Orthopedic Board Review MCQs: Elbow & Foot | Part 23

Question 1

A 32-year-old woman sustained an injury to her left upper extremity in a motor vehicle accident. Examination reveals a 2-cm wound in the mid portion of the dorsal surface of the upper arm and deformities at the elbow and forearm; there are no other injuries. Her vital signs are stable, and she has a base deficit of minus 1 and a lactate level of less than 2. Radiographs are shown in Figures 9a and 9b. In addition to urgent debridement of the humeral shaft fracture, management should include

Explanation

DISCUSSION: With a severe injury to the upper extremity, the best opportunity for achieving a good functional result for a floating elbow is immediate debridement of the open fracture, followed by internal fixation of the fractures. The ability to do this depends on the patient’s physiologic status. In this patient, the procedure is acceptable because she has normal vital signs and no chest or abdominal injuries, and normal physiologic parameters (base excess and lactate) show adequate peripheral perfusion. The surgical approaches will be determined by the associated injury patterns and open wounds. In this patient, the humerus was debrided and stabilized through a posterior approach as was the medial condyle fracture. The ulna was fixed through an extension of the posterior incision and the radius through a separate dorsal approach.
REFERENCES: Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.
Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461.

Question 2

A patient sustained the injuries shown in the radiographs and clinical photograph seen in Figures 10a through 10c. The neurovascular examination is normal. The first step in emergent management of the extremity injuries should consist of

Explanation

DISCUSSION: The figures show an open tibial fracture, a femoral shaft fracture, and femoral head dislocation. The most urgent treatment is reduction of the femoral head, as timing to reduction has been correlated with preventing osteonecrosis. After reduction of the femoral head, the next priority is wound management, followed by stabilization of the femoral and tibial fractures with either splinting, traction, or external fixation.
REFERENCES: Sahin V, Karakas ES, Aksu S, et al: Traumatic dislocation and fracture-dislocation of the hip: A long-term follow-up study. J Trauma 2003;54:520-529.
Moed BR, WillsonCarr SE, Watson JT: Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am 2002;84:752-758.

Question 3

Figure 11 shows the radiograph of a 3-year-old girl who sustained a proximal radius injury. Appropriate initial management should include

Explanation

DISCUSSION: The patient has a displaced radial neck fracture. Displaced radial neck fractures with angulation of more than 30° to 45° require reduction. Methods of attempted closed reduction include wrapping the arm with an Esmarch’s bandage and applying direct pressure over the maximum deformity of the radial head. More aggressive methods include a Kirschner wire used as a joystick or intramedullary reduction as described by the Metaizeau technique. Open reduction should be avoided because of complications such as stiffness or osteonecrosis. Indications for open reduction are irreducible displacement of more than 45° with severe restriction of forearm rotation.
REFERENCES: Leung AG, Peterson HA: Fractures of the proximal radial head and neck in children with emphasis on those that involve the articular cartilage. J Pediatr Orthop

2000;20:7-14.
Radomisli TE, Rosen AL: Controversies regarding radial neck fractures in children. Clin Orthop 1998;353:30-39.
Skaggs DL, Mirzayan R: The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am 1999;81:1429-1433.
Gonzalez-Herranz P, Alvarez-Romera A, Burgos J, et al: Displaced radial neck fractures in children treated by closed intramedullary pinning (Metaizeau technique). J Pediatr Orthop 1997;17:325-331.

Question 4

Figures 12a and 12b show the radiographs of a 56-year-old man with diabetes mellitus who has had left foot swelling with no pain for the past several weeks. He denies any history of trauma. Examination reveals warmth, moderate swelling, no tenderness, and mild pes planus with standing. Pulses are palpable, and his sensory examination is grossly intact to light touch. Standing radiographs are shown in Figures 12c and 12d. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs show tarsometatarsal joint subluxation without fragmentation. The clinical history and delay in presentation with the radiographic findings suggest a neuropathic or Charcot arthropathy involving the midfoot area. Intact sensory examination to light touch is not diagnostic for an intact peripheral neurologic system; monofilament testing is a more accurate office baseline examination for the presence of sensory peripheral neuropathy. With an acute traumatic Lisfranc fracture-dislocation, a history of a traumatic event is necessary, and radiographic abnormalities are expected, although nonstanding radiographs still may be misleading. Acquired pes planus due to posterior tibial tendon rupture may have negative nonstanding radiographs. Standing radiographs may reveal pes planus. However, intermetatarsal disruption is not expected as seen in a Lisfranc abnormality. Localized osteomyelitis of the foot without a penetrating injury or cutaneous ulceration is extremely unlikely and does not fit with the clinical picture described. An isolated metatarsal stress fracture would show osseous irregularity without the instability pattern pictured.
REFERENCES: Brodsky JW: The diabetic foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 895-969.
Myerson MS: Diabetic neuroarthropathy, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 439-465.

Question 5

A 25-year-old student sustains the injury shown in Figures 13a through 13c after falling off a curb. Initial management should consist of

Explanation

DISCUSSION: The radiographs reveal a fracture entering the 4-5 intermetatarsal articulation, consistent with a zone 2 injury. This classically is also referred to as a Jones fracture. The history and radiographic findings indicate this is an acute fracture, which guides management. A zone 1 fracture enters the fifth tarsometatarsal joint, and a zone 3 fracture is a proximal diaphyseal fracture distal to the 4-5 articulation. Initial management is usually nonsurgical and consists of non-weight-bearing in a short leg cast. This method has been shown to result in a better healing rate compared to weight bearing as tolerated.
REFERENCES: Rosenberg GA, Sterra JJ: Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg 2000;8:332-338.
Lawrence SJ, Botte MJ: Jones’ fracture and related fractures of the proximal fifth metatarsal. Foot Ankle 1993;14:358-365.

Question 6

What structure is most often injured in a volar proximal interphalangeal joint dislocation?

Explanation

DISCUSSION: Closed ruptures of the central slip of the extensor tendon may occur with volar proximal interphalangeal joint dislocation, forced flexion of the proximal interphalangeal joint, or blunt trauma to the dorsum of the proximal interphalangeal joint. The other structures are not typically injured in proximal interphalangeal joint dislocations. Treatment typically requires static splinting of the proximal interphalangeal joint. In the more common dorsal proximal interphalangeal joint dislocation, the volar plate is injured, and early range of motion may be started after reduction.
REFERENCES: Doyle JR: Extensor tendons: Acute injuries, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1925.
Newport ML: Extensor tendon injuries in the hand. J Am Acad Orthop Surg 1997;5:59-66.

Question 7

What patient factor is predictive of better outcomes for surgical management of a displaced calcaneal fracture compared to nonsurgical management?

Explanation

DISCUSSION: A recent randomized trial of surgical versus nonsurgical management of calcaneal fractures showed that patients who were on workers’ compensation did poorly with surgical care. These patients had less favorable outcomes regardless of their initial management. Factors such as age, smoking, and vasculopathies compromise skin healing, leading to greater surgical risks. The best results were obtained in patients who are younger than age 40 years, have unilateral injuries and are injured during noncompensable activities. Women tend to do better with surgery than men.
REFERENCES: Howard JL, Buckley R, McCormack R, et al: Complications following management of displaced intra-articular calcaneal fractures: A prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17:241-249.
Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.

Question 8

Figures 14a and 14b show the initial radiographs of an 18-year-old man who fell while snowboarding. Figures 14c and 14d show the radiographs obtained following closed reduction. Examination reveals that the elbow is stable with range of motion. Management should now consist of

Explanation

DISCUSSION: The initial radiographs reveal a simple elbow dislocation without associated fractures. After successful closed reduction, the range of stability should be assessed. If the elbow is stable, nonsurgical management should consist of a short period of immobilization followed by range-of-motion exercises. Immobilization for more than 3 weeks results in significant elbow stiffness. Surgical repair is indicated for dislocations that are irreducible, have associated fractures, or where stability cannot be maintained with closed treatment.
REFERENCES: Cohen MS, Hastings H II: Acute elbow dislocations: Evaluation and management. J Am Acad Orthop Surg 1998;6:15-23.
O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 409-420.

