Free Orthopedic MCQs 2022, Dec, 16 | 12:00 am

ORTHOPEDIC MCQS ONLINE 015 TRAUMA

CLINICAL SITUATION FOR QUESTIONS 1 THROUGH 3

Figures 1a and 1b are the radiographs of a 70-year-old retired man who falls while skiing and injures his right hip. He had no preceding hip pain. After the fall, he is unable to ambulate and is transferred down the mountain by the ski patrol and taken to a hospital.

Question 1 of 101

The major blood supply to the femoral head comes from which vessel?

- Lateral femoral circumflex artery
- Medial femoral circumflex artery
- Artery of the ligamentum teres
- Inferior gluteal artery

PREFERRED RESPONSE: 2 - Medial femoral circumflex artery

Question 2 of 101

A formal multidisciplinary team approach to the comanagement of geriatric patients with hip fracture has been shown to lead to

- decreased intraoperative blood loss.
- decreased surgical time.
- decreased inpatient mortality.
- decreased per-patient costs.

PREFERRED RESPONSE: 4 - decreased per-patient costs.

Question 3 of 101

Which factor is a potential disadvantage of total hip arthroplasty compared to hemiarthroplasty for treatment of displaced femoral neck fracture in older patients with higher functional demands?

- Increased long-term overall costs
- Increased risk for dislocation
- Increased risk for revision surgery
- Decreased postsurgical function

PREFERRED RESPONSE: 2 - Increased risk for dislocation

DISCUSSION

The main source of blood supply to the femoral head is the deep branch of the medial femoral circumflex artery. The lateral femoral circumflex artery and artery of the ligamentum teres contribute to a lesser degree, while the inferior gluteal artery has a minimal contribution. This vascular supply is compromised with displaced femoral neck fractures and results in a high rate of osteonecrosis. This is a reason to consider arthroplasty for older patients who may not be able to tolerate multiple procedures.

Studies evaluating comanagement protocols for the treatment of hip fractures in patients older than age 60 have demonstrated significant improvements in mortality, length of stay, complication and readmission rates, and ambulatory status at time of discharge while decreasing costs. Surgical time, blood loss, time to surgery, and inpatient mortality have not been altered.

Total hip arthroplasty is more frequently recommended for primary treatment of displaced femoral neck fractures in older, active patients who would have otherwise been treated with hemiarthroplasty. Risk for acetabular erosion is alleviated, implant survival is longer, and revision surgery rates are lower, as are overall long-term costs. Postsurgical function is not compromised and may actually be better. Dislocation rates are increased (up to 10%), although these rates may be lessened with recent improvements in component design that allow for use of larger femoral heads.

Question 4 of 101

A 30-year-old man was involved in a high-speed motorcycle collision and sustained the injury shown in Figure 4a. Hypotension ensued shortly after arrival in the emergency department. Figure 4b is the initial contrast pelvic CT image with an unrecognized blush consistent with arterial bleeding. During surgical repair, the patient was noted to have active bleeding and an angiogram was obtained (Figure 4c). Which structure is the likely cause of his bleeding?

- Superior gluteal artery
- Branch of the external iliac artery
- Branch of the pudendal artery
- Branch of the femoral artery

PREFERRED RESPONSE: 3 - Branch of the pudendal artery

DISCUSSION

Pelvic bleeding occurs predominantly from disruption of the posterior venous plexus and bleeding from the fractured bone. Occasionally arterial bleeding is seen, with injury to the superior gluteal artery most common. Anterior pelvic bleeding occurs from injury to the obturator artery (commonly from a pubic bone fracture laceration) and less frequently from the pudendal artery near the symphysis. The location of the bleeding on CT and angiography images does not correspond to the superior gluteal, external iliac, or femoral arteries.

RESPONSES FOR QUESTIONS 5 THROUGH 8

- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation

Please choose from the responses to identify the most likely complication in each scenario.

Question 5 of 101

An active 79-year-old woman with the radiograph and intraoperative image shown in Figures 5a and 5b undergoes open reduction and internal fixation (ORIF) of her proximal humerus fracture.

- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation

PREFERRED RESPONSE: 1 - Avascular necrosis, head collapse, and screw penetration

Question 6 of 101

A 73-year-old woman sustains a displaced 3-part proximal humerus fracture. At the time of surgery, she has a massive rotator cuff tear in addition to the proximal humerus fracture. She is treated with total shoulder arthroplasty (TSA).

- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation

PREFERRED RESPONSE: 4 - Glenoid component loosening

Question 7 of 101

An 82-year-old woman with osteoporosis has increased pain and difficulty using her arm 3 weeks after undergoing ORIF of her 4-part proximal humerus fracture.

- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation

PREFERRED RESPONSE: 2 - Fixation failure and varus collapse

Question 8 of 101

A 79-year-old woman with a massive rotator cuff tear presents to the emergency department with pain and difficulty moving her arm 7 weeks after undergoing reverse TSA for a displaced 4-part proximal humerus fracture.

- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation

PREFERRED RESPONSE: 6 - Shoulder dislocation

DISCUSSION

The complication rate is high after surgical treatment of proximal humerus fractures, particularly in elderly patients with osteoporotic bone. In patients treated with ORIF, common complications include varus malunion (16%), avascular necrosis (10%), screw penetration (8%), and infection (4%). In cases involving a dislocation of the humeral head, avascular necrosis is more common. In patients treated with hemiarthroplasty or TSA, complications include component loosening, infection, and dislocation. TSA is associated with

glenoid loosening in patients with rotator cuff incompetence and should be avoided in these patients. Reverse TSA is a potential solution for this population. Dislocation and postoperative infection are potential complications after reverse TSA.

Question 9 of 101

9C 9D

Figures 9a through 9d are the radiographs of a 21-year-old woman who is involved in a high-speed motor vehicle collision and sustains an isolated right closed-foot injury. Before surgery, the patient is advised about the relatively poor long-term outcomes associated with this injury. What is the most common reason for functional limitations after surgical treatment in this scenario?

- Subtalar arthritis
- Osteonecrosis
- Nonunion
- Varus malunion

PREFERRED RESPONSE: 1 - Subtalar arthritis

DISCUSSION

When a displaced talar neck fracture occurs, the rate of osteonecrosis is high; however, many revascularize the talus without collapse. A nonunion can occur but is less common than osteonecrosis and arthritis. A varus malunion can be debilitating and lead to subtalar arthritis. In a fracture with the talar body dislocated posteromedially (such as in this example) neurologic deficits in the tibial nerve distribution are common but typically improve with urgent

reduction. Studies show that posttraumatic subtalar arthritis is common after this injury and is the most likely cause of long-term functional impairment.

CLINICAL SITUATION FOR QUESTIONS 10 THROUGH 12

10A

10B

10C

Figure 10a is the radiograph of a 30-year-old man who sustained an injury in a motor vehicle collision.

Question 10 of 101

This patient underwent fixation and his radiographs (Figures 10b and 10c) at 6 weeks are shown. What was the failure mode for this implant?

- Varus collapse and hardware failure
- Screw cut out in the femoral head
- Failure of distal screws and loss of fixation
- Lack of patient compliance

PREFERRED RESPONSE: 1 - Varus collapse and hardware failure

Question 11 of 101

The biomechanical reason for implant failure in this case is related to

- lack of medial cortical contact secondary to comminution.
- lack of friction fit of plate to bone.
- varus malreduction of the fracture.
- poor bone quality in the femoral head and diaphysis.

PREFERRED RESPONSE: 1 - lack of medial cortical contact secondary to comminution.

Question 12 of 101

Among the options listed below, what is the best treatment for the complication shown in Figure 10c?

- Removal of hardware and bone grafting
- Removal of hardware and total hip arthroplasty (THA)
- Removal of hardware and revision using a first-generation femoral nail
- Removal of hardware and revision using a second-generation femoral nail

PREFERRED RESPONSE: 4 - Removal of hardware and revision using a second-generation femoral nail

DISCUSSION

Proximal femur fractures can be treated using a variety of implants including intramedullary nails, blade plates, and locking plates (now precontoured proximal femur plates). The comminution and lack of medial cortical support may predispose these fractures to nonunion.

The recent popularity of locking plates for proximal femur treatment has increased their use for this fracture; however, a disproportionately high rate of failure of these plates, including early implant failure with plate and screw breakage, cut out with varus collapse, and nonunion have been reported.?

Malreduction predisposes these fractures to failure. The initial postoperative radiographs do not reveal a varus malreduction because the tip of the greater trochanter is below the center of the femoral head.

Once failure occurs, the best fixation method among the options detailed is an intramedullary nail (second generation with screws into the femoral head) and restoration of alignment. THA is usually not recommended for treatment of subtrochanteric femur fractures in young patients.

Question 13 of 101

Which medication or supplement is recommended to promote healing of atypical subtrochanteric fractures?

- Bisphosphonates
- Teriparatide
- Vitamin D
- Glucosamine chondroitin

PREFERRED RESPONSE: 2 - Teriparatide

DISCUSSION

Use of teriparatide in association with fracture fixation promotes healing because these fractures are associated with delayed healing. The other responses are not associated with healing of these fractures.

Question 14 of 101

14A

14B

An 18-year-old man was involved in an altercation during which he sustained the injuries shown in Figures 14a and 14b. His Glasgow Coma Scale (GCS) score is 11 (a GCS score of 9-12 indicates moderate head injury). The neurosurgeons elect to not place an intracranial pressure (ICP) monitor. The patient responds appropriately to stimuli and is hemodynamically stable. What is the most appropriate initial treatment?

- Knee immobilizer
- Immediate spanning external fixation
- Immediate intramedullary nailing
- Immediate plate fixation

PREFERRED RESPONSE: 2 - Immediate spanning external fixation

DISCUSSION

Although management of femoral shaft fractures in patients with head injuries remains controversial, most practitioners agree that "damage-control principles" are appropriate for patients with evolving head injuries. This patient has a subarachnoid hemorrhage and a decreased GCS but is responding appropriately. The best treatment is a damage-control approach for the femur that will cause minimal blood loss and allow the brain injury (and swelling) to equilibrate. External fixation can be performed expeditiously and with minimal blood loss, which will reduce further injury to the brain. Special attention should be paid to maintaining cerebral perfusion pressure higher than 70 mmHg. Admission to the intensive care unit is recommended for monitoring of this injury. Knee immobilizers are not tolerated well by young muscular men with femur shaft fractures. A GCS score of 11 or higher can be observed without ICP monitoring.

Question 15 of 101

The most common reason for proximal femur fracture fixation failure (Figure 15) is secondary to which common deformity?

- Varus
- Valgus
- Malrotation
- Shortening

PREFERRED RESPONSE: 1 - Varus

DISCUSSION

Malposition of a proximal lag screw may result in cut-out similar to that seen with a sliding hip screw. Varus malreduction also can result in implant failure. Studies have shown no difference in complication or healing rates when comparing short and long cephallomedullary nails.

CLINICAL SITUATION FOR QUESTIONS 16 THROUGH 20

A 23-year-old man sustains multiple injuries in a high-speed motor vehicle collision. Among his injuries are a right transverse-posterior wall acetabular fracture, a left open tibia fracture with compartment syndrome, and a right calcaneus fracture.

Question 16 of 101

After initial evaluation he is taken to the operating room urgently and undergoes debridement of his open tibia fracture, 4-compartment fasciotomy, and intramedullary nailing of the fracture. Negative pressure wound therapy (NPWT) is chosen for the open wound and fasciotomy sites. NPWT in this scenario will

- remove bacteria from the wound and decrease risk for infection.
- promote wound contraction, making primary closure less likely.
- promote local wound perfusion.
- decrease compartment pressures.

