UPDATED ORTHOPEDIC MCQS

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. 

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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?

1. Total hip arthroplasty 

2. Bipolar hemi-arthroplasty 

3. Sliding hip screw 

4. Percutaneous screw fixation 

5. Cephalomedullary nail fixation 

Corrent answer: 5 

The radiographs demonstrate a reverse obliquity intertrochanteric femur fracture. Compared to the more stable intertrochanteric femur fracture, a reverse oblique intertrochanteric hip fracture is not optimally treated with a sliding hip screw. Compression along a sliding hip screw is designed to create compression along the plane of the fracture, however in a reverse obliquity fracture pattern as seen here, shear force is created causing medial displacement of the femoral shaft and screw cutout.  

Haidukewych et al showed in their retrospective review of 55 consecutively treated reverse obliquity intertrochanteric fractures, that patients treated with a sliding hip screw had nearly a 56% failure rate (9/16). The failure rate of patients treated with a blade plate was only 13%.  

Sadowski et al showed in their prospective randomized trial in patients with a reverse obliquity or transverse intertrochanteric fracture who were randomized to either a 95 degree screw-plate or cephalomedullary nail a much higher failure rate for the plate-screw implant. Implant failure was seen in 7/19 patients treated with the 95 degree screw plate and only 1/30 in the intramedullary nail group. Both articles support the use of a blade plate or cephalomedullary nail for reverse obliquity fractures. 

An example of screw cutout and medial displacement is seen in Illustration A.

 

13) A 42-year-old male sustains the closed injury shown in Figure A. Which of the following factors is associated with improved outcomes with open reduction and internal fixation? 

1. Age > 40 

2. Smoking 

3. Male sex

4. No worker's compensation involvement 

5. Career as construction worker 

Corrent answer: 4 

The clinical and radiographic presentation is consistent with a closed, displaced, comminuted calcaneus fracture. Non-worker's compensation patients have improved outcomes with operative treatment. 

Buckley et al performed a multicenter prospective randomized study of over 300 displaced calcaneus fractures comparing nonoperative vs. operative treatment. They looked at patient satisfaction, SF-36 scores, and Bohler’s angle. They showed improved outcome in at least one measure after an operation vs. no operation for intraarticular calcaneal fractures in: 1) Women 2) Age <30 3) Non Smokers 4) Light work laborers 5) Non worker’s compensation patients.  

Sanders et al reviews calcaneus fractures, including treatment techniques. They recommend getting two-dimensional computed tomographic scans in both the coronal and the transverse plane. They report with operative treatment, the goal is restoring not only articular congruency, but also the shape and alignment of the calcaneus.  

 

14) A 36-year-old male is brought to the trauma center following a motor vehicle accident. Physical exam shows a deformed left lower extremity with a 1-cm open wound over the anterolateral aspect of his leg. Radiographs are provided in Figures A and B. Which of the following interventions has been shown in the literature to decrease the occurrence of infection at the fracture site?

1. Operative debridement within 6 hours of injury 

2. Immediate prophylactic antibiotic administration 

3. Immediate stabilization with internal fixation after debridement 4. Irrigating with a saline solution that is mixed with an antibiotic 5. Irrigating with high pressure pulsatile lavage following surgical debridement 

Corrent answer: 2

The clinical scenario and radiographs are consistent with a Gustilo and Anderson type 3A open tibia fracture.  

Melvin et al review the evidenced-based literature and make recommendations for the initial evaluation and management of open tibial shaft fractures. The time elapsed before antibiotic administration and adequate surgical debridement of all contamination are the only factors definitively shown to reduce infection and improve outcome. Traditional recommendations have suggested surgical debridement of open fractures occur within 6 hours of injury. However, there is no literature to support this time window. Certainly, open fractures should be addressed with urgency, but there is no evidence reporting a definitive time window. There is insufficient data to recommend gram negative coverage with gentamicin for all open fractures although this is a common practice. The addition of antibiotics to the irrigation solution has been shown to decrease bacterial load, but it has also demonstrated host tissue necrosis and delayed wound healing. There is not sufficient data to support its use over a castile soap solution or normal saline. Similarly, high pressure pulsatile lavage decreases bacterial load, but also seeds bacteria deeper within the soft tissues and harms host tissues. There is no evidence to support pulsatile lavage over gravity flow. 

 

15) A 34-year-old female is involved in a motorcycle crash. She sustains a talus fracture with associated dislocation of the subtalar joint and maintained congruence of the tibiotalar and talonavicular joints as shown in Figure A. The fracture has healed and she now has symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. What is the most likely deformity causing these symptoms?

1. Combined varus and plantar malunion 

2. Isolated varus malunion 

3. Isolated valgus malunion 

4. Isolated dorsal malunion 

5. Isolated plantar malunion 

Corrent answer: 4 

Figure A displays a Hawkins Type 2 talar neck fracture. (Hawkins classification shown in Illustration A). Malunion after inaccurate reduction of talar neck fractures has a reported incidence as high as 32%, with varus malunion occurring most frequently. Dorsal malunion can occur when the body is not properly derotated during reduction and the head fragment remains dorsal to the body. Dorsal malunion can lead to symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. Canale found that 3 of the 4 patients with dorsal malunion improved following dorsal beak resection of the talar neck. Patients with varus malunion have decreased subtalar range of motion(especially eversion), walk with the foot internally rotated, and often complain of excessive weight bearing on the lateral border of the foot.  

Level 4 evidence from Canale and Kelly found that varus malunion occurred most frequently in Hawkins type 2 fractures that had been treated in a closed manner.

 

16) What is the Injury Severity Score (ISS) for a patient with an open chest wound (Abbreviated Injury Scale, AIS=4), colon transection (AIS=4), femoral fracture (AIS=3), shoulder dislocation (AIS=2), and a thyroid gland contusion (AIS=1) 

1. 11 

2. 13 

3. 41 

4. 45 

5. 46 

Corrent answer: 3 

Injury Severity Score (ISS) scores are used to define injury severity for research purposes. The score is based on anatomic and severity indicies. Injury severity is based upon the AIS (abbreviated injury scale). AIS scores range from 1-6 where 1 is a minor laceration or contusion and 6 is a unsurvivable severe injury. An example of a 6 is a crushed head or brain whereas a 5 is a crushed larynx. Open pelvic fracture and femoral shaft fracture come in at 3 and large joint dislocations are a level 2 injury. ISS is the sum of the squares for the highest AIS grades in the three most severely injured ISS body regions. An ISS greater than 18 reflects multiply injured patients and that a transfer to a trauma center is indicated. So in this case, it would be (4x4)+(4x4)+(3x3)= 16+16+9=41. The AIS table can be found in Miller Review on page 699.  

Recently, the New Injury Severity Score (NISS) has been developed and found by some authors (Lavoie et al & Balogh et al) to be more reliable indicator of

length of stay and ICU stay. The NISS differs from the ISS in that the NISS sums the squares of the 3 most significant injuries (even if they occur in the same anatomic area). The ISS sums the 3 most significant injuries in 3 separate anatomic areas. 

 

17) A 42-year-old male sustains a closed, isolated ulna shaft fracture with 2mm displacement and 3 degrees valgus angulation. He is treated conservatively with early range of motion but presents at one year with a painful atrophic nonunion. What treatment is indicated at this time? 

1. Dynamic splinting 

2. Open autogenous cancellous bone grafting 

3. Open reduction internal fixation with autogenous bone grafting 4. Closed reduction and percutaneous pinning 

5. Use of an implantable ultrasound device 

Corrent answer: 3 

Appropriate treatment of an atrophic nonunion of the ulna includes open reduction and internal fixation with autogenous bone grafting. The atrophic nature of the nonunion reveals that biology, and not necessarily stability, is the major issue of the nonunion. The referenced article by Ring et al reviews a case series of these patients and found that even in the face of significant preoperative bone resorption, good clinical outcomes and union rate is possible with open plating and grafting. The article by Street reviews intramedullary nailing/pinning of the forearm, and found a 7% nonunion rate with this technique. 