Question 9

A 12-year-old boy sustains open comminuted midshaft tibial and fibular fractures while playing indoor soccer. The wound is grossly clean and measures 7 cm with some periosteal stripping. Antibiotics and tetanus toxoid are administered immediately in the emergency department. Following irrigation and debridement of the wound in the operating room, treatment should include

Explanation

DISCUSSION: Open fractures in children have similar rates of short-term complications such as compartment syndrome, vascular injury, and nerve injury when compared to adult fractures. Primary wound closure should be used for Gustillo and Anderson type 1 or uncomplicated type 2 fractures after surgical debridement. Skeletal stabilization may consist of external fixation, flexible nails, or casting with or without supplementary pin fixation. For an open comminuted midshaft fracture, external fixation is the treatment of choice. Reamed intramedullary nailing is contraindicated in children with an open physis. Plate fixation has a high complication rate in severe open fractures.
REFERENCES: Jones BG, Duncan RD: Open tibial fractures in children under 13 years of age-10 years experience. Injury 2003;34:776-780.
Bartlett CS III, Weiner LS, Yang EC: Treatment of type II and type III open tibia fractures in children. J Orthop Trauma 1997;11:357-362.
Robertson P, Karol LA, Rab GT: Open fractures of the tibia and femur in children. J Pediatr Orthop 1996;16:621-626.
Cullen MC, Roy DR, Crawford AH, et al: Open fracture of the tibia in children. J Bone Joint Surg Am 1996;78:1039-1047.

Question 10

Which of the following is an advantage of unreamed nailing of the tibia compared to reamed nailing?

Explanation

DISCUSSION: The debate between reamed versus unreamed intramedullary nailing of the tibia continues. Although unreamed nailing was proposed for open fractures to minimize infection, its simplicity made it appealing for closed fractures. However, most studies to date show that the only advantage of unreamed nailing is less surgical time. All studies show higher nonunion rates with increased hardware failure and increased time to union for unreamed nailing. Even in open fractures graded up to Gustilo Grade IIIA, the reamed tibial nail performs better.
REFERENCES: Larsen LB, Madsen JE, Hoiness PR, et al: Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years’ follow-up. J Orthop Trauma 2004;18:144-149.
Blachut PA, O’Brien PJ, Meek RN, et al: Interlocking intramedullary nailing with or without reaming for the treatment of closed fractures of the tibial shaft: A prospective randomized study. J Bone Joint Surg Am 1997;79:640-646.

Question 11

A 12-year-old boy sustained a both bone forearm fracture 10 weeks ago and underwent closed reduction and casting. Examination now reveals that the injury is healed, but he is unable to extend his little and ring fingers of the injured hand with his wrist extended. Full extension is possible with the wrist flexed. A radiograph and clinical photograph are shown in Figures 15a and 15b. The remainder of his hand and wrist examination and neurologic evaluation in the hand are normal. What is the most likely diagnosis?

Explanation

DISCUSSION: In this patient, examination reveals an inability to extend the fingers with the wrist extended, but full extension is possible with wrist flexion. These findings demonstrate isolated tenodesis of the flexor digitorum to the ring and little fingers. These findings are not consistent with compartment syndrome or nerve injury. Scarring or entrapment of tendons in forearm fractures can occur.
REFERENCES: Watson PA, Blair W: Entrapment of the index flexor digitorum profundus tendon after fracture of both forearm bones in a child. Iowa Orthop J 1999;19:127-128.
Shaw BA, Murphy KM: Flexor tendon entrapment in ulnar shaft fractures. Clin Orthop 1996;330:181-184.
Kolkman KA, van Niekerk JL, Rieu PN, et al: A complicated forearm greenstick fracture: Case report. J Trauma 1992;32:116-117.
Hendel D, Aner A: Entrapment of the flexor digitorum profundus of the ring finger at the site of an ulnar fracture: A case report. Ital J Orthop Traumatol 1992;18:417-419.

Question 12

An otherwise healthy 35-year-old woman reports dorsal wrist pain and has trouble extending her thumb after sustaining a minimally displaced fracture of the distal radius 3 months ago. What is the next most appropriate step in management?

Explanation

DISCUSSION: Extensor pollicis longus tendon rupture can occur after a fracture of the distal radius, even a minimally displaced one. Poor vascularity of the tendon within the third dorsal compartment is the suspected etiology, not the displaced fracture fragments. Tendon transfer will suitably restore active extension of the thumb interphalangeal joint.
REFERENCES: Christophe K: Rupture of the extensor pollicis longus tendon following Colles fracture. J Bone Joint Surg Am 1953;35:1003-1005.
Hove LM: Delayed rupture of the thumb extensor tendon: A 5-year study of 18 consecutive cases. Acta Orthop Scand 1994;65:199-203.

Question 13

Figure 16a shows the radiograph of a 34-year-old woman who sustained a basicervical fracture of the femoral neck. The fracture was treated with a compression screw and side plate. Seven months postoperatively, she continues to have significant hip pain and cannot bear full weight on her hip. A recent radiograph is shown in Figure 16b. Management should now consist of

Explanation

DISCUSSION: The patient sustained a high-angle femoral neck fracture. The follow-up clinical findings and radiograph show that she now has a nonunion with failed internal fixation. The joint appears preserved. In a healthy, young patient, arthroplasty of the femoral head, although possible, is not ideal. Excellent healing and function can be obtained in 70% to 80% of patients with femoral neck nonunion with a valgus intertrochanteric osteotomy.
REFERENCES: Marti RK, Schuller HM, Raaymakers EL: Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br 1989;71:782-787.
Ballmer FT, Ballmer PM, Baumgaertel F, et al: Pauwels osteotomy for nonunions of the femoral neck. Orthop Clin North Am 1990;21:759-767.

Question 14

An 18-year-old man was in a motor vehicle accident and sustained a closed head injury, right displaced scapular body and glenoid fractures, a right proximal humeral fracture, fractures of ribs one through three, facial fractures, and bilateral pubic rami fractures with minimal displacement. He has a systolic blood pressure of 80/40 mm Hg despite fluid resuscitation. A radiograph is shown in Figure 17. Spiral CT does not identify any thoracic or abdominal injuries. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has sustained high-energy upper extremity and chest injuries. He continues to remain hemodynamically unstable with no obvious thoracic or abdominal injury responsible for bleeding. The pelvic fracture is unlikely to be causing significant bleeding. A scapulothoracic dissociation and possible disruption of one of the great vessels of the upper extremity should be considered. Evaluation of peripheral pulses or blood pressure indices bilaterally in the upper extremities is a simple way to evaluate the need for further work-up. If there is any discrepancy or further concern, angiography of the involved extremity is necessary.
REFERENCES: Althausen PL, Lee MA, Finkemeier CG: Scapulothoracic dissociation: Diagnosis and treatment. Clin Orthop 2003;416:237-244.
Witz M, Korzets Z, Lehmann J: Traumatic scapulothoracic dissociation. J Cardiovasc Surg 2000;41:927-929.

Question 15

What is the major difference in outcome following open reduction and internal fixation (ORIF) of the tibial plafond at 2 to 5 days versus 10 to 20 days?

Explanation

DISCUSSION: Long-term outcomes following tibial plafond fractures treated with ORIF are satisfactory in most patients despite a high incidence of posttraumatic osteoarthritis. If ORIF is delayed until 10 to 20 days following injury, the major difference in outcomes is fewer complications associated with wound healing. Ankle strength, pain, range of motion, and the development of arthritis are equal regardless of the time until fixation.
REFERENCES: Sirkin M, Sanders R, DePasquale T, et al: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 1999;13:78-84.
Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.

