Orthopedic Ob Trauma C Review | Dr Hutaif Trauma & Frac -...

Figure B demonstrates an isolated medial femoral condyle fracture. Lateral locked plating is not an appropriate technique for this fracture.
The fracture shown in Figure B is an AO B type (partial articular fracture). This fracture is best treated with open reduction internal fixation through a medial approach, with lag screw and buttress plate fixation.
Figures A, C, D and E show supracondylar distal femur fractures that can be treated with ORIF with a fixed-angle device such as lateral locked plating.
Incorrect Answers:

. Fixed angle fixation is appropriate for comminuted extra-articular distal femur fractures.
Answers 3, 4, 5. ixed angle fixation is appropriate for comminuted intraarticular distal femur fractures. Non-locked plating for type C (complete articular) distal femur fractures has been associated with varus malalignment.

A 70-year-old female with a history of poorly controlled diabetes mellitus presents with purulent ulcers along the plantar aspect of her right forefoot and exposed metatarsal bone. She elects to undergo an amputation. She is insensate to the midfoot bilaterally. Her ankle-brachial index (ABI) for her right posterior tibial artery is 0.4. Further preoperative evaluation demonstrates a transcutaneous oxygen pressure of 45 and an albumin of 3.4. Which of the following would be a contraindication to performing a Syme amputation (ankle disarticulation) in this patient?

1) Albumin of 3.4

2) Active osteomyelitis

3) ABI of 0.4 for the posterior tibial artery

4) Transcutaneous oxygen pressure of 45

5) Peripheral neuropathy

A Syme amputation (ankle disarticulation) is a function-preserving amputation option that allows for terminal weight bearing, however strict criteria must be met for a patient to undergo successful Syme amputation. An ankle-brachial index (ABI) less than 0.5 for the posterior tibial artery in a patient with diabetes would be a contraindication for this procedure as success is dependent on the vascular supply of posterior tibial artery to the plantar flap and heel pad.
Pinzur et al retrospectively reviewed their results when performing a single-stage Syme ankle disarticulation in patients with diabetes either for peripheral neuropathy or infection. Patients with ABIs less than 0.5 for the posterior tibial artery had significantly decreased healing rates and smokers had a three-fold increased risk of postoperative infection.
Incorrect Answers:
Answer 1: Albumin of 3.4 indicates adequate preoperative nutrition. Albumin of
2.0 or less would be concerning for increased wound healing risk.
Answer 2: Osteomyelitis was the indication for amputation in a number of diabetic patients in the referenced study, and should not preclude Syme amputation unless the hindfoot and/or distal tibia is involved
Answer 4: Transcutaneous 02 pressure of 45 signifies adequate oxygenation and vascularity. Less than 30 is generally considered a cutoff for adequate vascularity.
Answer 5: Peripheral neuropathy with recurrent ulceration was an indication for amputation in the referenced study.

A 35-year-old-male sustains the fracture seen in Figure A. Which of the following reduction forces must be applied to the proximal fragment to correct the deformity commonly seen in these fractures?
1) Adduction and extension

2) Abduction and extension

3) Adduction and flexion

4) Abduction and flexion

5) External rotation

Figure A demonstrates a displaced subtrochanteric femur fracture with an intact lesser trochanter. The pull of iliopsoas on the lesser trochanter as well as the intact external rotators and gluteal musculature results in the the proximal fragment being in a flexed and externally rotated or abducted position (the most common post operative deformity). Reduction manuevers must be biologically friendly but also counteract the flexion/abduction moment. Lundy's review article discusses evaluation and treatment of subtrochanteric fractures. The review article details the various implants often used which include 95 degrees plates, femoral reconstruction nails, or trochanteric femoral nails with interlocking options. Lundy's article discourages the use of the 135 degree screw and side plate combo due to high failure rates in these fracture patterns. Bedi et al also review treatment of these fractures and discuss common
problems of malunion, nonunion, and implant failure. The article reviews reduction techniques that are soft tissue friendly, as well as the use of appropriate implants in these fracture types.

A 12-year-old male sustains an ulnar fracture with an associated posterior-lateral radial head dislocation. After undergoing closed reduction, the radiocapitellar joint is noted to remain non-concentric. What is the most likely finding?

1) Lateral ulnar collateral ligament disruption

2) Anterior band of the medial collateral disruption

3) Posterior band of the medial collateral ligament disruption

4) Annular ligament interposition

5) Anconeus muscle interposition

In pediatric Monteggia fractures the annular ligament is commonly interposed in the radiocapitellar joint.
Bado initially described and classified Monteggia fractures. The most common injury pattern is an extension type 1 with anterior radial head dislocation and apex anterior ulnar shaft fracture. The apex of the ulna fracture determines the direction of the radial head subluxation or dislocation. Adults typically require ORIF of the ulna. These fractures in children are often treated non-operatively with closed reduction if the ulna fracture is transverse and stable. Type III is the one most commonly associated with irreducibility of the radial head because of interposition of the annular ligament. The incidence of posterior interosseous nerve injury is high with this lesion. The nerve deficit usually completely resolves rapidly and spontaneously.
Tan et al reviewed their treatment of 35 children with Type I and Type III Monteggia fractures. All radial heads were explored and the interposed annular ligament was stretched out of the joint space. They noted that none of the patients had any recurrent dislocation or subluxation.
Ring et al in their review stress the importance of an anatomic reduction of the ulna to restore the reduction of the radial head.