 

18) A 62-year-old man falls on his porch and sustains an elbow injury. A radiograph is provided in Figure A. Which of the following is the best treatment?

1. Closed reduction and long arm casting 

2. Early motion with a hinged elbow brace 

3. Open reduction internal fixation with a tension band construct 4. Open reduction internal fixation with a plate 

5. Fragment excision and advancement of the triceps tendon Corrent answer: 4 

The radiograph shows an olecranon fracture with articular comminution and depression of a large intra-articular fragment. This pattern is best treated with plate fixation to support the articular reduction.  

Bailey et al reviewed 25 cases of olecranon fractures (simple and comminuted fracture patterns) treated with plate fixation. All 25 went on to union. There were no major complications reported. Twenty percent of patients underwent hardware removal at a later date for prominence.  

Hak et al review the treatment options available for olecranon fractures. Simple intra-articular fractures without comminution are suitable for tension band fixation. Comminution of the articular surface is an indication for plate fixation and may benefit from bone graft to support depressed articular segments. Osteoporotic patients or fractures with severe comminution may do better with fragment excision and advancement of the triceps. 

 

19) When viewing pelvic injury radiographs, which of the following describes the findings diagnostic of an isolated transverse acetabular fracture?

1. Fracture line crossing the acetabulum with disruption of the iliopectineal and ilioischial lines 

2. Disruption of the iliopectineal and ilioischial lines, with extension into the iliac wing and obturator ring 

3. Disruption of the iliopectineal and ilioischial lines, with extension into the obturator ring 

4. Isolated disruption of the iliopectineal line, with an intact ilioischial ine 5. Isolated disruption of the ilioischial line, with an intact iliopectineal ine 

Corrent answer: 1 

Transverse acetabular fractures separate the innominate bone into two fragments, the superior iliac and the inferior ischiopubic, by a single fracture line that crosses the acetabulum horizontally. The iliopectineal and ilioischial lines are disrupted on the AP pelvis radiograph. Axial CT scan of this fracture pattern at the level of the dome will show a vertical anterior to posterior fracture line. Illustrations A-C show AP and Judet pelvic radiographs of a transverse fracture. Illustration D demonstrates the axial CT appearance of this fracture type. Answer choice 2 is describing a both column injury or anterior column posterior hemitransverse, and answer choice 3 describes a T-type fracture pattern. Answer choices 4 and 5 describe an anterior column and posterior column injury respectively. Judet et al provide one of the first comprehensive reviews on acetabular surgical approaches, fracture types, and radiographic anatomy. Illustration E demonstrates the acetabular classification scheme developed by Judet.

 

 

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20) A patient undergoes the treatment seen in Figure A for a displaced intertrochanteric femoral fracture. With use of this construct, a starting point 3 mm anterior to the center of the piriformis fossa has which of the following benefits? 

 

1. Improved placement of screws through the nail into the femoral head 2. Decreased risk of varus alignment 

3. Decreased risk of joint penetration 

4. Decreased risk of avascular necrosis of femoral head 

5. Decreased risk of iatrogenic proximal femur fracture 

Corrent answer: 1 

Figure A shows an intertrochanteric fracture treated with a cephalomedullary device. A starting point slightly anterior to the piriformis fossa (starting point for standard antegrade femoral nail) has the benefit of improved placement of screws through the nail and into the femoral head. This is due to the fact that the hip is anteverted and the femoral neck arises from the anterior portion of the proximal femur. Therefore, by moving the nail anterior, that will increase the distance between the head screw and the posterior cortex of the neck and lead to a “straight” shot into the center of the femoral head. 

Johnson et al investigated the effect of starting hole position, fracture component length, reamed diameter, and nail type on the potential for femoral bursting and fracture instability. They found the most significant factor in the proximal femoral component was found to be the position of the starting hole.

They found excessive anterior displacement greater than 6 mm from the neutral axis of the medullary canal consistently caused high hoop stresses at the level of the fracture, which can increase the possibility of iatrogenic fracture. Posterior starting points increase the risk of possible distal femur anterior cortex impingement/fracture. 

Ostrum et al showed that lateral starting points should be avoided in order to avoid varus reduction when using a trochanteric antegrade nail in subtrochanteric fractures. They recommended a slightly medial starting point. 

 

21) An 11-year-old child has a tibia-fibula fracture following a fall from a swing. The fracture is reduced and placed in a long leg splint in the emergency room. What is considered the earliest sign or symptom of a developing compartment syndrome of the leg? 

1. pain out of proportion to injury 

2. pale appearance of the foot 

3. loss of the ability to move the toes 

4. decreased sensation in the foot 

5. decreased pulses in the foot 

Corrent answer: 1 

The Willis reference states “the single most important symptom of impending compartment syndrome is pain out of proportion to the injury." This symptom requires a conscious patient. Most children requiring a reduction for a displaced upper or lower extremity fracture will become comfortable soon after the reduction has been completed. Children requiring frequent analgesia or complaining loudly about pain should be examined very carefully for possible compartment syndrome.” The key wording in this question is “earliest indicator”. Pulselessness, paralysis, pallor, and parasthesias are all late indicators.  

The Willis article also lists the most reliable signs of a developing compartment syndrome as severe pain with passive stretching of the involved compartment, pain with palpation of the involved compartment, sensory disturbances 

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22) When discussing treatment options with a 35-year-old healthy male with an isolated, closed tibial shaft fracture, the surgeon should inform him that in comparison to closed treatment, the advantages of intramedullary nail fixation include all of the following EXCEPT? 

1. Quicker time to union 

2. Decreased risk of malunion 

3. Decreased risk of compartment syndrome 

4. Decreased risk of shortening 

5. Quicker return to work 

Corrent answer: 3 

All of the answer choices are correct except #3. Intramedullary nailing can increase the risk of compartment syndrome.  

In a study of 94 tibial fractures, Finkemeier reported 10 (11%) had compartment syndromes. Three of the 10 patients developed the compartment syndrome postoperatively.  

In comparing IM nailing to non-op, Bone et al showed that IM nailing had a shorter time to union (mean, 18 vs 26 weeks; p = 0.02), lower non-union rate (2% vs 10%), decreased incidence of shortening (2% vs 27%), and quicker return to work (mean, 4 vs 6.5 months), but no difference in compartment syndrome (0% in both groups).  

The classic article cited by Sarmiento el al. reported that closed treatment with use of a prefabricated functional below-the-knee brace was effective in a study of 1000 closed diaphyseal fractures of the tibia with an incidence of nonunion of only 1.1%. However, those authors had very strict criteria for use of the fracture-brace (exclusion criteria included intact fibula and tibial shortening >2cm). 

 

23) A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. Two-point discrimination is now >10mm in these fingers. Radiographs show a well-fixed fracture in good alignment. What is the most appropriate treatment at this time?

1. Strict elevation 

2. Removal of hardware 

3. Immediate carpal tunnel release 

4. Carpal tunnel release if no resolution at 6-12 weeks 

5. Trial of night splinting 

Corrent answer: 3 

This patient had mild median parasthesias preoperatively that have significantly worsened postoperatively. Immediate carpal tunnel release is the most appropriate next step in treatment. 

Mack et al reported on ten cases of acute carpal tunnel syndrome (ACTS) and six cases of nerve contusion in patients with acute median neuropathy associated with blunt wrist trauma. The patients with ACTS initially had normal sensation and subsequently developed objective sensory loss (2-point discrimination greater than 15 mm) in the median nerve distribution associated with severe wrist pain. In contrast, patients with nerve contusion injuries had immediate sensory loss and symptoms were nonprogressive. Four of five patients with ACTS who underwent carpal tunnel release within 40 hours of the onset of numbness had normal 2-point discrimination within 96 hours. Neuropathy, secondary to nerve contusion without coexisting ACTS, may be treated initially by observation.  

Ford et al reported of five cases of ACTS. Four with delayed treatment had poor outcomes while the one patient with early CTR had full recovery. All patients with ACTS had increasing and severe pain in the wrist with parasthesia and impaired sensation in the median distribuation. These symptoms initially weren’t present after wrist trauma, but developed rapidly in the next few hours. 