Question 16

Figure 18a shows the initial lateral radiograph of a 6-year-old girl who sustained a fracture in a motor vehicle accident and was treated in a cast 1 year ago. She now has the valgus deformity seen in Figure 18b. Treatment should consist of

Explanation

DISCUSSION: Proximal tibial metaphyseal fractures may result in late genu valgum as a result of asymmetric growth of the proximal tibia. These patients are best treated with observation because the deformity is likely to remodel. Osteotomy is not indicated and potentially will lead to recurrence. Stapling of the medial tibial physis is appropriate in patients who have a severe and progressive deformity.
REFERENCES: Cozen L: Knock-knee deformity in children: Congenital and acquired. Clin Orthop 1990;258:191-203.
Jackson DW, Cozen L: Genu valgum as a complication of proximal tibial metaphyseal fractures in children. J Bone Joint Surg Am 1971;53:1571-1578.
Brammar TJ, Rooker GD: Remodeling of valgus deformity secondary to proximal metaphyseal fracture of the tibia. Injury 1998;29:558-560.
Ogden JA, Ogden DA, Pugh L, et al: Tibia valga after proximal metaphyseal fractures in childhood: A normal biologic response. J Pediatr Orthop 1995;15:489-494.
Salter RB, Best TN: Pathogenesis of progressive valgus deformity following fractures of the proximal metaphyseal region of the tibia in young children. Instr Course Lect 1992;41:409-411.

Question 17

Figure 19 shows the radiograph of a 45-year-old woman who has a painful nonunion. Treatment should consist of

Explanation

DISCUSSION: The radiograph reveals a reverse obliquely subtrochanteric/intertrochanteric fracture. Open reduction and internal fixation should be accomplished with a 95° fixed angle device. An intramedullary nail with screw fixation into the head is another possible technique. Either method should correct the varus deformity. Exchange of a high-angled screw and plate device to a longer side plate and bone grafting does not afford any improvement in the mechanical stability. Hardware removal and retrograde intramedullary nailing is not indicated for this level of a proximal femoral injury. Placement of an implantable bone stimulator may change local biologic factors but would not enhance mechanical stability. The patient’s femoral head is intact without signs of collapse; therefore, hardware removal, proximal femoral resection, and total hip arthroplasty are not warranted.
REFERENCES: Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Koval KJ, Zuckerman JD: Intertrochanteric fractures, in Rockwood & Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 1635-1681.

Question 18

A 7-year-old boy has a swollen and deformed right arm after falling off his bicycle. Radiographs reveal a completely displaced posterolateral supracondylar humeral fracture. Examination reveals a warm, pink hand and forearm but absent pulses. What is the next most appropriate step in management?

Explanation

DISCUSSION: The incidence of vascular injury in supracondylar humeral fractures is directly related to the degree and direction of displacement. Significant posterior lateral displacement tends to result in brachial artery and median nerve injuries, and posterior medial displacement may lead to radial nerve injury. The brachial artery is always injured at the level of the fracture; therefore, angiography or MRA will not assist in locating the injury. The treatment of choice is surgical reduction and stabilization of the fracture, followed by reassessment of the vascular status. If the hand is pink and warm or pulses can be detected with doppler, it is reasonable to follow the extremity closely after surgery. If the arm becomes pulseless and white, immediate anterior exploration of the arm is indicated. The artery is often entrapped in the fracture and once extricated, will provide adequate blood flow. If the artery is injured, a primary repair or vein graft is needed.
REFERENCES: Shaw BA: The role of angiography in assessing vascular injuries associated with supracondylar humerus fractures remains controversial. J Pediatr Orthop 1998;18:273.
Sabharwal S, Tredwell SJ, Beauchamp RD, et al: Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop 1997;17:303-310.
Schoenecker PL, Delgado E, Rotman M, et al: Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma 1996;10:410-415.

Question 19

What is the treatment of choice for the injury shown in Figures 20a through 20c?

Explanation

DISCUSSION: The radiographs show multiple carpometacarpal dislocations. Reduction is often obtainable but difficult to maintain. Internal fixation is required to maintain the reduction, preferably with Kirschner wires. Closed reduction and percutaneous pinning is preferred by some surgeons. Others recommend open reduction to remove irreconstructable osteochondral fragments from the individual joints and to ensure correct reduction of the carpometacarpal joints. Kirschner wires are removed at 6 to 8 weeks.
REFERENCES: Prokuski LJ, Eglseder WA Jr: Concurrent dorsal dislocations and fracture-dislocations of the index, long, ring, and small (second to fifth) carpometacarpal joints. J Orthop Trauma 2001;15:549-554.
Lawlis JF III, Gunther SF: Carpometacarpal dislocations: Long-term follow-up. J Bone Joint Surg Am 1991;73:52-59.

Question 20

A 32-year-old man has intense right hand and wrist pain, a deformed wrist, and numbness in his fingers after falling off his motorcycle. This is an isolated injury. Examination reveals a swollen wrist, normal capillary refill to all fingers, and limited flexion of all fingers. Radiographs are shown in Figures 21a and 21b. Neurologic examination of the hand will most likely reveal

Explanation

DISCUSSION: The patient has a perilunate dislocation. A volar dislocation of the lunate is often associated with median nerve dysfunction. This injury to the wrist is often overlooked because of its benign clinical appearance and the presence of other injuries, as it is caused by high-energy mechanisms.
REFERENCES: Ruby LK, Cassidy C: Fractures and dislocations of the carpus, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1297-1300.
Habernek H, Weinstabl R, Kdolsky R, et al: Volar lunate fracture-dislocations of the wrist: Case report for two patients treated with external frame and internal open reduction. J Trauma 1998;45:975-978.

Question 21

A 55-year-old woman fell and sustained an elbow dislocation with a coronoid fracture and a radial head fracture. The elbow is reduced and splinted. What is the most common early complication?

Explanation

DISCUSSION: The patient has a dislocation of the elbow with displaced coronoid process and radial head fractures. The elbow is extremely unstable after this injury, and recurrent dislocation in a splint is the most common early complication. Skeletal stabilization of the fractures is required to restore stability of the joint. Characteristics of the fractures will determine the techniques required to restore stability.
REFERENCES: Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551.
Ring D, Jupiter JB: Fracture-dislocation of the elbow. J Bone Joint Surg Am 1998;80:566-580.

Question 22

A 25-year-old man sustained the closed injury shown in Figures 22a and 22b. Examination reveals that this is an isolated injury, and he is hemodynamically stable. Treatment should consist of

Explanation

DISCUSSION: The treatment of choice for closed diaphyseal femoral fractures in adults is reamed intramedullary nailing with static interlocking. Reaming allows placement of a larger, stronger implant and offers better healing rates than unreamed nailing. Static interlocking ensures that there is no loss of reduction because of underappreciated fracture lines or comminution.
REFERENCES: Brumback RJ, Virkus WW: Intramedullary nailing of the femur: Reamed versus nonreamed. J Am Acad Orthop Surg 2000;8:83-90.
Brumback RJ, Ellison TS, Poka A, et al: Intramedullary nailing of femoral shaft fractures: Part III. Long-term effects of static interlocking fixation. J Bone Joint Surg Am 1992;74:106-112.

Question 23

Figure 23 shows the radiograph of an elderly man who fell on his right arm. What is the most important determinate of a good outcome following this injury?

Explanation

DISCUSSION: Minimally displaced fractures of the proximal humerus have a good outcome if physical therapy is initiated within 2 weeks of the injury. Results are not affected by age, open reduction and internal fixation, or involvement of the greater tuberosity. Immobilization for longer than 3 weeks will often result in stiffness.
REFERENCES: Koval KJ, Gallagher MA, Marsicano JG, et al: Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am 1997;79:203-207.
Hodgson SA, Mawson SJ, Stanley D: Rehabilitation after two-part fractures of the neck of the humerus. J Bone Joint Surg Br 2003;85:419-422.

Question 24

A 40 year-old-man was involved in a motor vehicle accident and sustained the pelvic injury seen in Figures 24a and 24b. Definitive management of the injury should consist of reduction by

Explanation

DISCUSSION: The radiograph reveals disruption of the symphysis pubis and a displaced left sacral fracture. A posterior injury with displacement of greater than 1 cm is unstable, and a sacral fracture is particularly unstable. Surgical stabilization is required for these unstable anterior and posterior injuries. External fixation provides little stability to an unstable posterior pelvic injury. Reduction and internal fixation of the symphysis pubis and sacral fracture will provide the most stable pelvis with the least resultant deformity and allow patient mobilization.
REFERENCES: Tile M: Management of pelvic ring injuries, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 168-202.
Kabak S, Halici M, Tuncel M, et al: Functional outcome of open reduction and internal fixation for completely unstable pelvic ring fractures (type C): A report of 40 cases. J Orthop Trauma 2003;17:555-562.