PREFERRED RESPONSE: 3 - promote local wound perfusion.

Question 17 of 101

Nine hours after surgery you are contacted because the patient has continued tachycardia and ongoing resuscitation needs. The NPWT canister has been emptied 3 times in the last 8 hours and contains sanguinous fluid. In addition to continued resuscitation, what is the most appropriate next step?

- Order the NPWT applied to wall suction to allow less frequent emptying of the canister.
- Clamp off the suction device and return to the operating room for wound exploration.
- Turn the suction down from -125 mm Hg to -50 mm Hg.
- Take the patient for angiography and possible embolization.

PREFERRED RESPONSE: 2 - Clamp off the suction device and return to the operating room for wound exploration.

Question 18 of 101

On postinjury day 3 the patient undergoes open reduction and internal fixation of his right acetabular fracture via a Kocher-Langenbeck approach. On postoperative day 5 he is noted to have persistent serous drainage without any localized signs of infection. Incisional NPWT used in this setting would likely result in

- infection.
- a sealed wound (more rapidly than sealing would occur with a compressive dressing).
- hematoma formation.
- it can electively delay flap coverage for 3 to 4 weeks.

PREFERRED RESPONSE: 2 - a sealed wound (more rapidly than sealing would occur with a compressive dressing).

Question 19 of 101

The patient undergoes repeat debridements for the open tibia fracture and associated compartment syndrome. It becomes apparent that the medial open fracture wound is not amenable to primary closure. NPWT is useful in this setting because

- it will stabilize the soft-tissue environment while the patient awaits flap coverage.
- it will promote granulation of the wound over the exposed fracture site to prevent flap coverage.
- it will promote fracture healing.
- it can electively delay flap coverage for 3 to 4 weeks.

PREFERRED RESPONSE: 1 - it will stabilize the soft-tissue environment while the patient awaits flap coverage.

Question 20 of 101

The patient subsequently requires split-thickness skin grafting over his lateral fasciotomy wound during soft-tissue reconstruction. In this setting, NPWT

- will likely improve incorporation of the graft.
- will provide an inconsistent bolster to the graft.
- should be used directly over the skin graft.
- should be used at the donor site to promote faster healing.

PREFERRED RESPONSE: 1 - will likely improve incorporation of the graft.

DISCUSSION

NPWT increases wound perfusion. The dressing may help decrease risk for wound infection, but will not do so by removing bacteria. It also helps to prevent wound contracture to improve the likelihood of primary wound closure. NPWT can help to improve tissue edema and will not elevate compartment pressure.

Hemorrhage is the most common major complication associated with NPWT. This risk is highest when NPWT is used in areas of major vessels and vessels that have been ligated and for patients undergoing anticoagulation therapy. Specialized white polyvinyl alcohol sponges are available to prevent adherence to vessels, exposed nerves, or exposed bone. NPWT should not be used directly over exposed major vessels. If major bleeding occurs, a return to the operating room for wound exploration is recommended.

Incisional NPWT is an effective treatment for persistent serous drainage. Wounds that drain persistently seal more quickly and pose lower risk for infection when incisional NPWT is used vs compressive dressings. Incisional NPWT has also demonstrated benefit when used on high-risk postsurgical wounds of the tibial plateau, pilon, and calcaneus. It has not been shown to contribute to increased risk for wound dehiscence or hematoma.

NPWT stabilizes the soft-tissue environment and does not necessitate frequent dressing changes. Despite this benefit, a delay of flap coverage after NPWT still poses higher risk for infection than early coverage. Consequently, flaps should not be delayed for long. NPWT promotes the formation of granulation

tissue and can be used over exposed bone, but it would not be expected to form granulation tissue over an exposed fracture site or hardware or promote fracture healing.

NPWT provides an excellent bolster for a skin graft and improves skin graft incorporation. It needs to be applied with nonadherent dressings to prevent adherence to the skin graft. NPWT is generally not used at skin grafting donor sites.

Question 21 of 101

Preventing "missed" femoral neck fractures associated with ipsilateral femoral shaft fractures is best achieved with

- an examination.
- dedicated anteroposterior and lateral hip radiographs.
- thin-cut pelvic CT images with coronal and sagittal reconstructions.
- MRI.

PREFERRED RESPONSE: 3 - thin-cut pelvic CT images with coronal and sagittal reconstructions.

DISCUSSION

Ipsilateral femoral neck and shaft fractures occur in up to 6% of femur fractures. A femoral neck fracture is often vertical and nondisplaced. A high degree of suspicion is necessary to avoid "missed" femoral neck fractures in patients with this condition. Although an examination and dedicated hip radiographs help to avoid missed injuries, a significant decrease in missed

injuries has been described with the use of thin-cut pelvic CT images. In patients who undergo trauma, a pelvic CT scan is often performed to assess for associated injuries and is easily reviewed to examine the femoral neck. Although MRI is advocated to identify isolated occult femoral neck fractures, CT has been described as the method of choice with which to identify ipsilateral femoral neck and shaft fractures in the trauma population. Currently, no literature supports the use of MRI in this population.

CLINICAL SITUATION FOR QUESTIONS 22 THROUGH 25

Figure 22 is the anteroposterior radiograph of a 44-year-old firefighter who falls from his road bike and sustains a closed midshaft clavicle fracture. He chooses surgical treatment with open reduction and internal fixation (ORIF).

Question 22 of 101

What is the most common complication of nonsurgical treatment for this injury?

- Anterior chest wall numbness
- Symptomatic malunion
- Nonunion
- Pneumothorax

PREFERRED RESPONSE: 3 - Nonunion

Question 23 of 101

Which variable is a risk factor for nonunion of displaced clavicle fractures?

- Adolescence
- Displacement exceeding 100%
- Transverse fracture
- Male gender

PREFERRED RESPONSE: 2 - Displacement exceeding 100%

Question 24 of 101

The patient decides to undergo surgery with open reduction and plate fixation. What is the most common reason for revision surgery after plate fixation of a clavicle fracture?

- Supraclavicular nerve entrapment
- Symptomatic malunion
- Nonunion
- Hardware irritation/prominence

PREFERRED RESPONSE: 4 - Hardware irritation/prominence

Question 25 of 101

Which structure(s) is/are most at risk with surgical treatment of displaced clavicle fractures with ORIF?

- Subclavian artery
- Subclavian vein
- Brachial plexus
- Supraclavicular nerves

PREFERRED RESPONSE: 4 - Supraclavicular nerves

DISCUSSION

Complications associated with nonsurgical treatment of displaced midshaft clavicle fractures are uncommon. Although intrathoracic and local vascular complications have been reported with clavicle fracture, subclavian artery aneurysm and pneumothorax are rare. Malunion to some degree is inevitable with nonsurgical treatment of displaced clavicle fractures, but only about 9% of patients develop symptomatic malunion. Nonunion occurs in about 15% of patients.

Previously identified risk factors for nonunion of clavicle fractures include female gender, displacement exceeding 100%, comminution, and advanced age. Research demonstrates the strongest risk factors are smoking, comminution, and fracture displacement. Rate of nonunion in 1 study was approximately 13%. Murray and associates showed that by estimating the risk of nonunion using their model and operating only on fractures with at least a 40% chance of nonunion, they would only need to operate on 1.7 patients to prevent 1 nonunion (decreased from 7.5 procedures per nonunion if operating on all displaced midshaft fractures). This data could potentially be used to limit unnecessary procedures and decrease costs associated with treatment of clavicle fractures.

Hardware removal is the most common reason for revision surgery. Symptomatic malunion and supraclavicular nerve entrapment are rare after surgery. Nonunion is uncommon (in fewer than 2% of cases). The main reason for revision surgery is hardware removal to address local irritation/prominent hardware or infection.

An anatomical study demonstrated that in 97% of clavicles, 2 to 3 branches of the supraclavicular nerve were crossing the clavicle with wide location variability in the zone in which most clavicle fractures occur and surgery would take place. The subclavian vein and artery and brachial are rarely injured,

although there are case reports of injury to all either by the displaced fracture fragments or errant hardware.

CLINICAL SITUATION FOR QUESTIONS 26 AND 27

Figures 26a through 26c are the radiographs of a 50-year-old athlete who sustained an injury to his right foot; the foot was plantar flexed and another player landed on the posterior aspect of his heel. After sustaining the injury he was unable to bear weight, and 3 days later he was seen in the emergency department because of persistent pain and tenderness over his midfoot.

Question 26 of 101

CT images reveal a purely ligamentous injury. Which treatment produces the best results?

- Open reduction and internal fixation (ORIF) of the fracture
- Early fusion of the first and second tarsometatarsal joints
- Nonweight-bearing activity for 6 weeks
- Weight bearing with a camwalker

PREFERRED RESPONSE: 2 - Early fusion of the first and second tarsometatarsal joints

Question 27 of 101

ORIF of the injury was chosen (as illustrated in Figure 27). Long-term results may include

- improved American Orthopaedic Foot & Ankle Society (AOFAS) scores as compared to scores obtained following fusion.
- pes planovalgus.
- persistent pain and arthritis.
- hindfoot pain.

PREFERRED RESPONSE: 3 - persistent pain and arthritis.

DISCUSSION

The injury mechanism describes axial loading to a plantar-flexed foot and is classic for Lisfranc injury. If the initial films are not diagnostic as in this case, weight-bearing films are a reasonable next step. Radiographic widening of 2 mm or more between the second metatarsal base and medial cuneiform (as

compared to the other side) is diagnostic; occasionally, a "fleck" sign (a small bony fragment noted in the Lisfranc joint) may indicate an avulsion fracture. Clinical signs include plantar ecchymosis, tenderness over the Lisfranc joint, and an inability to bear weight. Anatomic ORIF or fusion are the options for treatment, and results for ligamentous injuries are better when fusion is performed. Better AOFAS scores have been demonstrated with fusion, and a higher incidence of pain and arthritis have been noted with fixation. No significant difference has been seen regarding hardware failure, and hindfoot pain is not a consideration.

Question 28 of 101

67-year-old right-hand-dominant man who is an avid golfer sustains an unstable distal radius fracture on his right side. He undergoes a closed reduction with acceptable alignment. After discussing surgical vs nonsurgical management and recovery, the patient decides to have surgery. He made this decision because he was told that his
1. - functional outcome at 1 year would be worse with nonsurgical management.
2. - radiographs will look better after surgery.
3. - grip strength will be better with surgical intervention.
4. - overall long-term outcome can improve with formal occupational therapy after surgery.
  
  PREFERRED RESPONSE: 3 - grip strength will be better with surgical intervention.
  
  DISCUSSION
  
  The optimal treatment of distal radius fractures in elderly patients remains controversial. Both surgical and nonsurgical management of distal radius fractures produce identical functional outcomes at 1 year. Although many patients have better motion early with surgery, only grip strength has been shown to be significantly better at 1 year. Radiographic outcome has not been correlated with functional outcome, and complications are also equivalent. Independent prescribed therapy has been better than formal occupational therapy for range of motion, but no differences in functional outcome were seen as assessed by Disabilities of the Arm, Shoulder and Hand scores.
  