 

24) A 20-year-old man falls from his bicycle. He is going to be scheduled for open reduction internal fixation. What best describes the injury shown in Figure A and B?

 

1. Coronoid fracture 

2. Capitellum fracture with extension into the trochlea 

3. Radial head and capitellum fracture 

4. Isolated capitellum fracture 

5. Trochlea fracture 

Corrent answer: 2 

The radiographs shows a coronal shear fracture of the capitellum with extension into the trochlea, which would be classified as a Type IV fracture under the Bryan and Morrey classification system which was modified by McKee to include this specific injury. The lateral radiograph in Figure B and Illustration A is an example of the "double arc" sign representing an injury to both the trochlea and capitellum. The treatment of choice for a displaced Type IV fracture is open reduction internal fixation.  

Dushuttle et al demonstrated that absence of the capitellum did not lead to valgus instability unless the medial collateral ligament was injured, suggesting that excision of highly comminuted fractures could be performed.  

The reference by Grantham et al looked at a series of capitellum fractures and recommended the choice of treatment should be selective and individualized

depending on age, character of the bone, and type of fracture.  

McKee et al in their case review described this coronal injury pattern and their results for ORIF of these fractures. 

 

 

25) An 85-year-old woman falls and injures her elbow in her non dominant arm. Radiographs are shown in Figure A and B. She also suffers from severe osteoporosis, lives independently, and is a low level community ambulator. Which of the following is the most appropriate treatment?

 

1. Hinged elbow brace 

2. Olecranon osteotomy, articular ORIF, locked lateral plating 3. Triceps-splitting approach with double plate fixation 

4. Total elbow arthroplasty 

5. Casting for 4 weeks then ROM 

Corrent answer: 4 

Total elbow arthroplasty (TEA) is ideal for treating comminuted osteoporotic fractures of the distal humerus in low demand elderly patients. Outcomes are good to excellent with quick return of stability and functional motion but with carrying weight restriction of 5 lbs. ORIF would be the best choice for younger individuals with better bone quality.  

Cobb described the outcomes of 21 total elbow arthroplasties in elderly patients all of which had good or excellent results without evidence of component loosening. The mean motion was 25 to 130 degrees. Complications included fracture of the ulnar component in one patient after another fall, ulnar neurapraxia in three, and reflex sympathetic dystrophy in one.  

McKee et al. performed a randomized controlled study of TEA versus fixation and found that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF. They also found that although elderly patients with this injury have an increased baseline DASH score, they appear to accommodate to objective limitations in function with time. 

Frankle et al. retrospectively compared TEA to plate fixation for distal humerus fractures in the elderly and found a significant improvement in outcomes and revision rates with TEA as compared to plate fixation. The differences were seen most in women with associated comorbidities, such as rheumatoid arthritis, osteoporosis, and conditions requiring the use of systemic steroids. 

 

26) Coupled with reduction of the syndesmosis, which of the following interventions is most important when surgically addressing the ankle malunion shown in Figure A?

 

1. Placement of an osteochondral allograft 

2. Fibular lengthening osteotomy 

3. Calcaneofibular ligament release 

4. Medial malleolar shortening osteotomy 

5. Deltoid ligament imbrication 

Corrent answer: 2 

Late correction with a corrective osteotomy of a fibular malunion associated with diastasis of the ankle mortise (Illustrations A and B) is an effective means of salvaging function in a joint otherwise destined to be stiff and painful.  

The referenced study by Offierski et al reports that the factors that determined the success of the revision were the duration of the malunion, the quality of the reduction achieved, and the condition of the articular cartilage at the time of revision.  

The referenced study by Chao et al reported that the fibular lengthening osteotomy was crucial in regaining the anatomy and stability of the ankle mortise.  

The referenced study by Weber et al is a review of the technique of such an osteotomy, with commentary regarding its clinical success even if mild degenerative changes are seen. They also note that no differences are seen in outcomes between oblique and step-cut osteotomies. 

The referenced study by Weber and Simpson is a case series of corrective

lengthening osteotomies after malunited ankle fractures. They report that a lengthening and/or rotational osteotomy of a malunited fibula is successful in preventing further ankle arthrosis if no more than minimal degenerative radiographic changes are seen. 

 

 

 

27) All of the following implants offer adequate fracture fixation of the injury shown in Figure A EXCEPT:

 

1. Trochanteric entry point cephalomedullary nail 

2. Piriformis fossa entry point cephalomedullary nail 

3. Dynamic hip screw 

4. Fixed angle blade plate 

5. 95 degree dynamic condylar screw 

Corrent answer: 3 

Currently, cephalomedullary nails are used widely for reverse obliquity fractures because they limit medialization of the shaft fragment unlike sliding hip screws. 

The Haidukewych et al study quoted demonstrated the superiority of fixed angle devices such as blade-plates or dynamic condylar screws over the sliding (or dynamic) hip screws. Reverse obliquity intertrochanteric fractures of the femur are recognized as biomechanically different from standard intertrochanteric fractures. The rate of failure of internal fixation for this fracture pattern was higher than the rates in most reports of internal fixation of intertrochanteric fractures devices. 

OrthoCash 2020

28) A 27-year-old woman gives birth by normal spontaneous vaginal delivery. Two weeks after delivery she reports anterior pelvic pain and a radiograph is obtained (Figure A). What is the next step in management? 

 

1. Pelvic external fixator 

2. Open reduction and reconstruction plating of the symphysis 3. Protected weightbearing and binder as needed and observation 4. Open reduction and wiring of the symphysis 

5. Symphysiotomy 

Corrent answer: 3 

The clinical presentation and radiograph is consistent with an open-book type parturition-induced pelvic dislocation.  

The case series by Kharrazi et al reports four patients treated with open-book type parturition-induced pelvic dislocations. The authors advocate nonoperative treatment with bedrest and a properly positioned pelvic binder in the acute setting for patients with a postpartum symphyseal diastasis less than 4.0 cm. All four patients had significant symptoms and radiographic widening (anterior splaying) of the sacroiliac joints. The three patients who had presented acutely were treated with closed reduction and application of a pelvic binder, while two had closed reduction of their pelvic dislocation while anesthetized with a general anesthetic. At latest follow-up the diastasis at the pubic symphysis reduced to an average of 1.7 cm (range: 1.5-2.0) The authors advocate nonoperative treatment with bedrest and a properly positioned pelvic binder in the acute setting for patients with a symphyseal diastasis of 4.0 cm of less and operative treatment for diastasis greater than 4cm. 

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29) A 30-year-old patient sustains a comminuted tibia fracture and is treated with minimally invasive plating, shown in Figure A. The patient returns to the office 2 weeks after the surgery and reports persistent numbness over most of the dorsum of the foot, but motor exam is normal. What is the most likely explanation? 

 

1. unrecognized compartment syndrome 

2. common peroneal nerve injury 

3. superficial peroneal nerve injury 

4. sural nerve injury 

5. tibial nerve injury 

Corrent answer: 3 

Superficial peroneal nerve (SPN) injury is a known complication of percutaneous plating of proximal tibial fractures with the LISS system as seen in Figure A. 

The Less Invasive Stabilization System (LISS) is a minimally invasive implant that uses indirect fracture reduction techniques. When using the LISS system, percutaneous screw placement increases the risk of injury to nearby structures because they are not necessarily visualized. The superficial peroneal nerve exits the superficial fascia of the leg approximately 8 cm above the tip of the

lateral malleolus. The nerve then travels from posterior to anterior in the vicinity of the distal aspect of the 13-hole proximal tibia LISS plate (near holes 11-13). In a patient of shorter stature, the nerve could cross the distal portion of a 9-hole plate.  

Deangelis et al. performed a cadaveric study using Less Invasive Stabilization System (LISS) plates and found that the average distance from the SPN to the center of holes 11, 12, and 13 was 10.0 mm, 6.8 mm, and 2.7 mm respectively. They recommended using a larger incision and careful dissection down to the plate in this region to minimize the risk of damage to the nerve.  