Question 25

A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most reliable method of predicting a tear of the interosseous membrane?

Explanation

DISCUSSION: The Weber and Lauge-Hansen fracture classifications suggest that the interosseous membrane (IOM) is torn with certain fracture patterns. In a recent study that evaluated ankle fractures with MRI, Nielson and associates identified 30 patients with IOM tears. Ten of the tears did not correspond with the level of the fibular fracture. The authors concluded that stability of the syndesmosis should not be based on the level of the fibular fracture alone but should also include an intraoperative stress test. Transsyndesmotic fixation should be considered for those fractures where the intraoperative stress test demonstrates instability. A widened medial clear space may occur with a deltoid injury and distal fibular fracture in the absence of a significant tear of the interosseous membrane.
REFERENCE: Nielson JH, Sallis JG, Potter HG, et al: Correlation of interosseous membrane tears to the level of the fibular fracture. J Orthop Trauma 2004;18:68-74.

Question 26

When performing a flexor tendon repair of a digit other than the thumb, what structures of the flexor tendon sheath should be preserved?

Explanation

DISCUSSION: The A2 and A4 pulleys are considered the most important parts of the pulley system. If these two structures are preserved, 80% of finger flexion can be maintained. If the pulley system is not left intact or is not reconstructed, “bow-stringing” of the flexor tendons occurs with loss of full flexion. The A2 pulley is over the proximal phalanx and the A4 pulley is over the middle phalanx.
REFERENCES: Doyle JR: Anatomy of the finger flexor tendon sheath and pulley system.

J Hand Surg Am 1988;13:473-484.
Strickland JW: Flexor tendon injuries: I. Foundations of treatment. J Am Acad Orthop Surg 1995;3:44-54.

Question 27

A distal radius fracture in an elderly man is strongly predictive for what subsequent injury?

Explanation

DISCUSSION: Fractures of the distal radius increase the relative risk of a subsequent hip fracture significantly more in men than in women. A previous spinal fracture has an equally important impact on the risk of a subsequent hip fracture in both genders.
REFERENCE: Haentjens P, Autier P, Collins J, et al: Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women: A meta-analysis. J Bone Joint Surg Am 2003;85:1936-1943.

Question 28

A 13-year-old girl injures her ankle playing soccer. Radiographs reveal a displaced Tillaux fracture. CT scans are shown in Figure 25. What is the most important consideration for appropriate management?

Explanation

DISCUSSION: Tillaux and triplane fractures occur in adolescents as the result of an external rotation injury of the ankle. As seen on the CT scan, the growth plate starts to close during adolescence; therefore, growth arrest resulting in limb-length discrepancy or angulation is less of a concern in this age group than achieving joint congruity. The joint should be surgically reduced if displacement is greater than 2 mm to minimize the chances of late arthrosis.
REFERENCES: Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment.

J Am Acad Orthop Surg 2001;9:268-278.
Kling TF Jr: Operative treatment of ankle fractures in children. Orthop Clin North Am 1990;21:381-392.
Duchesneau S, Fallat LM: The Tillaux fracture. J Foot Ankle Surg 1996;35:127-133.

Question 29

What measure of physiologic status best evaluates whether an injured patient is fully resuscitated and best predicts that perioperative complications will be minimized following definitive stabilization of long bone fractures?

Explanation

DISCUSSION: Serum lactate levels can be used to evaluate the effectiveness of the resuscitation of patients who have multiple injuries. Even after resuscitation, patients may have occult hypoperfusion as defined by a serum lactate level of greater than 2.5 mmol/L. The studies referenced indicate that these patients are at increased risk of perioperative complications such as organ failure or adult respiratory distress syndrome if definitive surgical fixation of the orthopaedic injuries is pursued prior to correction of the occult hypoperfusion. The other markers may be an indication of current physiology but have not been correlated with perioperative risks.
REFERENCES: Blow O, Magliore L, Claridge JA, et al: The golden hour and silver day: Detection and correction of occult hypoperfusion within 24 hours improves outcomes from major trauma. J Trauma 1999;47:964-977.
Crowl A, Young JS, Kahler DM, et al: Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J Trauma 2000;48:260-267.
Shulman AM: Prediction of patients who will develop prolonged occult hypoperfusion following blunt trauma. J Trauma 2004;57:725-800.

Question 30

Based on the findings seen in the radiograph in Figure 26, emergent management should consist of

Explanation

DISCUSSION: The radiograph shows a volarly dislocated lunate. Initial emergent treatment of perilunate dislocations should consist of closed reduction and splinting, especially if the patient exhibits median nerve compression. Open reduction and pinning or ligament repair are necessary but are not emergent. A dorsal approach is sometimes required for ligament repair or bony visualization; however, this can be done in a more semi-elective manner.
REFERENCES: Isenberg J, Prokop A, Schellhammer F, et al: Palmar lunate dislocation. Unfallchirurg 2002;105:1133-1138.
Ruby LK: Fractures and dislocations of the carpus, in Browner BD, Jupiter JB (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1367-1372.

Question 31

A 10-year-old girl has a midshaft both bone forearm fracture. After attempted closed reduction, alignment consists of bayonet apposition, 10° of malrotation, and 8° of volar angulation. Management should now consist of

Explanation

DISCUSSION: Acceptable alignment in both bone forearm fractures is related to age and location. In children younger than age 9 years, angulations of 15° and malrotation of 45° are acceptable. In children older than age 9 years, acceptable alignment is 10° of angulation and 30° of malrotation. Bayonet apposition is acceptable provided that the angular and rotational reductions are held within these guidelines. A long arm cast provides better control of deforming forces than a short arm cast.
REFERENCES: Do TT, Strub WM, Foad SL, et al: Reduction versus remodeling in pediatric distal forearm fractures: A preliminary cost analysis. J Pediatr Orthop B 2003;12:109-115.
Flynn JM: Pediatric forearm fractures: Decision making, surgical techniques, and complications. Instr Course Lect 2002;51:355-360.
Ring D, Waters PM, Hotchkiss RN, et al: Pediatric floating elbow. J Pediatr Orthop 2001;21:456-459.
Noonan KJ, Price CT: Forearm and distal radius fractures in children. J Am Acad Orthop Surg 1998;6:146-156.

Question 32

In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by

Explanation

DISCUSSION: In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by the use of a direct lateral approach to the ankle. The superficial peroneal nerve and its branches exit the fascial hiatus approximately 9 cm to 10 cm proximal to the tip of the distal fibula with a range of 4 cm to 13 cm, and their course is typically anterior to the midlateral plane of the fibula. However, small branches may course across the surgical plane directly laterally. A posterior-lateral approach diminishes the risk of injury to the superficial peroneal nerve and its branches; however, by moving farther posterior, the sural nerve and its branches may be at increased risk. Cast immobilization may injure the cutaneous nerves about the ankle; however, the risks are greater with surgical intervention. A medial or anterior-medial approach to the ankle will not injure the superficial peroneal nerve at the ankle level.
REFERENCES: Redfern DJ, Sauve PS, Sakellariou A: Investigation of incidence of superficial peroneal nerve injury following ankle fracture. Foot Ankle Int 2003;24:771-774.
Miller SD: Ankle fractures, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1341-1366.

Question 33

A 54-year-old man sustained a small superficial abrasion over the left acromioclavicular joint after falling from his bicycle. Examination reveals no other physical findings. Radiographs show a displaced fracture of the lateral end of the clavicle distal to a line drawn vertically to the coracoid process. Management should consist of

Explanation

DISCUSSION: Displaced clavicular fractures lateral to the coracoid process (Neer type II and III) are best managed nonsurgically with sling immobilization and physical therapy, starting with pendulum exercises and progressing to active-assisted exercises when comfortable. Supervised therapy should be performed for 3 months or until full painless motion is achieved. In one study by Robinson and Cairns, this form of treatment provided patients with a 86% chance of avoiding a secondary reconstructive procedure.
REFERENCES: Robinson CM, Cairns DA: Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am 2004;86:778-782.
Deafenbaugh MK, Dugdale TW, Staeheli JW, et al: Nonoperative treatment of Neer type II distal clavicle fractures: A prospective study. Contemp Orthop 1990;20:405-413.

