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

Orthopedic MCQS Trauma 0018

Orthopedic MCQS online Trauma 0018

AAOS TRAUMA

self Assessment 2018

Question 1 of 100 A 32-year-old man has a closed mid-shaft spiral humeral fracture after a fall. After a discussion of his treatment options, he wants to proceed with surgical management. When counseling him about open reduction internal fixation (ORIF) versus intramedullary nailing (IMN), what is the primary difference in outcomes between the two procedures?

Lower rate of iatrogenic radial nerve injury with ORIF
Lower rate of shoulder complications with
Higher rate of union with ORIF
Higher rate of infection with ORIF Answer: B

Discussion: There has been an abundance of studies designed to compare ORIF with IMN of humeral shaft fractures. When the most well-designed and rigorous studies are pooled and reviewed, the only consistent difference that can be found is a higher incidence of shoulder complications with IMN compared with ORIF. No significant differences have been shown with regard to nerve injury, union, or infection.

Recommended reading:

Cadet ER, Yin B, Schulz B, Ahmad CS, Rosenwasser MP. Proximal humerus and humeral shaft nonunions. J Am Acad Orthop Surg. 2013 Sep;21(9):538-

47. doi: 10.5435/JAAOS-21-09-538. Review. Erratum in: J Am Acad Orthop Surg. 2013 Nov;21(11):21a. PubMed PMID: 23996985.
Hierholzer C, Sama D, Toro JB, Peterson M, Helfet DL. Plate fixation of ununited humeral shaft fractures: effect of type of bone graft on healing. J Bone Joint Surg Am. 2006 Jul;88(7):1442-7. PubMed PMID: 16818968.

Question 3 of 100

Figure 1 is the radiograph of a 49-year-old man who sustained a closed injury to his

left shoulder in a motor vehicle collision. He underwent uncomplicated ORIF (see Figure 2), but at his first post-operative visit he had persistent pain and deformity (see Figure 3). What is the primary factor contributing to this complication?

Excessive working length of the construct
Lack of inferomedial calcar support
Unsatisfactory reduction of the fracture
Plate length is insufficient Answer: B

Discussion:The fixation construct most likely failed due to a lack of inferomedial calcar support. Biomechanical and clinical studies have emphasized the importance of medial calcar support in preventing varus collapse. This can be accomplished in a number of ways, including anatomic reduction of the medial calcar, long locking screws that engage the inferomedial humeral head, or medial cortical reconstruction with a fibular strut.

The working length of the construct is not excessively long, and the plate length is sufficient. Though there remains a gap at the fracture site, the overall reduction is satisfactory and not the primary cause for fixation failure.

Question 4 of 100

CLINICAL SITUATION

Figures 1 and 2 are the radiographs of a 35-year-old man who has elbow pain after falling from a ladder onto an outstretched hand. Examination reveals elbow pain, swelling, limited motion, and normal neurologic function.

A pathognomonic radiographic feature of this injury is a

radiocapitellar joint dislocation.
fat pad sign.
proximal radioulnar joint dislocation.
double arc sign.

Answer: D

Ideal visualization of the fragment during surgery is provided through a laterally based elbow approach (Kaplan or Kocher) with the patient in the supine position. Extension of the approach can be accomplished by releasing the lateral collateral ligament origin, which must be repaired to prevent post-operative instability. Posterior comminution and lateral column impaction are occasionally seen. When present, a posterior approach with an olecranon osteotomy is considered an alternative, but still does not allow ideal visualization of the anterior articular cartilage or safe angles for anterior to posterior screw placement. Therefore, the posterior approach not the preferred approach.

Headless screws are useful because this is typically a partial articular injury and screw orientation is ideally from anterior to posterior. The anterior entry of the screw should be buried beneath the articular cartilage margin.

Question 5 of 100

CLINICAL SITUATION

What is the typical intra-operative patient position for treatment of this injury?

Supine
Lateral
Prone
Beach chair Answer: A

Question 6 of 100

CLINICAL SITUATION

The surgical exposure that provides optimal visualization to treat this injury is

medial approach to the elbow.
anterior approach to the cubital fossa.
posterior approach to the elbow.
lateral approach to the elbow. Answer: D

Discussion: Coronal shear fractures of the distal end of the humerus are rare. Failure to recognize the fracture pattern can lead to poor patient outcomes secondary to poor surgical decision making. The double arc sign is considered a pathognomonic finding on the lateral elbow radiograph seen in Figure 2. This is created by the subchondral bone of the capitellum and lateral trochlear ridge. Excessive internal rotation of the fracture fragment or a subpar lateral radiograph can make recognition of this sign difficult. Ideal visualization of the fragment during surgery is provided through a laterally based elbow approach (Kaplan or Kocher) with the patient in the supine position. Extension of the approach can be accomplished by releasing the lateral collateral ligament origin, which must be repaired to prevent post-operative instability. Posterior comminution and lateral column impaction are occasionally seen. When present, a posterior approach with an olecranon osteotomy is considered an alternative, but still does not allow ideal visualization of the anterior articular

cartilage or safe angles for anterior to posterior screw placement. Therefore, the posterior approach not the preferred approach.

Question 7 of 100

CLINICAL SITUATION

What type of screws should be available for stabilization of this injury?

Headless
Cannulated
Titanium
Dual core Answer: A

Coronal shear fractures of the distal end of the humerus are rare. Failure to recognize the fracture pattern can lead to poor patient outcomes secondary to poor surgical decision making. The double arc sign is considered a pathognomonic finding on the lateral elbow radiograph seen in Figure 2. This is created by the subchondral bone of the capitellum and lateral trochlear ridge. Excessive internal rotation of the fracture fragment or a subpar lateral radiograph can make recognition of this sign difficult.

ligament origin, which must be repaired to prevent post-operative instability. Posterior comminution and lateral column impaction are occasionally seen. When present, a posterior approach with an olecranon osteotomy is considered an alternative, but still does not allow ideal visualization of the anterior articular cartilage or safe angles for anterior to posterior screw placement. Therefore, the posterior approach not the preferred approach.

Question 8 of 100

Figures 1 and 2 are the radiographs of a 46-year-old man with left shoulder pain and

limited range of motion two years after a proximal humerus fracture, which was treated non-operatively. He has forward elevation to 100 degrees with pain at the terminal arc of motion. A subsequent MRI reveals no soft tissue abnormality. After a failed course of non-operative treatment, what is the most appropriate surgical treatment?

Arthroscopic tuberoplasty
Valgus-producing osteotomy
Humeral hemiarthroplasty
Reverse total shoulder arthroplasty Answer: B

Discussion: The patient has a varus malunion of his left proximal humerus. There are no signs of advanced glenohumeral arthrosis or osteonecrosis. After failed nonsurgical treatment, the surgery most likely to improve his symptoms is a valgus-producing osteotomy of the proximal humerus. Arthroscopic tuberoplasty addresses

massive rotator cuff tears or greater tuberosity malunions, but does not address the varus alignment of the articular surface. Humeral hemiarthroplasty can address the deformity but would sacrifice an otherwise normal humeral head in a relatively young patient. Reverse total shoulder arthroplasty would not be indicated in a patient this age with an intact rotator cuff.

Question 9 of 100

Figures 1 and 2 are the radiographs of a 44-year-old man who comes to the

emergency department after a fall from a ladder with pain and a closed injury to his left shoulder. He undergoes open reduction internal fixation (ORIF) of his left proximal humerus fracture. A postoperative radiograph is shown in Figure 3. What best describes the function of the intramedullary fibular allograft?

Provides additional purchase for proximal articular screws
Provides additional purchase for diaphyseal screws
Decreases union time across the zone of comminution
Restores medial cortical support to prevent varus collapse Answer: D

Discussion: The patient has a surgical neck fracture with medial calcar comminution. In patients where this cannot be anatomically reconstructed to provide cortical support, a fibular allograft can be used to prevent varus collapse. A “push” screw can be seen in Figure 3, which was used to medialize the graft into a biomechanically favorable position for this fracture pattern. Although the allograft theoretically provides the other benefits listed, they are not the primary indication for this injury.

Question 10 of 100

CLINICAL SITUATION

Figures 1 and 2 are the radiographs of a 19-year-old man with a closed right humeral shaft fracture as well as a right femoral shaft fracture and a left ankle fracture-dislocation after a motor vehicle collision. On initial examination, he is noted to have a complete radial nerve palsy of his right upper extremity.

What represents the best indication for surgical management of the humeral shaft fracture in this patient?

Radial nerve palsy
Extensive fracture comminution
Polytraumatized patient
Distal third diaphyseal fracture Answer: C

Discussion: The patient sustained a comminuted extra-articular distal humeral diaphyseal fracture. In isolation, this fracture would still be amenable to an attempt at closed treatment. His radial nerve palsy alone does not warrant open management, as early exploration has not shown a significant benefit in a closed fracture. In addition, despite the comminution and distal extent of the fracture, it is still amenable to closed treatment, though it may be at higher risk for malunion. However, in this patient with multiple lower extremity injuries, fixation of the humerus can facilitate early mobilization and weight-bearing with his right upper extremity, representing a relative indication for surgical management.

The posterior triceps-reflecting approach described can be extended proximally to the level of the axillary nerve. The radial nerve must be found and protected, but the dissection can be carried well proximal to it and the medial triceps origin. The anatomic neck of the humerus cannot be visualized through this approach.

The plate functions as a neutralization plate, as multiple lag screws are seen placed outside of the plate, suggesting anatomic reduction and fixation of the fracture prior to applying the plate.

The working length of the plate is the distance between the proximal and distal screws closest to the fracture. The length of screw purchase in bone represents the working length of the screw, not the plate. The other answer choices describe dimensions of the plate and the fixation construct, not its working length.

Question 11 of 100

CLINICAL SITUATION

After a discussion with the patient, surgery is chosen for the right humerus. A posterior triceps-reflecting approach is selected. What structure marks the most proximal extent of the humerus that can be exposed through this approach?

Axillary nerve
Radical nerve
Origin of the medial head of the triceps
Anatomic neck of the proximal humerus Answer: A

early mobilization and weight-bearing with his right upper extremity, representing a relative indication for surgical management.

The plate functions as a neutralization plate, as multiple lag screws are seen placed outside of the plate, suggesting anatomic reduction and fixation of the fracture prior to applying the plate.

Question 12 of 100

CLINICAL SITUATION

Postoperative radiographs are shown in Figures 3 and 4. How does the plate function?

Neutralization
Compression
Bridging
Buttressing

Answer: A

The plate functions as a neutralization plate, as multiple lag screws are seen placed outside of the plate, suggesting anatomic reduction and fixation of the fracture prior to applying the plate.

Question 13 of 100

CLINICAL SITUATION

The working length of the plate is best described as the length

of the plate.
of screw purchase in bone.
between the screws closest to the fracture.
between the screws furthest from the fracture. Answer: C

The plate functions as a neutralization plate, as multiple lag screws are seen placed outside of the plate, suggesting anatomic reduction and fixation of the fracture prior to applying the plate.

Question 14 of 100

What is the best treatment option for complex proximal humerus fractures in the

low-demand patient population?

Hemiarthroplasty
Reverse total shoulder arthroplasty
Locked-plate fixation
Nonoperative treatment Answer: D

Discussion: In the recent meta-analysis by Mao and associates, there was no evidence to support the use of any of the operative modalities to treat 3- and 4-part fractures of the proximal humerus in low-demand patients. Although surgeons and patients will differ in their treatment algorithms, the recent meta-analysis showed lower complications with nonoperative treatment for these complex fractures. New treatment modalities involving fibular strut allograft, reverse total shoulder arthroplasty for elderly patients with an incompetent rotator cuff, and locked-plate fixation may prove to be superior to nonoperative treatment in select patient populations. However, not one operation has been shown to be superior to nonoperative treatment in the low-demand patient population with complex proximal humerus fractures.

Question 15of 100

CLINICAL SITUATION

Figure 1 is the radiograph and Figure 2 is the CT image of a 45-year-old woman who fell about 20 feet off her balcony. These images show an isolated, open injury with a 3-cm open medial wound.