  RECOMMENDED READINGS
  
  Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing non-operative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597. PubMed PMID: 22159849. View Abstract
  
  at PubMed
  
  Egol KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N. Distal radial fractures in the elderly: operative compared with non-operative treatment. J Bone Joint Surg Am. 2010 Aug 4;92(9):1851-7. doi: 10.2106/JBJS.I.00968. PubMed PMID: 20686059.View Abstract at
  
  PubMed
  
  Souer JS, Buijze G, Ring D. A prospective randomized controlled trial comparing occupational therapy with independent exercises after volar plate fixation of a fracture of the distal part of the radius. J Bone Joint Surg Am. 2011 Oct 5;93(19):1761-6. doi: 10.2106/JBJS.J.01452. PubMed PMID: 22005860.View Abstract at PubMed
  
  Question 29 of 101
  
  Figure 29 is the anteroposterior radiograph of a 60-year-old man who is involved in a motorcycle collision and airlifted to a trauma center. The patient is hypotensive and tachycardic upon arrival and fluid resuscitation is underway. He has a scrotal hematoma and his bilateral lower extremities are externally rotated. What is the first step in managing this scenario?
  1. - Obtain CT images of the pelvis
  2. - Angiography
  3. - Place external fixation
  4. - Apply a pelvic binder
  PREFERRED RESPONSE: 4 - Apply a pelvic binder
  
  DISCUSSION
  
  A pelvic binder or sheet can be applied right away to reduce and stabilize the pelvis more quickly than is possible with an external fixator. Pelvic ring injuries are associated with a high incidence of mortality mainly because of the potential for retroperitoneal hemorrhage. A pelvic circumferential compression device allows for force-controlled circumferential compression. It can effectively reduce pelvic ring injuries and poses minimal risk for overcompression and complications. Reduction of external rotation injuries is comparable to definitive fixation reduction and does not cause significant overcompression of internal rotation injuries. Angiography is used to assess persistent hemodynamic instability after initial stabilization of the pelvic ring with the binder or sheet. CT images should be obtained after initial resuscitation.
  
  RECOMMENDED READINGS
  
  Olson SA, Reilly MC, eds. Acetabular and Pelvic Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:15-42.
  
  Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma. 2005 Sep;59(3):659-64. PubMed PMID: 16361909.View Abstract at PubMed
  
  Question 30 of 101
  
  An 82-year-old woman falls from a standing height and sustains a proximal humerus fracture. Which factor is the best predictor of ischemia of the humeral head?
  1. - Fracture pattern involving 4 parts
  2. - Humeral head angulation exceeding 45 degrees
  3. - Posteromedial calcar length of less than 8 mm attached to the humeral head
  4. - Glenohumeral dislocation
  PREFERRED RESPONSE: 3 - Posteromedial calcar length of less than 8 mm attached to the humeral head
  
  DISCUSSION
  
  Humeral head ischemia that occurs following proximal humerus fractures is closely associated with the amount of posteromedial calcar bone attached to the humeral head. Fractures that exit within 8 mm of the posteromedial edge of the head more commonly are ischemic (compared to fractures that have more than 8 mm of posteromedial calcar still attached). Four-part fracture patterns are a moderate predictor of humeral head ischemia, with an accuracy of 0.67. Angulation of the humeral head exceeding 45 degrees also is a moderate predictor of humeral head perfusion, with an accuracy of 0.62. Glenohumeral dislocation is a poor predictor of humeral head ischemia.
  
  RECOMMENDED READINGS
  
  Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004 Jul-Aug;13(4):427-33. PubMed PMID: 15220884. View Abstract at PubMed
  
  Xu J, Zhang C, Wang T. Avascular necrosis in proximal humeral fractures in patients treated with operative fixation: a meta-analysis. J Orthop Surg Res. 2014 Apr 27;9(1):31. [Epub ahead of print] PubMed PMID: 24767176. View Abstract at PubMed
  
  Question 31 of 101
  
  An atypical bisphosphonate-associated femur fracture would show which features?
  1. - Lateral cortical thickening at the subtrochanteric region with a fracture line extending to the medial side
  2. - Lateral cortical thickening at the supracondylar region with a fracture line extending to the medial side
  3. - Stress fracture of the femoral neck
  4. - Reverse obliquity intertrochanteric femur fracture
  PREFERRED RESPONSE: 1 - Lateral cortical thickening at the subtrochanteric region with a fracture line extending to the medial side
  
  DISCUSSION
  
  Patients sustaining atypical femur fractures have classic radiographic findings including medial beaking, lateral cortical thickening, and transverse or short oblique proximal (subtrochanteric) femur fracture.
  
  RECOMMENDED READINGS
  
  Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster DW, Ebeling PR, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Lane JM, McKiernan F,McKinney R, Ng A, Nieves J, O'Keefe R, Papapoulos S, Howe TS, van der Meulen MC, Weinstein RS, Whyte MP. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American society for bone and mineral research. J Bone Miner Res. 2014 Jan;29(1):1-23. doi:10.1002/jbmr.1998. Epub 2013 Oct 1. PubMed PMID: 23712442. View Abstract at PubMed
  
  Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA, Brown TD, Cheung AM, Cosman F, Curtis JR, Dell R, Dempster D, Einhorn TA, Genant HK, Geusens P, Klaushofer K, Koval K, Lane JM, McKiernan F, McKinney R, Ng A, Nieves J, O'Keefe R, Papapoulos S, Sen HT, van der Meulen MC, Weinstein RS, Whyte M; American Society for Bone and Mineral Research. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2010 Nov;25(11):2267-94. doi: 10.1002/jbmr.253. Erratum in: J Bone Miner Res. 2011 Aug;26(8):1987. PubMed PMID: 20842676. View Abstract at PubMed
  
  RESPONSES FOR QUESTIONS 32 THROUGH 35
  1. - Open reduction and internal fixation with a proximal humerus locking plate
  2. - Nonsurgical treatment
  3. - Arthroplasty
  Match the appropriate treatment listed with the clinical scenario described.
  
  Question 32 of 101
  
  A 78-year-old right-hand-dominant woman who lives independently falls down the stairs at her home. She has an isolated injury to her left shoulder and a history of hypertension and atrial fibrillation. Imaging reveals a proximal humerus fracture with a displaced fracture splitting the humeral head and a large displaced greater tuberosity fragment.
  1. - Open reduction and internal fixation with a proximal humerus locking plate
  2. - Nonsurgical treatment
  3. - Arthroplasty
  PREFERRED RESPONSE: 3 - Arthroplasty
  
  Question 33 of 101
  
  A 72-year-old right-hand-dominant woman sustains an isolated injury to her right shoulder after a fall while walking her dog. She lives independently and has a history of hypercholesterolemia. Her activities include walking, aerobics, and yoga. Imaging reveals a proximal humerus fracture with fracture of the surgical neck that is displaced 2 cm.
  1. - Open reduction and internal fixation with a proximal humerus locking plate
  2. - Nonsurgical treatment
  3. - Arthroplasty
  PREFERRED RESPONSE: 1 - Open reduction and internal fixation with a proximal humerus locking plate
  
  Question 34 of 101
  
  An 81-year-old left-hand-dominant woman who lives independently has a slip-and-fall accident while shopping. She has an isolated injury to her left shoulder and a history of coronary artery disease and hypertension. Imaging reveals a proximal humerus fracture with 50% translation at the surgical neck.
  1. - Open reduction and internal fixation with a proximal humerus locking plate
  2. - Nonsurgical treatment
  3. - Arthroplasty
  PREFERRED RESPONSE: 2 - Nonsurgical treatment
  
  Question 35 of 101
  
  An 80-year-old right-hand-dominant woman who lives independently falls in her home. She has an isolated injury to her right shoulder and a history of a total hip replacement for a femoral neck fracture (3 years prior). She has had a prior failed rotator cuff repair. Her daily activities include volunteering at her church and caring for her grandchildren. Imaging reveals a displaced proximal humerus fracture with comminution and 50% translation with varus angulation at the surgical neck. She also has displacement and comminution of the greater tuberosity.
  1. - Open reduction and internal fixation with a proximal humerus locking plate
  2. - Nonsurgical treatment
  3. - Arthroplasty
  PREFERRED RESPONSE: 3 - Arthroplasty
  
  DISCUSSION
  
  Treatment of proximal humerus fractures in elderly patients is controversial and requires consideration of the patient's functional demands and fracture characteristics. The majority of fractures can be treated nonsurgically. Nonsurgically treated fractures should be briefly immobilized before beginning pendulum exercises and elbow range of motion.
  
  Some patients are surgical candidates based upon functional demands and degree of displacement. Fractures that are reconstructible can be successfully treated with reduction and fixation or intramedullary nailing. If there is tuberosity involvement, plate fixation is preferable to intramedullary nailing. Factors that make fixation challenging and vulnerable to failure include poor bone quality and significant varus alignment. Relative indications for arthroplasty, especially in patients with poor bone quality, include initial varus alignment, head-splitting fractures, and 4-part fractures. Traditionally, hemiarthroplasty has produced reliable pain relief and unreliable function because of the difficulty associated with reconstruction of the tuberosities to restore rotator cuff function. Reverse shoulder arthroplasty may be a better option for patients who are arthroplasty candidates who have tuberosities that will not be reliably reconstructed or for those who have a pre-existing rotator cuff deficiency.
  
  RECOMMENDED READINGS
  
  Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Innovations in the management of displaced proximal humerus fractures. J Am Acad Orthop Surg. 2007 Jan;15(1):12-26.
  
  Review. PubMed PMID: 17213379. View Abstract at PubMed
  
  Cadet ER, Ahmad CS. Hemiarthroplasty for three- and four-part proximal humerus fractures. J Am Acad Orthop Surg. 2012 Jan;20(1):17-27. doi: 10.5435/JAAOS-20-01-017. Review. PubMed PMID: 22207515.View Abstract at PubMed
  
  Question 36 of 101
  
  Two femoral shaft fractures are shown in Figure 36. Each is fixed identically with the same intramedullary nail and interlocking screws. The fracture gap strain is higher in
  
  1 - A.
  
  2 - B.
  1. - neither; the strain is identical in A and B.
  2. - neither; the strain is dependent on femur length.
  PREFERRED RESPONSE: 1 - A.
  
  DISCUSSION
  
  Fracture gap strain is defined as deformation of granulation tissue within the fracture gap when a given force is applied. Normal strain is the change in length (? l) divided by the original length (l) when a given load is applied. The amount of deformation that a tissue can tolerate while functioning varies greatly. Intact bone has a normal strain tolerance of 2% (before it fractures), whereas granulation tissue has a strain tolerance of 100%. Bony bridging between the distal and proximal callus can only occur when local strain (ie, deformation) is less severe than the forming bone can tolerate. Therefore, treatment of fractures must optimize the strain environment to enable healing.
  
  Comminution, as shown in B, results in distribution of the motion between multiple fracture fragments. As a result, each fracture gap experiences less motion and strain is decreased. In simple fracture patterns as shown in A, small amounts of motion or even a small fracture gap results in a high-strain environment. Strain is dependent upon the length of the fracture gap but not on the length of the bone.
  
  RECOMMENDED READINGS
  
  Perren SM, Buchanan JS. The Concept of Interfragmentary Strain. Berlin, Heidelberg, New York: Springer-Verlag; 1980.
  
  Claes LE, Heigele CA. Magnitudes of local stress and strain along bony surfaces predict the course and type of fracture healing. J Biomech. 1999 Mar;32(3):255-66. PubMed PMID: 10093025.View Abstract at PubMed
  
  Question 37 of 101
  
  Figure 37 is the radiograph of a 31-year-old woman who has acute right hip pain after a fall. The treatment variables that are most important to maximize clinical outcome are
  1. - timing of fixation and capsulotomy.
  2. - timing of fixation and choice of implants.
  3. - quality of reduction and fixation.
  4. - choice of open reduction and capsulotomy.
  PREFERRED RESPONSE: 3 - quality of reduction and fixation.
  