All of the following are factors associated with transfer of patients to Level 1 trauma centers EXCEPT:

1) Male

2) Medicaid insurance

3) Injury severity score of 36

4) Caucasian race

5) One or more comorbidity

Caucasian race has not been found to be a predictor for transfer to a Level 1 trauma center.
The retrospective case-control study by Koval et al found that African-American race, presence of medical comorbidity, medicaid insurance, and male gender are predictors for transfer of patients to a trauma center that have ISS scores less than 9.
The article by Nathens et al found that lack of insurance was an independent predictor for transfer to a trauma center after adjusting for differences in injury severity. An injury severity score of 36 represents a patient that has sustained life-threatening polytrauma and should be transferred to a Level 1 trauma center.

A 34-year-old male falls from a roof and sustains a right elbow dislocation that is closed reduced in the emergency room. An AP radiograph is shown in Figure A. This injury pattern is at highest risk for which of the following?
1) Anterior interosseous nerve palsy

2) Varus posteromedial rotatory instability

3) Posterior interosseous nerve palsy

4) Valgus posterolateral rotatory instability

5) Elbow instability when pushing oneself up from a seated position in a chair

Anteromedial coronoid facet fracture and LCL injury following an elbow dislocation is commonly associated with varus posteromedial rotatory instability. Varus and posteromedial rotation force on the forearm results in rupture of the LCL from its humeral origin. As the LCL ruptures, the medial coronoid process is fractured as it impacts against and under the medial trochlea. Fracture involvement of the sublime tubercle, where the MCL attaches, can lead to more instability. Ulnar neuropathy can be seen following this injury pattern but AIN and PIN nerve palsy do not commonly characterize this injury pattern.
The review article by O'Driscoll highlights key points in diagnosis and management of capitellum, distal humerus, coronoid, and terrible triad injuries.
The article by Doornberg and Ring is a Level 4 study of 18 patients that sustained varus posteromedial rotational injuries resulting in anteromedial facet coronoid fractures. They found that lack of fixation at injury or malunion of the anteromedial facet were significant predictors of suboptimal functional outcome and development of arthrosis.
The anteromedial facet is highlighted in yellow as displayed in Illustration A. Illustration B depicts the lateral collateral ligament injury also evident during
varus stress fluroscopic examination, due to tension failure of the LCL off its humeral origin during the various mechanism.

Which of the following factors is most associated with malrotation during antegrade or retrograde femoral nailing?

1) Surgeon experience

2) Level of primary fracture line

3) Use of a piriformis starting portal

4) Fracture comminution

5) Closed reduction technique

Femoral malrotation after intramedullary nailing is unfortunately a possibility with either antegrade or retrograde nailing techniques. Malrotation and iatrogenic length changes are most common when comminution is present, as cortical reads are inherently limited.
Hufner et al report that malrotation (internal or external >15 degrees) was seen in 22% of their patients via CT scan after intramedullary nailing. There was a significant difference depending on the time of surgery, with significantly more malrotation during the night shift. Increased fracture comminution also significantly increased malrotation rates.
Incorrect Answers:
1,2,3,5: No significant increases were seen with the other answers listed above.

What is the most common type of malalignment after intramedullary nailing of distal 1/3 extra-articular tibia fractures using a infrapatellar approach when compared with plating?

1) Varus

2) Valgus

3) Translational

4) Shortening

5) Apex anterior

The most common type of malalignment after intramedullary nailing of distal 1/3 extra-articular tibia fractures using an infrapatellar approach when compared with plating is valgus malalignment.
Fixation of distal one-third tibial shaft fractures can be successfully treated with either intramedullary nailing or plating. The literature describes advantages and disadvantages to both approaches, however intramedullary nailing has been shown to lead to increased rates of valgus malunion. Recent studies have shown that using a suprapatellar approach may decrease the incidence of valgus malalignement.
Vallier et al performed a randomized prospective study to compare plate and nail stabilization for distal tibia shaft fractures by assessing complications and secondary procedures. One-hundred and four patients were randomized to either reamed intramedullary nailing, or medial distal tibia plate fixation.
Primary angular malalignment was identified in 17 patients (16.3%). This included four patients treated with tibial plating (8.3%) and 13 patients treated with nails (23%, P = 0.02). Eight of these (7.7% of all patients) had malalignment between 6° and 10° of angulation. Valgus was the most common
angular deformity, accounting for 70% of angular deformity cases.
Avilucea et al. looked at the immediate postoperative alignment of distal tibia fractures (within 5 cm of the tibial plafond) treated with suprapatellar intramedullary nail (IMN) insertion compared with the infrapatellar technique. They found primary angular malalignment of ≥5 degrees occurred in 35 (26.1%) patients with infrapatellar IMN insertion and in 5 (3.8%) patients who underwent suprapatellar IMN insertion. They conclude suprapatellar IMN technique results in a significantly lower rate of malalignment compared with the infrapatellar IMN technique.
Incorrect Answers:
Answer 1, 3,4, and 5: Vallier et al. found that valgus was the most common angular deformity.