The best delayed definitive surgical fixation plan would include

lateral plating of the fibula and a percutaneous medial column plate.
intramedullary fixation of the fibula and an anterolateral tibial plate.
open medial column plating, percutaneous screw fixation of the joint, and lateral fibular plating.
screw fixation of the medial column with an anterolateral tibial plate and lateral fibular plating

Answer: D

Discussion: The timely administration of antibiotics has been shown to be the best initial treatment to reduce the incidence of infection following an open fracture. Life threatening injuries must first be addressed. But in this isolated open pilon fracture, antibiotics should be initiated early along with tetanus prophylaxis. Reduction and splinting would stabilize the fracture but these interventions should follow antibiotic coverage. Emergency department irrigation is controversial. Closed reduction and splinting, external fixation, CT scan, and delayed open reduction internal fixation would be the preferred sequence of management. External fixation to provide provisional limb stabilization would be indicated in this length unstable C type injury to provide soft tissue stabilization and prevent further chondral injury. Splinting alone would not prevent shortening and would not allow soft tissue recovery. CT scans prior to limb stabilization are not warranted because the patterns make more sense after the restoration of gross length, rotation and alignment in the external fixator. Initial fibular fixation is also not recommended in this case because the location of incisions could affect the definitive surgical tactic. In this multi-fragmentary fibular injury, anatomic reduction would be challenging and malreduction could occur and influence subsequent reconstructions. Delayed open reduction internal fixation is ideal after the resolution of soft tissue swelling.

Question 16 of 100

CLINICAL SITUATION

Figure 1 is the radiograph and Figure 2 is the CT image of a 45-year-old woman who fell about 20 feet off her balcony. These images show an isolated, open injury with a 3-cm open medial wound.

Three years following surgery, which parameter will most likely predict a poor clinical outcome and failure to return to work?

Accuracy of joint line restoration
Amount of comminution
Lower level of education
Open fracture Answer: C

Anterolateral buttress plating of the tibial component and lateral plating of the fibula would best resist the valgus compression failure of the lateral column. The medial side failed in tension and plating in this location would not biomechanically resist the valgus displacement. Articular reduction could also be carried out from the anterolateral side with joint reconstruction building back to the posterolateral fragment. Secondary to the central articular impaction, isolated screw fixation would

not provide stability to the metaphyseal comminution. Medial columnar screws could be used to secure the medial tension failure and would limit surface implants in the location of the open wounds.

Failure to attain a high school diploma has been related to poorer outcomes following treatment of high-energy pilon fractures. Quality of reduction does lead to better overall results but still has a drastic impact on functional outcomes. The complexity of the initial fracture also does not lead to differing outcomes at longterm follow up.

Question 17 of 100

CLINICAL SITUATION

Figures 1 and 2 are the radiographs of a 68-year-old woman who comes to the emergency department after stepping into a hole and twisting her ankle. She is complaining of isolated ankle pain and is unable to bear weight.

After closed manipulative reduction and splint placement, she is scheduled for operative treatment. The stability of the syndesmosis should be evaluated after

fixation of the lateral malleolus.
fixation of the medial malleolus.
fixation of the posterior malleolus.
all planned fixation is completed.

Answer: D

Discussion: The radiographs reveal a trimalleolar ankle fracture dislocation with an associated distal tibiofibular syndesmotic disruption. Medial and lateral malleolar stabilization are consistently agreed upon. The decision to stabilize the posterior malleolus is more controversial. Posterior malleolar stabilization accomplishes the following:

Restores incisura competence thereby reducing the incidence of syndesmotic malreduction by creating containment
Assists in stabilizing the syndesmosis via the posterior inferior tibiofibular ligament, potentially limiting the need for additional syndesmotic stabilization
Maximizes the surface area for ankle joint loading
Enhances posterior translational stability of the talus

The traditional indication for stabilization of the posterior malleolus is based on fragment size. However, fracture orientation varies and makes evaluation of the fragment size challenging with a lateral radiograph alone. The three primary types include the posterolateral oblique, medial extension, and shell. Because of the additive syndesmotic stability which is gained through the deep deltoid ligament and medial malleolar fixation, the anterior talofibular ligament and lateral malleolar fixation, and the posterior inferior tibiofibular ligament and posterior malleolar fixation, syndesmotic stability should only be assessed after all other points of instability that are planned for fixation are fixed.

Syndesmotic instability should be assessed with direct manipulation on both the anteroposterior and lateral views with special attention to the lateral view. Syndesmotic reduction should be assessed either through open visualization or by comparing closed reduction parameters (clear space, overlap, and fibular position on the lateral view) with the patient’s contralateral side (assuming no injury). This is more effective than using population norms secondary to the two types of syndesmotic morphologies which create different absolute values for these parameters.

Question 18 of 100

CLINICAL SITUATION

Figures 1 and 2 are the radiographs of a 68-year-old woman who comes to the emergency department after stepping into a hole and twisting her ankle. She is complaining of isolated ankle pain and is unable to bear weight.

How is syndesmotic instability best assessed intra-operatively?
1. By comparing tibiofibular overlap with population norms
2. By comparing tibiofibular clear space with population norms
3. Intra-operative tibiofibular squeeze test
4. Intra-operative radiographic stress examination Answer: D
Discussion: The radiographs reveal a trimalleolar ankle fracture dislocation with an associated distal tibiofibular syndesmotic disruption. Medial and lateral malleolar stabilization are consistently agreed upon. The decision to stabilize the posterior malleolus is more controversial. Posterior malleolar stabilization accomplishes the following:
Restores incisura competence thereby reducing the incidence of syndesmotic malreduction by creating containment
Assists in stabilizing the syndesmosis via the posterior inferior tibiofibular ligament, potentially limiting the need for additional syndesmotic stabilization
Maximizes the surface area for ankle joint loading
Enhances posterior translational stability of the talus

The traditional indication for stabilization of the posterior malleolus is based on fragment size. However, fracture orientation varies and makes evaluation of the fragment size challenging with a lateral radiograph alone. The three primary types include the posterolateral oblique, medial extension, and shell. Because of the additive syndesmotic stability which is gained through the deep deltoid ligament and medial malleolar fixation, the anterior talofibular ligament and lateral malleolar fixation, and the posterior inferior tibiofibular ligament and posterior malleolar fixation, syndesmotic stability should only be assessed after all other points of instability that are planned for fixation are fixed.

Syndesmotic instability should be assessed with direct manipulation on both the anteroposterior and lateral views with special attention to the lateral view. Syndesmotic reduction should be assessed either through open visualization or by comparing closed reduction parameters (clear space, overlap, and fibular position on the lateral view) with the patient’s contralateral side (assuming no injury). This is more effective than using population norms secondary to the two types of syndesmotic morphologies which create different absolute values for these parameters.

Question 19 of 100

CLINICAL SITUATION

Figures 1 and 2 are the radiographs of a 68-year-old woman who comes to the emergency department after stepping into a hole and twisting her ankle. She is complaining of isolated ankle pain and is unable to bear weight.

How is syndesmotic reduction best assessed intra-operatively?
1. By comparing tibiofibular overlap with population norms
2. By comparing tibiofibular clear space with population norms
3. By comparing images with the patient’s contralateral uninjured side
4. By measuring the talocrural angle Answer: C
Discussion: The radiographs reveal a trimalleolar ankle fracture dislocation with an associated distal tibiofibular syndesmotic disruption. Medial and lateral malleolar stabilization are consistently agreed upon. The decision to stabilize the posterior

malleolus is more controversial. Posterior malleolar stabilization accomplishes the following:
Restores incisura competence thereby reducing the incidence of syndesmotic malreduction by creating containment
Assists in stabilizing the syndesmosis via the posterior inferior tibiofibular ligament, potentially limiting the need for additional syndesmotic stabilization
Maximizes the surface area for ankle joint loading
Enhances posterior translational stability of the talus

The traditional indication for stabilization of the posterior malleolus is based on fragment size. However, fracture orientation varies and makes evaluation of the fragment size challenging with a lateral radiograph alone. The three primary types include the posterolateral oblique, medial extension, and shell. Because of the additive syndesmotic stability which is gained through the deep deltoid ligament and medial malleolar fixation, the anterior talofibular ligament and lateral malleolar fixation, and the posterior inferior tibiofibular ligament and posterior malleolar fixation, syndesmotic stability should only be assessed after all other points of instability that are planned for fixation are fixed.

Syndesmotic instability should be assessed with direct manipulation on both the anteroposterior and lateral views with special attention to the lateral view. Syndesmotic reduction should be assessed either through open visualization or by comparing closed reduction parameters (clear space, overlap, and fibular position on the lateral view) with the patient’s contralateral side (assuming no injury). This is more effective than using population norms secondary to the two types of syndesmotic morphologies which create different absolute values for these parameters.

Question 20 of 100

CLINICAL SITUATION

Figures 1 and 2 are the radiographs of a 68-year-old woman who comes to the emergency department after stepping into a hole and twisting her ankle. She is complaining of isolated ankle pain and is unable to bear weight.

Our understanding of malreduction of the syndesmosis has changed over the years based on changes in technique and imaging. Our current understanding is that malreduction of the syndesmosis
1. occurs only when the ankle is in plantarflexion.
2. never occurs and is not possible.
3. is primarily dependent upon clamp application.
4. is dependent upon the anterior width of the talus. Answer: C
Discussion: The radiographs reveal a trimalleolar ankle fracture dislocation with an associated distal tibiofibular syndesmotic disruption. Medial and lateral malleolar stabilization are consistently agreed upon. The decision to stabilize the posterior malleolus is more controversial. Posterior malleolar stabilization accomplishes the following:
Restores incisura competence thereby reducing the incidence of syndesmotic malreduction by creating containment
Assists in stabilizing the syndesmosis via the posterior inferior tibiofibular ligament, potentially limiting the need for additional syndesmotic stabilization
Maximizes the surface area for ankle joint loading
Enhances posterior translational stability of the talus

The traditional indication for stabilization of the posterior malleolus is based on fragment size. However, fracture orientation varies and makes evaluation of the fragment size challenging with a lateral radiograph alone. The three primary types include the posterolateral oblique, medial extension, and shell. Because of the additive syndesmotic stability which is gained through the deep deltoid ligament and medial malleolar fixation, the anterior talofibular ligament and lateral malleolar fixation, and the posterior inferior tibiofibular ligament and posterior malleolar fixation, syndesmotic stability should only be assessed after all other points of instability that are planned for fixation are fixed.

Syndesmotic instability should be assessed with direct manipulation on both the anteroposterior and lateral views with special attention to the lateral view. Syndesmotic reduction should be assessed either through open visualization or by comparing closed reduction parameters (clear space, overlap, and fibular position on the lateral view) with the patient’s contralateral side (assuming no injury). This is more effective than using population norms secondary to the two types of syndesmotic morphologies which create different absolute values for these parameters.

Question 21 of 100

CLINICAL SITUATION

Figures 1 and 2 are the radiographs of a 68-year-old woman who comes to the emergency department after stepping into a hole and twisting her ankle. She is complaining of isolated ankle pain and is unable to bear weight.

Anatomic reduction and stabilization of the posterior malleolus fracture component
1. does not affect syndesmotic stability.
2. restores the integrity of the incisura fibularis.
3. should be based only on size criteria.
4. must precede lateral malleolar fixation. Answer: B
Discussion: The radiographs reveal a trimalleolar ankle fracture dislocation with an

associated distal tibiofibular syndesmotic disruption. Medial and lateral malleolar stabilization are consistently agreed upon. The decision to stabilize the posterior

malleolus is more controversial. Posterior malleolar stabilization accomplishes the following:
Restores incisura competence thereby reducing the incidence of syndesmotic malreduction by creating containment
Assists in stabilizing the syndesmosis via the posterior inferior tibiofibular ligament, potentially limiting the need for additional syndesmotic stabilization
Maximizes the surface area for ankle joint loading
Enhances posterior translational stability of the talus

The traditional indication for stabilization of the posterior malleolus is based on fragment size. However, fracture orientation varies and makes evaluation of the fragment size challenging with a lateral radiograph alone. The three primary types include the posterolateral oblique, medial extension, and shell. Because of the additive syndesmotic stability which is gained through the deep deltoid ligament and medial malleolar fixation, the anterior talofibular ligament and lateral malleolar fixation, and the posterior inferior tibiofibular ligament and posterior malleolar fixation, syndesmotic stability should only be assessed after all other points of instability that are planned for fixation are fixed.

Syndesmotic instability should be assessed with direct manipulation on both the anteroposterior and lateral views with special attention to the lateral view. Syndesmotic reduction should be assessed either through open visualization or by comparing closed reduction parameters (clear space, overlap, and fibular position on the lateral view) with the patient’s contralateral side (assuming no injury). This is more effective than using population norms secondary to the two types of syndesmotic morphologies which create different absolute values for these parameters.

Question 22 of 100

CLINICAL SITUATION

Figures 1 and 2 are the radiographs of a 68-year-old woman who comes to the emergency department after stepping into a hole and twisting her ankle. She is complaining of isolated ankle pain and is unable to bear weight.

