (ORIF) for this specific fracture pattern?

Explanation

Operative fixation of severely shortened (>2 cm) and completely displaced midshaft clavicle fractures significantly reduces the rate of nonunion and symptomatic malunion compared to conservative management.

Question 53

A 72-year-old female sustains a 4-part proximal humerus fracture. She has a history of severe osteoporosis and osteoarthritis of the glenohumeral joint. Which of the following is the most appropriate surgical treatment?

Explanation

In elderly patients with 4-part proximal humerus fractures, poor bone quality, and preexisting glenohumeral osteoarthritis, reverse total shoulder arthroplasty provides superior and more predictable functional outcomes than ORIF or hemiarthroplasty.

Question 54

Following intramedullary nailing of a proximal third tibial shaft fracture, the fracture is most commonly observed to deviate into which deformity?

Explanation

Proximal third tibial shaft fractures classically displace into valgus and procurvatum (apex anterior) during intramedullary nailing. This is due to the pull of the patellar tendon and the anatomical path of the nail insertion.

Question 55

A 38-year-old male sustains a pelvic ring injury and presents with a large, fluctuant swelling over the greater trochanter with ecchymosis. What is the underlying pathophysiology of this specific soft tissue lesion?

Explanation

A Morel-Lavallee lesion is a closed degloving injury where subcutaneous tissue is sheared off the underlying deep fascia. This creates a potential space that fills with blood, lymph, and necrotic fat, carrying a high risk of infection.

Question 56

A 6-year-old boy falls on an outstretched hand and sustains a Bado Type I Monteggia equivalent fracture. Which of the following describes this classic injury pattern?

Explanation

A Bado Type I Monteggia fracture involves an anterior dislocation of the radial head associated with a fracture of the ulnar diaphysis that is angulated anteriorly. It is the most common Bado type in the pediatric population.

Question 57

A 45-year-old female sustains a 'terrible triad' injury to the elbow. During surgical reconstruction, after fixing the coronoid and radial head, the elbow remains persistently unstable in extension. What is the next most appropriate step?

Explanation

The standard surgical algorithm for a terrible triad injury involves fixation of the coronoid and radial head, followed by repair of the lateral ulnar collateral ligament (LUCL). This restores posterolateral rotatory stability.

Question 58

When treating a completely displaced intra-articular distal radius fracture with a volar locking plate, the plate must be placed proximal to the watershed line to minimize the risk of which complication?

Explanation

The watershed line is the distal margin of the pronator quadratus fossa. Placing a volar plate distal to this line significantly increases the risk of flexor tendon irritation and subsequent rupture, most commonly the flexor pollicis longus (FPL).

Question 59

A 25-year-old agricultural worker sustains a Gustilo-Anderson Type IIIA open tibia fracture heavily contaminated with soil. In addition to a first-generation cephalosporin and an aminoglycoside, what prophylactic antibiotic is indicated?

Explanation

Agricultural injuries or heavily soil-contaminated open fractures carry a high risk of clostridial infection. High-dose penicillin is added to the antibiotic regimen specifically to provide coverage against Clostridium perfringens.

Question 60

A 7-year-old girl sustains an extension-type supracondylar fracture of the humerus that is posteromedially displaced. Which nerve is at the highest risk of injury in this specific displacement pattern?

Explanation

In extension-type supracondylar fractures with posteromedial displacement, the proximal fragment is driven anterolaterally, putting the radial nerve at the highest risk of injury. Posterolateral displacement endangers the median nerve and brachial artery.

Question 61

A 30-year-old male sustains a high-energy basicervical femoral neck fracture. To minimize the risk of avascular necrosis, which of the following is the most critical principle of management?

Explanation

In young adults with femoral neck fractures, urgent anatomic reduction and stable internal fixation are critical to minimize the risk of avascular necrosis and nonunion. While capsulotomy is debated, anatomic reduction is universally recognized as paramount.

Question 62

A 35-year-old male sustains a subtrochanteric femur fracture. During intramedullary nailing, the proximal fragment is typically difficult to reduce due to unopposed muscle forces. What is the characteristic deformity of the proximal fragment and the primary muscle responsible for its flexion?

Explanation

The proximal fragment in a subtrochanteric fracture is flexed by the iliopsoas, abducted by the gluteus medius and minimus, and externally rotated by the short external rotators. Understanding these deforming forces is critical for proper reduction prior to intramedullary nailing.

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

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

Key Takeaway

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

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