A 33-year-old secretary presents three months after a motor vehicle collision with a mild asymmetry to her sternal area and difficulty swallowing. She denies any complaints of respiratory distress or upper extremity paresthesias. Her upper extremity neurovascular exam shows no deficits. A 3-D computed tomography image is shown in Figure A. What is the most appropriate treatment for this patient?
1) Nonoperative treatment with a sling and unrestricted activity in 3 months

2) Open reduction in the operating room with thoracic surgery back-up

3) Closed reduction in the office with local anesthetic

4) Closed reduction in the operating room with thoracic surgery back-up

5) Nonoperative treatment with immediate unrestricted active range of motion of the shoulder

The clinical presentation is consistent with a chronic sternoclavicular dislocation, which is defined as being greater than 3 weeks old. The 3D CT image shows posterior displacement of the medial clavicle relative to the sternum. Chronic anterior dislocations are recommended to be treated conservatively, especially if not symptomatic, but as this is a posterior dislocations, current recommendations are to treat them with reduction in order to avoid delayed issues with the medial clavicle interacting with the mediastinal structures.
The review article by Wirth and Rockwood notes the following complications with posterior dislocation: respiratory distress, venous congestion or arterial insufficiency, brachial plexus compression, and myocardial conduction abnormalities. They recommend reconstruction of the costoclavicular ligaments with resection of the medial claviclar head as needed for unstable or symptomatic injuries.

A 35 year-old female presents after prolonged extrication from a motor vehicle collision complaining of severe pelvic pain. Physical examination reveals diminished perianal sensation. She is otherwise neurologically intact. Figures A through D are radiographs and representative CT cuts of her injury. Which of the following nerve roots has likely been injured by the acute trauma?
1) L3

2) L4

3) L5

4) S1

5) S2

The clinical scenario is consistent with a high-energy sacral fracture. The radiographs in figures A and B demonstrate a sacral fracture with posterior displacement of the right hemipelvis seen on the inlet view. Figures C and D are axial and sagittal CT images which show a displaced fracture of the right
hemisacrum along with a transvere fracture component through the S3 body . Diminished perianal sensation is concerning for an S2 nerve root injury.
Mehta et al reviewed the current management of sacral fractures. They note that the S1 and S2 nerve roots are more likely to be injured with sacral fractures as they occupy 1/3 to 1/4 of the neural foramina, as opposed to S3 and S4, which only occupy 1/6 of the neural foramina.
Robles reviewed the current literature to ascertain principles of evaluation and treatment for transverse sacral fractures. The author notes that injury to nerve roots S2 to S5 is manifested by impairment of urinary and anal continence and sexual function.
The first illustration demonstrates the sacral nerve root dermatomal distribution. The second shows a pelvic cadaver dissection demonstrating the sacral nerve roots as they exit the foramina.

A 44-year-old male is struck by a vehicle while riding his bike. In the trauma bay, he complains of right shoulder pain . Upper extremity physical exam reveals no neurologic deficits, and an initial radiograph of the shoulder is shown in Figure A. A CT scan of the shoulder shows 1cm of posterior displacement of the tuberosity fragment. Which of the following is true regarding this injury?
1) It is usually associated with a posterior shoulder dislocation

2) The subscapularis muscle is the main deforming force

3) Non-operative treatment of this displaced injury results in good long term shoulder function

4) Open reduction and internal fixation is the treatment of choice

5) Associated rotator cuff tears are uncommon

The radiograph in Figure A demonstrates a posteriorly displaced greater tuberosity fracture. These injuries are often associated with anterior shoulder dislocations, and concomitant rotator cuff tears. The subscapularis attaches to the lesser tuberosity, and is not a deforming force. Open reduction and internal fixation (ORIF) is usually the treatment of choice, and it is well accepted that more than 5mm of displacement is an indication for surgery in patients that require overhead function of the arm.
Flatow et al evaluated 12 patients who were an average of five years status post ORIF of displaced greater tuberosity fractures. All fractures healed without postoperative displacement. Six patients had an excellent result and six had a good result.
Platzer et al retrospectively analyzed functional and radiographic results of 52 patients with operative treatment of displaced greater tuberosity fractures at an average time of 5.5 years from surgery compared to 9 patients with equivalent injuries treated non-operatively. Evaluation of the results of the surgical study group and the nonoperative control group, patients with reduction and fixat ion of greater tuberosity fractures had significantly better
results on shoulder function than did those with conservative treatment.

Which of the following is a recognized predictor of mortality after hip fracture?

1) American Society of Anesthesiologist (ASA) classification

2) Post-operative weight bearing status

3) Fracture comminution

4) Fixation device used

5) Type of anesthetic used

American Society of Anesthesiologist (ASA) classification is predictive of post-surgical mortality in hip fracture patients.
The ASA classification (detailed in Illustration A) was initially developed in 1963 and has been shown to be predictive of post-surgical mortality in hip fracture patients. Basic categories are as follows: 1= normal, healthy; 2= mild systemic disease; 3= severe systemic disease, not incapacitating; 4= severe incapacitating systemic condition, constant threat to life; 5= moribund patient; 6 = brain dead, organs being donated.
Richmond et al. looked at 836 patients treated for a hip fracture and found that this injury is not associated with significant excess mortality among patients older than age 85. However, in younger patients, those with ASA classifications of 3 or 4 have significant excess mortality following hip fracture that persists up to 2 years after injury.
Holt et al. investigated the relationship between a number of patient and management variables and mortality after surgery for fracture of the hip. Data relating to 18,817 patients were obtained from the Scottish Hip Fracture Audit database. They found that type of anesthetic did not adversely affect the 30 or 120 day mortality rate.