What is the morphology of the posterior malleolar fracture component?
1. Always posteromedial
2. Always posterolateral
3. Varies in morphology
4. Is best assessed on the lateral radiograph Answer: C
Discussion: The radiographs reveal a trimalleolar ankle fracture dislocation with an

associated distal tibiofibular syndesmotic disruption. Medial and lateral malleolar stabilization are consistently agreed upon. The decision to stabilize the posterior malleolus is more controversial. Posterior malleolar stabilization accomplishes the following:
Restores incisura competence thereby reducing the incidence of syndesmotic malreduction by creating containment
Assists in stabilizing the syndesmosis via the posterior inferior tibiofibular ligament, potentially limiting the need for additional syndesmotic stabilization
Maximizes the surface area for ankle joint loading
Enhances posterior translational stability of the talus

The traditional indication for stabilization of the posterior malleolus is based on fragment size. However, fracture orientation varies and makes evaluation of the fragment size challenging with a lateral radiograph alone. The three primary types include the posterolateral oblique, medial extension, and shell. Because of the additive syndesmotic stability which is gained through the deep deltoid ligament and medial malleolar fixation, the anterior talofibular ligament and lateral malleolar fixation, and the posterior inferior tibiofibular ligament and posterior malleolar fixation, syndesmotic stability should only be assessed after all other points of instability that are planned for fixation are fixed.

Syndesmotic instability should be assessed with direct manipulation on both the anteroposterior and lateral views with special attention to the lateral view. Syndesmotic reduction should be assessed either through open visualization or by comparing closed reduction parameters (clear space, overlap, and fibular position on the lateral view) with the patient’s contralateral side (assuming no injury). This is more effective than using population norms secondary to the two types of syndesmotic morphologies which create different absolute values for these parameters.

Question 23 of 100

CLINICAL SITUATION

Figures 1 and 2 are the radiographs of a 35-year-old man who is brought into the emergency department after a motor vehicle collision. He is complaining of isolated knee pain. Examination reveals swelling, blood filled blisters, popliteal ecchymosis, joint line pain, and limited knee joint motion. His pulses and sensation are normal.

This knee injury is best described as a

posterior partial articular tibial plateau fracture.
lateral split depression tibial plateau fracture.
knee dislocation with a posterior cruciate ligament avulsion.
bicondylar tibial plateau fracture. Answer: A

Discussion: Posterior partial articular tibial plateau fractures are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the lateral radiograph include maintenance of continuity between the anterior articular surface and tibial shaft along with subluxation of the knee joint with excessively anterior tibial station (the femoral condyles remain with the fractured posterior articular pieces while the remainder of the tibia subluxes anteriorly).

Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT scan will clarify the misconception and allow for better surgical decision making.

Attempting to visualize, reduce, and stabilize a posterior partial articular pattern in the supine position from an anterior approach is fraught with difficulties. Prone positioning is preferred for definitive fixation. Surgical approaches vary, but typically incorporate a posteromedial interval deep to the popliteus and soleus to provide buttress plating to the posterior column of the tibia.

Question 24 of 100

CLINICAL SITUATION

Initial surgical management should consist of

closed reduction and percutaneous screw placement.
open reduction internal fixation through an anterior midline approach.
spanning external fixation and closed manipulative realignment.
ring fixation.

Answer: C

typically incorporate a posteromedial interval deep to the popliteus and soleus to provide buttress plating to the posterior column of the tibia.

Question 25 of 100

CLINICAL SITUATION

Figures 3 through 8 are the axial and sagittal CT scan sections of the injury. Intra-operative patient positioning for definitive fixation should be

prone.
lateral.
supine.
sloppy lateral.

Answer: A

femoral condyles remain with the fractured posterior articular pieces while the remainder of the tibia subluxes anteriorly).

Question 26 of 100

CLINICAL SITUATION

The surgical approach for definitive reduction and stabilization of this pattern is

anterior midline.
anterolateral.
medial parapatellar.
posteromedial.

Answer: D

Posterior partial articular tibial plateau fractures are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the lateral radiograph include maintenance of continuity between the anterior articular surface and tibial shaft along with subluxation of the knee joint with excessively anterior tibial station (the femoral condyles remain with the fractured posterior articular pieces while the remainder of the tibia subluxes anteriorly).

stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT scan will clarify the misconception and allow for better surgical decision making.

Question 27 of 100

CLINICAL SITUATION

Figures 1 through 3 are the radiographs of a 25-year-old man who is brought to the emergency department after a motorcycle collision. He is complaining of isolated knee pain. Examination reveals swelling, popliteal ecchymosis, joint line pain, and limited knee joint motion. His pulses and sensation are normal.

This knee injury is best described as a

posterior partial articular tibial plateau fracture.
lateral split depression tibial plateau fracture.
medial plateau fracture dislocation.
knee dislocation with lateral collateral ligament tear.

Answer: C

Discussion: Medial plateau fracture dislocations are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the anteroposterior radiograph include an intact lateral column (lateral articular surface still in continuity with tibial shaft), centrolateral articular impaction, shortening, and condylar widening. The medial femoral condyle stays with the fractured medial tibial plateau segment.

Supine positioning is preferred for definitive fixation, but surgical approaches vary. Attempting to stabilize a medial partial articular pattern in the supine position from a lateral utility approach is fraught with difficulties. Lateral locked plating is not designed for this indication. The lateral utility approach allows for visualization of the centrolateral impaction and lateral meniscal peripheral capsular avulsion repair, but when used alone leads to biomechanically unsound implant placement. The primary plate should be on the medial side of the tibia rather than the intact lateral column.

Question 28 of 100

CLINICAL SITUATION

Initial surgical management should consist of

closed reduction and percutaneous screw placement.
open reduction internal fixation through an anterior midline approach.
spanning external fixation and closed manipulative realignment.
ring fixation.

Answer: C

but when used alone leads to biomechanically unsound implant placement. The primary plate should be on the medial side of the tibia rather than the intact lateral column.

Question 29 of 100

CLINICAL SITUATION

Figures 4 through 8 are the axial and coronal CT scan sections of the injury. Intra-operative patient positioning for definitive fixation should be

prone.
lateral.
supine.
sloppy latera

Answer: C

Question 30 of 100

CLINICAL SITUATION

The surgical approach for definitive reduction and stabilization of this pattern is

direct posterior.
direct lateral.
posterolateral.
posteromedial.

Answer: D

but when used alone leads to biomechanically unsound implant placement. The primary plate should be on the medial side of the tibia rather than the intact lateral column.

Question 31 of 100

CLINICAL SITUATION

Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision. On examination, she has well-healed scars and a well-healed flap on the medial aspect at the level of the fracture. She reports having an infection after the initial surgery, which resulted in debridement of the soft tissue and need for the local rotational flap. There are no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is healthy and has no comorbidities.

What is the best next step in the patient’s evaluation?

Complete metabolic workup
Advanced imaging with a CT scan
Laboratory studies for CBC, ESR and CRP
Nuclear medicine studies

Answer: C

but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone non-union, especially in the femur.

Question 32 of 100

CLINICAL SITUATION

Based on the radiographs shown in Figures 1 and 2, her tibia is a

pseudarthrosis.
hypertrophic nonunion.
healed fracture.
atrophic nonunion.

Answer: B

Discussion: The patient had an open fracture that was initially treated with what appears to be appropriate irrigation and debridement and intramedullary nail placement. The post-operative infection and need for rotational flap is worrisome, but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone nonunions, especially in the femur.

Question 33 of 100

Suprapatellar intramedullary nailing for tibia fractures when compared to

infrapatellar nailing is associated with

decreased knee range of motion.
increased incidence of malalignment.
less anterior knee pain.
changes in the patellofemoral joint.

Answer: C

Discussion: Suprapatellar nailing has been very useful in the management of proximal tibia fractures, allowing a better reduction. Both arthroscopy and MRI have been utilized after suprapatellar nailing to evaluate for changes in the patellofemoral joints, and no significant changes can be attributed to this technique. In a comparative study between suprapatellar nailing and standard (infrapatellar) nailing, both techniques showed excellent range of motion and no significant differences between the methods. In a separate study, it was noted that patients who underwent suprapatellar nailing did not complain of anterior knee pain that is often seen with standard nailing.

Question 34 of 100 CLINICAL SITUATION

Assuming her workup is negative for any other causes, what is the best treatment option?

Observation for a month
Plate the tibia after removing the nail
Autogenous bone graft to the tibia
Exchange nailing of the tibia

Answer: D

Question 35 of 100 Figure 1 shows a patient with an open tibia fracture who presents to the emergency department after a propeller injury in brackish water (river water and sea water). What is the most appropriate antibiotic coverage for this patient?

Gentamicin and penicillin
Cefazolin and penicillin
Doxycycline and ceftazidime
Vancomycin and sulfamethoxazole-trimethoprim

Answer: C

Discussion: The clinical photo shows significant soft tissue wounds with associated tibia fracture. With the amount of soft tissue damage and periosteal stripping this would be classified as a Gustilo Type IIIB injury. The brackish water environment where this particular injury occurred influences the antibiotic choice secondary to the particular organisms found in this setting. Brackish water is made up of both fresh and salt water with common organisms that include Vibrio species, Aeromonas hydrophila, Pseudomonas species, Erysipelothrix rhusiopathiae, and Mycobacterium marinum. The combination of both Doxycycline (tetracycline) and Ceftazidime (third-generation cephalosporin) cover these particular pathogens. Standard antibiotic coverage for Gustilo Type I and II injures is 1st generation cephalosporin (cefazolin), with Type III being 1st generation cephalosporin and aminoglycoside (cefazolin and gentamicin) or a fluoroquinolone. In Type III injuries, Penicillin is commonly added in barnyard injuries for extended coverage of

soil-borne pathogens (clostridial species). Vancomycin is not indicated for coverage in marine environments, rather it is more commonly used for populations with a high prevalence of nosocomial infections. Sulfamethoxazole-trimethoprim is not used for open fracture coverage.

Question 36 of 100 A 56-year-old woman sustains a type IIIB open tibial shaft fracture. She undergoes irrigation and debridement and intramedullary nailing with flap coverage 24 hours later. Cultures are taken pre-debridement and post-debridement. She develops a surgical site infection at 6 weeks, which requires removing the hardware and placing

show

Commented [1]:

an external fixator. Deep cultures are most likely to pathogens found in

pre-debridement cultures.
post-debridement cultures.
neither debridement culture.
anaerobic specimens.

Answer: C

Discussion: One study found only 8% of organisms grown on pre-debridement cultures eventually caused infection; 7% of cases with negative pre-debridement cultures became infected. Of cases that did become infected, pre-debridement cultures grew the infecting organism only 22% of the time. Post-debridement cultures were more accurate in predicting infection. However, of cases that became infected, the infecting organism was present on post-debridement cultures only 42% of the time. It is concluded that pre-debridement and post-debridement bacterial cultures from open fracture wounds are of essentially no value. It is recommended that they not be done.

In another study, before any interventions were performed, initial aerobic and anaerobic cultures of the wounds of 117 consecutive open extremity fractures grades I through III were obtained. The results of these cultures were correlated with the development of a wound infection. If an infection occurred, the organism grown from the infected wound was compared with any organism grown from the primary wound cultures. Of the initial cultures, 76% (89/117) did not demonstrate any growth, while the other 24% (28/117) only grew skin flora. There were only 7 (6%) wound infections, and 71% (5/7) initially did not grow any organisms. Of the isolates that grew from the initial cultures, none were the organisms that eventually led to

47

wound infections. The use of primary wound cultures in open extremity injuries has no value in the management of patients suffering from infections after long bone open extremity fractures.

Question 37 of 100 A 58-year-old man has a painful, warm, erythematous and fluctuant area over his left olecranon. An aspiration would be most likely to reveal
1. Staphylococcus aureus.
2. Streptococcus pyogenes.
3. Enterococcus faecalis.
4. Psuedomonas aurigonosa.

Answer: A

Discussion: Staphylococcus aureus is the most common causative organism in septic bursitis, making up 80% or more of cases of culture-proven septic bursitis (https://www.uptodate.com/contents/septic-bursitis). Staphylococcus aureus was the most frequent pathogen (217 out of 256 or 85%), followed by Streptococcus pyogenes (16), other streptococci (15), Enterococcus faecalis (4) and coagulase-negative staphylococci (2). Staphylococcus aureus is the most common causative organism in septic bursitis, making up 80% or more of cases of culture-proven septic bursitis (https://www.uptodate.com/contents/septic-bursitis). Staphylococcus aureus was the most frequent pathogen (217 out of 256 or 85%), followed by Streptococcus pyogenes (16), other streptococci (15), Enterococcus faecalis (4) and coagulase-negative staphylococci (2).

