ORTHOPEDIC MCQS FREE 2023
1) What percentage of patients will complain of knee pain at the time of union of a tibial shaft fracture treated with a reamed intramedullary nail?
1. <10%
2. 10-33%
3. 33-50%
4. 50-75%
5. >75%
Corrent answer: 4
Anterior knee pain is the most common complication after intramedullary nailing of the tibia. Dissection of the patellar tendon and its sheath during transtendinous nailing was thought to be a contributing cause of chronic anterior knee pain.
The referenced paper by Toivanen et al. compared two different nail-insertion techniques in 50 patients who were randomized to treatment with paratendinous or transtendinous nailing. Sixty-seven percent of the transtendinous and seventy-one percent of the paratendinous approaches resulted in patients with postoperative anterior knee pain. The same authors published an 8 year follow-up which showed that the percentage dropped down to 29%, but there was still no advantage of paratendinous over the transtendinous approach.
In the more recent study by Lefaivre with an average patient follow up of 14 years, knee pain was present in greater than 70% of the respondents.
2) A 28-year-old man is thrown from his motorcycle and sustains the closed injury seen in Figure A. The limb remains neurovascularly intact. What is the most appropriate initial treatment of this injury?
1. Bulky compressive splint
2. Open reduction and internal fixation
3. Closed intramedullary nailing
4. Spanning external fixation
5. Hinged spanning external fixation
Corrent answer: 4
Figure A shows a significantly displaced, high-energy proximal tibia fracture with intra-articular extension. Appropriate initial treatment includes application of a spanning external fixation device with fasciotomy if needed.
The referenced article by Egol et al noted a low rate of wound infection, improved access to soft tissues, prevention of further articular damage, and osseous stabilization. They reported the downside being residual knee stiffness.
3) The mangled extremity severity score (MESS) utilizes all of the following variables EXCEPT:
1. Limb ischemia
2. Shock
3. Patient age
4. Skeletal and soft tissue injury
5. Time from admission to surgery
Corrent answer: 5
The MESS is a tool utilized to help predict limb salvage success versus primary amputation at the time of presentation. As a screening tool for amputation, this scoring system has a high specificity but low sensitivity, as scores lower than 7 may also ultimately need amputation. All of the variables except choice #5 are part of the scoring system.
The scoring system is as follows: 1. Skeletal / soft-tissue injury: Low energy = 1; Medium energy = 2; High energy = 3; very high energy = 4; 2. Limb ischemia: Pulse reduced or absent but perfusion normal = 1; Pulseless = 2; Cool, paralyzed, insensate = 3; 3. Shock: normotensive = 0; transient hypotension = 1; persistent hypotension = 2; 4. Age: < 30 = 0; 30-50 = 1; >50 = 2. Limb category scores are doubled for ischemia > 6 hours. The system's original designers reported a cutoff of 7 as predicting amputation.
The referenced study by Ly et al found that the scoring system did not predict functional outcomes at 6 or 24 months. They also found that the Limb Salvage Index; the Predictive Salvage Index; the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score; and the Hannover Fracture Scale-98 all did not predict outcomes at 6 or 24 months.
4) A 62-year-old man slips on ice and sustains an elbow dislocation. Post-reduction imaging reveals a highly comminuted radial head fracture and coronoid fracture through its base. What is the most appropriate treatment?
1. Early passive range-of-motion in a hinged elbow brace
2. Application of a static spanning external fixator for 6 weeks 3. Radial head excision, coronoid excision, and repair of the lateral ulnar collateral ligament and medial collateral as needed
4. Radial head excision, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed 5. Radial head replacement, open reduction internal fixation of the coronoid,
and repair of the lateral ulnar collateral ligament and medial collateral as needed
Corrent answer: 5
The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and/or stiffness from prolonged immobilization. Therefore radial head replacement and open reduction internal fixation of the coronoid is the most appropriate treatment.