A 25-year-old male sustains an ankle fracture dislocation and undergoes open reduction and internal fixation. He returns to clinic five months following surgery complaining of continued ankle pain and instability with weight bearing. His immediate post-operative AP radiograph is seen in Figure A. Which of the following could have prevented this patient from developing persistent pain?
1) Deep deltoid ligament repair

2) Quadricortical syndesmotic screw fixation

3) Restoration of fibular length and rotation

4) Lateral collateral ligament complex repair

5) Use of two syndesmotic screws

The patient presents with continued ankle pain and instability following open reduction and internal fixation. The radiograph in figure A demonstrates inadequate restoration of fibular length, likely leading to continued tibiotalar instability.
Illustration A demonstrates fibular malreduction with dislocation of the fibula anterior to the tibial incisura. Illustration B shows a comminuted fibula fracture along with a measurement of length from an intact fibula. The arc from the lateral process of the talus to the peroneal groove of the distal fibula is known as the "dime" sign and should remain unbroken if fibular length has been restored. Illustration C demonstrates the use of a push-pull screw and lamina spreader to regain length intraoperatively for a comminuted fibula fracture.
Chu and Weiner review management of malunions of the distal fibula. The authors state that restoration of fibular length, alignment and rotation leads to reduction of the talus, provides a buttress to talar motion in the setting of an incompetent deltoid, and allows the syndesmotic ligaments to heal at the appropriate tension.
Wikeroy et al conducted a study of patients from a prior prospective, randomized control trial comparing different methods of syndesmotic fixation. There was no significant difference in outcomes between tricortical or quadricortical 3.5mm screw fixation, however worse outcomes were seen with associated posterior malleolar fractures, obesity, a difference in sydesmotic width of 1.5mm or greater, and a CT confirmed tibio-fibular synostosis.
Sinha et al present a simple technique for fibular lengthening in the setting of distal fibula malunion. They found high union rates and improved AOFAS scores at short-term follow up with their technique.

A 34-year-old male presents with the right posterior wall acetabular fracture shown in Figure A. What is the most accurate method to test for hip stability in this patient?
1) The Keith method

2) The Moed method

3) The Calkins method

4) Dynamic fluoroscopic examination of the hip under anesthesia

5) A history of associated hip dislocation

Dynamic fluoroscopic examination of the affected hip under anesthesia is considered the best method of predicting hip stability. Fragment size, which can be calculated using the Keith, Moed, or Calkins method, can be used to predict hip stability radiographically, however they are not as accurate. In general it is thought that posterior wall fractures involving less than 20% of the posterior wall are stable, whereas those involving greater than 40%-50% are unstable. Unfortunately, this leaves an indeterminent zone (20-40%) which does not provide guidance in treatment.
Moed et al retrospectively reviewed 33 patients with posterior wall fractures who underwent dynamic fluoroscopic stress testing and compared the results of this testing to the Moed, Calkins, and Keith method of hip stability prediction. They found that the Moed method is the only reliable technique that is predictive of hip stability for small fracture fragments while also being predictive of instability for large fracture fragments. However, they also stated that there remain a substantial number of fractures involving 20% or more of the posterior wall that are both stable and unstable by examination under anesthesia. Therefore, they recommend dynamic fluoroscopic examination for assessment of hip stability in the presence of a posterior wall fracture.
Moed et al in their second paper reviewed all patients with less than a ≤50% of the acetabular wall fracture, adequate imaging, and documented EUA results.
The group looked at multiple variables including fracture fragment size,
superior exit point of the fracture, center-edge angle, acetabular index, Tönnis angle, lateralized head sign, crossover sign, posterior wall sign, ischial spine sign, and hip version. Their conclusion was that no one variable was able to predict stability or instability and they continue to recommend EUA.
Tornetta et al conducted a study in which dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management to determine subtle signs of instability. Of the 41 fractures, 38 were found to be stable and 91% of these had good or excellent outcomes at
2.7 years. They concluded that dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment.
incorrect answers:
1. > Keith Method - Depth of the fracture segment in injured hip is compared to the contralateral intact posterior wall depth at the level of the fovea
2. > Moed - Depth of the fracture segment in the injured hip is compared to contralateral posterior wall depth at the level of the greatest amount of fracture involvement
3. > Calkins - Length of posterior acetabular arc from each hip is compared at the level of the greatest amount of fracture involvement.

A 23-year-old male is an unrestrained driver in a motor vehicle accident and sustains an unstable pelvic ring fracture. During fluoroscopic-aided fixation, a lateral sacral view is used for proper placement of which of the following fixation methods?