Question 38 of 100 A 65-year-old woman with type II diabetes mellitus (most recent Hgb A1C was 8.2) has had 3 days of left knee pain. Physical examination of the left knee reveals erythema, warmth and a large effusion. Range of motion is painful and limited to 30 degrees of flexion. She is found to be hypotensive and not responding to volume resuscitation. She requires phenylephrine to maintain Mean Arterial Pressure (MAP) of 70. ESR and CRP are elevated and Lactate is 3.1 mmol/L. What is the next best intervention for this patient’s treatment?

Administration of broad spectrum IV antibiotics
Irrigation and debridement in OR followed by broad spectrum IV antibiotics
NSAIDS and observation with repeat ESR and CRP in 24 hours
Joint aspiration and blood cultures

Answer: D

Discussion: The patient is demonstrating signs of septic shock. Administration of antibiotics should not be delayed. Aspirating the knee joint and obtaining blood cultures can be rapidly accomplished to obtain accurate specimens. This should be followed immediately by administration of broad spectrum IV antibiotics. Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain mean arterial pressure (MAP) ≥ 65 mmHg and having a serum lactate level > 2mmol/L (18 mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%.

Question 39 of 100 A 58-year-old man with a 50-year history of osteomyelitis of the left tibia has a painful ulceration of the anterior lower limb. Figure 1 is the clinical photograph of the wound, which had purulent discharge and an unpleasant odor. Figures 2 and 3 are radiographs of the left tibia. A biopsy reveals malignant degeneration. What are the most likely findings?

Reticulosarcoma
Squamous cell carcinoma
Fibrosarcoma
Malignant fibrous histiocytoma

Answer: B

Discussion: Squamous cell carcinoma is the most common type of malignant tumor deriving from chronic osteomyelitis. The most frequently affected site is the tibia, followed by the femur. When the neoplasm invades the bone, there is either osteolytic erosion or a pathological fracture. Diagnosis is confirmed by biopsy at all suspicious wound sites. The malignant transformation most often results in squamous cell carcinoma and much more rarely in fibrosarcoma, osteosarcoma, reticulosarcoma, malignant fibrous histiocytoma or angiosarcoma. Many experts accept amputation as the best treatment option for carcinomatous transformation of chronic bone infections.

Question 40 of 100 A 56-year-old man with poorly controlled diabetes mellitus has rapidly developing and advancing erythema, warmth and swelling with bullae formation on the left lower extremity. These findings appear to be advancing proximally several millimeters per hour. Culture results are most likely to reveal

group A Streptococcus.
Methicillin-resistant staphylococcus aureus.
Clostridium.
polymicrobial infection.

Answer: D

Discussion: Necrotizing fasciitis (NF) results in the death of the body's soft tissue. It is a severe disease of sudden onset that spreads rapidly. Symptoms include red or purple skin in the affected area, with severe pain, fever, and vomiting. The most commonly affected areas are the limbs and perineum. Early diagnosis is difficult as the disease often looks like a simple superficial skin infection in the early stages. While a number of laboratory and imaging modalities can raise the suspicion for necrotizing fasciitis, the gold standard for diagnosis is a surgical exploration in the setting of high suspicion. When in doubt, a small "keyhole" incision can be made into the affected tissue. If a finger easily separates the tissue along the fascial plane,

the diagnosis is confirmed and an extensive debridement should be performed. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score can be utilized to risk stratify people who have signs of cellulitis and determine the likelihood of necrotizing fasciitis being present. It uses six serologic measures, including C-reactive protein, total white blood cell count, hemoglobin, sodium, creatinine and glucose.

Polymicrobial synergistic infection was the most common cause of necrotizing fasciitis (48 patients; 53.9%) with streptococci and enterobacteriaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus (63 patients; 70.8%).

Question 41 of 100 Six weeks after open reduction internal fixation of a closed tibial pilon fracture, a patient has a draining wound with surrounding erythema and swelling. Radiographs show lucency around screws. What is the most appropriate treatment sequence?

Start IV antibiotics, obtain wound swab for culture, perform irrigation and debridement and retain hardware
Start IV antibiotics, obtain deep soft tissue and bone cultures in OR, perform irrigation and debridement and remove hardware
Obtain wound swab for culture, start IV antibiotics, perform irrigation and debridement and remove hardware
Obtain deep bone and soft tissue cultures in OR, start IV antibiotics, perform irrigation and debridement and remove hardware

Answer: D

Discussion: Management of acutely infected wounds is primarily surgical. Osteomyelitis frequently involves Orthopaedic hardware, which would ideally be removed or replaced given biofilm involvement. Multiple operative cultures of fluid collections, soft tissues and bone should routinely be obtained. Culture yield is highest if cultures are obtained before empiric antibiotic treatment is started. Tissue samples are greatly preferred to swabs, which are notoriously inaccurate.

Question 42 of 100 CLINICAL SITUATION

A 56-year-old woman has a closed left elbow injury after she fell onto her outstretched upper extremity. The injury and post-reduction radiographs are shown in Figures 1 through 4. She is neurovascularly intact.

What is the most likely pattern of instability?

Varus
Valgus
Varus posteromedial rotatory
Valgus posterolateral rotatory

Discussion: D

The patient sustained a radial head/neck fracture, a coronoid tip fracture, and an elbow dislocation, a constellation of injuries termed a “terrible triad.” These are most often the result of a valgus posterolateral rotatory instability pattern, as evidenced by a comminuted radial head fracture and a small coronoid tip fracture. Varus posteromedial injuries most often have an intact radial head and a large anteromedial coronoid facet fracture. Pure varus or valgus injuries to the elbow are rare.

alternatively a split in the EDC. The primary benefit of the Kaplan approach is to avoid iatrogenic injury to the lateral collateral ligament (LUCL), which lies more posterior to the approach. However, it does bring the dissection closer to the posterior interosseous nerve (PIN). The Kocher interval (b) is more posterior between extensor carpi ulnaris (ECU) and anconeus. In this case, the coronoid can be approached through the radial neck fracture, and the choice between Kaplan and Kocher approaches would not significantly impact this. The Kocher approach is in an internervous plane between the radial nerve (anconeus) and PIN (ECU), while the Kaplan approach may be variable depending on if the EDC is split and the innervation of the ECRB (radial vs PIN).

The coronoid tip fracture repair with suture can be performed as an anterior capsular repair. If the tip fracture is small, there is little bony contribution to stabilize the elbow. The brachialis would insert distal to the tip of the coronoid, and the anterior band of the medial collateral longus (MCL) would insert on the sublime tubercle more medially. Neither would be affected by the fracture in this example. At this time, it is controversial whether small coronoid tip fractures should be repaired in this setting.

This patient has a comminuted radial head and neck fracture with >3 fragments. In this setting, arthroplasty is the recommended treatment because studies have shown poor results with attempts at open reduction internal fixation. Radial head excision alone in the presence of a complex instability pattern is also not recommended as the radial head provides secondary stability with ligament

Question 43 of 100 CLINICAL SITUATION

In the operating room, a lateral approach is selected. A clinical photograph of the exposure is shown in Figure 5. What is the primary benefit of choosing the deep interval marked with [a], rather than [b]?

*Figure 5 - Used with permission from Cheung EV, Steinmann SP. Surgical approaches to the elbow. J Am Acad Orthop Surg. 2009 May;17(5):325-33. Review. PubMed PMID: 19411644.

Increased distance to the posterior interosseous nerve (PIN)
Decreased risk of damage to the lateral ulnar collateral ligament (LUCL)
Improved visualization of the coronoid fracture
Dissection through an internervous plane Discussion: B

Figure 5 shows two lateral approaches to the elbow, the Kaplan and the Kocher approach. The Kaplan approach (a) is a more anterior approach between the extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC), or alternatively a split in the EDC. The primary benefit of the Kaplan approach is to avoid iatrogenic injury to the lateral collateral ligament (LUCL), which lies more posterior to the approach. However, it does bring the dissection closer to the posterior interosseous nerve (PIN). The Kocher interval (b) is more posterior between extensor carpi ulnaris (ECU) and anconeus. In this case, the coronoid can be approached through the radial neck fracture, and the choice between Kaplan and Kocher approaches would not significantly impact this. The Kocher approach is in

an internervous plane between the radial nerve (anconeus) and PIN (ECU), while the Kaplan approach may be variable depending on if the EDC is split and the innervation of the ECRB (radial vs PIN).

Question 44 of 100 CLINICAL SITUATION

A suture repair of the coronoid is performed through bone tunnels. What is the main contribution to elbow stability provided by repair of this coronoid fracture?

Repair the anterior capsule
Repair the brachialis insertion
Repair the medial collateral ligament insertion
Restore the ulnohumeral articulation Discussion: A

Question 45 of 100 CLINICAL SITUATION

Intra-operatively, the radial head is noted to have 3 separate fragments in addition to a radial neck fracture. What is the best next step?

Closed treatment of the fracture
Radial head excision
Open reduction internal fixation
Radial head arthroplasty Discussion: D

the Kaplan approach may be variable depending on if the EDC is split and the innervation of the ECRB (radial vs PIN).

Question 46 of 100 Figures 1 and 2 are the radiographs of a 52-year-old man who fell from his height. He sustained a closed injury to his left elbow. He is neurovascularly intact. What is the best approach to address the coronoid fracture?

Olecranon osteotomy
Through the radial head excision
Flexor carpi ulnaris (FCU) split
Medial epicondyle osteotomy Discussion: C

The radiographs reveal a large medial coronoid fracture associated with an elbow dislocation. The radial head appears intact. This constellation of injuries represents a varus posteromedial rotatory instability pattern. Given the size of the fragment and the injury pattern, the coronoid warrants a direct approach and buttress plate fixation, which is best accomplished through a medial flexor carpi ulnaris splitting approach.

An olecranon osteotomy would be unnecessary and would still not allow buttress plating of the coronoid. The radial head is intact and should not be excised in this pattern. A medial epicondylar osteotomy could provide good visualization of the coronoid, but is unnecessarily invasive and risks further destabilizing the medial collateral ligament complex. Alternatively, a medial Hotchkiss over-the-top approach could also provide visualization of the fracture.

Question 47 of 100 Figure 1 is the injury anteroposterior pelvic radiograph, Figure 2 is the post-reduction anteroposterior hip radiograph, and Figures 3 and 4 are the axial and coronal CT scans of a 34-year-old woman involved in a motor vehicle collision. What is the most appropriate treatment option for this patient?

Operative fixation of femoral head and posterior wall
Operative fixation of posterior wall and acute total hip arthroplasty
Protected weight bearing for six weeks
Resection of the femoral head fragment Discussion: A

This patient has sustained an Pipkin IV femoral head/posterior wall acetabular fracture dislocation and would benefit from operative fixation. While resection of some small femoral head fracture fragments can be considered, this fragment is nearly half of the femoral head and should not be excised. Similarly, the fragment is not completely reduced or stable and, therefore, non-operative treatment with protected weight bearing is not appropriate.

Although the outcomes of such injuries with primary fixation are not consistently excellent, there is no role for acute total hip arthroplasty in this patient. Considerable

debate remains about whether patients with Pipkin IV injuries should be treated from anterior or posterior approaches. Advocates for the anterior approach cite less morbid exposure and direct access to the anterior portion of the femoral head with likely stable hip examination as enough of the posterior rim needed to be intact and present to cause the injury to the femoral head during the dislocation. Advocates of primary fixation of both injuries from a posterior approach with surgical hip dislocation cite access to both injuries through a single and verified safe approach and can also address remaining osseous debris and muscle and labral damage at the same time. Regardless, both treatment approaches include fixation of the femoral head and this should be pursued for this patient.

Question 48 of 100 CLINICAL SITUATION

Figure 1 is the anteroposterior radiograph of an 85-year-old man who fell from a standing position and landed directly on his left hip. In the emergency department, he complains of immediate pain and an inability to bear weight.

Compared to a total hip arthroplasty, a hemiarthroplasty is associated with a

decreased dislocation rate.
higher post-operative mortality rate.
lower incidence of revision surgery.
increased need for skilled nursing facility. Discussion: A

The treatment of hip fractures in the elderly population represents a major public

health priority and a source of ongoing debate among orthopaedic surgeons and anesthesiologists. Most of these injuries are treated with surgery in an expedient fashion. From the surgical perspective, there are certain special considerations in this population, including osteoporosis, pre-existing arthritis, age, activity level, and overall health that contribute to the type of surgical fixation performed.

Timing to surgery has been born out in the literature to be an important factor in regard to outcomes. Studies have shown that many of the extraneous pre-operative testing that we order rarely dictates care, but delays time to surgery. Additionally, multiple studies have demonstrated that urgent hip surgery can safely be performed while patients are on anticoagulants. The goal of surgical intervention is to provide a construct that can allow early mobilization and limit complications.