Question 34

A 47-year-old man sustained a degloving injury over the pretibial surface and anterior ankle region in a motor vehicle accident. After debridement and irrigation, there is inadequate tissue for closure of the exposed anterior tibial tendon and tibia. Prior to definitive soft-tissue coverage, management should consist of

Explanation

DISCUSSION: With soft-tissue loss, local or free flap coverage may be necessary to treat exposed tendon and bone. However, a vacuum-assisted closure device is a good temporizing dressing. It prevents external contamination, reduces edema around the wound, increases oxygen tension in the wound, and promotes the formation of granulation tissue. The use of this negative pressure device has been described in both acute traumatic and in chronic wound scenarios. If sufficient granulation tissue forms, closure may be by split graft, avoiding a more complex coverage procedure. Immediate skin grafting over the exposed anterior tibial tendon and tibia would have a low likelihood of success. Dressing changes with sulfasalazine may be beneficial in a burn wound to assist with removal of skin slough; however, in a granulating wound, the material may be toxic to early epithelialization. Xenograft is a foreign body and should not be applied to an acute contaminated open wound. Historically, a cross-leg flap was a treatment alternative for lower extremity soft-tissue loss; however, its current applications are extremely limited.
REFERENCES: Webb LX: New techniques in wound management: Vacuum assisted wound closure. J Am Acad Orthop Surg 2002;10:303-311.
Clare MP, Fitzgibbons TC, McMullen ST, et al: Experience with the vacuum assisted closure negative pressure technique in the treatment of non-healing diabetic and dysvascular wounds. Foot Ankle Int 2002;23:896-901.

Question 35

The humeral nonunion shown in Figure 27 is most likely to unite when using what method of treatment?

Explanation

DISCUSSION: The radiograph shows an atrophic nonunion of the humeral shaft. The management of humeral nonunions has been studied with compression plates and bone graft, as well as intramedullary nailing and bone graft. Compression plating with bone graft results in the highest rate of union. Compression plating by itself is not adequate, given the bone loss and lack of callous in this nonunion. Pulsed electromagnetic fields is a viable option for hypertrophic nonunions where there is inherent stability. Intramedullary nailing does not provide as much compression and stability as that achieved with compression plating.
REFERENCES: Pugh DM, McKee MD: Advances in the management of humeral nonunion.

J Am Acad Orthop Surg 2003;11:48-59.
McKee MD, Miranda MA, Riemer BL, et al: Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma 1996;10:492-499.

Question 36

An adult with a distal humeral fracture underwent open reduction and internal fixation. What is the most common postoperative complication?

Explanation

DISCUSSION: Most patients lose elbow range of motion after open reduction and internal fixation of a distal humeral fracture. Ulnar nerve dysfunction, nonunion, and infection all occur less commonly.
REFERENCES: Webb LX: Distal humerus fractures in adults. J Am Acad Orthop Surg 1996;4:336-344.
McKee MD, Wilson TL, Winston L, et al: Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82:1701-1707.

Question 37

The radiographs and CT scan seen in Figures 28a through 28d reveal what type of acetabular fracture pattern?

Explanation

DISCUSSION: The AP, obturator oblique, and iliac oblique views of the pelvis reveal a fracture that disrupts the iliopectineal and ilioischial lines, indicating a fracture that involves both anterior and posterior columns. However, it does not have the other features of anterior or posterior column fracture patterns. A displaced posterior wall fracture is also present, best seen on the obturator oblique view. The anterior to posterior directed fracture line on the CT scan indicates a transverse fracture; therefore, the patient has a transverse with posterior wall fracture pattern. A T-type fracture would be similar but would have a break into the obturator ring.
REFERENCES: Tile M: Describing the injury: Classification of acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 427-475.
Brandser E, Marsh JL: Acetabular fractures: Easier classification with a systematic approach. Am J Roentgenol 1998;171:1217-1228.

Question 38

A 26-year-old man sustained an isolated injury to his left hip joint in a motor vehicle accident. Closed reduction was performed, and the postreduction radiograph is shown in Figure 29. Management should now consist of

Explanation

DISCUSSION: The patient has a posterior fracture-dislocation of the hip and following reduction, an incarcerated fragment of bone resulted in an incongruent reduction. Whereas expedient removal of the fragment is required to limit articular cartilage damage, this situation is not an emergency and the procedure may be performed when the appropriate surgical team is available and the patient is stabilized. Skeletal traction through either the femur or tibia may relieve some pressure on the joint and prevent articular damage. Nonsurgical care for incarcerated fragments is contraindicated.
REFERENCES: Tile M, Olson SA: Decision making: Non operative and operative indications for acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum. Philadelphia, PA, Lippincott Williams and Wilkins, 2003, pp 496-532.
Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993, pp 337-339, p 507.

Question 39

A 35-year-old man is brought to the emergency department following a motorcycle accident. He is breathing spontaneously and has a systolic blood pressure of 80 mm Hg, a pulse rate of 120/min, and a temperature of 98.6° F (37° C). Examination suggests an unstable pelvic fracture; AP radiographs confirm an open book injury with vertical displacement on the left side. Ultrasound evaluation of the abdomen is negative. Despite administration of 4 L of normal saline solution, he still has a systolic pressure of 90 mm Hg and a pulse rate of 110. Urine output has been about 20 mL since arrival 35 minutes ago. What is the next best course of action?

Explanation

DISCUSSION: The patient is at risk for a pelvic vascular injury and major hemorrhage. This type of complication of pelvic trauma is highest in motorcyclists. Once it is recognized that the pelvic ring has opened, it is important to close that ring to tamponade any venous bleeding with a pelvic binder and to add a skeletal traction pin to the limb on the involved side. This will correct any translational displacement. The noninvasive pelvic binders or sheets are easy to apply and are very effective. They do not compromise future care and allow the surgeons access to the abdomen. External fixation or pelvic resuscitation clamps require a certain amount of skill to apply and are not always available. If the pelvic stabilization does not improve the hemodynamic parameters in 10 to 15 minutes, angiography is necessary.
REFERENCE: Mayo K, Kellam JK: Pelvic ring disruptions, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1052-1108.

Question 40

A healthy 25-year-old man sustains a grade IIIB open tibial fracture. Following appropriate debridement, irrigation, and stabilization with an external fixator, the soft-tissue injury is shown in Figure 30. What is the most appropriate definitive soft-tissue coverage procedure?

Explanation

DISCUSSION: This is a very large near circumferential defect with posterior as well as anterior skin and muscle injury. Bone is exposed. The posterior muscles cannot be rotated since they are part of the zone of injury. The bone and other poorly vascularized areas of this wound would not accept a skin graft. The best chance for limb salvage will be to obtain soft-tissue coverage with a free tissue transfer using the latissimus dorsi.
REFERENCES: Mathes SJ, Nahai F: Vascular anatomy of muscle: Classification and applications, in Mathes SJ, Nahai F (eds): Clinical Application for Muscle and Musculocutaneous Flaps. St Louis, MO, CV Mosby, 1982, p 20.
Bos GD, Buehler MJ: Lower-extremity local flaps. J Am Acad Orthop Surg 1994;2:342-351.

Question 41

A 25-year-old woman undergoes surgical treatment of a displaced proximal humeral fracture via a deltopectoral approach. At the first postoperative visit, she reports a tingling numbness along the anterolateral aspect of the forearm. What structure is most likely injured?

Explanation

DISCUSSION: Sensation along the anterolateral aspect of the forearm is supplied by the lateral antebrachial cutaneous nerve, the terminal branch of the musculocutaneous nerve. The musculocutaneous nerve can be injured by proximal humeral fractures or dislocations, and is also at risk during surgical exposure if excessive retraction is placed on the conjoint tendon. The musculocutaneous nerve enters the conjoint tendon 1 cm to 5 cm distal to the coracoid process.
REFERENCES: McIlveen SJ, Duralde XA, D’Alessandro DF, et al: Isolated nerve injuries about the shoulder. Clin Orthop 1994;306:54-63.
Warner JP: Frozen shoulder: Diagnosis and management. J Am Acad Orthop Surg

1997;5:130-140.