Pugh et al reported their experiences with this difficult population. Their protocol consisted of ORIF or replacement of the radial head, ORIF of the coronoid fracture, repair of the LCL and capsule, and repair of the MCL and/or hinged external fixation. Of the 36 cases, the outcome was graded as 28 excellent to good, 7 fair, and 1 poor. 8 cases required re-operation. The authors concluded that their surgical protocol restored sufficient elbow stability to allow early motion post-op, thereby enhancing the functional outcome. In fracture dislocation of the elbow with radial head and coronoid fracture, the radial head must be fixed or replaced to restore stability. The ORIF of coronoid fracture and radial head restores some valgus stability therefore MCL repair may not be needed. However, the varus stability must be restored by LCL repair.
5) Which of the following has been shown to have similar biochemical and clinical characteristics as iliac crest autograft?
1. BMP-2
2. BMP-7 with collagen matrix carrier
3. Hydroxyapatite cement
4. Platelet rich plasma with allograft cancellous bone carrier 5. Femoral intramedullary reaming contents
Corrent answer: 5
In multiple studies, femoral intramedullary reaming debris has been shown to have similar biochemical characteristics as iliac crest autograft. Intramedullary reaming products have osteogenic potential with viable cells while BMP's are osteoinductive cytokines.
Hoegel et al found that the reamings had alkaline phospatase activity, indicating living osteoblasts. The amount of activity was independent of the reamer sizes and reamer design.
Frolke et al concluded that reaming debris supports callus building (healing) as much as conventional iliac crest bone grafting in an animal fracture gap model.
The video shows a retrograde femoral autograft harvest using the RIA system.
6) After open reduction and internal fixation of long bone fractures, at what time period should C-reactive protein start to decrease?
1. 24 hours
2. 48 hours
3. 96 hours
4. 7 days
5. 12 days
Corrent answer: 2
C-reactive protein (CRP) should peak by 48 hours after surgical fixation of bony orthopedic injuries, and decrease thereafter. This is important to recognize, as an increasing CRP after 48 hours is predictive for postoperative infection, and is more predictive in the first postoperative week than local erythema, persistent serous drainage, and increasing serial ESR.
The first referenced study by Waleczek et al noted that CRP was the earliest sign of developing infection and that clinical diagnosis, ultrasound, and WBC counts all lagged significantly behind CRP as a diagnostic tool. They report that latency to the clinical diagnosis based on clinical signs, ultrasound, WBC in blood and wound drainage was up to 14 days, while there was no patient with CRP increasing after day 2 without an infection.
The second referenced article by de Zwart et al noted an increased sensitivity and specificity of CRP as compared to ESR in the scenario of a clinically suspected infection. They advocate for determination of two CRP-levels with a short interval to screen for a clinically suspected infection.
Furthermore, Mok et al found that CRP showed an exponential decrease with a half-life of 2.6 days in postoperative spine patients. They found that CRP is a reliable test in the early postoperative period compared with ESR.
OrthoCash 2020
7) Which of the following is the most appropriate clinical scenario to utilize locking plate and screw technology?
1. Intra-articular fracture
2. Oblique ulnar diaphyseal fracture
3. Osteoporotic periprosthetic distal femur fracture
4. Transverse tibial diaphyseal fracture
5. Spiral humeral diaphyseal-metaphyseal fracture
Corrent answer: 3
Conventional plating provides stable internal fixation when fractures are anatomically reduced. Stability of this type of fixation relies on the plate/bone interface and the friction that develops between this interface. Locked plates rely on the plate/screw interface, and each provides not only axial stability but also angular stability; each screw acts as a fixed angle device. Indications for locked plating for indirect reduction include: 1. metaphyseal/diaphyseal fractures 2. comminuted diaphyseal fractures 3. comminuted metaphyseal fractures. 4. short segment fixation. Locked plates are not indicated for displaced articular fractures unless anatomic rigid fixation of the articular surface is done first (locking technology cannot reduce fractures/lag segments together).
The referenced article by Gardner et al reviews locking technology and reminds us that compression technology using non-locking screws and plates is still needed for many fractures and is even required for proper treatment of some fractures.
The referenced article by Wagner is an instructional paper on how to use hybrid plating technology and reviews concepts such as the necessity of lag screw fixation before locking.