Studies demonstrate that arthroplasty is considered the gold standard for elderly patients with displaced femoral neck fractures. While there has been a recent debate about performing hemiarthroplasty versus total hip arthroplasty (THA), the consensus still exists that THA is complicated by a higher dislocation risk as compared to hemiarthroplasty.

Elderly patients cannot be partial weight bearing- they either are non-weight bearing or weight bearing as tolerated (WBAT). A goal of the surgical procedure chosen should be to allow the patient to be WBAT immediately after surgery.

Question 49 of 100 An active 80-year-old woman had operative management of an intertrochanteric fracture. She has been taking a bisphosphonate for osteoporosis treatment for the past 6 months. She wants to restart her bisphosphonate. What is the most appropriate recommendation?

Do nothing because it is not your expertise
Start on a bone forming therapy as the bisphosphonate failed
Restart her bisphosphonate within 1 week of surgery
Restart her bisphosphonate within 3 months of surgery Discussion: C

She needs to restart medication therapy to prevent worsening of her osteoporosis. A

case can be made for changing to a bone-forming agent but these require self-administration and are expensive. Because she wishes to remain on the bisphosphonate she may start within one week of surgery. It appears that there is no effect in fracture healing by starting bisphosphonates within one week of surgery.

Question 50 of 100

Surgical treatment of hip fractures in patients on clopidogrel should be delayed

for at least five days.
for at least three days.
until medical optimization.
until international normalized ratio (INR) is < 1.5. Discussion: C

While the effect of clopidogrel on platelets is irreversible and may take 7 to 10 days

to be completely reversed, there is no significant difference in bleeding or need for blood transfusions when comparing surgeries done after 1 to 2 days off clopidogrel or after 5 days and later. Since delay in treating hip fractures may result in worse outcomes, it has been recommended that surgery should not be delayed for patients on clopidogrel. The medication should be stopped on admission and the patient taken to the operating room once medically optimized. Clopidogrel has no effect on INR levels.

Question 51 of 100 Figure 1 is the radiograph of a 32-year-old man who is involved in a motor vehicle collision and sustains an injury to his right hip. Physical examination reveals that the right limb is significantly shorter than the left and is positioned in slight flexion and in neutral rotation. The decision is made to perform a closed reduction and conscious sedation with fentanyl and versed is given. During the attempted reduction, the limb is notably immobile with moderate force. What is the best next step?

Skeletal traction
Re-attempt closed reduction
Urgent CT scan and surgical reduction
Knee immobilizer Discussion: C

The clinical scenario depicted here is consistent with an irreducible femoral head

fracture dislocation. The standard posterior hip fracture dislocations has the leg notably flexed, internally rotated, and rather mobile with reduction attempts. In

contrast, the irreducible variant has the limb in slight flexion, neutral rotation, and the limb is relatively immobile in comparison.

The anteroposterior radiograph shows a subtle difference with the femoral head closed opposed to the supra-acetabular iliac bone. With the constellation of these findings, the diagnosis of an irreducible femoral head fracture dislocation is made and no further reduction attempts should be made. More forceful movements may cause an iatrogenic femoral neck fracture. Instead, appropriate advanced imaging should be obtained for pre-operative planning, appropriate advanced trauma life support (ATLS) protocol and resuscitation should occur, and the patient should be brought to the operating room for a formal open reduction internal fixation of the fracture

Question 52 of 100 A 36-year-old man has right shoulder pain after a fall from a bicycle. What is the most likely complication of nonsurgical treatment of the injury shown in Figure 1?

Nonunion
Symptomatic malunion
Skin breakdown
Acromioclavicular joint arthrosis Discussion: A

The patient has a Neer type II distal clavicle fracture with radiographic evidence of coracoclavicular ligament disruption. With non-surgical treatment, the most commonly reported complication is nonunion, with rates reported to be as high as 44%. However, many patients with distal clavicular nonunion remain asymptomatic. Symptomatic malunion and skin breakdown over the fracture site are certainly possible, but are less common than nonunion. Because the fracture does not extend into the acromioclavicular joint, post-traumatic arthrosis would not be expected.

Question 53 of 100 A 99-year-old woman sustains the injury shown in Figure 1 after falling from a standing position. What is the most cost-effective treatment?

Three cannulated screws
Long intramedullary nail
Sliding hip screw
Short intramedullary nail Discussion: C

Intertrochanteric hip fractures remain a common injury that orthopaedic surgeons manage. The optimal form of surgical stabilization for these injuries has been a topic of debate over the years. Recent studies have demonstrated equivalent outcomes between the use of sliding hip screws and intramedullary nails for stable fracture patterns. Recent guidelines have suggested that the use of sliding hip screws for stable fracture patterns can have a significant reduction in cost per case.

Question 54 of 100 The use of the Masquelet induced membrane technique for long bone infected nonunion involves two stages. The first stage consists of debridement of all involved soft tissue and bone, and

external fixation, insertion of an antibiotic cement spacer, and culture specific antibiotics.
placement of an antibiotic nail, immediate bone grafting of the defect, and culture specific antibiotics.
insertion of an antibiotic nail, place nothing in the bone void, and culture specific antibiotics.
placement of an antibiotic cement spacer, insertion of an antibiotic nail, and non-culture specific antibiotics.

Discussion: A

Mauffrey and associates describe their technique for the two.stage treatment of lon g bone osteomyelitis. The first stage involves a radicaldebridement, stabilization of

the bone with either external fixation or an antibiotic.coated intramedullary nail, pl acement of a polymethylmethacrylate spacer, and culture specific antibiotics. The s econd stage includes excision of the spacer and placement of autologous bonegraft.

Questio 55- of 100 As compared to hemiarthroplasty, results of total hip arthroplasty after displaced femoral neck fracture in an active elderly patient (older than 65 years) show

better functional outcomes.
lower dislocation rates.
worse functional outcomes.
similar outcomes. Discussion: A

Multiple prospective randomized studies have demonstrated that healthy, active elderly patients had better outcomes at 7 to 10 year follow ups after total hip arthroplasty for displaced femoral neck fractures. There were higher dislocation rates but improved function with no difference in other complications.

Question 56 of 100 When compared to limb salvage patients, who required free flaps and/or an ankle arthrodesis, patients treated with standard below knee amputation had

significantly worse two-year outcomes.
significantly better two-year outcomes.
a trend toward worse outcomes that were not significant.
a trend toward better outcomes that were not significant. Discussion: B

When compared to patients treated with standard below knee amputation, salvage patients who required free flaps and/or ankle arthrodesis had significantly worse two-year outcomes. They had overall sickness impact profile (SIP) scores that were

2.5 points higher and psychosocial SIP scores that were 8.4 points higher at 24 months (p = 0.014 and p = 0.013, respectively). Physical SIP scores were 3.7 points higher in the free flap and/or arthrodesis group but only approached statistical significance (p = 0.10). After adjusting for the need for free flap and/or arthrodesis, the salvage pathway had clinically, but not statistically, significantly better overall and psychosocial SIP scores than the patients with standard below knee amputation (p = 0.34 and p = 0.20, respectively).

Question 57 of 100 Post-traumatic stress disorder (PTSD) is increasingly being recognized as a problem following orthopaedic trauma. To improve the patient’s outcome, it is important for the orthopedist to recognize which patients might be at risk for PTSD. Which patient is most likely to have PTSD?

A male with a both bone forearm fracture
A female with a femur fracture
A male with multiple injuries
A female with a both bone forearm fracture Discussion: B

In reviewing the literature, it appears that females are four times more likely to develop PTSD than males. Furthermore, PTSD often lasts longer in females. Patients with a lower extremity fracture, including a pelvic fracture, are twice as likely to develop PTSD as compared to upper extremity fractures. It does not seem to make a difference if the patient has multiple injuries or has an isolated fracture.

Question 58 of 100 A 36-year-old man is involved in a motor vehicle collision and sustains a right posterior wall acetabular fracture. There is no reported history of dislocation and he has no prior history of hip trauma. Figure 1 is the anteroposterior pelvic radiograph and Figure 2 is the CT scan at the level where the fracture fragment is the largest. Based on this information, what is the best next step?

Nonoperative treatment with protected weight bearing
Examination under anesthesia to determine hip stability
Operative treatment due to the size of the wall fragment
Operative treatment due to a roof arc angle less than 45 degrees Discussion: B

Operative indications for posterior wall acetabular fractures include a fracture involving more than 50% of the posterior wall, incongruent hip joint, and intra-articular debris. The presence of a dislocation was previously thought to infer instability, however, this is not accurate. Roof arc angles do not apply to posterior wall fractures. Traditionally, fractures involving 20% to 50% of the posterior wall were thought to be indeterminate. And fractures involving less than 20% of the posterior wall were thought to be stable. Unfortunately, a large number of posterior wall fractures involved less than 50% of the posterior wall and the joint appears congruent under static views using any one of multiple published measuring techniques. Being able to determine the presence of stability in these patients is challenging, and misdiagnosing a patient with a stable hip in the setting of a posterior wall acetabular fracture can lead to a poor outcome.

Contemporary treatment proposes that all patients with a fracture involving less than 50% of the posterior wall undergo an examination under anesthesia to conduct dynamic stress testing as static views do not provide enough information. There are numerous reports of fractures that are less than 20% of the posterior wall that are unstable. If there is any question of hip stability, a stress examination is indicated. While the size of the posterior wall may not always correlate with instability, the location of the cranial exit may. Recent investigations also demonstrated that posterior wall fractures exiting within 5 mm of the acetabular dome are at high risk for instability.

Question 59 of 100 A 41-year-old man arrives at the trauma bay 45 minutes after a high-speed motor vehicle collision. Per EMS, the patient was restrained, the airbags deployed, and the extrication was prolonged. Upon arrival, he is intubated and his blood pressure is 60/21 and heart rate is 159. Figure 1 is the patient’s radiograph during trauma evaluation. What would be the most appropriate initial management of this injury in the trauma bay?

External fixation of his pelvis
Circumferential wrap placed around greater trochanters
Placement of a C-clamp
Open reduction internal fixation of his pelvis Discussion: B

A polytrauma patient creates a challenging situation for any care provider, but specifically the orthopaedic surgeon. During the initial workup of a polytrauma patient, the typical radiographic series includes a chest radiograph, AP pelvis, and lateral c-spine. Due to the significant morbidity associated with pelvic ring injuries, it is critical to temporarily address these injuries during the resuscitative process. Circumferential wrapping of the pelvis can easily be performed in the trauma bay and allow for pelvic volume containment and aid in the resuscitative process.

Additionally, it is not uncommon to miss less obvious injuries. A thorough and expeditious secondary survey can be performed in the trauma bay and any concerned areas should be imaged. It is important to decide whether to temporize versus definitively manage the patient’s orthopaedic injuries. And the status of the patient is critical when making these decisions. In the initial management of an unstable patient, temporizing measures should be employed. Once the patient is fully resuscitated and outside the window of a “second hit,” definitive management can occur. Measuring serum lactate has been found to be the most accurate measurement of someone’s resuscitation.

Question 60 of 100 A 23-year-old man sustains a closed mid-shaft fracture of the left clavicle after a fall from a bicycle. The fracture is completely displaced with mild comminution, but there is no tenting of the skin. When discussing treatment options with the patient, what is the primary benefit of open reduction internal fixation (ORIF) versus nonoperative treatment?

Improved cosmesis with ORIF
Decreased cost with ORIF
Reduced rate of secondary surgery with ORIF
Reduced rate of nonunion with ORIF Discussion: D

Multiple randomized, controlled trials have demonstrated a benefit to operative management of displaced mid-shaft clavicle fractures. However, much of the functional benefit of surgery seems to come from preventing nonunions and symptomatic malunions, rather than general improvement across all operative patients.

ORIF can improve cosmesis, but is not the primary benefit of ORIF. The most common complication after surgical management is hardware irritation/prominence and rates of removal have been reported as high as 25 to 30%. ORIF has also been shown to be a more expensive option than non-operative treatment.

Question 61 of 100 Figure 1 is the radiograph of a 19-year-old man who is involved in a rollover motor vehicle collision. Distal femoral skeletal traction and circumferential pelvic sheet is applied, with the resultant alignment seen in Figure 2. He undergoes an exploratory laparotomy and has a splenectomy. Pelvic angiography shows no embolizable source of bleeding. Resuscitation continues and the remainder of his trauma workup is negative. Over the next 36 hours, he becomes hemodynamically unstable again. What is the best next step?