1) Anterior column percutaneous screw placement

2) Posterior column percutaneous screw placement

3) Posterior iliosacral plating

4) Supra-acetabular pin placement

5) Percutaneous iliosacral screw placement

The lateral sacral view is used to place percutaneous iliosacral screws. Sacral alar morphology has been shown to be variable from patient to patient.
Therefore, intraoperative fluoroscopy is recommended. During placement of the screws, the L5 nerve root is at risk.
Routt et al (1997) examined the sacral slope and sacral alar anatomy in cadavers and a series of patients. They determined that the pelvic outlet and lateral sacral plain films provide the best plain radiographic view of the sacral ala. They recommended routine usage of these views intraoperatively to guide screw placement.
Routt et al (2000) reported on the early complications of percutaneous placement of iliosacral screws for treatment of posterior pelvic ring disruptions. While technically challenging, this technique leads to less blood loss and lower rates of infection compared to traditional open techniques.
Barei et al described methods of anterior and posterior pelvic ring disruptions. They determined that successful placement depends on accurate closed reduction, excellent intraoperative fluoroscopic imaging, and detailed preoperative planning. Early treatment decreased hemorrhage, provides patient comfort, and allows early mobilization.

A 23-year-old female is an unrestrained driver in a motor vehicle collision, sustaining the injury shown in Figure A. She subsequently undergoes reduction and percutaneous bilateral iliosacral screw placement. Which of the following is the most likely neurologic complication associated with percutaneous iliosacral screw insertion?
1) Weakness in knee extension

2) Decreased patellar reflex

3) Weakness in great toe extension

4) Weakness in ankle plantar flexion

5) Decreased Achilles reflex

Figure A shows an unstable bilateral pelvic ring injury. Percutaneous posterior iliosacral screw fixation places the L5 nerve root at risk as it courses across the sacral ala. Injury to the L5 nerve root would typically result in weakness in great toe extension and sensory changes on the dorsum of the foot. It is important to notice that L5 often partially innervates tibialis anterior along with L4, so weakness to ankle dorsiflexion may be present as well. Illustration A shows the post-operative films with bilateral iliosacral screws.
Routt et al examined the sacral slope and sacral alar anatomy in cadavers and a series of consecutive patients. They determined that the pelvic outlet and lateral sacral plain films provide the best plain radiographic views of the sacral ala. They recommended routine usage of these views intraoperatively to guide screw placement.
In another study, Routt et al reported on the early complications of percutaneous placement of iliosacral screws for treatment of posterior pelvic ring disruptions. While technically challenging, this technique leads to less blood loss and lower rates of infection compared to traditional open techniques.
Illustration B displays the root diagrams for sensation, reflex, and motor of the L4-S1 nerves.
Incorrect answers:
1: Weakness to knee extension would be caused primarily by an injury to the L4 nerve root.
2: Decreased patellar reflex would be caused primarily by an injury to the L4 nerve root.
4: Weakness in ankle plantar flexion would be caused primarily by an injury to the S1 nerve root.
5: Decreased Achilles reflex would be caused primarily by an injury to the S1 nerve root.

A 20-year-old patient presents after jumping from the window of a burning building with a sacral fracture. Which of the following fracture patterns seen in Figures A through E would give this patient the highest risk of associated nerve injury?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

Answering this question relies on knowledge of the Denis classification of sacral fractures and their associated risks of nerve injury. Figure A represents a Denis Zone 3 (medial to the foramina) sacral fracture, which has the highest associated risk of nerve injury.
Denis et al outlined a novel classification system of sacral fractures based on the position of the fracture line relative to the sacral foramina. The authors found a 56.7% incidence of nerve injury in fractures that extended medial to the sacral foramina (zone 3), compared with 28.4% for fractures through the
foramina (zone 2), and 5.9% for fractures lateral to the foramina (zone 1).
Mehta et al reviewed the current principles for management of sacral fractures. They note that bowel, bladder and sexual dysfunction occur in 76% of patients with zone 3 sacral fractures.
Illustration A below demonstrates the Denis classification of sacral fractures. Incorrect Answers:

Joint stability is critical for successful nonoperative management of posterior wall acetabular fractures. Recent evidence has established that dynamic fluoroscopic stress examination is the best method to determine joint stability in the setting of a posterior wall fracture. The obturator oblique view allows for the best evaluation of hip joint stability during examination for posterior wall fractures.
Grimshaw and Moed retrospectively reviewed the results of patients with posterior wall acetabular fractures managed nonoperatively after evaluation with dynamic fluoroscopic stress tests. At two year follow up, all had good to excellent Merle d’Aubigne clinical scores for hip function and no evidence of post-traumatic hip arthritis on AP pelvis radiographs.
Tornetta retrospectively reviewed his results managing patients with dynamic fluoroscopic stress examination for acetabular fractures which met radiographic nonoperative criteria. Good-to-excellent clinical results were seen in 91% of patients managed nonoperatively.
Tornetta reviewed management of acetabular fractures and Tornetta and Mostafavi separately reviewed management of hip dislocations. In both
articles, emphasis is placed on dynamic examination of posterior wall fractures as instability has been seen with fractures comprising as little as 15% of the posterior wall.
Illustration A demonstrates two fluoroscopic images from a dynamic stress exam of a patient with a posterior wall fracture. The image obtained in the obturator oblique view clearly demonstrates that the femoral head loses congruency with the acetabular dome.
Incorrect Answers:
Answers 1 & 2: Posterior wall fragment size less than 40% was historically used as an indirect measure of stability, however measurements of fragment size may be unreliable and instability has been seen with fractures much smaller than 40%