Question 42

A 7-year-old girl has pain and swelling of the right elbow after falling off her bicycle. Radiographs are shown in Figure 31. What is the most appropriate initial step in management?

Explanation

DISCUSSION: Lateral condylar fractures are challenging to treat because of late displacement and development of a nonunion that may lead to valgus instability, pain, or tardy ulnar nerve palsy. Fractures such as this one with more than 2 mm of displacement on any radiographic view are prone to nonunion and should be stabilized. Fractures with less than 2 mm of displacement usually are stable and may be treated nonsurgically. In these patients, careful follow-up is recommended within several days of casting to check for fracture displacement. Arthrography or MRI may be helpful in these minimally displaced fractures. Fractures with an intact articular cartilage surface, such as noted on these studies, are unlikely to displace further.
REFERENCES: Finnbogason T, Karlsson G, Lindberg L, et al: Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: A prospective radiographic investigation of fracture stability. J Pediatr Orthop 1995;15:422-425.
Attarian DE: Lateral condyle fractures: Missed diagnoses in pediatric elbow injuries. Mil Med 1990;155:433-434.
Flynn JC: Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-696.
Badelon O, Bensahel H, Mazda K, et al: Lateral humeral condylar fractures in children: A report of 47 cases. J Pediatr Orthop 1988;8:31-34.

Question 43

A 32-year-old man sustained a fracture of his upper arm in a motor vehicle accident. Radiographs are shown in Figure 32. Because of other associated injuries, surgical stabilization is chosen. What technique will result in the least complications and the best outcome?

Explanation

DISCUSSION: Most humeral fractures will heal with nonsurgical functional brace management. When the initial pain has subsided in a coaptation splint, the patient is converted to a functional brace and allowed to use the arm for activities. The fracture should heal within 6 weeks to 12 weeks with acceptable results. Surgery is indicated if there is vascular injury, open injury, floating elbow, chest injury, bilateral humeral fractures, or if a reduction cannot be obtained or maintained. The surgical treatment of choice is either antegrade reamed locked intramedullary nailing or plate osteosynthesis. Plate osteosynthesis appears to offer better results with respect to union, function, and risk of complications.
REFERENCES: Schemitsch EH, Bhandari M: Fractures of the humeral shaft, in Browner BD: Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1481-1511.
Chapman JR, Henley MB, Agel J: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166.

Question 44

A 56-year-old man sustained a nondisplaced extra-articular fracture of the proximal aspect of the third metatarsal after dropping a heavy object on his left foot. Management should consist of

Explanation

DISCUSSION: This injury pattern is one of a direct trauma to the mid aspect of the foot. Without additional forces involved, capsular ligamentous injury is not anticipated; therefore, the injury should be a stable pattern. Treatment should consist of protected weight bearing as tolerated in a walking boot or walking cast. Surgical intervention with open reduction and internal fixation, percutaneous pinning, or open reduction and internal fixation with primary tarsometatarsal joint fusion is not indicated with this pattern of injury. The use of external bone stimulation in this acute fracture setting is not indicated. With injuries to the midfoot area where the exact mechanism of injury is uncertain, there should be a high index of suspicion for an associated injury to the tarsometatarsal joint, and standing radiographs or stress radiographs should be obtained.
REFERENCES: Myerson MS: Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1265-1296.
Early JS: Fractures and dislocations of the midfoot and forefoot, in Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001,

pp 2181-2245.

Question 45

During a posterior approach to the glenoid with retraction as shown in Figure 33, care should be taken during superior retraction to avoid injury to which of the following structures?

Explanation

DISCUSSION: During a posterior approach to the shoulder for either a scapular fracture,

glenoid fracture, or posterior shoulder pathology, the interval between the teres minor and infraspinatus is split. Excessive superior retraction on the infraspinatus, or excessive dissection superomedially under the infraspinatus muscle and tendon can cause injury to the suprascapular nerve and/or artery. During dissection in this interval, the axillary artery and axillary nerve are well protected. A branch of the circumflex scapular artery ascends between the teres minor

and infraspinatus muscle, but it is at risk during dissection on the scapula in the mid portion of the interval and not during superior retraction. The profunda brachii artery is not present in

this interval.
REFERENCES: Jerosch JJ, Greig M, Peuker ET, et al: The posterior subdeltoid approach: A modified access to the posterior glenohumeral joint. J Shoulder Elbow Surg 2001;10:265-268.
Judet R: Surgical treatment of scapular fractures. Acta Orthop Belg 1964;30:673-678.
Kavanagh BF, Bradway JK, Cofield RH: Open reduction and internal fixation of displaced intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am 1993;75:479-484.

Question 46

A 42-year-old woman sustained a closed, displaced talar neck fracture in a motor vehicle accident. Which of the following is an avoidable complication of surgical treatment?

Explanation

DISCUSSION: Malunion of the talus is a devastating complication that leads to malpositioning of the foot and subsequent arthrosis of the subtalar joint complex. This is considered an avoidable complication in that accurate surgical reduction will minimize its development. Posttraumatic arthritis of the subtalar joint, osteonecrosis of the talus, posttraumatic arthritis of the ankle joint, and complex regional pain syndrome all may develop as a result of the initial traumatic event and may not be avoidable despite anatomic reduction.
REFERENCES: Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott, Williams and Wilkins, 2001, pp 2091-2132.
Daniels TR, Smith JW, Ross TI: Varus malalignment of the talar neck: Its affects on the position of the foot and on subtalar motion. J Bone Joint Surg Am 1996;78:1559-1567.

Question 47

Figures 34a through 34c show the radiographs of a 51-year-old woman who injured her elbow in a fall from standing height. Examination reveals that elbow range of motion is limited by pain only. Management should consist of

Explanation

DISCUSSION: The radiographs show a small minimally displaced radial head fracture that is amenable to nonsurgical management. Early range-of-motion exercises will best restore

function and minimize stiffness. A long arm cast for any length of time will result in severe elbow stiffness.
REFERENCES: Morrey BF: Radial head fracture, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 341-364.
Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.

Question 48

Figure 35 shows the radiograph of a 12-year-old boy who fell off a snowmobile and landed on his left shoulder. He has a closed injury. Management should consist of

Explanation

DISCUSSION: Proximal humeral fractures in children are classified as metaphyseal or Salter-Harris type I or II fractures, and most of these fractures are treated with closed methods. Eighty percent of the growth of the humerus comes from the proximal physis; therefore, tremendous remodeling potential is present. Indications for open reduction include open fractures or severely displaced fractures in adolescents with minimal growth remaining. Acceptable limits of reduction in adolescent proximal humeral fractures include bayonet apposition and angulation of less than 35°. Common blocks to reduction in adolescents include the biceps tendon and periosteum. For this fracture, use of a shoulder sling without reduction will lead to healing and an excellent result as the proximal humerus remodels.
REFERENCES: Kohler R, Trillaud JM: Fracture and fracture separation of the proximal humerus in children: Report of 136 cases. J Pediatr Orthop 1983;3:326-332.
Beaty JH: Fractures of the proximal humerus and shaft in children. Instr Course Lect 1992;41:369-372.
Dobbs MB, Luhmann SL, Gordon JE, et al: Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop 2003;23:208-215.
Beringer DC, Weiner DS, Noble JS, et al: Severely displaced proximal humeral epiphyseal fractures: A follow-up study. J Pediatr Orthop 1998;18:31-37.
Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus. J Pediatr Orthop B 1997;6:219-222.

Question 49

What is the most common complication requiring reoperation after dorsal plating for a distal radius fracture?

Explanation

DISCUSSION: The most common complication of dorsal plating is extensor tenosynovitis, which often causes pain and is a frequent reason for hardware removal. Other less frequent complications include loss of reduction and extensor tendon ruptures, with flexor tendon ruptures occuring to an even lesser degree.
REFERENCES: Rozental TD, Beredjiklian PK, Bozentka DJ: Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am 2003;85:1956-1960.
Kambouroglou GK, Axelrod TS: Complications of the AO/ASIF titanium distal radius plate system (pi plate) in internal fixation of the distal radius: A brief report. J Hand Surg Am 1998;23:737-741.