Repeat CT head scan
Repeat exploratory laparotomy
Perform surgical fixation of pelvic ring injury
Repeat pelvic angiography Discussion: D

The patient has a complete disruption of the symphysis pubis and right complete sacral fracture with vertical displacement of the right hemi-pelvis. Appropriate initial orthopaedic intervention includes circumferential pelvic sheeting and distal femoral skeletal traction. This reapproximates normal anatomy, decreases the pelvic volume, and provides some initial temporary stability that maintains any initial clots that occurred at the site of osseous and/or vascular injury. The remainder of the patient’s initial evaluation was negative except for the intra-abdominal injuries that were initially addressed during the exploratory laparotomy

Multiple treatment algorithms exist, however, in patients with continued, hemodynamic instability, the source of continued bleeding needs to be identified. Thus, the need for repeat angiography should not be discarded. There is a small subset of patients who will require repeat angiography with a previously identified site bleeding, a new site of bleeding, or a combination of both. Beyond identifying patients in need of possible angiography, risk factors to help identify the patients who are at higher risk of requiring repeat angiography include the following:

Continued hypotension
Need for greater than 2 units of packed red blood cells prior to angiography or greater than 6 units of packed red blood cells after angiography
Multiple vessels requiring embolization or super selective embolization performed during the initial procedure

Question 62 of 100 You receive a call from the trauma team leader about a patient with a mangled extremity. He asks you what is the best scoring system to use to decide between amputation and limb salvage, and what score predicts the need for amputation so he can get informed consent. What should you tell him?
1. A mangled extremity severity score (MESS) of 5 predicts amputation with high specificity and low sensitivity
2. A predictive salvage index (PSI) of 6 predicts amputation with low sensitivity and specificity
3. A limb salvage Index (LSI) of 4 predicts amputation with high sensitivity and low specificity
4. Scoring systems cannot be used because they are not predictive of functional recovery

Discussion: D

The performance of the indices in all of the injury-pattern groups indicates that these lower-

extremity injury_severity scoring systems havelimited usefulness and cannot be us ed as the sole criterion by which amputation decisions are made. Scores at or above the amputationthreshold should be used cautiously by a surgeon, who must decide the fate of a lower extremity with a high-energy injury.

Question 63 of 100 Figure 1 is the radiograph and Figure 2 is the clinical photograph of an 89-year-old woman who fell down a flight of steps. The most effective way to decrease the likelihood of infection in this patient is to immediately?

Go to the operating room for irrigation and debridement
Administer antibiotics
Perform skeletal stabilization
Irrigate the open wound in the emergency department Discussion: B

Open fractures can be challenging for an orthopaedic surgeon to treat. One of the biggest challenges is to prevent infection after gross contamination and exposure to the surrounding environment. Multiple studies have demonstrated that the most reliable way to reduce the risk of infection is to administer antibiotics as soon as possible after the injury occurred. Although important, the timing to surgical debridement and skeletal stabilization seem to have much less of an impact compared with the immediate administration of antibiotics. However, surgical debridement should be done within 24 hours of injury and perhaps earlier for high-risk injuries such as this one.

Question 64 of 100 Figure 1 is a 3-D CT surface rendered outlet image of a patient with pelvic fracture. What makes a safe S1 iliosacral screw placement most challenging?

Mammillary bodies
Steep alar slope
Residual S1 disk
Large, irregular S1 neural foramina Discussion: B

The CT surface rendered image reveals many findings present with sacral dysmorphism, including the upper sacral body relatively collinear with the iliac crests; steep alar slope; mammillary bodies; large, irregular S1 neural foramina; and a residual S1 disk. The other notable characteristics of tongue-in-groove sacroiliac joint and cortical indentation of the sacral ala are not visualized on this image. A patient is diagnosed with sacral dysmorphism if any of these characteristics are present in any degree, ranging from subtle to obvious, but not all characteristics are required.

Out of all the possible criteria, the steep alar slope is the most clinically relevant. This altered osseous corridor is now smaller and angled more acutely in both the anterior-posterior and the caudal-cranial directions. The dysmorphic alar osteology does not permit a transiliac transsacral style screw at the S1 level but does allow an iliosacral style screw. If this altered osteology is not identified pre-operatively, an extraosseous screw can be placed with potential neurologic or vascular injury.

The remainder of the criteria for sacral dysmorphism are listed in choices A, C, and

D. Although these criteria are present in the CT surfaced rendered image, they do not directly impact clinical practice. Instead, when viewed on standard radiographs or CT imaging, they help the surgeon recognize the presence of sacral dysmorphism. Once recognized, the altered S1 osteology can be fully appreciated and appropriate templating and intra-operative execution can occur without incident.

Question 65 of 100 CLINICAL SITUATION

Figures 1 through 4 are the radiographs of a 38-year-old man who is involved in a motor vehicle collision. He is stable and his injuries are isolated to the extremity shown in Figures 1 through 4 with no other non-musculoskeletal injury. He has no neurological or vascular dysfunction in the extremity.

What is the most devastating complication from this type of injury?

Osteonecrosis of the femoral head
Nonunion of the femoral neck fracture
Nonunion of the diaphyseal fracture
Infection of the femoral fracture Discussion: A

Osteonecrosis of the femoral head in a young person is not salvageable unless by total hip arthroplasty or vascularized fibular grafting. Nonunion of either fracture is treatable with either valgus osteotomy of the neck and revision fixation and grafting of the shaft. Infection is a problem but is treatable with a good result.

An anatomical reduction of the femoral neck fracture usually guarantees the best result for this fracture. This is best achieved through an open reduction. However, if the surgeon can assure that the neck is anatomically reduced closed then it would be acceptable. Fixation of the neck is best done using some form of compression to achieve stability and prevent collapse. Femoral shaft fixation is best done by a separate implant usually a retro grade nail.

It is taught that the neck is the priority so that it will reestablish the blood supply. However, what is important is the adequacy of the neck reduction and this can be difficult with the femur unstabilized. The most important aspect is what will get the best result for the femoral neck fracture.

The patient has a nonunion of the femoral neck. A valgus osteotomy is a very successful procedure for this condition even in the face of osteonecrosis of the head. There is enough room to do the osteotomy above the nail and get the plate screw around the nail.

Question 66 of 100 CLINICAL SITUATION

The patient has done well but returns in 6 months, complaining of groin pain, without thigh pain, when walking and during the night. In addition, the leg seems to be shorter (see Figures 5 and 6). Infection is ruled out and the patient has a normal erythrocyte sedimentation rate, C-reactive protein, and vitamin D levels. What is the best next step?

Non weight bearing and follow up in 3 to 6 months
Total hip arthroplasty
Valgus osteotomy
Revision fixation of the neck with bone graft Discussion: C

Question 67 of 100 Figures 1 and 2 are the radiographs of a 19-year-old woman who sustained a femoral shaft fracture in a motor vehicle collision. She was treated with a closed static locked reamed nail. At 8 months, she is still complaining of pain in the thigh with activity, has no limb length discrepancy and no rotational deformity. An infection and metabolic workup are normal. The CT scan is shown in Figure 3. What is the best next treatment?

Ultrasound
Exchange nailing
Continued observation with weight bearing
Adjunctive plate fixation with bone graft Discussion: B

This appears to be either a hypertrophic or oligotrophic nonunion with cortical contact. By enhancing the stability with a larger nail and stimulating blood flow by reaming, this nonunion will probably heal. Exchange nailing is not a 100% cure so the use of a bone graft or adjunctive plate fixation may also be considered.

Question 68 of 100 During the process of placing an iliosacral screw with fluoroscopic assistance, Figure 1 shows the outlet view, Figure 2 shows the inlet view, and Figure 3 shows the lateral view. At this point, the surgeon notes that the drill tip is above the iliac cortical density (ICD). This finding indicates the drill is

intraosseous and safe from neurovascular injury.
extraosseous and at risk for L5 nerve root injury.
extraosseous and at risk for S1 nerve root injury.
extraosseous and at risk for iliac vessel injury. Discussion: A

The intra-operative views show S1 iliosacral screw placement in a patient with noted sacral dysmorphism. The safe corridor for intraosseous screw placement proceeds from posterior to anterior and caudal to cranial. When placing a screw in these patients, the surgeon must understand the patient’s underlying osseous anatomy. The inlet view (Figure 2) shows the anterior cortical indentation, which shows the anterior limit of the safe screw pathway. The outlet view (Figure 1) shows the appropriate trajectory in relation to the S1 neuroforamen and the cortical density of the neuroforaminal tunnel as it courses from cranial to caudal, medial to lateral, and posterior to anterior.

When a lateral view (Figure 3) is checked, the drill tip is cranial to the ICD, however, it is still intraosseous. The slope of the S1 sacral ala can be see as well. The steep alar slope alters the normal relationship of the ICD to the sacral ala and the drill/wire/screw will appear cranial and anterior to the ICD. In patients with sacral dysmorphism, this is a normal and expected finding. The drill/wire/screw is intraosseous and safe at this point and is not in danger of neurovascular structure injury. If the drill was anterior to the anterior sacral indentation, the L5 nerve root would be at risk for injury. The drill has not passed medial enough to be into the neuroforaminal tunnel zone so the S1 nerve root injury is not a risk. Similarly, the drill has not passed medial or cranial enough to endanger the iliac vessels.

Question 69 of 100 Post-traumatic stress disorder (PTSD) frequently affects orthopaedic trauma patients. How does the timing of identifying PTSD have an effect on access to resources and the recovery process?

Early identification of PTSD lengthens the time of the recovery process
Early identification of PTSD does not affect the access to resources
Early identification of PTSD shortens the time of the recovery process
Early identification of PTSD decreases the access to resources Discussion: C

Early identification can help care teams provide the resources and support to offset the distress. Several options that help trauma patients navigate their short-term recovery include holistic approaches, pastoral care, coping skills, mindfulness, peer visitation, and educational resources.

Starr and associates showed that 51% of trauma patients met the criteria for the diagnosis of PTSD. Patients with PTSD had significantly higher Injury Severity Scores (p = 0.04), a higher sum of Extremity Abbreviated Injury Scores (p = 0.05), and a longer time to recovery than those without PTSD (p < 0.01).

Question 70 of 100 CLINICAL SITUATION

After the emergency department physician sees this patient, he consults cardiology. The cardiologist orders an echocardiogram to be performed immediately. What is the likely result of ordering this test?

Decreasing the patient’s length of stay
Increasing the patient’s time to surgery
Determining the type of anesthesia for surgery
Determining what service the patient will get admitted to Discussion: B

The treatment of hip fractures in the elderly population represents a major public health priority and a source of ongoing debate among orthopaedic surgeons and anesthesiologists. Most of these injuries are treated with surgery in an expedient fashion. From the surgical perspective, there are certain special considerations in this population, including osteoporosis, pre-existing arthritis, age, activity level, and overall health that contribute to the type of surgical fixation performed.

Question 71 of 100 CLINICAL SITUATION

What should this patient’s post-operative weight bearing status be?

Non-weight bearing
Weight bearing as tolerated
Toe touch weight bearing
Transfers with assistance Discussion: B

Question 72 of 100 Figure 1 is the trauma chest radiograph of a 35-year-old man who arrives at the emergency department after a motorcycle collision. He was intubated and sedated in the field, so a neurological examination cannot be obtained. The patient has a palpable, but thready, pulse in his right upper extremity. A consultation is called for the right clavicle fracture with a 2-cm open wound overlying the fracture site. What is the best next step?

Irrigation and debridement in the emergency room
Irrigation and debridement in the operating room
CT scan of the chest to assess for associated injuries
Pulse examination and brachial-brachial index Discussion: D

The chest radiograph reveals a distracted right clavicle fracture, which is highly concerning for scapulothoracic dissociation. Although all the options are reasonable, the most important initial step would be to rule out an associated vascular injury, which is common with a scapulothoracic dissociation.

On physical examination, this can be done with a pulse examination and brachial-brachial index. Based on the physical examination, advanced imaging can be ordered as needed. A chest CT can be performed to evaluate lateral displacement of the right

scapula compared to the left. The open fracture will also require urgent irrigation and debridement as well.

Question 73 of 100 In contrast to the findings of the Lower Extremity Assessment Project (LEAP), the Military Extremity Trauma Amputation/Limb Salvage (METALS) study demonstrated

that patients with limb salvage had better outcomes.
that patients with amputation had better outcomes.
no difference in outcomes with amputation or limb salvage.
that patients with limb salvage required fewer operations. Discussion: B

After adjustment for covariates, patients with an amputation had better scores in all short musculoskeletal function assessment (SMFA) domains compared with patients whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to the percentage of patients with depressive symptoms, pain interfering with daily activities (pain interference), or work/school status

Question 74 of 100 Figure 1 is the clinical photograph and Figure 2 is the radiograph of a 47-year-old woman who has foot pain and swelling after a fall. Her past medical history includes diabetes mellitus and a current smoker. What is the next step?. What is the next step?