Cole et al. retrospectively reviewed 77 tibia fractures treated with LISS and found that 91% healed without complication. In their cohort, there were no superficial peroneal nerve palsies and one deep peroneal nerve palsy. 

Figure A demonstrates AP and lateral x-rays of a tibial shaft fracture treated with a LISS plate. 

Incorrect Answers: 

A: compartment syndrome would have demonstrated pain out of proportion which the patient never complains of 

B, D, and E are all less likely to be injured with LISS plate application than the superficial peroneal nerve. 

 

30) A 20-year-old male is involved in a motorcycle accident and presents with the injuries shown in Figures A-F. The left ankle injury is open medially, with a clean 3cm laceration, and the right femur and tibia are closed. He has no visceral or head injury, and is hemodynamically stable. He is cleared to go to the operating room. Without taking into account order of fixation, how should his injuries be treated?

 

 

 

 

 

1. Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and casting 

2. External fixation of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF

3. Antegrade nailing of the femur, external fixation of the tibia and ankle after debridement 

4. Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF 

5. External fixation of the tibia and femur, and ankle debridement and external fixation 

Corrent answer: 4 

The patient is hemodynamically stable, has no other injuries, and is medically cleared for the operating room. Therefore, there is no need for damage control fixation.  

Ostrum et al conducted a review of 20 patients treated by percutaneous stabilization for ipsilateral fractures of the femur and tibial shafts. All patients were treated with a retrograde femoral intramedullary nail and a small diameter tibial intramedullary nail through a 4-cm medial parapatellar tendon incision. Six of the tibial shaft fractures required revision surgery, and no patients reported signs or symptoms of knee pain. Ostrum concluded that although this is an excellent treatment option for patients with ipsilateral femoral and tibial shaft fractures, the tibial fracture complication rates remain high.  

Franklin et al reviewed 38 cases of open ankle fractures that had been treated with immediate splinting, antibiotics, debridement, and internal fixation. They found that all of the fractures united, but three patients required subsequent ankle fusion because of cartilage damage noted at the initial operation. Of the thirty-five ankles with complete follow-up, the functional result was excellent in twenty-six and fair or poor in nine.  

 

31) A 33-year-old male is involved in a motor vehicle accident and suffers a right pilon fracture. Which of the bone fragments labeled on the distal tibia in the axial CT scan shown in Figure A is attached to the posterior inferior tibiofibular ligament?

 

1. A 

2. B 

3. C and B 

4. D 

5. A and D 

Corrent answer: 4 

Figure A is an axial CT scan slice of an intra-articular distal tibia fracture. The bands of the posterior tibiofibular ligament pass obliquely from the fibula to the posterolateral aspect of the distal tibia. The ligaments of the ankle often remain intact after a pilon fracture producing the major fracture segments consisting of posterolateral or Volkmann's fragment (labeled D), the anterolateral or Chaput fragment (labeled B), and the medial fragment (labeled C). The fibula is labeled A. Any surgical approach taken to treat this injuries should respect these attachments.  

Michelson reviews the important role of ankle ligamentous anatomy in his study on rotational ankle fractures.  

Hermans et al review the anatomy of the ankle syndesmosis and state that stress on the posterior inferior tibiofibular ligament results more often in a posterior malleolus avulsion fracture than in a rupture of the ligament. They go on to state that with direct reduction of the posterior malleolus avulsion fracture, the syndesmosis can often be stabilized. 

Illustration A shows the posterior inferior tibiofibular ligament highlighted in red on MRI imaging in a LEFT ankle (the CT image in the question is of a RIGHT ankle). 

 

 

32) What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window? 

1. External iliac artery 

2. Pudendal nerve 

3. Corona mortis 

4. L5 nerve root 

5. Ilioinguinal nerve 

Corrent answer: 4 

Care must be taken when placing a retractor on the anterior aspect of the sacrum, as the L4 and L5 nerve roots are both at risk.  

Illustration A shows a diagram of the lumbosacral plexus, indicating the proximity of the L4 and L5 nerve roots to the anterior sacrum and SI joint. 

The first referenced article by Atlihan et al reported on the anatomy of the anterior sacroiliac joint and reported that the L4 nerve root is within 1 cm of the joint at its inferior margin.  

The second article by Ebraheim et al found that the L4 and L5 nerve roots are 10 mm medial to the sacroiliac joint at the pelvic brim.

 

 

33) A 24-year-old man who sustained a gunshot wound to the abdomen ten hours earlier was brought to the emergency department. On physical examination he was found to have 4 of 5 weakness in his bilateral lower extremities. Radiographs are shown in Figure A. Computed tomography of the lumbar spine showed retained missile in the vertebral body and paraspinal soft tissues, but not within the spinal canal. His FAST was positive and he underwent an emergent exploratory laparotomy where an injury to the cecum was identified and treated. Management should now include which of the following?

 

1. Bullet fragment removal from a transabdominal approach 2. Bullet fragment removal from a retroperitoneal approach 

3. Broad-spectrum oral antibiotics for 3-5 days 

4. Broad-spectrum intravenous antibiotics for 7-14 days 

5. IV methylprednisolone at 5.4mg/kg/h for 48 hours 

Corrent answer: 4 

The patient in the scenario has a GSW to the lumbar spine with neurologic deficits but without a retained missile in the spinal canal. In patients with visceral injury, the treatment is broad-spectrum antibiotic coverage for 7 days. 

Kumar et al reviewed 33 patients with GSW to the spine and associated visceral injuries. They concluded that 7 days of antibiotic treatment targeted at colonic flora is the treatment of choice.  

Roffi et al reviewed 51 low-velocity GSW that perforated the viscus prior to the spine. They concluded that broad spectrum antibiotics combined with bedrest significantly reduced the risk of spinal or paraspinal infections. Furthermore, bullet removal had no effect on infection rates.  

Velmahos et al followed 153 GSW to the spine for 28 months. While rates of sepsis were higher in the lumbar spine than cervical and thoracic spine, they concluded that retained bullets do not increase the likelihood of septic complications. 

Incorrect Answers: 

Answer 1 & 2: Indications for surgery with a GSW to the lumbar spine include 1) spinal instability 2) a neurologic deficit is present that correlates with radiographic findings of neurologic compression by the missile. 3) Lead missile is in contact with the cerebrospinal fluid (CSF). This patient does not have any of these criteria. 

Answer 5: GSWs are a contraindication for spinal dose steroids. 

 

34) Which of the following is indicative of a patient who has been successfully resuscitated following a trauma? 

1. Urine output of 0.25 mL/kg/hour 

2. Lactic acid of 1.9 mmol/L 

3. Base deficit of 5.5 

4. Gastric mucosal pH of 6.5 

5. Pulse pressure of 15

Corrent answer: 2 

Rapid fluid resuscitation is the cornerstone of therapy for hypovolemic shock. Fluid should be infused at a rate sufficient to rapidly correct the deficit. If the estimated blood loss is greater than 30% of the total volume (class III), blood replacement is also indicated. In general, a favorable response to fluid replacement therapy includes increased urinary output (at least 0.5ml/kg/hr), improved level of consciousness, increased peripheral perfusion, and changes in vital signs (such as increased BP, increased pulse pressure, and decreased heart rate). Lab values that are important include lactic acid, which is increased if the shock is severe enough to cause anaerobic metabolism, and decreased serum bicarbonate which leads to a negative base deficit. Successful resuscitation in a shock patient will therefore lead to a falling lactate and normalizing pH. Successful resuscitation in a shock patient will therefore lead to a falling lactate (i.e. <2.0mmol/L) and a normalizing pH. 

Incorrect Answers:  

1: Urine output should be at least 0.5ml/kg/hr. 

3: Base deficit should be less than 2. 

4: Gastric mucosal pH is different than gastric fluid pH, and should be greater than 7.2. 

5: Pulse pressure should be greater than 15mmHg. 