  DISCUSSION
  
  Femoral neck fractures are potentially devastating injuries for physiologically young patients. Studies have demonstrated that the timing of fixation is not
  
  as critical to outcome or to avascular necrosis prevention as other factors. Experimental evidence supports capsulotomy to improve femoral head blood flow. Relative biomechanical advantages are associated with different implants; however, a surgeon can obtain good fixation with a variety of devices. For a physiologically young patient, an open reduction is often required to obtain the desired anatomic reduction; however, if the desired result can be achieved with closed reduction, open reduction is not required. Anatomic reduction of the fracture and biomechanically sound fixation consistently yield optimal results.
  
  RECOMMENDED READINGS
  
  Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004 Aug;86-A(8):1711-6. PubMed PMID: 15292419.View Abstract at PubMed Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br. 2004 Sep;86(7):1035-40.
  
  PubMed PMID: 15446534.View Abstract at PubMed
  
  Question 38 of 101
  
  A 55-year-old man fell off a bicycle and sustained the injury shown in Figures 38a through 38c. Which fracture pattern best describes this injury?
  
  A
C
1. - Anterior column posterior hemitransverse
2. - Anterior column
3. - Anterior wall
4. - Associated both-column

PREFERRED RESPONSE: 2 - Anterior column

DISCUSSION

This is an anterior column fracture with dome impaction. The obturator oblique view and both CT images show disruption of the anterior column. Both CT images also reveal an intact posterior column, which eliminates anterior column posterior hemitransverse and associated both-column fracture types as correct responses. An anterior wall fracture would not extend up into the ilium.

CLINICAL SITUATION FOR QUESTIONS 39 THROUGH 41

Figure 39 is the standing radiograph of a 20-year-old college student who injures his foot while playing intramural football. Initial radiograph findings are reportedly normal, but 1 week after injury he still cannot bear weight. You see him in the clinic and note swelling of his foot and plantar ecchymosis.

Question 39 of 101

What is the strongest structure supporting the tarsometatarsal (TMT) complex of the midfoot?

1 - Oblique interosseous ligament

2 - Deep band of the plantar oblique ligament

3 - Dorsal oblique ligament

4 - First TMT ligament

PREFERRED RESPONSE: 1 - Oblique interosseous ligament

Question 40 of 101

What radiographic finding is consistent with a Lisfranc injury?

1 - Dorsal and plantar aspects of the metatarsals (MTs) correspond with the cuneiforms and cuboid on the lateral view.

2 - The medial border of the second MT is aligned with the medial border of the middle cuneiform on the anteroposterior view.

3 - The medial border of the fourth MT is aligned with the medial border of the cuboid on the oblique view.

4 - Diastasis between the first and second MT is 3.5 mm.

PREFERRED RESPONSE: 4 - Diastasis between the first and second MT is 3.5 mm.

Question 41 of 101

Primary arthrodesis is associated with which outcome when compared to outcomes associated with open reduction and internal fixation (ORIF) without arthrodesis?

1 - Decreased secondary surgeries

2 - Increased pain

3 - Increased risk for infection

4 - Poorer function at 2-year follow-up

PREFERRED RESPONSE: 1 - Decreased secondary surgeries

DISCUSSION

There are longitudinal, oblique, and transverse ligaments at the TMT complex that are further defined by their location as dorsal, interosseous, or plantar. There are 3 ligaments between the medial cuneiform and the second MT base, the most important of which is the oblique interosseous ligament, which is also known as the Lisfranc ligament. Plantar and dorsal oblique ligaments contribute to stability to a lesser degree. The dorsal ligaments are weakest and may be the first to fail in a Lisfranc injury.

The second MT base should be aligned with the middle cuneiform at the medial borders, and the fourth MT base should be aligned with the cuboid at the medial borders on the oblique view. The dorsal and plantar aspects of the MTs

should align with the cuneiforms/cuboid on the lateral view. Any malalignment should raise the suspicion of a Lisfranc injury. Diastasis between the second MT and the first MT/medial cuneiform complex of more than 2 mm indicates injury, as does TMT joint subluxation of 2 mm more than seen on the uninjured contralateral side. Diastasis between the first and second MT up to 2.7 mm can be normal. Another radiographic sign of injury includes avulsion fracture of the second MT base or medial cuneiform. Additional imaging studies that may be helpful in identifying subtle injuries include weight-bearing radiographs and CT or MRI images.

Two prospective randomized studies compared primary fusion with ORIF Lisfranc injuries. The second study included fracture-dislocations, whereas the first looked at primarily ligamentous injuries. Results conflicted with an earlier study demonstrating improved results (less pain, better function) with primary fusion, while a more recent study showed no difference. Neither study showed worse results with primary fusion, and the rate of secondary surgery was more common in the ORIF group (salvage arthrodesis or hardware removal).

Question 42 of 101

Which ligament attaches to the bony fragment identified by the CT image arrows in Figures 42a and 42b?

1 - Posterior tibiotalar ligament

2 - Posterior-inferior tibiofibular ligament (PITFL)

3 - Interosseous ligament (IOL)

4 - Anterior-inferior tibiofibular ligament (AITFL) ?

PREFERRED RESPONSE: 2 - Posterior-inferior tibiofibular ligament (PITFL)

DISCUSSION

The distal tibiofibular syndesmosis is a ligamentous complex that consists of the AITFL, PITFL, intertransverse ligament (ITL), and IOL. The PITFL originates on the posterior inferior aspect of the tibia (Volkmann tubercle) and inserts on the lateral malleolus. The AITFL originates on the anterolateral aspect of the tibia (Chaput tubercle) and inserts on the distal anterior aspect of the fibula (Wagstaffe tubercle). The ITL is a group of fibers running transversely just inferior to the PITFL. As a group, these structures maintain the appropriate tibial plafond and talus relationship throughout physiologic range of motion.

CLINICAL SITUATION FOR QUESTIONS 43 THROUGH 46

A 46-year-old healthy right-hand-dominant man falls and sustains the injury shown in Figures 43a and 43b.

Question 43 of 101

What is the treatment of choice?

1 - Nonsurgical treatment

2 - Open reduction and internal fixation (ORIF)

3 - Hemiarthroplasty

4 - Total shoulder arthroplasty (TSA)

PREFERRED RESPONSE: 2 - Open reduction and internal fixation (ORIF)

Question 44 of 101

If the patient undergoes ORIF, which strategy is essential to minimize fixation failure?

1 - Use of all locking screws

2 - Use of cancellous allograft for defect management

3 - Achieving at least 3 points of fixation in the humeral head

4 - Restoration of medial cortical support

PREFERRED RESPONSE: 4 - Restoration of medial cortical support

Question 45 of 101

A similar fracture is treated with ORIF and a locking plate for an active 73-year-old right-hand-dominant woman. Which patient characteristic is most likely to contribute to possible fixation failure?

1 - Hand dominance

2 - Level of activity

3 - Osteoporosis

4 - Rotator cuff incompetence

PREFERRED RESPONSE: 3 - Osteoporosis

Question 46 of 101

The 73-year-old patient undergoes shoulder hemiarthroplasty. What is a risk factor for a poor outcome?

1 - Tuberosity nonunion

2 - Hand dominance

3 - Female gender

4 - BMI higher than 30

PREFERRED RESPONSE: 1 - Tuberosity nonunion

DISCUSSION

Surgical treatment is favored for young, active patients with displaced proximal humerus fractures. Nonsurgical treatment is favored to treat fractures with minimal displacement among low-demand elderly patients. When ORIF is used, a number of strategies are employed to prevent failure, including restoration of medial cortical support (medial calcar), incorporation of the rotator cuff into the construct, and placement of screws of adequate length to gain purchase in the subchondral bone of the humeral head. Intramedullary allograft is not routinely required but is useful when dealing with osteoporotic bone. Cancellous allograft has not been shown to prevent

failure. Varus collapse and failure of fixation are more prevalent in patients with osteoporotic bone, and, in these cases, strategies for supplemental fixation are advisable. In cases of severe osteoporosis, comminution, or poor bone quality, shoulder arthroplasty may be a better choice. Without a functioning rotator cuff, as would happen with a tuberosity nonunion, outcomes after shoulder hemiarthroplasty and TSA are poor.

RESPONSES FOR QUESTIONS 47 THROUGH 50

1 - Stress distribution

2 - Stress concentration

49 A

50A B

For each pattern detailed or depicted, select the appropriate condition. Question 47 of 101

A simple fracture pattern that is nonanatomically reduced with a 3-mm gap and treated with an 8-hole locking plate with 4 bicortical locking screws placed on each side of the fracture

1 - Stress distribution

2 - Stress concentration

PREFERRED RESPONSE: 2 - Stress concentration

Question 48 of 101

A multifragmentary fracture pattern that is bridge plated to restore length and alignment and treated with a 12-hole locking plate with 4 bicortical locking screws placed on each side of the fracture

1 - Stress distribution

2 - Stress concentration

PREFERRED RESPONSE: 1 - Stress distribution

Question 49 of 101

Figures 49a through 49c

1 - Stress distribution

2 - Stress concentration

PREFERRED RESPONSE: 2 - Stress concentration

Question 50 of 101

Figures 50a and 50b

1 - Stress distribution

2 - Stress concentration

PREFERRED RESPONSE: 1 - Stress distribution

Figure 50c Figure 50d

DISCUSSION

When comparing stress distribution and stress concentration, the focus is primarily on the implant. Stress is equal to force divided by the area over which that force is distributed. When the area is small, concentration of stress occurs. When the area is large, distribution of stress occurs. The practical importance is most easily understood via an analogy (Figures 50c and 50d). Consider a ruler. If the goal were to break the ruler, placing your thumbs close together would be a logical choice. This hand position concentrates the forces over a small area (stress concentration). Now imagine that the ruler is a bone

and your thumbs are screws placed on each side of a fracture. If a bending load is applied, the same small area of the plate is cycled. Metal can sustain a limited number of cycles before fatigue failure occurs. If the bone does not heal before this time, construct failure ensues. In a scenario in which prolonged healing times are expected, leaving a larger segment of the plate unsupported (ie, moving the center screws further away from each other) would distribute implant stress. This must be balanced with the goal of stability and the basic science of bone healing.

CLINICAL SITUATION FOR QUESTIONS 51 THROUGH 53

Figures 51a and 51b are the radiographs of a 55-year-old man who was involved in a motor vehicle collision. The patient has pain and deformity of his right knee. Examination reveals crepitus and swelling about the knee with gross motion of the distal femur. There is an 8-cm lateral open wound with exposed bone and gross contamination.

51A

52A B C D

Question 51 of 101

Immediate surgical treatment should consist of irrigation and debridement of the fracture and

1 - bridging external fixation.

2 - a retrograde intramedullary nail.

3 - a tibial traction pin.

4 - open reduction and internal fixation (ORIF) with plate fixation.

PREFERRED RESPONSE: 1 - bridging external fixation.

Question 52 of 101

The patient undergoes ORIF as shown in Figures 52a and 52b. Three months later, he develops a deformity and pain. Radiographs are shown in Figures 52c and 52d. Early hardware failure in the management of distal femur fractures has been linked to

1 - the use of nonlocking screws in the proximal fragment.