Splinting with delayed open reduction internal fixation (ORIF)
Splinting with nonoperative management secondary to comorbidities
Splinting with emergent operative reduction and fixation
Emergent casting with equinus foot position Discussion: C

The radiograph and clinical photograph show a displaced calcaneal tuberosity with impending posterior soft tissue compromise. This represents a surgical urgency, requiring prompt diagnosis and treatment. If treatment is delayed, the posterior skin will suffer necrosis and will likely require soft tissue reconstruction.

Although the patient has associated comorbidities, delayed ORIF would be inappropriate as the posterior soft tissues will deteriorate unless treatment is initiated. Nonoperative management is not an option because the displaced tuberosity will not improve with time. Although equinus splinting can temporary relieve the pressure on the posterior soft tissues, this would not definitively relieve the posterior skin pressure or reduce the tuberosity displacement.

Question 75 of 100 During the process of placing an S2 transiliac transsacral style screw with fluoroscopic assistance, Figure 1 shows the outlet view, Figure 2 shows the inlet view, and Figure 3 shows the lateral view. At this point during the procedure, the drill tip is

intraosseous and safe from neurovascular injury.
extraosseous and at risk for S1 nerve root injury.
extraosseous and at risk for S2 nerve root injury.
extraosseous and at risk for iliac vessel injury. Discussion: A

The intra-operative views show placement of an S2 transiliac transsacral style screw in a patient with sacral dysmorphism. This is most notably shown by the anterior sacral indentations seen on the inlet view (Figure 2). In these patients, the S1 corridor does not allow for a transiliac transsacral style screw. Instead, these patients typically have a larger S2 osseous corridor which will accommodate the transiliac transsacral style screw. At this point in the procedure, the drill is in the sacral ala and has not reached the neuroforaminal tunnel. The inlet view (Figure 2) shows the drill to be traversing the S1 anterior sacral indentations, which would be concerning if the screw is at the S1 level. Instead, the screw is at the S2 level and the lateral view

(Figure 3) confirms the drill is intraosseous. Although the S1 or S2 nerve roots could be damaged during screw placement at this level, none of the structures listed above are at risk with the current position of the drill.

Question 76 of 100 Preventing heterotopic ossification (HO) following fracture surgery of an injured joint using non-steroidal anti-inflammatory drugs (NSAIDs) or radiation is associated with

better results from NSAIDs.
nonunion of the fracture.
expected fracture union rates.
better results from radiation. Discussion: B

The only fact that appears consistent between most studies and reviews is that either radiation or NSAIDs will cause nonunion of the fracture in the injured joint to prevent HO. The effectiveness of either radiation and/or NSAIDs in the prevention of HO is debatable with no real evidence that either of them work consistently.

Question 77 of 100 Figure 1 is radiograph of a 96-year-old woman who fell down two steps and comes to the emergency department with an inability to bear weight and right hip pain. Figure 2 is the post-traction radiograph. What intra-operative event would increase the rate of failure when using a sliding hip screw (SHS) to treat this fracture pattern?

Penetration of the femoral head with the guide wire
Obtaining a tip apex distance of less than 25mm
Fracture of the lateral wall
Using a 2-hole SHS instead of a 4-hole SHS

Discussion: C

The integrity of the lateral wall of the proximal femur when treating intertrochanteric femur fractures has been identified as a predictor of successful outcomes. Multiple studies have identified that a thin or “incompetent” lateral wall increases the likelihood of intra-operative lateral wall blowout. This intra-operative complication has been shown to significantly increase the likelihood of post-operative hardware failure and the need for reoperation. Therefore, most identify the integrity of the lateral wall as a predictor of fracture pattern stability and a radiographic sign to guide implant choices. Hsu and associates reference the determination of the competency of the lateral wall.

Question 78 of 100 CLINICAL SITUATION

Figure 1 is the radiograph of a 67-year-old woman who is involved in a motor vehicle collision and sustains an isolated injury to her left hip. She is a community ambulatory who does not use any assistive devices.

She undergoes a closed reduction in the emergency department. Figures 2 through 5 are post-reduction CT images. What is the ideal surgical approach to address this fracture?

Kocher-Langenbeck
Ilioinguinal
Extended iliofemoral
Anterior intrapelvic Discussion: A

The patient sustained a posterior wall fracture dislocation. For acetabular fractures, the position of the limb in space at the time of impact (in terms of the amount of flexion/extension, internal/external rotation, and adduction/abduction) will dictate the fracture pattern. For posterior wall fracture patterns, the limb is in some degree of flexion, adduction, and internal rotation. Other combinations are possible to contribute to an acetabular fracture but not likely to contribute to a posterior wall pattern.

This posterior wall fracture pattern can be addressed from a standard Kocher-Langenbeck approach for both fixation and arthroplasty. There is no significant cranial or anterior extension of the fracture that would necessitate a modified posterior approach or greater trochanteric osteotomy. The other listed approaches would not be appropriate.

Indications for total hip arthroplasty are continuing to evolve and many patient-specific and fracture specific variables are involved. Several studies have investigated this issue and the common variables that influence the success of primary fixation are related to the age of the patient, greater than 50 years as well as associated bone quality and how these are affected with the fracture. The presence of marginal impaction suggests significant insult to the cartilage. In the presence of pre-existing cartilage wear, the likelihood of success with primary fixation is decreased. The presence of significant comminution of the fracture (greater than 3 fragments) also suggests decreased success with primary fixation. The other factors listed can contribute to perioperative morbidity but not as clearly when compared to the three listed in answer A. In the clinical setting of a patient older than 50 years old with a comminuted fracture, marginal impaction, and femoral head damage, there should be serious consideration for combined fracture fixation and acute total hip arthroplasty. Delayed arthroplasty can be an option in some patients, but clinical outcomes have not been as favorable as acute combined treatment.

Although urethral tears, rib fractures, and subdural hematoma are commonly involved with high-energy accidents and are routinely investigated through advanced trauma life support (ATLS) protocols, the ipsilateral knee has not received such focus. In a recent multi-center study, 15% of patients were found to have ipsilateral knee symptoms within a period of 1 year from the date of injury. The patterns of knee injury included 56 fractures (29%), 49 ligamentous lesions (25%), and 88 miscellaneous (46%) causes, including bone bruises, wounds, and swelling.

Multi-ligamentous knee injuries can be occult and a detailed examination of the knee should be standard in these patients upon secondary and tertiary surveys.

Question 79 of 100 CLINICAL SITUATION

Which factors will lead a surgeon to pursue fracture fixation and acute total hip arthroplasty instead of fixation alone?

Age > 50 years, marginal impaction, posterior wall comminution
BMI > 50, femoral head damage, prior hip surgery
Posterior wall comminution, worker’s compensation injury, femoral head damage
Age > 50 years, history of smoking, diabetes mellitus Discussion: A

posterior approach or greater trochanteric osteotomy. The other listed approaches would not be appropriate.

Question 80 of 100 CLINICAL SITUATION

In this patient, what other potential injury can be associated with this fracture pattern and is commonly overlooked?

Urethral tear
Ipsilateral knee
Rib fractures
Subdural hematoma Discussion: B

there should be serious consideration for combined fracture fixation and acute total hip arthroplasty. Delayed arthroplasty can be an option in some patients, but clinical outcomes have not been as favorable as acute combined treatment.

Question 81 of 100 Figure 1 is the radiograph of a 25-year-old man who injured his left lower extremity. He is intubated and sedated for other injuries sustained. At 1:00 am his nurse calls with the concern that his leg “feels tight.” What is the most accurate way to diagnose compartment syndrome?

Palpating his left lower extremity compartments
Increasing paresthesia in his foot
Diastolic blood pressure minus intracompartmental pressure is less than 30 mmHG
Intracompartmental pressure is greater than 25 mmHG Discussion: C

The diagnosis of acute compartment syndrome is a challenge. The clinical diagnosis can be made using specific clinical findings. In this scenario, however, the patient is

intubated and sedated and the only clinical examination available is palpation of the lower extremity compartments and pulse examination. The published literature suggests that these clinical signs are unreliable. Given the lack of diagnostic certainty due to a limited clinical exam, the use of objective evidence makes sense. Compartment pressure monitoring has been advocated for the past four decades. The use of perfusion pressure instead of absolute pressure has been shown to be more physiologically relevant. As the literature supports, fasciotomies can be avoided if the perfusion pressure (diastolic blood pressure minus compartment pressure) is greater than 30 mmHg.

Question 82 of 100 Deep vein thrombosis (DVT) prophylaxis is recommended for what fracture after surgery?

Hip fractures
Olecranon fractures
Distal radius fractures
Lisfranc injuries Discussion: A

DVT prophylaxis for hip fractures requires 10 to 14 days of pharmacological anticoagulation. However, the American College of Chest Physicians recommends a longer period (up to 35 days) for hip fractures.

The Pentasaccharide in Hip-Fracture Surgery (PENTHIFRA) study compared fondaparinux, a synthetic inhibitor of factor Xa, with enoxaparin. This was a large, multi-center, randomized, double-blind trial of 1,711 patients with hip fractures. Despite no differences in clinically relevant bleeding rates, the incidence of total venous thromboembolism was significantly lower in the fondaparinux study group (8% vs 19%, p <.001). Based on the PENTHIFRA study, the total recommended duration of fondaparinux was 4 weeks after surgery.

Injuries below the knee or in the upper extremity do not need any prophylaxis, unless the patient has other risk factors. Overall, the risk of DVT for olecranon and wrist fractures are extremely low. Therefore, olecranon and wrist injuries, if isolated, do not merit DVT prophylaxis.

Question 83 of 100 Figures 1 and 2 are the radiographs and Figure 3 is the axial CT cut of a 47-year-old man who has pain in his right elbow after a fall from his roof. On examination, he is

noted to have an effusion and his range of motion is limited by pain. What is the most appropriate definitive treatment for this injury?

Closed treatment with early mobilization
Open reduction internal fixation
Distal humeral hemiarthroplasty
Total elbow arthroplasty Discussion: B

The patient presents with a coronal plane injury to his capitellum and trochlea as well as a partial articular radial head fracture. Given his displaced, intra-articular fracture, open reduction internal fixation is the most appropriate treatment in this case.

If his radial head were an isolated injury, then closed treatment with early mobilization would be satisfactory. If the patient was older and had an unreconstructable fracture, then arthroplasty, either with a distal humeral hemiarthroplasty or a total elbow arthroplasty, would be a reasonable option.

Question 84 of 100 A 35-year-old woman is being resuscitated after a motor vehicle collision. She has a major pulmonary contusion, a mild head injury, and an open femoral shaft fracture with about a 4-cm skin laceration over the anterolateral aspect of the mid-thigh with

what appears to be viable muscle. The patient also has a lateral compression fracture of the pelvis and a fracture of her humerus. Her blood pressure is 90mmHg systolic with a heart rate of 120. She is receiving her second unit of packed red blood cells. Her lactate is 7 mmol/L, pH 7.3, and base excess -8.0 mmol/L. What is the best next step?

Traction for the femur fracture and splint for the humerus
Emergent debridement and stabilization of femur and humerus fractures
Emergent debridement and reamed intramedullary nailing (IMN) fixation of the femur and splinting of the humerus fracture
Traction for the femoral shaft fracture and immediate open reduction internal fixation (ORIF) of the humeral shaft fracture

Discussion: A

The debate between early total care and damage control has evolved to the early appropriate care protocol based on the patient’s biochemical response to resuscitation. Using the protocol of having the lactate and a normalizing base excess and pH has shown that early fracture fixation within 36 hours is possible with a decreased length of stay and fewer complications.

Question 85 of 100 CLINICAL SITUATION

Figures 1 through 3 are the anteroposterior pelvis, hip and lateral hip radiographs of a 39-year-old man who is involved in a motor vehicle collision and sustains an isolated injury to his right hip and diaphyseal femur.

Femoral neck fractures in young adults are frequently comminuted. What is the most common location for comminution to occur?

Superior and anterior
Superior and posterior
Inferior and anterior
Inferior and posterior Discussion: D

The patient sustained a high-energy femoral neck fracture. The Pauwel’s classification is made by evaluating the angle of the fracture. Degree I is from 0 to 30, Degree II is from 30 to 50, and Degree III is greater than 50. There is no Degree IV.

Due to the muscular forces of the iliopsoas, external rotators, and abductors acting on the fracture fragments, the common deformity associated with this fracture would be hip flexion, external rotation, and shortening.

Due to the high energy needed to cause such an injury in a young patient with good bone quality, there is often comminution. A recent study demonstrated that significant comminution (> 1.5 cm) was present in 96% of their patient cohort with posterior (84%) and inferior (94%) being the most common sites.