 

35) A 22-year-old female is struck by a truck and sustains the injury seen in figure A. What deformities are most commonly seen in treating this injury with an intramedullary nail?

 

1. Apex anterior and varus 

2. Apex anterior and valgus 

3. Apex posterior and varus 

4. Apex posterior and valgus 

5. Rotational 

Corrent answer: 2 

Proximal tibial shaft fractures treated with intramedullary nails are most commonly malreduced with apex anterior and valgus deformities. Several techniques are available to overcome this malalignment: proximal and lateral nail starting point, usage of a femoral distractor or temporary plating, suprapatellar nailing, and lateral parapatellar approaches.  

A final technical trick is the usage of blocking (Poller) screws - the referenced article by Ricci et al had 100% correction and maintenance of reduction with usage of blocking screws without other adjunct techniques. They report a union rate of >90% in this small series. 

 

36) When treating a stable 2-part intertrochanteric hip fracture with a sliding hip screw construct, what is the minimum number of screw

holes that are needed in the side plate for successful fixation? 

1. One 

2. Two 

3. Three 

4. Four 

5. Five 

Corrent answer: 2 

A two part stable intertrochanteric femur fracture can be treated with a sliding hip screw, with good biomechanical and clinical results.  

The referenced article by Bolhofner et al reviews a series of 69 patients with a sliding hip screw and two hole side plate and notes that they did not have any failure of the side plate construct.  

The referenced article by McLoughlin et al is a biomechanical evaluation of 2 versus 4 hole plates and found that peak load in the failure test was not found to be statistically different between the two-hole and four-hole designs. In cyclic testing, the two-hole configuration exhibited statistically smaller fragment migration in both shear and distraction than the four-hole design. 

 

37) A 25-year-old male is involved in an high-speed motor vehicle collision and sustains a closed femoral shaft fracture. During further evaluation, a CT scan of the chest/abdomen/pelvis reveals a non displaced ipsilateral femoral neck fracture. Which of the following treatment options will most likely achieve anatomic healing of the femoral neck and minimize the risk of complications? 

1. Retrograde femoral nail followed by compression hip screw 2. Lag screw fixation followed by plating of the femoral shaft 3. Antegrade femoral nail followed by lag screw fixation 

4. Lag screw fixation followed by retrograde femoral nail 

5. Proximal femoral locking plate 

Corrent answer: 4 

An ipsilateral femoral neck fracture occurs in approximately 6% to 9% of all femoral shaft fractures. A comminuted midshaft femoral fracture secondary to axial loading should alert the treating physician to the possibility of an associated femoral neck fracture. As a result, trauma CT scans should be reviewed for non to minimally displaced femoral neck fractures during the

initial work up.  

Watson et al did a retrospective review of 13 patients who had healing complications develop after their index surgical procedure for ipsilateral femoral shaft and neck fractures. Six of the eight (75%) femoral neck nonunions occurred after the use of a second generation, reconstruction-type intramedullary nail. Factors contributing to nonunion of the femoral shaft were the presence of an open fracture, use of an unreamed, small diameter intramedullary nail, and prolonged delay to weightbearing. Lag screw fixation of the femoral neck fracture and reamed intramedullary nailing for shaft fracture stabilization were associated with the fewest complications.  

Peljovich et al discuss that several treatment options are described in the literature, but no clear consensus exists regarding the optimal treatment of neck/shaft fractures. Due to the the potentially devastating complications of the femoral neck fracture in young patients (avascular necrosis, nonunion, and malunion), the neck fracture should be treated first followed by the shaft. Current recommendations involve treating the neck with a sliding hip screw versus cannulated screws followed by intramedullary nailing of the femoral shaft. 

 

38) A through-knee disarticulation has been shown to have what advantage over a traditional above-knee (transfemoral) amputation? 

1. Decreased rate of prosthesis adjustment 

2. Less postoperative time to final prosthesis fitting 

3. Decreased neuroma formation 

4. Decreased rate of revision 

5. Less energy expenditure with ambulation 

Corrent answer: 5 

A through-knee disarticulation has been shown to have decreased energy expenditure with ambulation, improved limb proprioception, improved sitting capabilities, decreased hip joint flexion contracture incidence, and improved lever arm for mobilization.  

Knee disarticulation is also recommended in children to prevent overgrowth of the distal femur which may be seen in transfemoral amputations (if the physis remains open). No difference in prosthesis fitting has been shown between transfemoral amputation and through-knee disarticulation. The referenced

paper by Pinzur et al is a excellent review of knee disarticulation, from technique to outcomes. 

 

39) A 65-year-old female presents with the injury seen in Figures A and B after a motor vehicle collision. She is hemodynamically unstable and undergoes emergent pelvic supra-acetabular external fixation followed by laparotomy. She is now hemodynamically stable and cleared for surgery. She has no evidence of neurologic deficit on examination. Which of the following factors is a relative contraindication to open reduction and plating of her posterior pelvic injury from an anterior approach? 

 

 

1. Sacral fracture 

2. Prior laparotomy 

3. Supra-acetabular external fixtator

4. Parasymphyseal fractures 

5. Ipsilateral proximal femur fracture 

Corrent answer: 1 

An anterior approach to the sacroiliac (SI) joint is indicated with displaced SI joint dislocations that cannot be reduced with closed or percutaneous techniques. One contraindication to anterior exposure of the SI joint is comminuted sacral fracture patterns.  

Posterior pelvic ring injuries that are unable to be reduced by closed techniques may require open reduction via anterior or posterior approaches. Relative contraindications to anterior approach include comminuted sacral fractures, morbid obesity, iliac wing external fixation, and ipsilateral diverting colostomy. In the presence of a comminuted sacral fracture, aggressive medial dissection would be required and would place the L5 nerve root at risk.  

Simpson et al describe their initial results with open reduction and internal fixation of the SI joint via an anterior exposure in a series of 16 patients. They note that sacral alar comminution is a contraindication to the anterior approach 

Jones provides an overview of the operative treatment of posterior pelvic ring injuries. He demonstrates reduction and fixation techniques via both anterior and posterior exposures.  

Incorrect Answers: 

Answer 2: Prior laparotomy is not a contraindication to open anterior approach if the bowel is in continuity and there is no evidence of wound infection Answer 3: Supracetabular external fixation does not interfere with anterior approach to the SI joint 

Answer 4: Anterior pelvic ring injuries such as parasymphyseal fractures do not affect the choice of approach 

Answer 5: An ipsilateral proximal femur fracture does not affect the choice of approach 

 

40) A 45-year-old homeless hemophiliac male presents with chronic tibial osteomyelitis. Which of the following factors has been shown to predict a better prognosis? 

1. Polymicrobial infection 

2. Use of external fixation 

3. Infection with Methicillin-resistant Staphylococcus aureus

4. Metaphyseal infection 

5. Contralateral lower extremity amputation 

Corrent answer: 4 

Success in the treatment of chronic tibial osteomyelitis is dependant on various factors including patient factors (immunocompetency of patient, nutritional status), injury factors (severity of injury as demonstrated by segmental bone loss), and infection factors (the extent and location of infection – metaphyseal infections heal better than mid-diaphyseal infections).  

Cierny’s article states that factors affecting prognosis and treatment include: residual foreign materials and/or ischemic and necrotic tissues, host compromise, inappropriate antibiotic coverage, and the lack of patient cooperation or desire.  

The second referenced article by Cierny reviews the significant increase in success over the last 20 years in treating infected tibial nonunions, due to pharmacological and technological advances. He reports an increase in limb salvage from 78% to 93% with modern protocols. 

Incorrect Answers: 

Answer 1: Polymicrobial infection portends a worse prognosis than a single organism. 

Answer 2: External fixation has not been shown to improve outcomes in chronic osteomyelitis. 

Answer 3: MRSA infections are a risk factor for poor outcomes. Answer 5: Contralateral extremity amputation increases the risk of poor outcomes. 

 

41) A 30-year-old male sustains the injury seen in Figure A after a motor vehicle collision. Which of the following is the most likely complication at 2-year follow-up?