2 - the length of the plate used.

3 - distal placement of the plate.

4 - comminution of the fracture.

PREFERRED RESPONSE: 2 - the length of the plate used.

Question 53 of 101

When applying a locking plate to the lateral aspect of the distal femur, medial translation of the distal femur occurs with respect to the diaphysis ("golf-club deformity"). This deformity was created by

1 - placement of the plate too posterior.

2 - placement of the plate too proximal.

3 - placement of the plate too anteriorly on the shaft.

4 - placement of the plate too anteriorly on the condyles.

PREFERRED RESPONSE: 1 - placement of the plate too posterior.

DISCUSSION

This patient should undergo immediate irrigation and debridement of the fracture. Secondary to gross contamination, there is concern for initial definitive treatment. ?

Because of the contamination, temporary stabilization will allow for better soft-tissue management and a second look prior to definitive internal fixation. Tibial traction pin placement for skeletal traction is less than ideal because it confines patients to bed rest. With external fixation, a patient can mobilize.

Obtaining CT images prior to ORIF will aid in preoperative planning. Locked plating of supracondylar distal femur fractures has not been without complications. In a large study of patients undergoing surgical fixation, it was found that a key failure factor was plate length. A plate longer than 9 holes (shaft) that allows for at least 8 holes proximal to the fracture is ideal. Other risk factors that led to implant failure in this study were obesity, open fractures, smoking, and younger age. There has not been an association with early failure using nonlocked screws or the degree of comminution. Both may be factors in long-term failure if there is delayed healing or nonunion development. ?

The golf-club deformity has been a long-standing problem in the management of distal femur fractures when a plate is applied too posteriorly. This was true when 95-degree dynamic condylar plates or blade plates were used, and this still holds true for locking plates. Distal placement of the plate also leads to this deformity because in both situations medialization of the condyles occurs. Placing the plate too anterior on the shaft can lead to compromised fixation and early failure, whereas placement anterior on the condyles can lead to

hardware pain or intra-articular screw penetration into the patella-femoral joint. Proximal placement of the plate would not result in the deformity and is not a common problem because of the contour of the plate. If the plate were applied too proximal, the condyles would be lateralized and/or insufficient points of fixation could occur.

Question 54 of 101

A 53-year-old man is involved in a motor vehicle collision and sustains the closed distal femur fracture seen in Figures 54a and 54b. A precontoured distal femoral locking plate is selected for fixation. A locking construct should be used to

A B

- make the construct as rigid as possible and minimize strain to promote primary bone healing.
- make the construct as rigid as possible and provide a high-strain environment to promote primary bone healing.
- provide a fixed-angle construct and bridge the area of comminution to minimize strain and promote secondary bone healing.
- provide a fixed-angle construct and bridge the area of comminution to provide a high-strain environment and promote secondary bone healing.

PREFERRED RESPONSE: 3 - provide a fixed-angle construct and bridge the area of comminution to minimize strain and promote secondary bone healing.

DISCUSSION

This patient has a comminuted distal femur fracture. A fixed-angle device such as a locking plate is preferred to confer angular stability to the construct and prevent varus collapse. The strategy to promote union of the fracture is to provide a low-strain environment to allow bone healing. Strain is determined by the amount of motion over the length of a fracture. In the case of a noncomminuted fracture, the fracture surfaces can be compressed and rigid fixation applied to abolish strain and promote primary bone healing without callus. In the case of a comminuted fracture, the preferred fixation strategy

focuses on distributing motion along the length of the fracture to provide a low-strain environment that will promote secondary bone healing and callus formation.

Question 55 of 101

An 83-year-old right-hand-dominant woman sustains a displaced right extra-articular distal radius fracture and is treated with closed reduction and casting. At her 4-week follow-up visit, radiographs demonstrate a volar tilt of -5 degrees and 4 mm of positive ulnar variance. Which treatment is recommended?

- No additional reduction and continued treatment in the cast
- Repeat closed reduction and cast application
- Closed reduction and percutaneous skeletal fixation
- Open reduction and internal fixation

PREFERRED RESPONSE: 1 - No additional reduction and continued treatment in the cast

DISCUSSION

Studies demonstrate that surgical treatment of distal radius fractures in elderly people does not result in improved outcomes. Although nonsurgical treatment resulted in worse radiographic findings for this patient, these findings did not translate into worse functional outcomes.

Question 56 of 101

Figure 56 is the radiograph of a 62-year-old noninsulin-dependent woman with diabetes who twisted her ankle while walking and felt a pop. At the emergency department she describes heel pain. What is the best course of action?

- Protected weight-bearing activity for 6 weeks
- Closed reduction and cast application
- Urgent open reduction and internal fixation
- Excision of the calcaneal tuberosity

PREFERRED RESPONSE: 3 - Urgent open reduction and internal fixation

DISCUSSION

The radiograph reveals a displaced calcaneal tuberosity fracture. Displacement of a large tuberosity fragment necessitates urgent fracture reduction and stabilization. Delayed reduction results in compromise of the skin and soft tissues at the posterior heel. This injury occurs frequently in patients with diabetes. Protected weight-bearing activity does not address the displaced fragment or the threatened skin. Closed reduction, if possible, will not maintain the tuberosity fragment in a reduced position and will likely result in redisplacement. The fragment is large enough that it may be fixed and not excised. The Achilles tendon inserts on the displaced tuberosity fragment, so tuberosity reduction and fixation is necessary to achieve proper Achilles function.

RESPONSES FOR QUESTIONS 57 THROUGH 59

- High strain
- Low strain

For each fracture detailed, select the appropriate description. Question 57 of 101

A simple fracture pattern that is anatomically reduced and compressed and treated with an 8-hole conventional plate with 4 bicortical conventional screws placed on each side of the fracture

- High strain
- Low strain

PREFERRED RESPONSE: 2 - Low strain

Question 58 of 101

A multifragmentary fracture pattern that is bridge plated, restoring length and alignment, and treated with a 12-hole locking plate with 4 bicortical locking screws placed on each side of the fracture

- High strain
- Low strain

PREFERRED RESPONSE: 2 - Low strain

Question 59 of 101

A transverse humeral shaft fracture that occurs between a stiff arthritic shoulder joint; a stiff, arthritic elbow joint is treated nonsurgically in a hanging-arm cast

- High strain
- Low strain

PREFERRED RESPONSE: 1 - High strain

DISCUSSION

In 1977, Perren and Cordey penned a German manuscript that first described an interpretation of mechanical influences on tissue differentiation. This became known as the Strain Theory of Perren. In 1980, a second manuscript by the same authors was published in English. Within this manuscript, Perren wrote, "These thoughts about the mechanical influences on tissue differentiation are not intended as conclusive evidence since precise data are still not available, but we hope that they will stimulate thought and provide a basis for discussion." More than 30 years later, these thoughts continue to stimulate discussion and research on cell mechanotransduction. This theory is still being manipulated in surgical theatres all around the world in an attempt to more consistently achieve fracture healing. Strain is a magnitude of deformation. As typically defined, it is the change in dimension of a deformed object during loading divided by its original dimension. This is difficult to work with intraoperatively. The fraction below illustrates a simpler way to regard this concept:

Strain = Magnitude of displacement between fragments during loading / Total resting distance between fragments after stabilization

By remembering that low strain generally leads to bone formation and healing, it is possible to manipulate this fraction intraoperatively to achieve success. When a simple fracture pattern is anatomically reduced and compressed, then the total resting distance between fragments after stabilization approaches 0. This means the numerator must be near 0 to achieve a low-strain environment. This is what occurs in absolute stability (no motion between fracture fragments under physiologic load) and primary bone healing occurs. When a multifragmentary fracture pattern is treated with bridge plating, the total resting distance between fragments after stabilization is a larger number (consider the additive distance between the different fragments). In this case, the numerator can be larger to achieve a low-strain environment. This is what happens in relative stability (controlled motion between fracture fragments under physiologic load). Secondary bone healing occurs. Now consider the third scenario: a simple fracture pattern that is fixed with a small gap. The total resting distance is still a small number. Based on the theory, eliminating motion by creating a stiff construct should lead to healing, but it does not. Creating absolute stability with a gap means that primary bone healing cannot occur (because cutting cones cannot cross the gap) and secondary bone healing cannot occur (because there is not enough motion to induce callus formation). This is where the strain theory breaks down and how many nonunions occur. In the fourth scenario, a high-strain environment is present and commonly leads to a nonunion (as predicted by the theory). The simple fracture pattern is too mobile, and nonfunctional callus often occurs.

Question 60 of 101

The condition seen in Figure 60 is attributable to

- improper nail placement.
- wrong implant choice.
- patient noncompliance.
- radius of the curvature of the implant.

PREFERRED RESPONSE: 4 - radius of the curvature of the implant.

DISCUSSION

Cephallomedullary implants for treatment of proximal femur fractures have gained in popularity over the last decade. Although these implants have improved outcomes for certain fracture types, multiple complications are associated with this implant. Failure may occur secondary to implant design (for example, mismatch of curvature of the nail to the femur, which can result in distal anterior cortical perforation).

Question 61 of 101

Figure 61 is the radiograph of a 42-year-old man who falls from a roof and sustains a right calcaneus fracture. His hindfoot is moderately swollen without skin wrinkling and the skin is intact and viable. Neurologic examination findings are normal and the dorsalis pedis pulse is strong and palpable. What is the best treatment plan at this time?

- Immediate open reduction and internal fixation (ORIF) via an extensile lateral approach
- Casting in a plantar-flexed position for 6 weeks
- Splinting with follow-up in 10 to 14 days to check for resolution of swelling
- Splinting with a repeat examination in 1 to 2 days

PREFERRED RESPONSE: 4 - Splinting with a repeat examination in 1 to 2 days

DISCUSSION

This patient has a displaced tuberosity of the calcaneus. A high rate of posterior skin breakdown is associated with these fracture types. The skin should be checked within 10 to 14 days when these fractures occur. The skin is swollen and not acutely at risk, so an immediate ORIF via an extensile lateral approach is not warranted. Immobilizing the ankle in a plantar-flexed position can take some tension off the posterior skin with this fracture type but should

not be definitive treatment. Splinting with repeat examination in 1 to 2 days is the preferred response because of the short follow-up for a repeat skin check. If the skin is at risk when a fracture of this type occurs, the ankle can be immobilized in plantar flexion to relieve tension on the skin. Immediate repair with either open or percutaneous techniques may be necessary if the skin remains at risk.

Question 62 of 101

A 55-year-old active left-hand-dominant woman sustains a minimally displaced (less than 2 mm displaced) left proximal humerus fracture that involves fractures of the greater tuberosity and surgical neck. Her activities include tennis and golf. What is the best treatment for this patient?

- Nonsurgical treatment
- Percutaneous skeletal fixation
- Open reduction and internal fixation
- Total shoulder arthroplasty

PREFERRED RESPONSE: 1 - Nonsurgical treatment

DISCUSSION

Literature guiding indications for surgical vs nonsurgical treatment of proximal humerus fractures is not definitive. Many of the recommendations are based on older, nonrandomized series. Newer data suggest that surgical and nonsurgical treatment provide comparable results. Although surgical treatment is preferred for treatment of displaced fractures, fractures with minimal displacement are best managed without surgery.

Question 63 of 101

Figures 63a through 63c are the radiographs of a 19-year-old woman who sustained injuries in a motorcycle collision. Which initial treatment will result in the best functional outcome and lowest pain scores at 2 years?