Question 50

Figures 36a and 36b show the radiographs of a 48-year-old woman who smokes cigarettes and sustained a segmental femoral shaft fracture in a motor vehicle accident 9 months ago. Initial management consisted of stabilization with a reamed statically locked intramedullary nail. She now reports lower leg pain that increases with activity. In addition to advising the patient to quit smoking, management should include

Explanation

DISCUSSION: The patient has an oligotrophic nonunion of the distal femoral fracture. Although the proximal fracture appears incompletely united, it was stable at exchange nailing. The treatment of choice is exchange reamed nailing to at least 2 mm above the nail in place. Bone grafting is debatable. Recent studies have shown a 70% to 75% success rate with exchange nailing only, so in nonhypertrophic nonunions, bone grafting can be considered. Nonsurgical management consisting of observation or external stimulation runs the risk of implant failure. Plate fixation is acceptable but is considered a second choice because of the need to consider stabilization of the proximal fracture until union is achieved. Also, plate fixation definitely requires bone grafting.
REFERENCES: Webb LX, Winquist RA, Hansen ST: Intramedullary nailing and reaming for delayed union or nonunion of the femoral shaft: A report of 105 consecutive cases. Clin Orthop 1986;212:133-141.
Weresh MJ, Hakanson R, Stover MD, et al: Failure of exchange reamed intramedullary nailing for ununited femoral shaft fractures. J Orthop Trauma 2000;14:335-338.
Hak DG, Lee SS, Goulet JA: Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma 2000;14:178-182.

Question 51

A 45-year-old man falls on an outstretched hand and sustains a terrible triad injury of the elbow. Intraoperatively, after fixation of the radial head and repair of the lateral ulnar collateral ligament (LUCL), the elbow remains unstable in extension. What is the most appropriate next step?

Explanation

In a terrible triad injury, the coronoid fracture should be addressed if the elbow remains unstable after radial head fixation and LUCL repair. The coronoid is a primary restraint to posterior translation of the ulna, and stabilizing it restores the anterior buttress.

Question 52

A 30-year-old sustained a Hawkins Type III talar neck fracture 8 weeks ago, treated with ORIF. A subchondral radiolucent band is seen on the dome of the talus on an AP ankle radiograph. What does this radiographic finding indicate?

Explanation

The subchondral radiolucent band is known as Hawkins sign. It represents subchondral atrophy secondary to hyperemia, indicating that the talar body has an intact vascular supply and avascular necrosis is unlikely.

Question 53

A 25-year-old motorcyclist sustains a severely comminuted open tibial shaft fracture with a 12-cm soft-tissue defect and exposed bone after extensive debridement. Pulses are symmetric to the contralateral limb. According to the Godina principles, to optimize outcomes, soft-tissue coverage with a free flap should ideally be performed within what timeframe?

Explanation

Godina originally described that early free flap coverage within 72 hours for severe open tibial fractures significantly reduces flap failure and infection rates. Modern literature supports coverage as early as safely possible, making 72 hours the best classical and board-tested answer.

Question 54

A 68-year-old woman with osteopenia falls and sustains a comminuted, displaced intra-articular distal humerus fracture. Due to severe comminution and poor bone quality, total elbow arthroplasty (TEA) is planned. Which of the following is a strict contraindication to acute TEA in this setting?

Explanation

Active joint infection is an absolute contraindication to any total joint arthroplasty, including the elbow. Triceps dysfunction is a relative contraindication or requires a triceps-sparing approach, but active infection precludes immediate arthroplasty entirely.

Question 55

A 22-year-old football player sustains a twisting injury to his midfoot. Weight-bearing radiographs reveal a 3 mm widening between the bases of the first and second metatarsals, with a small avulsion fracture off the base of the second metatarsal. What is the most appropriate management for this athlete?

Explanation

This patient has a displaced Lisfranc injury with a classic fleck sign indicating avulsion of the Lisfranc ligament. In competitive athletes with displaced injuries (>2 mm diastasis), operative stabilization via ORIF or primary arthrodesis is required to restore stable midfoot anatomy.

Question 56

A 35-year-old multitrauma patient with bilateral femur fractures arrives at the trauma bay. Which of the following physiologic parameters is the strongest indication to proceed with damage control orthopedics (external fixation) rather than early total care (intramedullary nailing)?

Explanation

A base deficit worse than -6 mEq/L or a lactate > 2.5 mmol/L indicates inadequate tissue perfusion and physiologic exhaustion, making the patient 'borderline' or 'unstable'. In such scenarios, damage control orthopedics is preferred to avoid the 'second hit' of intramedullary nailing.

Question 57

What is the recommended sequence of surgical reconstruction for a "terrible triad" injury of the elbow?

Explanation

The standard surgical sequence for a terrible triad injury of the elbow (radial head fracture, coronoid fracture, and elbow dislocation) is fixation of the coronoid, followed by the radial head, and finally repair of the lateral collateral ligament (LCL).

Question 58

A 25-year-old athlete presents with midfoot pain after an axial load to a plantarflexed foot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. The primary ligament injured in this condition connects which two structures?

Explanation

The Lisfranc ligament is a critical interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is essential for the stability of the tarsometatarsal joint complex.

Question 59

According to the Lower Extremity Assessment Project (LEAP) study, which of the following statements regarding severe lower extremity trauma is most accurate?

Explanation

The LEAP study demonstrated that functional outcomes at two years are similar between patients who undergo limb salvage and those who undergo amputation. Initial absence of plantar sensation was found not to be a reliable predictor of long-term functional outcome.

Question 60

A 40-year-old female presents with a displaced fracture of the capitellum that includes the lateral trochlear ridge. According to the Bryan and Morrey classification, what type of fracture is this, and what is the preferred treatment?

Explanation

A Type IV Bryan and Morrey capitellum fracture involves the capitellum and extends medially to include the lateral trochlear ridge. Open reduction and internal fixation is indicated to restore joint congruity and elbow stability.

Question 61

Six weeks following open reduction and internal fixation of a Hawkins Type II talar neck fracture, an anteroposterior radiograph of the ankle reveals subchondral radiolucency in the talar dome. This radiographic finding indicates which of the following?

Explanation

The presence of subchondral radiolucency in the talar dome at 6 to 8 weeks post-injury is known as the Hawkins sign. It represents subchondral osteopenia secondary to hyperemia, indicating intact vascularity and a low risk of avascular necrosis.

Question 62

A 28-year-old male sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III) after a fall from a height. Which of the following fixation constructs provides the most biomechanical stability for this specific fracture pattern?

Explanation

Pauwels type III femoral neck fractures have a vertical orientation and high shear forces. A fixed-angle device, such as a sliding hip screw, provides superior biomechanical stability compared to parallel cancellous screws alone in these high-shear patterns.

Question 63

During an olecranon osteotomy approach for open reduction and internal fixation of an intra-articular distal humerus fracture, what is the optimal shape of the osteotomy to maximize stability upon repair?

Explanation

A chevron (V-shaped) osteotomy with the apex pointing distally is preferred because it provides excellent inherent rotational and translational stability when repaired. This shape maximizes the bony contact area to promote healing.

Question 64

A 35-year-old roofer falls and sustains a displaced intra-articular calcaneus fracture. An extensile lateral approach is planned. Which of the following structures is most at risk during the inferior limb of the incision?

Explanation

The sural nerve crosses the lateral aspect of the hindfoot and is at significant risk of injury during the inferior limb of the extensile lateral approach to the calcaneus. Careful full-thickness flap elevation is critical to protect it.

Question 65

A 42-year-old male arrives in the trauma bay with an APC-III pelvic ring injury and a systolic blood pressure of 75 mm Hg. A pelvic binder is applied. What is the correct anatomical placement for the pelvic binder to effectively reduce pelvic volume?

Explanation

To effectively reduce pelvic volume and stabilize the pelvic ring in an anteroposterior compression (APC) injury, a pelvic binder or sheet must be centered at the level of the greater trochanters. Placing it over the iliac crests is ineffective and can exacerbate the deformity.

Question 66

A 22-year-old collegiate basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. He is treated with intramedullary screw fixation. This specific fracture location is prone to nonunion primarily due to which of the following vascular anatomical features?