: A history of hip dislocation was thought to indicate a more unstable fracture. In the level IV study by Grimshaw and Moed, patients with an associated hip dislocation who were stable under stress exam had no significant difference in outcome with nonoperative management.
Answer 5: The iliac oblique view is used to evaluate the anterior wall and posterior column. Displacement or instability of the posterior wall would not be seen with this view

A 64-year-old woman is thrown off a horse, sustaining the injury shown in Figures A and B. She undergoes surgical fixation as seen in Figures C through E. What is the most commonly reported complication of this procedure?
1) Axillary nerve injury

2) Valgus migration of the fracture

3) Nonunion

4) Hardware failure

5) Screw penetration

The patient in the scenario has a 2-part proximal humerus fracture treated with a locking plate as seen in Figures A-E. The most common complication with the use of this implant is screw penetration. The terms screw cut out and penetration are often used interchangeably in the literature with cut out appearing more frequently in reports regarding intertrochanteric fractures.
Owsley et al retrospectively reviewed 53 proximal humerus fractures treated with locking plates and the same post-operative protocol. The most common complication was screw cut out or penetration, followed by varus displacement. They concluded that 3 and 4-part fractures in patients over 60 years have a higher incidence of failure.
Agudelo et al retrospectively reviewed 153 patients at a level-one trauma center treated with proximal humerus locking plates, investigating modes of failure for the implant. They determined that varus malreduction (head-shaft angle
A 25-year-old male sustained a closed midshaft femur fracture following a motor vehicle collision. He is taken to the operating room for supine intramedullary nail fixation of the fracture. Figure A is a lateral fluoroscopic view of the distal femur taken just prior to distal interlocking screw placement. What change in position (with the Carm stationary) would be expected to produce a perfect lateral view of the interlocking hole?
1) Raising the leg

2) Lowering the leg

3) Internal (or external) rotation of the leg

4) Abduction (or adduction) of the leg

5) Fluoroscopic magnification

Interlocking of intramedullary nails using fluoroscopy requires attention to detail. A true lateral of the intramedullary nail is present when "perfect circle" views of interlocking holes are present. Once perfect circles are obtained, the drill can be advanced parallel to the fluoroscopic beam.
Knowledge of the implications of the appearance of the interlocking holes when "perfect circles" are not present can be helpful in minimizing the number of manipulations and fluoroscopic exposure. Widening of the interlocking hole in the proximal-distal direction (as is seen in this case) signifies the need for an adjustment in the abduction/adduction plane. Similarly, widening of the interlocking hole in the anterior-posterior plane signifies the need for an adjustment in the internal/external rotation plane (Answer 3).
Raising or lowering the leg (Answer A and B) should not have major effects of the appearance of the interlocking hole. Similarly, magnification of the C-arm (Answer D) will not affect the appearance. Internal/external rotation will result in widening in the anterior-posterior plane (as this dimension is currently adequate). Abduction or adduction will result in creating "perfect circles" (Answer 4). The position of the leg may hint to which of these is correct. If further widening occurs in the proximal-distal direction, the opposite maneuver will correct to the proper position.

A 46-year-old male is involved in a motor vehicle accident and suffers a proximal humerus fracture. Operative treatment is recommended, and plate fixation is performed through an extended anterolateral acromial approach. Which of the following structures is at increased risk of injury using this surgical exposure compared to the deltopectoral approach?

1) Musculocutaneous nerve

2) Posterior humeral circumflex artery

3) Axillary nerve

4) Cephalic vein

5) Anterior humeral circumflex artery

The anterolateral acromial approach was developed to allow less invasive treatment of proximal humerus fractures. The plane of the avascular anterior
deltoid raphe is utilized, and the axillary nerve is at particular risk of injury and must be identified and protected. With this approach, anterior dissection near the critical blood supply is avoided, substantial muscle retraction is minimized, and the lateral plating zone is directly accessed.
Gardner et al evaluated 23 patients who had acute displaced fractures of the proximal humerus treated with the anterolateral acromial approach and either a locking plate or an intramedullary nail. At one year post-op, there were no axillary nerve deficits, and they found that the approach allowed direct access to the lateral fracture planes for fracture reduction and plate placement or safe nail and interlocking screw placement.
Gardner et al, in another study, performed cadveric dissection using the extended anterolateral acromial approach and measured multiple parameters regarding the axillary nerve. The nerve was predictably found approximately 35 mm from the prominence of the greater tuberosity.
Morgan et al performed a cadaveric study to describe the anatomic insertion point of the deltoid onto the proximal humerus. They found that the deltoid insertion is long and broad, and that placement of 4.5-mm plate would result in detaching 13.5 mm of its insertional footprint. This would leave half of the insertion still attached to the humerus.
Illustration A shows the position of the axillary nerve in relation to the approach.

Which of the following statements is true regarding brake travel time after surgical treatment of complex lower extremity trauma?