Numerous outcome studies have been performed on patients after stabilization of femoral neck fractures, and multiple factors can affect the outcomes identified. Out of the variables listed, the quality of the surgical reduction has been shown to have the largest impact on fracture healing and clinical outcomes. The time until surgery was historically thought to impact the rate of osteonecrosis but this has not been found to be the case in more contemporary studies. There are numerous implants being used to stabilize these fractures, ranging from cannulated screws to sliding hip screw constructs and static and dynamic locking implants. At this time, there is no clear consensus on the best implant to use.

The final intra-operative images reveal reduction and fixation with the use of 3 cannulated screws as well as a medial femoral neck buttress plate. While reduction and fixation can occur through the use of a Watson-Jones, it would not be possible to place the medial buttress plate in this instance. Therefore, only the Heuter (also commonly referred to as the distal limb of the Smith-Petersen) could provide such access.

Question 86 of 100 CLINICAL SITUATION

What factor has been shown to best influence the outcome of the patient after stabilization of their femoral neck fracture?

Type of implant used
Quality of fracture reduction
Time to surgical fixation
Time until weight bearing allowed Discussion: B

found to be the case in more contemporary studies. There are numerous implants being used to stabilize these fractures, ranging from cannulated screws to sliding hip screw constructs and static and dynamic locking implants. At this time, there is no clear consensus on the best implant to use.

Question 87 of 100 Figures 1 and 2 are the radiographs of a 51-year-man who was shot in the right thigh. Which factor would likely lead to fracture malrotation during definitive fixation?

Location of the fracture
Fracture comminution
Patient’s body habitus
Antegrade nailing Discussion:B

Fracture characteristics can lead to difficulties when determining appropriate rotation. Studies have shown that increased fracture comminution has led to increased malrotation rates. Appropriate use of a systematic approach to judging the rotation of the femur can decrease the likelihood of malrotation and lead to more optimal results. Surgeon experience, patient’s body habitus, and type of nail has not been demonstrated in the literature to significantly influence the ability to obtain acceptable rotation

Question 88 of 100 Which treatment option listed is best for each patient described? Figure 1 is the radiograph of a 72-year-old woman who fell while hiking

In situ percutaneous screws
Open reduction and percutaneous screws
Compression hip screw
Cephalomedullary nail
Hemiarthroplasty
Total Hip arthroplasty
Discussion: D

Figure 1 shows a reverse obliquity intertrochanteric fracture with displacement of the lesser trochanter. Cephalomedullary nail fixation is indicated in this pattern secondary to the obliquity of the fracture line.

Figure 2 shows a displaced transcervical femoral neck fracture in a low-demand patient. Hemiarthroplasty is an effective treatment modality to allow early weight bearing and mobilization in this patient. Early mobilization reduces perioperative morbidity. Percutaneous screw fixation and open reduction internal fixation is associated with up to 40% failure rates in this patient population. Although total hip arthroplasty is an option, it is not indicated for this low-demand patient with no radiographic evidence of hip osteoarthritis.

Figure 3 shows a stable valgus impacted femoral neck fracture. This stable pattern is amenable to percutaneous screw fixation. This would allow early weight bearing and would prevent further fracture displacement. Open reduction is not indicated because the fracture does not need a reduction

Figure 4 shows a traction radiograph showing a high-energy 2-part standard obliquity intertrochanteric femur fracture. This would be amenable to open reduction internal fixation with a compression hip screw. Open reduction would likely be indicated secondary to the fracture displacement and failure of realignment with traction.

Figure 5 shows a displaced basicervical femoral neck/intertrochanteric fracture with pre-existing hip osteoarthritis. In an active patient with existing osteoarthritis, total hip arthroplasty is indicated to restore hip function. A calcar replacing type of arthroplasty might be needed secondary to the fracture pattern. Open reduction internal fixation is also an option, but would likely require implant removal and conversion to total hip arthroplasty after fracture healing, which would subject the patient to a second surgery and the associated morbidity.

Question 89 of 100 Which treatment option listed is best for each patient described? Figure 2 is the radiograph of an 80-year-old who is limited to household ambulation with a cane and fell from ground level.
1. In situ percutaneous screws
2. Open reduction and percutaneous screws
3. Compression hip screw
4. Cephalomedullary na
5. Hemiarthroplasty Discussion: E

Figure 1 shows a reverse obliquity intertrochanteric fracture with displacement of the lesser trochanter. Cephalomedullary nail fixation is indicated in this pattern secondary to the obliquity of the fracture line.

Figure 2 shows a displaced transcervical femoral neck fracture in a low-demand patient. Hemiarthroplasty is an effective treatment modality to allow early weight bearing and mobilization in this patient. Early mobilization reduces perioperative morbidity. Percutaneous screw fixation and open reduction internal fixation is associated with up to 40% failure rates in this patient population. Although total hip arthroplasty is an option, it is not indicated for this low-demand patient with no radiographic evidence of hip osteoarthritis.

Figure 3 shows a stable valgus impacted femoral neck fracture. This stable pattern is amenable to percutaneous screw fixation. This would allow early weight bearing and would prevent further fracture displacement. Open reduction is not indicated because the fracture does not need a reduction

Figure 4 shows a traction radiograph showing a high-energy 2-part standard obliquity intertrochanteric femur fracture. This would be amenable to open reduction internal fixation with a compression hip screw. Open reduction would likely be indicated secondary to the fracture displacement and failure of realignment with traction.

Figure 5 shows a displaced basicervical femoral neck/intertrochanteric fracture with pre-existing hip osteoarthritis. In an active patient with existing osteoarthritis, total hip arthroplasty is indicated to restore hip function. A calcar replacing type of arthroplasty might be needed secondary to the fracture pattern. Open reduction internal fixation is also an option, but would likely require implant removal and conversion to total hip arthroplasty after fracture healing, which would subject the patient to a second surgery and the associated morbidity.

Question 90 of 100

Which treatment option listed is best for each patient described?

Figure 5 is the radiograph of a 69-year-old active man with pre-existing hip pain who fell from a ladder.

In situ percutaneous screws
Open reduction and percutaneous screws
Compression hip screw
Cephalomedullary nail
Hemiarthroplasty
Total Hip arthroplasty

Discussion: F

would likely be indicated secondary to the fracture displacement and failure of realignment with traction.

Question 91 of 100

Which treatment option listed is best for each patient described?

Figure 4 is the radiograph of a 65-year-old after a motorcycle collision.

In situ percutaneous screws
Open reduction and percutaneous screws
Compression hip screw
Cephalomedullary nail
Hemiarthroplasty
Total Hip arthroplasty

Discussion: C

Question 92 of 100

Which treatment option listed is best for each patient described?

Figure 3 is the radiograph of a 78-year-old who fell from ground level.

In situ percutaneous screws
Open reduction and percutaneous screws
Compression hip screw
Cephalomedullary nail
Hemiarthroplasty
Total Hip arthroplasty Discussion: A

would likely be indicated secondary to the fracture displacement and failure of realignment with traction.

Question 93 of 100

There are many bone graft substitutes and fracture healing adjuncts

available. Please match the biologic property most associated with reamer irrigator aspirator bone graft.

Osteoinductive
Osteoconductive
Osteogenic
Osteogenic and osteoconductive
Osteogenic and osteoinductive
Osteoconductive and osteoinductive
Osteogenic, osteoconductive and osteoinductive Discussion: G

Autogenous bone graft remains the gold standard for grafting procedures because of its osteogenic, osteoinductive and osteoconductive properties. This is true for either iliac crest bone grafts or bone obtained from the intramedullary canal via the reamer irrigator aspirator system. Although bone marrow aspirate is from the patient, its lack of “structure” makes it osteogenic and osteoinductive only. Demineralized bone matrix obtained from cadaveric sources is “dead” bone but contains small amounts of bone morphogenic proteins (BMPs) that are osteoinductive. Furthermore, demineralized bone matrix has structure to it, adding osteoconductive capabilities as well.

Although carriers are used in the implantation of BMPs, the BMPs are purely osteoinductive. Ceramics are synthetic bone substitutes/graft extenders and only provide a scaffold and are considered osteoconductive. Allograft bone is dead bone and, thus, is osteoconductive.

Question 94 of 100

There are many bone graft substitutes and fracture healing adjuncts

available. Please match the biologic property most associated with platelet rich plasma.

Osteoinductive
Osteoconductive
Osteogenic
Osteogenic and osteoconductive
Osteogenic and osteoinductive
Osteoconductive and osteoinductive
Osteogenic, osteoconductive and osteoinductive

Discussion: A

Question 95 of 100

There are many bone graft substitutes and fracture healing adjuncts

available. Please match the biologic property most associated with bone morphogenic protein.

Osteoinductive
Osteoconductive
Osteogenic
Osteogenic and osteoconductive
Osteogenic and osteoinductive
Osteoconductive and osteoinductive
Osteogenic, osteoconductive and osteoinductive Discussion: A

Question 96 of 100

There are many bone graft substitutes and fracture healing adjuncts

available. Please match the biologic property most associated with bone marrow aspirate.

Osteoinductive
Osteoconductive
Osteogenic
Osteogenic and osteoconductive
Osteogenic and osteoinductive
Osteoconductive and osteoinductive
Osteogenic, osteoconductive and osteoinductive Discussion: E

Question 97 of 100

There are many bone graft substitutes and fracture healing adjuncts

available. Please match the biologic property most associated with ceramics.

Osteoinductive
Osteoconductive
Osteogenic
Osteogenic and osteoconductive
Osteogenic and osteoinductive
Osteoconductive and osteoinductive
Osteogenic, osteoconductive and osteoinductive Discussion: B

Question 98 of 100 There are many bone graft substitutes and fracture healing adjuncts available. Please match the biologic property most associated with demineralized bone matrix.

Osteoinductive
Osteoconductive
Osteogenic
Osteogenic and osteoconductive
Osteogenic and osteoinductive
Osteoconductive and osteoinductive
Osteogenic, osteoconductive and osteoinductive

Discussion: F

Autogenous bone graft remains the gold standard for grafting procedures because of its osteogenic, osteoinductive and osteoconductive properties.

This is true for either iliac crest bone grafts or bone obtained from the intramedullary canal via the reamer irrigator aspirator system. Although bone marrow aspirate is from the patient, its lack of “structure” makes it osteogenic and osteoinductive only. Demineralized bone matrix obtained from cadaveric sources is “dead” bone but contains small amounts of bone morphogenic proteins (BMPs) that are osteoinductive. Furthermore, demineralized bone matrix has structure to it, adding osteoconductive capabilities as well. Although carriers are used in the implantation of BMPs, the BMPs are purely osteoinductive. Ceramics are synthetic bone substitutes/graft extenders and only provide a scaffold and are considered osteoconductive. Allograft bone is dead bone and, thus, is osteoconductive.

Question 99 of 100 There are many bone graft substitutes and fracture healing adjuncts available. Please match the biologic property most associated with autogenous iliac crest bone graft.

Osteoinductive
Osteoconductive
Osteogenic
Osteogenic and osteoconductive
Osteogenic and osteoinductive
Osteoconductive and osteoinductive
Osteogenic, osteoconductive and osteoinductive

Discussion: G

proteins (BMPs) that are osteoinductive. Furthermore, demineralized bone matrix has structure to it, adding osteoconductive capabilities as well. Although carriers are used in the implantation of BMPs, the BMPs are purely osteoinductive. Ceramics are synthetic bone substitutes/graft extenders and only provide a scaffold and are considered osteoconductive. Allograft bone is dead bone and, thus, is osteoconductive.

Question 100 of 100 There are many bone graft substitutes and fracture healing adjuncts available. Please match the biologic property most associated with allograft cancellous bone.

Osteoinductive
Osteoconductive
Osteogenic
Osteogenic and osteoconductive
Osteogenic and osteoinductive
Osteoconductive and osteoinductive
Osteogenic, osteoconductive and osteoinductive

Discussion: B

substitutes/graft extenders and only provide a scaffold and are considered osteoconductive. Allograft bone is dead bone and, thus, is osteoconductive

Orthopedic MCQS Trauma 0018

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Orthopedic MCQS Trauma 0018

Commented [1]:

Which treatment option listed is best for each patient described?

Which treatment option listed is best for each patient described?

Which treatment option listed is best for each patient described?

There are many bone graft substitutes and fracture healing adjuncts

available. Please match the biologic property most associated with reamer irrigator aspirator bone graft.

There are many bone graft substitutes and fracture healing adjuncts

available. Please match the biologic property most associated with platelet rich plasma.

There are many bone graft substitutes and fracture healing adjuncts

available. Please match the biologic property most associated with bone morphogenic protein.

There are many bone graft substitutes and fracture healing adjuncts

available. Please match the biologic property most associated with bone marrow aspirate.

There are many bone graft substitutes and fracture healing adjuncts

available. Please match the biologic property most associated with ceramics.