Explanation

A true Jones fracture occurs at the metaphyseal-diaphyseal junction of the fifth metatarsal. This region is a vascular "watershed" area with limited blood supply, leading to a higher risk of delayed union or nonunion.

Question 67

A 38-year-old female falls on an outstretched hand and sustains a comminuted radial head fracture. On examination, she complains of severe wrist pain and has tenderness over the distal radioulnar joint (DRUJ). Which of the following treatments is contraindicated?

Explanation

The patient has an Essex-Lopresti injury, characterized by a radial head fracture, interosseous membrane disruption, and DRUJ dislocation. Radial head excision alone is contraindicated as it will lead to proximal migration of the radius and chronic wrist pain.

Question 68

A 25-year-old male presents with a closed tibial shaft fracture and complains of pain out of proportion to his injury. His blood pressure is 110/70 mm Hg. Compartment pressure measurements reveal an anterior compartment pressure of 35 mm Hg. Which of the following criteria best indicates the need for emergent fasciotomy?

Explanation

The threshold for emergent fasciotomy in compartment syndrome is typically a delta pressure (diastolic blood pressure minus intracompartmental pressure) of less than 30 mm Hg. This is more reliable than absolute pressure measurements alone.

Question 69

A 55-year-old patient with long-standing diabetes presents with a swollen, warm, and erythematous foot. Radiographs reveal fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?

Explanation

Eichenholtz Stage 1 (Fragmentation) is characterized clinically by a warm, swollen, erythematous foot and radiographically by joint subluxation, bony fragmentation, and debris. Stage 2 shows coalescence with absorption of debris, and Stage 3 shows bony remodeling.

Question 70

A 6-year-old boy falls from monkey bars and sustains a proximal third ulnar shaft fracture with an associated anterior dislocation of the radial head. According to the Bado classification, what type of Monteggia lesion is this?

Explanation

A Bado Type I Monteggia fracture-dislocation involves a fracture of the proximal or middle third of the ulna with an anterior dislocation of the radial head. It is the most common type in the pediatric population.

Question 71

A 24-year-old male sustains a low-velocity gunshot wound to the thigh resulting in a comminuted midshaft femur fracture. The bullet passed cleanly through the soft tissues without hitting major neurovascular structures. What is the most appropriate management?

Explanation

Low-velocity gunshot wounds resulting in femur fractures without major neurovascular compromise or massive soft tissue destruction can typically be managed safely with local wound care, tetanus prophylaxis, short-course antibiotics, and standard intramedullary nailing.

Question 72

A professional football player sustains a hyperdorsiflexion injury to his first metatarsophalangeal (MTP) joint, resulting in a tear of the plantar plate, commonly referred to as "turf toe." What is the primary biomechanical role of the sesamoids in the first MTP joint?

Explanation

The sesamoids are embedded within the flexor hallucis brevis tendons. They function to absorb weight-bearing forces, protect the flexor hallucis longus tendon, and increase the mechanical advantage of the intrinsic flexor musculature.

Question 73

A 45-year-old man falls on an outstretched hand and sustains a 'terrible triad' injury of the elbow. He undergoes operative management. To restore elbow stability, what is the most widely accepted sequence of surgical reconstruction for this specific injury pattern?

Explanation

The standard surgical sequence for a terrible triad injury is fixation of the coronoid first, followed by repair or replacement of the radial head, and finally repair of the lateral collateral ligament. Medial collateral ligament repair or hinged external fixation is only added if the elbow remains unstable after these steps.

Question 74

A 25-year-old athlete complains of midfoot pain after a forced plantarflexion injury. A weight-bearing radiograph demonstrates 2 mm of widening between the first and second metatarsal bases and a 'fleck sign'. Which of the following ligaments is primarily disrupted?

Explanation

The 'fleck sign' represents an avulsion fracture at the attachment of the Lisfranc ligament. The true Lisfranc ligament is the strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal.

Question 75

A 30-year-old male sustains a high-energy Pauwels type III femoral neck fracture in a motor vehicle collision. To biomechanically optimize fixation and minimize the high shear forces that typically lead to varus collapse, which construct is most appropriate?

Explanation

Pauwels type III fractures are highly vertical and subjected to significant shear forces, making them prone to varus collapse. A fixed-angle device such as a sliding hip screw (often supplemented with a derotational screw) provides superior biomechanical stability against vertical shear compared to multiple cancellous screws.

Question 76

A 40-year-old roofer falls from a ladder and sustains an intra-articular calcaneus fracture. Preoperative radiographs reveal a Bohler's angle of 5 degrees. What is the primary functional purpose of restoring Bohler's angle during surgical fixation?

Explanation

Restoring Bohler's angle correlates directly with restoring the height of the calcaneus and the normal length-tension relationship of the Achilles tendon. This is critical for recovering the plantarflexion lever arm and normalizing gait mechanics.

Question 77

A 35-year-old female presents with a highly comminuted distal humerus fracture after a fall. Imaging identifies a type IV capitellum fracture according to the McKee modification of the Bryan and Morrey classification. What specific finding defines this fracture type?

Explanation

A Type IV capitellum fracture involves a coronal shear fracture that propagates medially to include the capitellum and a large portion of the trochlea. This often produces the classic 'double-arc sign' on a lateral radiograph.

Question 78

A 28-year-old male construction worker is crushed by heavy equipment, sustaining an anteroposterior compression (APC) type III pelvic ring injury. Examination reveals blood at the urethral meatus and a high-riding prostate on digital rectal exam. What is the most appropriate next step in his urologic evaluation?

Explanation

Blood at the meatus and a high-riding prostate strongly suggest a urethral disruption, which is highly associated with pelvic ring disruptions. A retrograde urethrogram (RUG) must be performed prior to the insertion of a Foley catheter to prevent converting a partial tear into a complete transection.

Question 79

A 22-year-old snowboarder sustains a forced dorsiflexion injury of the ankle, resulting in a Hawkins type III talar neck fracture. According to the Hawkins classification, this fracture pattern involves subluxation or dislocation of which specific joints?

Explanation

In the Hawkins classification for talar neck fractures, Type I is nondisplaced, Type II involves subtalar subluxation/dislocation, Type III involves subtalar and tibiotalar subluxation/dislocation, and Type IV (Canale modification) involves subtalar, tibiotalar, and talonavicular disruption.

Question 80

A 5-year-old boy sustains a Gartland type III supracondylar humerus fracture. On initial presentation, the radial pulse is absent, but the hand is pink and warm. Following closed reduction and percutaneous pinning, the hand remains pink and well-perfused, but the pulse is still absent on Doppler. What is the most appropriate next step?

Explanation

A 'pulseless, pink' hand after anatomic reduction of a pediatric supracondylar humerus fracture indicates adequate collateral circulation. Current guidelines recommend close inpatient observation rather than immediate vascular exploration, as the pulse typically returns over hours to days.

Question 81

A 45-year-old agricultural worker sustains a Gustilo-Anderson IIIB open tibial shaft fracture deeply contaminated with soil and manure. In addition to immediate tetanus prophylaxis and aggressive surgical debridement, which antibiotic regimen is most appropriate based on current trauma guidelines?

Explanation

For severe open fractures (Type III), a first-generation cephalosporin and an aminoglycoside provide necessary gram-positive and gram-negative coverage. In the presence of heavy agricultural or fecal contamination, high-dose penicillin must be added to cover Clostridium species to prevent gas gangrene.

Question 82

A 26-year-old male complains of severe, escalating leg pain 12 hours after an intramedullary nailing of a tibia fracture. He has extreme pain with passive toe stretch. Compartment pressures are measured. Which threshold is currently widely accepted as the absolute indication for four-compartment fasciotomies?

Explanation

A Delta P (diastolic blood pressure minus the measured compartment pressure) of less than 30 mm Hg is widely accepted as the most reliable objective threshold for diagnosing acute compartment syndrome and mandates emergent fasciotomy.

Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

Orthopedic Board Review MCQs: Elbow, Foot, Trauma & Fracture | Part 23

Key Takeaway

Orthopedic Board Review MCQs: Elbow, Foot, Trauma & Fracture | Part 23

Chapter Index