1) Brake travel time is significantly increased until 6 weeks after patient begins weight bearing

2) Return of normal brake travel time takes longer after long bone fracture compared to articular fractures

3) Normal brake travel time correlates with improved short musculoskeletal
functional assessment scores

4) Brake travel time is significantly reduced until 8 weeks after patient begins weight bearing

5) Brake travel time returns to normal when weight bearing begins

Brake travel time (BTT) has been shown to be significantly increased until 6 weeks after initiation of weight bearing in both long bone and articular fractures of the right lower extremity.
Egol et al used a computerized driving simulator to compare BTT in three groups of patients; 1)control group, 2)long bone lower extremity fracture group, 3)lower extremity articular fracture group. They concluded that BTT was significantly increased until 6 weeks after initiation of weight bearing in both long bone and articular fractures of the right lower extremity, and that short musculoskeletal functional assessment scores improved with respect to function and other indexes, but did not correlate with improvement in BTT.
An earlier study by Egol et al looked at total brake time as it related to distance traveled by the automobile before braking at 6, 9, and 12 weeks after operative fixation of a right ankle fracture. When compared with controls, braking time was shown to return to normal by 9 weeks post-operatively, and no significant association was found between the functional scores and this normalization.
Giddins et al provide a review of the literature, the law and the views of the major motor insurers related to driving after injury or operations.

What acetabular component is best appreciated on an obturator oblique radiograph of the pelvis as seen in Figure A?
1) Ilioischial line

2) Posterior column

3) Posterior wall

4) Anterior wall

5) Sacroiliac joint

Letournel and Judet developed a schematic representation of the acetabulum as being contained within asymmetric long anterior and short posterior arms of an inverted “Y”.
On the bony pelvis, the ilioischial component becomes that posterior column and the iliopectineal line becomes the anterior column. The Judet-Letournel classification system is based on this scheme. By careful evaluation of landmarks on a standard AP pelvis radiograph, as well as on 45-degree oblique obturator and iliac views, the extent of injury can be determined accurately.
The AP view usually demonstrates the six fundamental landmarks relatively well as seen in illustration A. The obturator oblique view reveals additional information about the anterior column and posterior wall(see illustration A(B),
B). In an obturator oblique view the x-ray beam is centered on and almost perpendicular to the obturator foramen. The iliac oblique view visualizes the posterior column and anterior wall (illustration A(C), C). This view also shows the best detail of the iliac wing as the radiographic beam is roughly perpendicular to the iliac wing. Inclusion of the opposite hip is essential for evaluation of symmetrical contours that may have slight individual variations
and to evaluate the width of the normal articular cartilage in each view in a pelvic series (AP, Judet's) .

Which of the following fractures seen in Figures A through E would be amenable to fixation with a construct using tension band principles?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

In order for a fracture to be successfully treated with tension band principles the bone must be eccentrically loaded, the construct must be applied on the tensile side, and the opposite cortex must be able to withstand compressive
forces. Of the fractures seen in Figures A-E, the subtrochanteric fracture seen in Figure A best meets the criteria for stabilization according to tension band principles.
Kinast et al retrospectively compared their results with 95 degree blade plate fixation of subtrochanteric fractures utilizing the blade plate as a dynamic tension band. They performed either wide exposure of the fracture site with autogenous bone grafting according to AO technique at the time (group 1), or indirect reduction techniques without bone grafting the medial side as advocated by Mast et al (group 2). The authors found 100% union rates at six months with indirect reduction techniques without bone grafting (group 2), and emphasize the key concepts of preservation of the medial soft tissues and intraoperative pretensioning of the plate.
Illustration A demonstrates the principles of tension band fixation specifically applied to the femur. Within Illustration A, Figure C shows the correct application of a plate along the lateral cortex to resist tensile forces, along with incorrect application of the plate along the medial cortex (Figure D) or in a fracture pattern with an absent opposite cortex (Figure E). Illustration B shows an example of blade plate fixation of a subtrochanteric fracture.
Incorrect Answers:
Answer 2. Figure B demonstrates a comminuted proximal tibia fracture. Although the tibia is eccentrically loaded and an implant applied to anterior cortex could function as a tension band, the posterior comminution would lead to collapse.
Answer 3. Figure C demonstrates a comminuted distal humeral shaft fracture. Again,the comminution prevents application of a tension band construct Answer 4: Figure D shows a valgus impacted proximal humerus fracture.
Eccentric loading is absent for this type of fracture
Answer 5: Figure E demonstrates a comminuted olecranon fracture with extension distal to the coronoid process. Although tension band constructs are commonly used for olecranon fractures, the comminution and distal extension of this fracture would prevent application of a tension band.

Which of the following is an advantage of computer-assisted navigation used to place medullary nail interlocking screws compared to a freehand techinque?

1) Reduced fluoroscopy time

2) More reliable placement of interlocking screws through the nail

3) Reduced procedure time

4) Increased quality of fluoroscopic images

5) Improved accuracy of screw length

Computer-assisted navigation has been shown to reduce radiation exposure for surgeons when performing interlocking of medullary nails compared to freehand technique.
Ricci et al compared two fluoroscopic navigation tracking technologies, optical and electromagnetic versus standard freehand fluoroscopic targeting, in a standardized foam block model for placement of interlocking screws. They found that fluoroscopy time (seconds) and number of fluoroscopy images were significantly less when using the computer-guided systems than for freehand-unguided insertion. Average distance of pin placement from the target in the foam blocks was significantly greater for controls than for each of the navigated systems.
Suhm et al performed a prospective controlled clinical study to compare fluoroscopic guidance with fluoroscopy-based surgical navigation for distal locking of intramedullary implants. The surgical navigation group showed increased procedure time, but equivalent precision with reduced radiation exposure. There was no significant difference in the technical reliability
between both groups.