 

1. Avascular necrosis 

2. Hip instability 

3. Malunion 

4. Chondrolysis 

5. Ipsilateral medial knee degenerative changes 

Corrent answer: 1 

Figure A shows a displaced femoral neck fracture. Avascular necrosis (AVN) and nonunion are the two most common complications after femoral neck fractures in the young adult.  

Dedrick et al found nonunion of the fracture site was observed in 20% and avascular necrosis in 36% of young patients with femoral neck fractures. In addition, they reported that of patients with subcapital fractures, 83% developed nonunion or avascular necrosis, compared to 21% with a more distal femoral neck fracture. 

 

42) A 40-year-old male laborer sustained a fall from height and has isolated pelvic pain. He is otherwise hemodynamically stable. A radiograph is shown in Figure A. A stress examination under anesthesia does not show any further anterior diastasis or posterior pelvic ring displacement. Computed tomography reveals no asymmetry of the sacroiliac joints. What is the most appropriate management of this injury?

 

1. protected weight-bearing and pain control 

2. open reduction and internal fixation 

3. skeletal traction followed by open reduction and internal fixation 4. pelvic external fixation 

5. pelvic external fixation followed by sacroiliac screws 

Corrent answer: 1 

This patient sustained an open-book pelvic fracture with a pubic symphysis diastasis of less than 2.5cm. From the Young and Burgess classification, he has anteroposterior compression (AP) type 1 injury. Treatment of this is protected weight-bearing and symptomatic treatment. Stress examination can be utilized in order to ensure that the injury is, in fact, a APC-1 injury, and not a more severe posterior injury that would require operative intervention. 

 

43) A 40-year-old woman is involved in motorcycle accident 2 hours ago and sustains an isolated right leg injury shown in Figure A. She has dopplerable posterior tibial and dorsalis pedis artery signals with less than 2 second capillary refill as shown in Figure B. Sensation is intact in the distribution of the tibial nerve but decreased in the distribution of the peroneal nerve. She is cleared by the general surgery trauma team to go to the operating room for treatment of her leg. What is the most appropriate Gustilo classification and initial treatment for her injury?

 

 

1. Gustilo 3A with spanning external fixation and delayed definitive fixation with soft tissue coverage 

2. Gustilo 3A with immediate medial and lateral plating followed by delayed soft tissue coverage 

3. Gustilo 3B with spanning external fixation and delayed definitive fixation with soft tissue coverage 

4. Gustilo 3B with immediate medial and lateral plating followed by delayed soft tissue coverage 

5. Gustilo 3C with spanning external fixation and delayed definitive fixation with soft tissue coverage 

Corrent answer: 3 

The injury described above is a Type IIIB injury as per the Gustilo and Anderson classification. Type I injuries are low energy and have small soft tissue wounds (usually <1 cm in length) with minimal contamination. Type II injures have a wound >1 cm in length, but do not have extensive soft-tissue

damage, flaps, or avulsions. Type IIIA injuries are associated with soft-tissue damage secondary to high-energy trauma but have adequate soft-tissue coverage. Type IIIB injures exhibit severe periosteal stripping and bone exposure, often associated with massive contamination. These often require treatment with soft-tissue coverage procedures. Type IIIC fractures require vascular repair. The risk for infection in this scenario is as high as 44%, so placing definitive plate fixation is contraindicated when future debridement and soft tissue coverage procedures will be needed. External fixation provides excellent stability, provisional skeletal alignment, and minimal additional soft tissue injury. 

 

44) A 35-year-old male laborer falls off a ladder and sustains the injury shown in Figures A and B. He has a 2 cm laceration over the medial ankle with exposed bone and a normal neurovascular exam. What is the recommended initial treatment? 

 

1. Immediate open reduction and internal fixation 

2. Closed reduction and casting 

3. Irrigation and debridement and external fixation

4. Irrigation and debridement and splinting 

5. Amputation 

Corrent answer: 3 

Severe pilon fractures are generally the result of high energy trauma leading to bony comminution of the articular and metaphyseal bone. They are usually associated with significant soft tissue injury which prevents immediate definitive open reduction and internal fixation. In this situation, due to the soft tissue injury and open fracture, initial treatment should consist of irrigation and debridement and stabilization with external fixation. Definitive management such as open reduction and internal fixation is performed once the soft tissue swelling has improved and there is no evidence of infection. Sirkin et al published their results of a staged protocol for complex pilon injuries. Their data suggests the historically high rates of infection associated with ORIF of pilon fractures are likely due to attempts at immediate fixation through swollen, compromised soft tissues. 

 

45) A 27-year-old female sustains injuries to the left femur and ipsilateral tibia shown in Figures A and B following an ATV accident. Her injury severity score (ISS) is 27 for her musculoskeletal and abdominal injuries. Her left limb is neurovascularly intact and there are no signs of compartment syndrome. What is the most appropriate definitive management?

 

1. Intramedullary nailing of the tibia and femur 

2. External fixation of the tibia and femur 

3. Balanced skeletal traction 

4. Circular external fixation of the tibia and intramedullary nailing of the femur 5. Uniplanar external fixation of the tibia and intramedullary nailing of the femur 

Corrent answer: 1 

Polytrauma patients with ipsilateral femoral and tibial fractures (floating knee injuries) often require aggressive hemodynamic resuscitation and immediate stabilization via external fixation following tenets of damage-control orthopaedics. However, goals for definitive management of these fractures include obtaining anatomic alignment, early joint range of motion, and early weightbearing. If the floating knee injury is an isolated injury and the patient is hemodynamically stable then immediate intramedullary nailing of the tibia and femur is acceptable. Of the choices listed, intramedullary nailing of both the femoral and the tibial fracture is the optimal form of fixation for these transverse fractures. The technique of antegrade intramedullary nailing of both the femur and the tibia has been well described. Retrograde femoral nails and antegrade tibial nails can be advantageous because it allows simultaneous surgical setup for both the femoral and the tibial fracture.

 

46) All of the following are true statements regarding compartment syndrome in the pediatric patient EXCEPT: 

1. Increasing analgesic requirement is an important indicator for the diagnosis of compartment syndrome in children 

2. Duration of compartment syndrome prior to treatment is the most important variable in determining the outcome 

3. Mechanism of injury is the best predictor of compartment syndrome development 

4. Traditional hallmarks of adult compartment syndrome may be more challenging to detect in pediatric compartment syndrome 

5. Careful patient positioning and the use of prophylactic fasciotomy are methods of preventing compartment syndrome 

Corrent answer: 3 

Compartment syndrome can often be difficult to diagnosis in the pediatric patient. Mechanism of injury is not the best predictor of compartment syndrome development or diagnosis in pediatric patients. It is important to note that functional outcome following compartment syndrome in patients is inversely related to the duration of elevated tissue pressures before surgical fasciotomy.  

Level 4 evidence by Bae et al reviewed 33 children with compartment syndrome. They found that all 10 compartment syndrome patients that had access to nurse or patient controlled analgesia (PCAs), during their initial evaluation, demonstrated an increasing requirement for pain medication. 

Matsen et al reviewed 24 children with compartment syndrome with the most common causes being fracture, vascular injury, and tibial osteotomy. The study concluded that is imperative that a compartment syndrome be identified and treated as promptly as possible. 

 

47) A 27-year-old male is involved in a motor vehicle accident and sustains the injury shown in Figures A through E. The articular surface is depressed 2 mm while there is 3 mm of condylar widening. Valgus instability of the knee is noted. Which of the following is most important to long-term success in surgical treatment of this case?

 

 

 

1. Restoration of joint stability 

2. Repair of associated meniscal pathology 

3. Surgical fixation within 48 hours of injury 

4. Correction of the articular depression 

5. Tibial condylar diastasis < 3 mm 

Corrent answer: 1 

The clinical presentation and imaging studies are consistent with a tibial plateau fracture. Restoration of joint stability has been shown to be the strongest predictor of long term outcomes.  