- Open reduction and internal fixation (ORIF)
- Closed reduction and percutaneous pinning
- Nonsurgical management with closed reduction and casting
- Primary arthrodesis of the first and second tarsometatarsal joints

PREFERRED RESPONSE: 4 - Primary arthrodesis of the first and second tarsometatarsal joints

DISCUSSION

Ligamentous injuries to the tarsometatarsal and intermetatarsal joints are commonly a result of high-energy mechanisms. These injuries have resulted in worse outcomes following ORIF than Lisfranc injuries, which involve fractures. Multiple injury patterns may occur, with some injuries involving mostly the ligamentous structures. Ligamentous Lisfranc injuries treated with primary arthrodesis have been shown to result in improved American Orthopaedic Foot & Ankle Society scores and lower Visual Analog Scale pain scores at 2-year follow-up than injuries treated with ORIF. ORIF with either plate or screw fixation has resulted in higher rates of secondary surgeries and lower functional scores. Nonsurgical management is not recommended for displaced injuries. Cast placement is recommended for patients with midfoot sprains with displacement of less than 2 mm. Nonanatomic reductions have been associated with poor results. Closed reduction and percutaneous pinning is unlikely to achieve an anatomic reduction and stable fixation.

Question 64 of 101

A 36-year-old healthy man was thrown from a horse and sustained the injury shown in Figures 64a and 64b. His left buttock has a significant hematoma

with a "fluid wave," and the skin overlying the area is anesthetic (diminished sensation). How should this patient's injuries be treated?

- Early open debridement of the hematoma and open reduction and internal fixation (ORIF) of the fracture with immediate wound closure
- Aspiration and culture of the hematoma, delayed debridement of the hematoma, ORIF, and wound closure
- Nonsurgical management of the wound and fracture
- Early percutaneous debridement of the hematoma followed by delayed ORIF

PREFERRED RESPONSE: 4 - Early percutaneous debridement of the hematoma followed by delayed ORIF

DISCUSSION

The treatment of a pelvic and/or acetabular fracture associated with a Morel-Lavallee lesion is fraught with complications. The recommendations are to debride open followed by ORIF, closing only the fascia and leaving the remaining wound open, or performing a percutaneous debridement followed by delayed ORIF. Risk for wound breakdown and infection are higher with other treatment modalities. Cultures are not necessary because they can be positive, but are generally not the infecting organism if infection ensues. The posterior wall fracture pattern mandates surgical management, so nonsurgical management is not appropriate.

CLINICAL SITUATION FOR QUESTIONS 65 THROUGH 67

A 25-year-old man with a Gustilo IIIB open tibia fracture is treated with initial irrigation and debridement. Negative pressure wound therapy (NPWT) is initiated while awaiting definitive flap coverage. After 48 hours, the sponge is changed and erythema is noted at the wound edges.

Question 65 of 101

What is the most likely cause of the erythema?

- Acute bacterial infection
- Allergic reaction to the sponge material
- Mechanical irritation from contact of the sponge with intact skin
- Skin necrosis from the original trauma

PREFERRED RESPONSE: 3 - Mechanical irritation from contact of the sponge with intact skin

Question 66 of 101

What is the NPWT mechanism of action?

- Increased blood flow to the wound
- Increased antibiotic concentration in the wound
- Angiogenic effect of sponge material on the wound bed
- Thermal necrosis kills pathogens at the wound edges

PREFERRED RESPONSE: 1 - Increased blood flow to the wound

Question 67 of 101

In which scenario is application of NPWT contraindicated?

- Fasciotomy wound after compartment syndrome
- Exposed bone after debridement
- Surgical wound that cannot be closed because of tension
- Surgical tumor bed after excision while awaiting final pathology and definitive closure

PREFERRED RESPONSE: 4 - Surgical tumor bed after excision while awaiting final pathology and definitive closure

DISCUSSION

The most common complication associated with NPWT is a rash on the skin resulting from contact with a suction sponge. In a 2001 study by Webb and Schmidt, 2.2% of patients treated with NPWT had a rash that resolved within 48 hours. To minimize risk for this rash, care should be taken to avoid overlap of the sponge onto intact skin. If skin overlap is unavoidable, a lower-pressure setting should be used.

Acute bacterial infection is possible in this scenario, but there would likely be additional findings such as purulence in the wound itself. Similarly, an acute allergic reaction could be found within the wound and not just at the skin edge. Skin irritation from excessive adhesive plastic tension can result in blistering or shearing avulsion but not skin-edge erythema. Skin necrosis from the original trauma would result in skin-edge duskiness instead of erythema.

A study by Timmers and associates showed a statistically significant increase in microvascular blood flow to the skin under a sponge at subatmospheric pressures. Angiogenesis occurs in the area of the wound vacuum from the negative pressure and increased blood flow, not from the sponge material itself. There has been no indication that antibiotic concentration is increased in the setting of negative pressure therapy because antibiotics would be evacuated along with the fluid. NPWT does not result in increased temperatures that would kill pathogens.

NPWT is contraindicated in the setting of neoplasm because its effect on tumors is unknown. There is potential for increased angiogenesis in residual tumor cells, which could lead to recurrence or even metastasis. NPWT has been used safely and effectively for coverage of open fractures between initial debridement and definitive coverage. Fasciotomy wounds are frequently covered with NPWT dressings on a temporary basis with excellent results.

NPWT has been used to temporize wounds with exposed bone before flap coverage. Wounds with excessive tension frequently can be closed after short-term coverage with NPWT dressings.

Question 68 of 101

Which technical error most likely could contribute to a poor outcome for this patient?

- Failure to perform a capsulotomy
- Failure to use a fixed-angle device
- Failure to achieve reduction of the fracture
- Failure to protect postoperative weight bearing

PREFERRED RESPONSE: 3 - Failure to achieve reduction of the fracture

Question 69 of 101

The patient is at highest risk for which complication?

- Postoperative infection
- Heterotopic ossification
- Malunion
- Nonunion

PREFERRED RESPONSE: 4 - Nonunion

DISCUSSION

The quality of femoral neck fracture reduction was the key outcome factor in a number of studies. Capsulotomy is performed when achieving open reduction of the femoral neck. In rare cases in which acceptable closed reduction is achieved capsulotomy has been advocated, but poor anatomic reduction is more likely to negatively influence the outcome. Although some biomechanical data suggest that fixed-angle implants may be advantageous, this has not been demonstrated in well-controlled clinical studies. If reduction is not achieved, protecting postoperative weight bearing is not likely to improve outcomes.

Failure to achieve anatomic reduction of the femoral neck frequently leads to nonunion and varus collapse. Postoperative infection and/or heterotopic ossification are not typically seen in closed reduction and percutaneous stabilization of femoral neck fractures. Nonunion is more common than malunion of displaced femoral neck fractures.

Question 70 of 101

A 36-year-old man was injured in a motorcycle collision and sustained the injury shown in Figure 70. He has a blood pressure (BP) of 70/40 mm Hg, pulse of 148 beats per minute (bpm), and Glasgow Coma Scale score of 6 (scores lower than 8 indicate severe brain injury), and there is negligible urine output. His airway is secure and intravenous (IV) access is obtained. Two liters of warm crystalloid solution are given; repeated vital signs reveal the same BP and a pulse of 142 bpm. What is the best next step?

- Administer IV fluids and then reassess vital signs before making further decisions
- Pelvic binder and IV fluids
- Pelvic binder and immediate transfusion
- Pelvic binder, IV fluids, type and cross-match, and then transfuse

PREFERRED RESPONSE: 3 - Pelvic binder and immediate transfusion

DISCUSSION

This patient has an anteroposterior compression pelvic fracture associated with shock. In patients with closed pelvic fractures and hypotension, mortality rises to approximately 1 in 4 (10%-42%) and hemorrhage is the major reversible contributing factor. Initial management of a major pelvic disruption associated with hemorrhage requires hemorrhage control and rapid fluid resuscitation. A pelvic binder should be placed to reduce pelvic volume. The patient has signs and symptoms of class IV hemorrhage, which include marked tachycardia exceeding 140, a significant decrease in BP, and a very narrow pulse pressure. Urinary output is negligible, and mental status is markedly depressed. The skin is cold and pale. The degree of exsanguination with class IV hemorrhage is immediately life threatening, and rapid transfusion and immediate surgical intervention are necessary. Nonresponse to fluid administration indicates persistent blood loss. Blood preparation should be emergency blood release. Type and cross-match of blood can be used for additional resuscitation in transient responders.

RESPONSES FOR QUESTIONS 71 THROUGH 74

- Retrograde intramedullary (IM) nailing
- Open reduction and internal fixation (ORIF) with screws alone
- Locking condylar plate
- Circular external fixation
- Lateral and medial plates

Which treatment option listed is best for each patient described? Question 71 of 101

71A

A 54-year-old healthy man with the condition seen in Figures 71a through 71d

- Retrograde intramedullary (IM) nailing
- Open reduction and internal fixation (ORIF) with screws alone
- Locking condylar plate
- Circular external fixation
- Lateral and medial plates

PREFERRED RESPONSE: 3 - Locking condylar plate

Question 72 of 101

72A

A 65-year-old polytrauma patient with the injury seen in Figures 72a and 72b

- Retrograde intramedullary (IM) nailing
- Open reduction and internal fixation (ORIF) with screws alone
- Locking condylar plate
- Circular external fixation
- Lateral and medial plates

PREFERRED RESPONSE: 1 - Retrograde intramedullary (IM) nailing

Question 73 of 101

32-year-old with the injury seen in Figures 73a and 73b

- Retrograde intramedullary (IM) nailing
- Open reduction and internal fixation (ORIF) with screws alone
- Locking condylar plate
- Circular external fixation
- Lateral and medial plates

73 A

PREFERRED RESPONSE: 3 - Locking condylar plate

Question 74 of 101

74 A

25-year-old with the injury seen in Figures 74a and 74b

- Retrograde intramedullary (IM) nailing
- Open reduction and internal fixation (ORIF) with screws alone
- Locking condylar plate
- Circular external fixation
- Lateral and medial plates

PREFERRED RESPONSE: 2 - Open reduction and internal fixation (ORIF) with screws alone

DISCUSSION

Figures 71a through 71d reveal a severe intra-articular distal femur fracture that is best treated with ORIF with a locking condylar plate. A retrograde IM nail is not an ideal option for this application. Lateral and medial nonlocking plates have gone by the wayside in favor of locked plating and fixed-angle devices. External fixation will not allow for articular reconstruction and is best reserved for temporary stabilization of these fractures. Screws alone will not address this injury

Figures 72a and 72b reveal an extra-articular distal femur fracture that is best treated with an IM nail, which would also allow for earlier weight bearing. Screw fixation alone is inappropriate, and this does not necessitate medial and lateral plate fixation. Although a locking condylar plate could be used, blood loss in a polytrauma patient may be problematic. ?

Figures 73a and 73b show a comminuted supracondylar femur fracture with complex intra-articular involvement. This would be treated using the same application as seen in Figures 71a through 71d.

Figures 74a and 74b reveal a coronal plane fracture of the medial femoral condyle, which can be treated with screws alone.

Question 75 of 101

Figures 75a through 75d show the radiographs of an 85-year-old woman who fell from a step and sustained a right proximal femur fracture. Six months after surgery she has knee pain. What is the most likely cause of her pain?