The referenced study by Egol et al is a review paper that notes that locked plates and conventional plates rely on completely different mechanical principles to provide fracture fixation and in so doing they provide different biological environments for healing. They report that locked plates are indicated for: indirect fracture reduction, diaphyseal/metaphyseal fractures in osteoporotic bone, and with bridging severely comminuted fractures.
8) Which muscles cause the fracture displacement of the proximal fragment shown in figure A?
1. gluteus maximus and adductors
2. gluteus maximus and rectus femoris
3. gluteus medius and hamstrings
4. gluteus medius and iliopsoas
5. rectus femoris and hamstrings
Corrent answer: 4
The gluteus medius attaches to the greater trochanter, leading to abduction, while the iliopsoas attaches to the lesser trochanter, leading to flexion. French et al evaluated forty-five Russell-Taylor Type 1B subtrochanteric femoral fractures which were stabilized using an interlocked cephalomedullary nail. The intraoperative complication rate was 13.5%; and the most frequent complication was a varus malreduction. The primary reason for this was failure to counteract the muscle forces acting on the proximal fragment combined with the adducted position of the distal femur during portal creation. This problem can be avoided if the position of the proximal fragment is evaluated carefully and reduced before guidewire insertion.
9) Which of the following is true of a knee disarticulation as compared to a transtibial amputation?
1. Faster self-selected walking speeds
2. Improved performance on the Sickness Impact Profile (SIP) questionnaire
3. Physicians were more satisfied with the cosmetic appearance 4. Decreased use of a prosthetic
5. Decreased dependence with patient transfers
Corrent answer: 4
Knee disarticulation level is associated with the worst functional result 2 years after injury (compared to transmetatarsal, Symes, AKA, or BKA). The prosthetic use is decreased with a knee disarticulation as compared to a transtibial amputation.
The cohort study by MacKenzie et al prospectively followed 161 patients that were part of the Lower Extremity Assessment Project (LEAP). These patients underwent an above-the-ankle amputation at a trauma center within 3 months following the injury and followed for 2 years. This study revealed that through the-knee amputations had significantly worse scores for the objective performance measures of self-selected walking speed, independence in transfers, walking, and stair-climbing. Through-the-knee amputees also had worse SIP scores than AKA and BKA patients. Physicians were also less satisfied with both the clinical and the cosmetic recovery of the patients with a through-the-knee amputation. It should be noted that patients with a BKA had a faster walking speed than those with an AKA. Despite the worse SIP scores for through-the-knee amputations, patients actually reported less pain than those with an AKA or BKA, though this wasn't statistically significant.
10) During open reduction and internal fixation of a both bone forearm fracture, restoration of the radial bow has been most associated with which of the following?
1. Improvement in wrist extension strength
2. Improvement in wrist flexion strength
3. Restoration of forearm rotation
4. Restoration of elbow range of motion
5. Decreased incidence of synostosis
Corrent answer: 3
Restoration of the anatomy of the radial bow directly correlates with the range of motion postoperatively (pronation-supination).
The referenced study by Schemitsch et al found that restoration of the normal radial bow was related to the functional outcome. A good functional result
(more than 80 percent of normal rotation of the forearm) was associated with restoration of the normal amount and location of the radial bow. Similarly, the recovery of grip strength was associated with restoration of the location of the radial bow toward normal.
11) In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures?
1. Interosseous ligament
2. Anterior inferior tibiofibular ligament
3. Posterior inferior tibiofibular ligament
4. Deltoid ligament
5. Tibiotalar ligament
Corrent answer: 2
The Chaput fragment, highlighted by the arrow in Illustration A, is the anterolateral fragment of the distal tibia. This section of bone attaches to the anterior inferior tibiofibular ligament and is often hinged off this structure due to the fracture. A pilon fracture is often split into three main fragments at the joint level (Illustration B): Chaput fragment (anterolateral), Volkmann fragment (posterolateral), and a medial fragment. The Volkmann fragment is the attachment site of the posterior inferior tibiofibular ligament. The Wagstaff fragment is the fibular corollary to the Chaput fragment, and serves as the other attachment of the anterior inferior tibiofibular ligament.
12) A 55-year-old male is involved in a motor vehicle accident and sustains the injury seen in Figure A. What is the most appropriate treatment for this type of injury?