Honkonen reviewed 131 tibial condyle fractures and determined that articular stepoff <3mm and tibial widening <5mm did not negatively effect outcomes. In contrast, 70% of knees with moderate to severe malalignment went on to functionally unacceptable outcomes. They suggested operative fixation for all medial uni and bicondylar fractures, any lateral fractures with >5 degrees of

valgus tilt, >3mm of articular depression, >5mm of condylar widening, or >5 degrees of valgus malalignment.  

In the Marsh et al JAAOS symposium review, the authors noted that fractures with up to 10mm of articular depression and joint stability obtained acceptable functional outcomes. They also cited a 20 year follow-up which indicated that articular step-off alone was not a predictor of poor long-term results. More importantly, when instability is present with other factors, including step-off and central depression, poor results followed.  

Illustrations A and B show the intraoperative films. Illustration C reviews the Schatzker classification system.

 

 

 

 

48) A 45-year-old male is involved in a motor vehicle accident and sustains the injury shown in Figures A-D. Which of the following is the most appropriate approach for surgical fixation of this fracture?

 

 

 

1. Ilioinguinal 

2. Kocher-Langenbeck 

3. Stoppa 

4. Stoppa with lateral window 

5. Extended iliofemoral 

Corrent answer: 2 

The images demonstrate a posterior column acetabular fracture. These are best surgically treated with a Kocher-Langenbeck approach, which allows access to the posterior column and posterior wall. Figure A shows disruption of the ilioischial line with an intact iliopectineal line which is diagnostic of this fracture pattern. The CT image in Figure D shows the characteristic horizontal (coronal) orientation of the column fracture when viewed on an axial CT. Illustration A shows the radiographic landmarks used in diagnosing acetabular fractures. Illustrations B and C show the orientation of column and wall fractures respectively. Ilioinguinal and Stoppa approaches allow access for

anterior column fixation and symphysis fixation respectively. The extended iliofemoral approach can be used to treat both column injuries, but has high rates of post-operative heterotopic ossification.

 

 

 

 

49) A 33-year-old male presents 9 months after a fall from 15 feet. He complains of continued pain over his left arm and you elicit pain and gross movement with palpation of his humerus. Infectious workup is negative and a radiograph is shown in Figure A. What is the most appropriate next step in his management?

 

1. Reassurance and appropriate followup 

2. Sarmiento bracing 

3. Use of a bone stimulator 

4. Exchange humeral nailing 

5. IM nail removal, open reduction internal fixation with bone grafting Corrent answer: 5 

This patient has developed a hypertrophic non-union of his left humerus following IM nailing. This will not go on to union without surgical intervention. McKee et al. reviewed 21 cases of humeral nonunion after failed intramedullary humeral nails. Although technically difficult, open reduction internal fixation with plating and bone grafting was more successful in union in 9/9 cases, vs exchanged humeral nailing which was only successful in 4/10 cases. Seven of the nonunions were atrophic, 2 were hypertrophic in the ORIF group. The authors conclude that the extent of humeral bone loss after failure of primary humeral nailing makes open reduction internal fixation with compression and bone grafting the most acceptable method of treating this problem.  

It should be noted, however, that the use of bone grafting in the presence of a hypertrophic nonunion is controversial and has not been definitively proven in the literature to increase healing rates.

 

50) A 47-year-old male sustains an isolated posterior wall acetabulum fracture after a motor vehicle collision and undergoes open reduction and internal fixation. Post-operative radiographs are shown in Figure A. Which of the following has been shown to correlate most closely with good outcomes following ORIF of posterior wall fractures? 

 

1. Degree of displacement seen on preoperative AP pelvis view 2. Degree of displacement seen on preoperative Judet views 3. Degree of displacement seen on preoperative pelvic CT scan 4. Degree of displacement seen on postoperative Judet views 5. Degree of displacement seen on postoperative pelvic CT scan 

Corrent answer: 5 

Moed et al performed a study to determine the clinical outcome in patients in whom a displaced fracture of the posterior wall of the acetabulum had been treated by open reduction and internal fixation. They were able to show good to excellent clinical results for patients who underwent anatomic reduction and internal fixation of posterior wall acetabulum fractures as assessed using radiographs. Fractures in elderly patients and patients who sustained extensive comminution were more likely to have worse clinical result.  

In a separate study, Moed et al. evaluated the results of 67 patients who underwent ORIF of a posterior wall fractures by assessing the accuracy of postoperative AP pelvis, obturator oblique films, iliac oblique films, and CT scans. They found that postoperative pelvic CT scan was the most accurate way to judge final fracture reduction and was able to pick up residual fracture displacements that were not seen on postoperative plain radiographs. They concluded that the accuracy of reduction as assessed on postoperative CT scan was the most reliable indicator of clinical outcomes.

 

51) A 68-year-old male sustains the humeral shaft fracture shown in Figures A and B. Upon presentation, he is unable to extend his thumb, fingers, and wrist. After 4 months of non-operative management, the fracture has healed, but his physical exam is unchanged. What is the next most appropriate step in management?

 

 

1. EMG and nerve conduction tests followed by possible surgical exploration 2. Continued observation 

3. Immediate surgical exploration

4. Shoulder MRI 

5. CT scan of the humerus 

Corrent answer: 1 

The clinical presentation is consistent for a residual radial nerve palsy 4 months after a humeral shaft fracture. An EMG is indicated at this time to evaluate the status of the nerve recovery.  

A radial nerve injury which occurs during a humeral shaft fracture or after bracing is not an indication for immediate exploration. Most often, the nerve function returns without surgical intervention. An EMG should be performed at 3-5 months to evaluate the status of the nerve recovery. If fasciculations are present, then this represents recovery, and observation should be continued. If fibrillations are present, this represents denervation, and surgical exploration should be considered. 

Pollock et al followed 24 humeral-shaft fractures with associated radial-nerve injuries, 2 of which required open exploration and all recovered. They recommend careful observation for return of nerve function and exploration at 3.5-4 months after injury if there is still no clinical or EMG evidence of recovery.  

Bostman et al reviewed 59 immediate and 16 secondary radial nerve palsies and no support emerged for routine early exploration in either group.  

Figures A and B show an oblique fracture at the junction of the middle and distal 1/3 of the humeral shaft. 

Illustration A shows the relative close position of the radial nerve to the humerus at the midlevel of humerus, and why it is at risk with a humerus shaft fracture. 

 

OrthoCash 2020

52) A 56-year-old male sustains a Type IIIB open, comminuted tibial shaft fracture distal to a well-fixed total knee arthroplasty that is definitively treated with a free flap and external fixation. Nine months after fixator removal, he presents with a painful oligotrophic nonunion. Laboratory workup for infection is negative. Passive knee range of motion is limited to 15 degrees. What is the most appropriate treatment for his nonunion? 

1. Knee manipulation under anesthesia 

2. Cast immobilization and use of a bone stimulator 

3. Unilateral external fixation 

4. Intramedullary nailing 

5. Compression plating 

Corrent answer: 5 

At 9 months, observation is no longer an option, as the fracture is not healing and is adjacent to a arthrofibrotic joint. Plate osteosynthesis has been shown to be an effective method of treatment for patients who have had an open fracture of the tibia that has failed to unite after external fixation and/or immobilization in a cast.  

Wiss et al reported a series of fifty tibial non-unions with a similar clinical scenario. He reported that, with compression plating, 92% of the nonunions healed without further intervention. In their study, 39/50 patients, had autogenous bone grafting in addition to compression plating. 

 

53) What muscles are responsible for the most common deformity after antegrade intramedullary nailing for a subtrochanteric femur fracture? 

1. Hip abductors and iliopsoas muscle 

2. Hip internal rotators and iliopsoas muscle 

3. Quadriceps and iliopsoas muscle 

4. Hamstring and iliopsoas muscle 

5. Quadriceps and hip adductors 

Corrent answer: 1 

The most common deformity after antegrade nailing of a subtrochanteric femur fracture is varus and procurvatum (or flexion). This is caused by the hip abductors and iliopsoas pulling the proximal fragment into abduction and flexion, while the distal fragment is pulled into adduction from the adductors.