- Nail radius of curvature
- Osteoarthrosis
- Nonunion of fracture
- Improper starting point for nail

PREFERRED RESPONSE: 1 - Nail radius of curvature

DISCUSSION

Three cases of anterior distal femoral cortex penetration during intramedullary nailing for subtrochanteric fractures were documented by Ostrum and Levy in a 2005 study. Case 1 involved a Zimmer (Warsaw, Indiana) M/DN antegrade femoral nail, Case 2 involved a Stryker (Mahwah, New Jersey) long-stem Gamma nail, and Case 3 a DePuy Synthes (West Chester, Pennsylvania) titanium femoral nail with spiral blade locking. The anterior Zimmer nail penetration resulted in a displaced supracondylar fracture, which subsequently required revision. The Gamma nail as well as the DePuy Synthes nail were left impaled through the distal femoral cortex, and the subtrochanteric fractures went on to union. The anteroposterior radius of curvature for the Zimmer, long Gamma, and DePuy Synthes nails is 257 cm, 300 cm, and 150 cm, respectively. It is estimated that the radius of curvature of the femoral diaphyseal canal is 114 to 120 cm. It appears that the difference in femoral anteroposterior bow between the bone and the implant is a contributing factor to distal femoral anterior cortex penetration in intramedullary nailing of subtrochanteric fractures. There is no evidence of osteoarthrosis on the radiographs. Although nonunion is possible, based on the radiographic findings it is more likely that this patient's pain is attributable to the curvature of the nail. The lateral image of the hip reveals an appropriate starting point for the device.

RESPONSES FOR QUESTIONS 76 THROUGH 78

- Nonsurgical treatment with closed reduction and immobilization
- Early mobilization with physical therapy initiated within 2 weeks
- Open reduction and internal fixation (ORIF) with locked implants
- Use of supplemental bone graft or substitutes
- Arthroplasty
- Workup for osteoporosis and counseling

Which intervention listed is most appropriate to address each scenario described?

76A B

Question 76 of 101

A 75-year-old man fell on his outstretched hand and sustained the fracture seen in Figures 76a and 76b. What is the preferred initial treatment?

- Nonsurgical treatment with closed reduction and immobilization
- Early mobilization with physical therapy initiated within 2 weeks
- Open reduction and internal fixation (ORIF) with locked implants
- Use of supplemental bone graft or substitutes
- Arthroplasty
- Workup for osteoporosis and counseling

PREFERRED RESPONSE: 1 - Nonsurgical treatment with closed reduction and immobilization

Question 77 of 101

In addition to the treatment plan, which intervention would also benefit this patient?

- Nonsurgical treatment with closed reduction and immobilization
- Early mobilization with physical therapy initiated within 2 weeks
- Open reduction and internal fixation (ORIF) with locked implants
- Use of supplemental bone graft or substitutes
- Arthroplasty
- Workup for osteoporosis and counseling

PREFERRED RESPONSE: 6 - Workup for osteoporosis and counseling

Question 78 of 101

78A

Figures 78a and 78b are the emergency department radiographs of an 83-year-old woman who tripped and braced herself against a wall; this was followed by shoulder pain. Which intervention would provide optimal treatment for this patient?

- Nonsurgical treatment with closed reduction and immobilization
- Early mobilization with physical therapy initiated within 2 weeks
- Open reduction and internal fixation (ORIF) with locked implants
- Use of supplemental bone graft or substitutes
- Arthroplasty
- Workup for osteoporosis and counseling

PREFERRED RESPONSE: 2 - Early mobilization with physical therapy initiated within 2 weeks

DISCUSSION

Low-energy fractures in elderly patients typically are treated with nonsurgical care that involves early immobilization followed by early rehabilitation/therapy, especially when proximal humerus and distal humerus fractures are involved. Physical therapy should be initiated within the first 2 weeks. If surgery is needed ORIF is preferred for most fractures, but replacement may improve outcomes for unreconstructable fractures. The use of hemiarthroplasty vs reverse shoulder replacement is currently being debated.

For treatment of distal radius fractures in elderly patients, cast immobilization for about 6 weeks will allow for optimal fracture healing. This should be followed by aggressive therapy to improve range of motion and function. Moderately displaced fractures in elderly patients will result in satisfactory outcomes even though reduction may not be "anatomic."

RESPONSES FOR QUESTIONS 79 THROIUGH 83

- Percutaneous screw fixation
- Open reduction and internal fixation (ORIF) with a lateral plate
- ORIF with a posteromedial plate
- Dual plating

Which definitive surgical plan listed best addresses each injury pattern described?

Question 79 of 101

79A

40-year-old with the fracture seen on CT images in Figures 79a through 79c

1 - Percutaneous screw fixation

2 - Open reduction and internal fixation (ORIF) with a lateral plate

3 - ORIF with a posteromedial plate

4 - Dual plating

PREFERRED RESPONSE: 3 - ORIF with a posteromedial plate

Question 80 of 101

80 A

35-year-old with the injury pattern seen on the radiographs in Figures 80a and 80b

1 - Percutaneous screw fixation

2 - Open reduction and internal fixation (ORIF) with a lateral plate

3 - ORIF with a posteromedial plate

4 - Dual plating

PREFERRED RESPONSE: 4 - Dual plating

Question 81 of 101

52-year-old with the injury seen on the CT image in Figure 81

1 - Percutaneous screw fixation

2 - Open reduction and internal fixation (ORIF) with a lateral plate

3 - ORIF with a posteromedial plate

4 - Dual plating

PREFERRED RESPONSE: 2 - Open reduction and internal fixation (ORIF) with a lateral plate

Question 82 of 101

82A

43-year-old with the injury pattern seen on the radiographs in Figures 82a and 82b

1 - Percutaneous screw fixation

2 - Open reduction and internal fixation (ORIF) with a lateral plate

3 - ORIF with a posteromedial plate

4 - Dual plating

PREFERRED RESPONSE: 1 - Percutaneous screw fixation

Question 83 of 101

83A

32-year-old with the injury pattern seen on the left lower extremity in CT images in Figures 83a and 83b

- Percutaneous screw fixation
- Open reduction and internal fixation (ORIF) with a lateral plate
- ORIF with a posteromedial plate
- Dual plating

PREFERRED RESPONSE: 2 - Open reduction and internal fixation (ORIF) with a lateral plate

DISCUSSION

In Figures 79a through 79c, CT images show a Schatzker IV medial tibial plateau fracture. This fracture is best treated with a medial incision and posteromedial plate, which will function as an antiglide or buttress plate. Percutaneous screw fixation is insufficient for this injury. Lateral fixation is not needed, and in many instances will not capture the medial fragment even with locking fixation. ?

In Figures 80a and 80b, the patient has a fairly well-aligned bicondylar tibial plateau fracture. The lateral joint is significantly depressed, necessitating open reduction and elevation with stabilization. The posteromedial fragment is often missed with single lateral locked plating and is best treated with a posteromedial plate. Percutaneous fixation does not address the joint depression.

In Figure 81, the patient has a classic split depression lateral tibial plateau fracture (Schatzker II). The joint must be reduced from a lateral approach and then supported and stabilized. Definitive ORIF with a lateral plate can be performed when appropriate.

In Figures 82a and 82b, the radiographs show a Schatzker I nondisplaced tibial plateau fracture that is amenable to percutaneous screw fixation if surgical intervention is required. The fracture pattern can be treated surgically, although, considering the comminution at the inferior aspect, late displacement could occur. The other surgical approaches mentioned are not required for this injury.

In Figures 83a and 83b, a lateral split depression tibial plateau fracture is noted (similar to the fracture seen in Figure 81). The same logic applies.

Question 84 of 101

A 19-year-old man was in a motorcycle accident. He sustained a grade IIIB open tibia fracture with a wide zone of injury to the surrounding soft tissue and a closed-head injury. The patient was treated emergently with irrigation, debridement, and external fixation. What is the most accurate statement regarding long-term functional and financial outcomes?

- Patients undergoing limb reconstruction are more satisfied.
- Long-term functional outcomes are superior in the amputation group.
- The percentage of patients who undergo amputation and return to work at 2 years is higher than the percentage of patients who undergo limb salvage who return to work at 2 years.
- The cost of amputation is 3 times higher than the cost of limb reconstruction.

PREFERRED RESPONSE: 4 - The cost of amputation is 3 times higher than the cost of limb reconstruction.

DISCUSSION

Lower Extremity Assessment Project data suggest that long-term functional outcomes and patient satisfaction at 7 years are equivalent between those

who undergo limb-salvage and primary amputations. Return to work is essentially the same between the 2 groups. The projected lifetime healthcare cost for patients treated with amputation is nearly 3 times higher than costs for those who are treated with limb-salvage procedures.

CLINICAL SITUATION FOR QUESTIONS 85 THROUGH 88

Figures 85a and 85b are the plain radiographs of a 38-year-old man who fell off the roof of a 2-story house and sustained an isolated injury to his right knee. Examination reveals a swollen leg with a knee effusion. The skin is intact, but there are some abrasions and an obvious deformity. His neurovascular examination reveals active dorsiflexion and plantar flexion with some pain and symmetric palpable pulses

85A

Question 85 of 101

How would you best classify this injury according to the Schatzker classification?

- Schatzker II
- Schatzker IV
- Schatzker V
- Schatzker VI

PREFERRED RESPONSE: 4 - Schatzker VI

Question 86 of 101

What is the best next step?

- Obtain CT images.
- Obtain ankle brachial indices.
- Obtain oblique views.
- Perform knee bridging external fixation.

PREFERRED RESPONSE: 4 - Perform knee bridging external fixation.

Question 87 of 101

87A

CT images are shown in Figures 87a through 87c. In addition to fixation of the tibial tubercle, what is the best treatment plan for this injury?

- Medial and lateral incisions with dual plates
- Midline incision with a lateral nonlocking plate
- Midline incision with dual locking plates
- Lateral incision with a lateral locking plate

PREFERRED RESPONSE: 1 - Medial and lateral incisions with dual plates

Question 88 of 101

A medial plate is best used to treat tibial plateau fractures when there is

- comminution of the lateral side.
- posteromedial fracture fragment.
- metaphyseal comminution.
- a lateral open fracture.

PREFERRED RESPONSE: 2 - posteromedial fracture fragment.

DISCUSSION

The patient's plain radiographs demonstrate a bicondylar tibial plateau fracture with complete separation of the diaphysis from the epiphysis, making this a Schatzker VI injury. Clinically, the patient is neurovascularly intact with symmetric palpable pulses, and ankle brachial indices are not necessary.

There is significant lateral tibial plateau displacement with the lateral femoral condyle down into the plateau defect. Considering the swelling, abrasions, and severity of the injury, a bridging external fixator is warranted followed by CT imaging.

The ligamentotaxis will provide better definition of the injury and joint fragments and allow for soft-tissue rest and subsidence of the swelling for eventual surgical intervention. Oblique views will not add as much information as CT imaging, which will show the bicondylar nature of the injury and the proximal tibia essentially split centrally with the tubercle as a separate fragment. A midline incision with medial and lateral plating has fallen out of

favor secondary to wound-healing complications. Comminution of the metaphysis or the lateral side is not an absolute indication for a medial plate. Open lateral fractures can still be managed with a laterally based plate depending on the soft-tissue injury.

CLINICAL SITUATION FOR QUESTIONS 89 THROUGH 91

Figures 89a and 89b are the radiographs of an 80-year-old woman who fell from a standing height.

A B

Question 89 of 101

When treating this patient, it is important to be familiar with her

- history of other fractures such as hip or distal radius fractures.
- history of athletic participation.
- marital and social status.
- symptoms in the contralateral shoulder.