The reference by French et al is a review on 45 patients with subtrochanteric fractures treated with cephalomedullary interlocked nailing. Based on femoral neck-shaft angle, 61% of the fractures were reduced in at least 5º varus. The authors attributed this malalignment to failure to counteract muscle forces acting on the proximal fragment, combined with the adducted position of the distal femur during portal creation.  

The reference by Ricci et al is a report of 403 femoral shaft fractures treated with intramedullary nailing. Patients with proximal femoral shaft fractures were found to have the highest incidence of malalignment. The most common deformity in this group was varus, followed by procurvatum (or flexion).  

 

54) A 34-year-old male has persistent anterolateral ankle pain after a snowboarding injury 1 week ago and is unable to bear weight. Three good quality radiographic views of the ankle are negative for fracture or other abnormalities. What is the next best step in management? 

1. Short leg cast application 

2. Bone scan 

3. MRI of ankle 

4. Diagnostic injection 

5. Repeat radiographs 

Corrent answer: 3 

Fractures of the lateral process of the talus are frequently overlooked and should always be considered in the differential diagnosis of ankle pain in snowboarders. The common mechanism for fracture is dorsiflexion of the ankle and eversion of the hindfoot.  

The reference by Vlahovich et al is a case report of a talus fracture in a snowboarder and argues the importance of CT scans in evaluating these injuries as radiographs may fail to show the injury and amount of displacement and comminution of the fracture.  

The reference by Tucker et al is a review of the literature which emphasized the importance of early diagnosis to avoid long term complications. They recommend short leg casting for nondisplaced fractures and surgery for displaced or comminuted fractures.

 

55) A 40-year-old male who sustained an open pilon fracture 2 weeks ago is scheduled for a below-the-knee amputation (BKA). What laboratory value is the best predictor for wound healing? 

1. serum albumin level 

2. total protein level 

3. calcium levels 

4. C-reactive protein 

5. ESR 

Corrent answer: 1 

Based on the choices above, the most important predictor of wound healing is the serum albumin level.  

Wound healing is based on several factors, which include the vascular status, the immune status, and the nutritional status of the patient. Some important clinical findings include an ankle brachial index (ABI) > 0.45, a total lymphocyte count > 1500/mm3 and a serum albumin > 3.0 g/dL.  

Kay et al. discuss the importance of the nutritional status in wound healing after lower extremity amputation procedures. They found eleven of 25 patients who were malnourished sustained either local or systemic complications postoperatively. They recommend that patients should undergo nutritional screening prior to elective lower extremity amputations, to help optimize their wound healing.  

Incorrect Answers  

Answer 2: While total protein is a marker of nutritional status, it is not as sensitive as the serum albumin for wound healing potential.  Answers 3, 4, 5: Calcium levels, C-reactive protein and ESR are not markers of wound healing  

 

56) A 30-year-old male sustains the injury shown in figure A and undergoes successful open reduction and internal fixation. Which of the following radiographic features is a good prognostic factor for this injury?

 

1. Talar dome subchondral lucency 

2. Talar dome subchondral sclerosis 

3. Diffuse osteopenia 

4. Associated medial malleolus fracture 

5. Talar lateral process fracture 

Corrent answer: 1 

Figure A demonstrates a talar neck fracture. A subchondral talar lucency at approximately 6 weeks postoperatively indicates revascularization of the talus and is a good prognostic factor for this injury (aka Hawkins' Sign and is exhibited by the arrows in Illustration A). 

The talar neck blood supply is tenuous and is susceptible to avascular necrosis. The reference by Hawkins classified talar neck fractures and correlated the incidence of avascular necrosis with the degree of displacement and severity of the fracture: Type I = Nondisplaced vertical fractures (AVN 10%). Type II = Displaced with subtalar dislocation/subluxation (AVN > 40%). Type III = Displaced with talar body dislocation (AVN >90%). Type IV = Displaced with talar head subluxation and body extrusion (AVN 100%).  

The reference by Canale et al reviewed long term outcomes after ORIF of talar neck fractures, and they found that good or excellent results were seen in only 59%. Salvage procedures such as triple arthrodesis, tibiocalcaneal fusion, and 

dorsal beak resection of the talar neck all resulted in a high percentage of satisfactory results, but talectomy did not.

 

 

57) A 45-year-old male undergoes open reduction internal fixation for a displaced olecranon fracture as shown in Figure A. What is the most common complication for this type of fixation? 

 

1. anterior interosseous nerve palsy 

2. osteomyelitis 

3. implant failure 

4. symptomatic implants 

5. avascular necrosis 

Corrent answer: 4 

The most common complication of an olecranon fracture treated with tension band wiring is symptomatic implants. This is largely related to the

subcutaneous nature of the olecranon. 

Macko and Szabo encountered a high incidence of complications related to the technique of tension-band wire fixation of displaced fractures of the olecranon in a five-year retrospective study of twenty patients. They reported that the most frequent complication of this construct is symptomatic prominence of the hardware which is usually due to improper seating at the time of surgery. Other complications reported include loss of fixation, skin breakdown, and infection. 

Hume and Wiss reported on 41 patients randomized to tension band wiring and plate fixation. They note that there was no difference in regards to elbow motion postoperatively, but plating required more operative time. Plating of these fractures resulted in a significantly increased rate of good clinical and radiographic results. 

Figure A shows an AP and lateral radiograph of an olecranon fracture treated with tension-band wiring.  

Incorrect Answers: 

Answer 1: This is a possibility with overpenetration of the wires through the anterior ulnar cortex, but not a common finding. 

Answer 2: This is not a common finding with this treatment method. Answer 3: Although implant failure is a possibility with this technique, this is not the most common complication. 

Answer 5: Avascular necrosis of the proximal ulna is not a common complication of this injury or treatment method. 

 

58) Which of the following percentages of normal circulating blood loss would first result in a patient with tachycardia and a narrowed pulse pressure? 

1. 5% 

2. 10% 

3. 25% 

4. 40% 

5. 50% 

Corrent answer: 3 

Hemorrhagic shock is divided into four classes - class I is <15% loss and shows compensation for the blood loss (no tachycardia/hypotension) and is

treated with crystalloid replacement as necessary. Class II is a loss of 15-30% and is the target of this question. In this class, vasoconstriction leads to maintenance of perfusion pressure and tachycardia helps maintain cardiac output in the face of a decreased overall volume. The vasoconstriction leads to an elevated diastolic pressure, which is the cause of the narrowed pulse pressure (the difference between systolic and diastolic). Treatment remains control of ongoing bleeding and crystalloid replacement. Class III is a 30-40% loss, and is the first stage where hypotension is present. Signs of end organ hypoperfusion, such as confusion and decreased urine output, is seen. Treatment is crystalloid replacement and blood product replacement. Class IV is a loss of >40% and is often fatal.  

Hak reviews the ATLS classification of hemorrhage in his review article on pelvic fractures and bleeding.  

Illustration A shows the hemorrhagic shock class table. 

 

 

59) A 47-year-old male sustains the closed injury seen in Figures A and B after failing to land a motorcycle jump. A post-reduction radiograph is seen in Figure C. Which of the following is the most appropriate treatment at this time?

 

 

1. Definitive closed treatment 

2. Addition of percutaneous pins 

3. Open reduction and internal fixation 

4. Tibiotalocalcaneal arthrodesis 

5. Primary subtalar arthrodesis 

Corrent answer: 3 

The clinical presentation and imaging studies are consistent with Hawkins II talar neck fracture, which by definition is a displaced talar neck fracture with subtalar dislocation/subluxation. Despite achieving an adequate reduction initially (shown in Figure C), there is no role for closed treatment of these unstable injuries, and the treatment of choice is open reduction and internal fixation.  

The referenced article by Bibbo et al describes these injuries: 32% of subtalar joints are irreducible to closed means (half with soft tissue block, half with bony block to reduction), 88% have co-existing injuries of the ipsilateral foot, 89% have radiographic subtalar arthrosis at 5 years (62% symptomatic).