PREFERRED RESPONSE: 1 - history of other fractures such as hip or distal radius fractures.

Question 90 of 101

When a fragility fracture is suspected, the workup should include

- calcium and vitamin D levels.
- a skeletal survey.
- a bone scan.
- urine analysis.

PREFERRED RESPONSE: 1 - calcium and vitamin D levels.

Question 91 of 101

Use of long-term (at least 5 years) bisphosphonate medications for osteoporosis is associated with

- increased risk for atypical femoral fractures.
- increased risk for femoral neck fractures.
- decreased risk for proximal humerus and wrist fractures.
- decreased risk for mandible osteonecrosis.

PREFERRED RESPONSE: 1 - increased risk for atypical femoral fractures.

DISCUSSION

Fragility or osteoporotic fractures are common in postmenopausal women and older men and include fractures of the proximal humerus and distal radius and hip and vertebral compression fractures. The most reliable predictor of a fragility fracture is a past fragility fracture; consequently, it is important to elicit history. Assessment of vitamin D and calcium levels is important when treating these patients because many of them have low levels.

Use of bisphosphonates for treatment of osteoporosis results in atypical femur fractures and a decrease in risk for fragility fractures (including hip fractures). There also are reports of osteonecrosis of the mandible with prolonged use of these drugs. Current medical literature suggests stopping these drugs after 3 to 5 years to allow bone remodeling.

CLINICAL SITUATION FOR QUESTIONS 92 THROUGH 95

A 23-year-old man is involved in a motorcycle collision and sustains a displaced transcervical femoral neck fracture with an associated open comminuted femoral shaft fracture.

Question 92 of 101

The patient is hypotensive and requires resuscitation, laparotomy, and splenectomy. He improves immediately but continued resuscitation is needed and his lactate level is 6.2 (reference range, 5.0-15 mg/dL). What is the most appropriate next step?

- Debridement of the open fracture wound and percutaneous fixation of the femoral neck fracture
- Debridement of the open fracture wound and external fixation of the femur
- Debridement of the open femur fracture, open reduction and internal fixation (ORIF) of the femoral neck via a Smith-Peterson approach, and external fixation of the femoral shaft
- Closed cephalomedullary nailing of the femur

PREFERRED RESPONSE: 2 - Debridement of the open fracture wound and external fixation of the femur

Question 93 of 101

A vertically oriented femoral neck fracture is unique because this pattern

- is more commonly found in elderly patients.
- favors bony union because the relatively longer fracture provides an increased surface area for healing.
- is biomechanically advantageous because more compression occurs at

the fracture site.
- is seen more commonly with associated femoral shaft fractures.

PREFERRED RESPONSE: 4 - is seen more commonly with associated femoral shaft fractures.

Question 94 of 101

The patient undergoes fixation of the associated femoral neck and shaft fractures. The most appropriate fixation construct is a

- piriformis entry reconstruction nail to fix both fractures.
- long proximal femur locking plate to fix both fractures.
- cannulated screw fixation of the femoral neck with retrograde nail fixation of the femoral shaft.
- antegrade nail fixation of the femoral shaft with cannulated screw fixation placed around an antegrade nail.

PREFERRED RESPONSE: 3 - cannulated screw fixation of the femoral neck with retrograde nail fixation of the femoral shaft.

Question 95 of 101

An anatomic reduction is obtained at the femoral neck. The most likely reason for development of avascular necrosis (AVN) in this scenario would be

- an ORIF delay exceeding 24 hours because of hemodynamic ?instability.
- an associated femur fracture.
- patient age and mechanism of injury.
- treatment with a closed reduction.

PREFERRED RESPONSE: 3 - patient age and mechanism of injury.

DISCUSSION

A damage-control approach is indicated for this patient. Debridement of the open fracture wound and rapid stabilization without an extensive surgical

approach are indicated. Rapid percutaneous fixation of the femoral neck would compromise long-term outcomes for this displaced fracture because obtaining a quality reduction and fixation construct is critical for the long-term outcome. This patient likely would not tolerate cephalomedullary nailing or open approaches very well at this time.

A vertically oriented (Pauwels 3) femoral neck fracture is more common in younger patients who sustain high-energy injuries. Because of the mechanism of injury, many of these patients have associated injuries. This is a biomechanically challenging fracture because the fracture is subject to shear forces rather than compression, making it inherently unstable. This type of fracture often necessitates different fixation strategies to counter shearing forces, such as use of a transversely oriented (Pauwels) screw to compress the fracture or a fixed-angle device.

The femoral neck fracture should be prioritized in this scenario. This does not necessarily mean that the femoral neck should be repaired first, but the strategy should emphasize optimal fixation of the femoral neck. It has been demonstrated that this is less successful when using a single implant to repair both fractures. It is possible to place femoral neck fixation around an antegrade femoral nail; however, it is much more likely that optimal fixation will be achieved with shaft fixation that does not obstruct placement of fixation for the femoral neck.

AVN is more common among physiologically young patients after femoral neck fractures. The higher energy of injury is a likely contributor. Closed reduction has not been shown to increase the risk for AVN when an anatomic reduction is obtained. A surgical delay of 24 hours does not cause AVN. Patients with associated femoral shaft fractures are not at increased risk for AVN; in fact, some studies have shown a relatively lower rate of AVN when a femoral neck fracture is associated with a femoral shaft fracture.

RESPONSES FOR QUESTIONS 96 THROUGH 99

- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)

Match the appropriate oral anticoagulant listed with the description. Question 96 of 101

This medication is a vitamin K antagonist and can be reversed.

- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)

PREFERRED RESPONSE: 1 - Warfarin (Coumadin)

Question 97 of 101

This medication, a direct thrombin inhibitor, may be excreted slowly in patients with renal insufficiency.

- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)

PREFERRED RESPONSE: 2 - Dabigatran (Pradaxa)

Question 98 of 101

This medication, a factor Xa inhibitor, offers the advantage of once-daily dosing.

- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)

PREFERRED RESPONSE: 3 - Rivaroxaban (Xarelto)

Question 99 of 101

This medication, a factor Xa inhibitor, currently is not approved for venous thromboembolism (VTE) prophylaxis.

- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)

PREFERRED RESPONSE: 4 - Apixaban (Eliquis)

DISCUSSION

Warfarin has a long clinical track record and is well known among most physicians. It is a vitamin K antagonist that can be monitored with prothrombin time (INR) testing and reversed with vitamin K and fresh frozen plasma if needed. Newer oral anticoagulants are becoming more common and offer the advantage of being rapidly active without a need for monitoring. These oral anticoagulants are not reversible, which can complicate the treatment of patients who present with bleeding or require surgery. Dabigatran (Pradaxa) is a direct thrombin inhibitor that is approved for stroke prevention in atrial fibrillation. It is not reversible, and a surgical delay of 24 to 48 hours is recommended for all but emergent surgeries. A longer delay is recommended with renal insufficiency. Rivaroxaban (Xarelto) is an oral factor Xa inhibitor that is approved for atrial fibrillation and the treatment of VTE and deep vein thrombosis prophylaxis. It offers the advantage of daily dosing. It

is not reversible and a surgical delay of 36 to 48 hours is recommended. Apixaban (Eliquis) is another factor Xa inhibitor for which twice-daily dosing is required. It is currently approved for stroke prevention in atrial fibrillation, and a surgical delay of 36 to 48 hours is recommended.

CLINICAL SITUATION FOR QUESTIONS 100 AND 101

A 55-year-old woman slipped on ice while getting out of her car and sustained the injury shown in Figure 100.

Question 100 of 101

Which material is preferred to fill the metaphyseal defect during open reduction and internal fixation?

- Recombinant human bone morphogenetic protein (BMP)-2
- BMP-7
- Calcium phosphate
- Polymethylmethacrylate

PREFERRED RESPONSE: 3 - Calcium phosphate

Question 101 of 101

What is the primary mechanism of degradation of calcium phosphate cement?

- Macrophage-mediated degradation
- Osteoclast-mediated degradation
- Giant-cell-mediated degradation
- Dissolution by interstitial fluid

PREFERRED RESPONSE: 2 - Osteoclast-mediated degradation

DISCUSSION

To treat depressed tibial plateau fractures, surgeons must elevate the depressed segments, which results in a metaphyseal bone void. This void can be filled with multiple materials, including autograft and allograft bone. The addition of BMP-2 or BMP-7 is not recommended to fill contained bone defects. These materials are indicated for application between bone and soft tissue and they do not provide the volume or strength to fill closed defects. Calcium phosphates have been use to fill these voids, demonstrating improved strength and resistance to subsidence when compared to autograft. Although polymethylmethacrylate is commonly used to fill bone voids in patients with cancer, it is not preferred in the setting of acute fracture because of the exothermic reaction that may compromise local bone healing. Although hydroxyapatite may be degraded by macrophage and giant-cell-mediated processes, the calcium phosphate degrades mainly by an osteoclast-mediated method. The calcium phosphate is not soluble in interstitial fluid, so simple dissolution does not occur.

ORTHOPEDIC MCQS ONLINE 015 TRAUMA

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ORTHOPEDIC MCQS ONLINE 015 TRAUMA

ORTHOPEDIC MCQS ONLINE 015 TRAUMA

CLINICAL SITUATION FOR QUESTIONS 1 THROUGH 3

Question 1 of 101

Question 2 of 101

Question 3 of 101

DISCUSSION

RECOMMENDED READINGS

Question 4 of 101

DISCUSSION

RECOMMENDED READINGS

RESPONSES FOR QUESTIONS 5 THROUGH 8

Please choose from the responses to identify the most likely complication in each scenario.

Question 5 of 101

Question 6 of 101

Question 7 of 101

Question 8 of 101

DISCUSSION

RECOMMENDED READINGS

Question 9 of 101

DISCUSSION

RECOMMENDED READINGS

CLINICAL SITUATION FOR QUESTIONS 10 THROUGH 12

Question 10 of 101

Question 11 of 101

Question 12 of 101

DISCUSSION

RECOMMENDED READINGS

Question 13 of 101

DISCUSSION

RECOMMENDED READINGS

Question 14 of 101

DISCUSSION

RECOMMENDED READINGS

Question 15 of 101

DISCUSSION

RECOMMENDED READINGS

CLINICAL SITUATION FOR QUESTIONS 16 THROUGH 20

Question 16 of 101

Question 17 of 101

Question 18 of 101

Question 19 of 101

Question 20 of 101

DISCUSSION

RECOMMENDED READINGS

Question 21 of 101

DISCUSSION

RECOMMENDED READINGS

CLINICAL SITUATION FOR QUESTIONS 22 THROUGH 25

Question 22 of 101

Question 23 of 101

Question 24 of 101

Question 25 of 101

DISCUSSION

RECOMMENDED READINGS

CLINICAL SITUATION FOR QUESTIONS 26 AND 27

Question 26 of 101

Question 27 of 101

DISCUSSION

RECOMMENDED READINGS

Question 28 of 101

DISCUSSION

RECOMMENDED READINGS

Question 29 of 101

DISCUSSION

RECOMMENDED READINGS

Question 30 of 101

DISCUSSION

RECOMMENDED READINGS

Question 31 of 101

DISCUSSION

RECOMMENDED READINGS

RESPONSES FOR QUESTIONS 32 THROUGH 35

Match the appropriate treatment listed with the clinical scenario described.

Question 32 of 101

Question 33 of 101

Question 34 of 101

Question 35 of 101