An 82-year-old nursing home resident falls onto his elbow while rising from a seated position. He has pain and swelling at the elbow without evidence of instability. His radiographs show a comminuted displaced olecranon fracture involving 25% of the articular surface with global osteopenia. Which of the following treatment options has a low risk of complications and a high likelihood of a functional elbow outcome?

1) Cast immobilization in 45 degrees of flexion for 8 weeks

2) Closed reduction and percutaneous pinning

3) ORIF with a tension band construct

4) ORIF with a locking plate

5) Cast immobilization in 90 degrees flexion

The patient in the scenario is a low-demand, elderly patient with a comminuted olecranon fracture. Recent studies have demonstrated good outcomes with
non-operative treatment of olecranon fractures in this patient population.
Hak (jaos'00) reviewed the treatment of olecranon fractures, recommending ORIF for displaced intra-articular fractures, either via tension band wiring or plate osteosynthesis based on fracture pattern and associated ligamentous disruption. For elderly, low-demand, osteoporotic patients, triceps advancement and fragment excision is an option in the case of severely comminuted, osteoporotic patients with a fracture involving
A 47-year-old male presents with a one month history of heel pain after starting marathon training. The heel is tender when squeezed. A foot radiograph is shown in Figure A, and an MRI is obtained which is shown in Figures B and C. What is the most likely diagnosis?
1) Osteomyelitis

2) Acute fracture

3) Subtalar arthritis

4) Achilles tendinitis

5) Stress fracture

The patients history, physical exam, and MRI findings are most consistent with the diagnosis of a stress fracture. Low signal on T1 and increased signal on T2-weighted images is the classic appearance of a stress fracture on magnetic resonance images. Usually the fracture appears as a linear signal band that arises from the cortex of the bone and extends perpendicular to the surface of the bone. Figures A and B show a linear area of enhancement in the posterior aspect of the calcaneus signifying a likely stress reaction from recent overtraining.
Boden et al review the pathogenesis and treatment of stress fractures. With regard to diagnosis, they state that it is primarily clinical, but imaging modalities such as plain radiography, scintigraphy, computed tomography, and magnetic resonance imaging may provide confirmation.
Gehrmann et al review stress fractures of the foot, and state that with regards to calcaneal stress injuries, MRI studies should be obtained for definitive diagnosis when radiographs are negative, and pain persists. With regards to
treatment, they state that these injuries usually heal with activity restrictions, heel-pad inserts, and protected weightbearing for a short period of time.

A 35-year-old right hand dominant man falls from a ladder and sustains the injury seen in Figure A. When discussing the risks and benefits of operative versus nonoperative treatment for his fracture, which of the following is true?
1) No difference in shoulder function

2) Higher risk of nonunion with operative management

3) Higher risk of symptomatic malunion or nonunion with nonoperative management

4) Earlier return to sport with nonoperative management

5) No difference in union rates

Historically, displaced midshaft clavicle fractures, as seen in Figure A, were managed nonoperatively. Recent literature has demonsrated improved outcomes with operative management of these fractures.
Khan et al review current concepts in the management of clavicle fractures. For displaced midshaft clavice fractures, operative treatment seems to result in improved patient and surgeon-based outcomes, decreased rates of malunion and nonunion, and shorter time to union.
Kim and McKee review recent evidence regarding the management of clavicle fractures. For midshaft clavicle fractures, the incidence of nonunion and symptomatic malunion with nonoperative management is higher than
previously believed. They state that risk factors include 100% displacement, comminution, increasing age and female gender.
Incorrect Answers
Answer 1. Recent randomized prospective trials have shown improved short term shoulder function with operative management of displaced midshaft clavicle fractures.
Answer 2. Nonunion rates of 7-15% have been shown with nonoperative management versus 2% with operative fixation
Answer 4. Earlier return to activities has been reported with operative management
Answer 5. As with answer 2, there is a significantly higher rate of nonunion with nonoperative management

Assuming the images represent isolated injuries, which of the following Figures demonstrates a Pipkin II femoral head fracture?
1) Figure A

2) Figure B

3) Figure C

4) Figure D

5) Figure E

Figure D represents a Pipkin II femoral head fracture, which is defined as a fracture which is superior to the fovea. Differentiation between Pipkin I and Pipkin II fractures can be important, as suprafoveal injuries often require surgical fixation. Illustration A demonstrates the Pipkin fracture types.
Droll et al review femoral head fracture evaluation and treatment. They discuss non-operative indications (typically reserved for Pipkin I injuries) which include an anatomic or near anatomic reduction (
A 20-year-old female presents following a motor vehicle collision with the injuries seen in Figures A and B. She was initially hypotensive and tachycardic however she now has stable vital signs following a 2 liter bolus of saline and 2 units of packed red blood cells. Which of the following would indicate that this patient has occult end-organ hypoperfusion and should be further resuscitated prior to definitive fixation?
1) Heart rate of 80 beats per minute

2) Systolic blood pressure of 120 mmHg

3) Base deficit of -1.8 mEq/L

4) Serum lactate of 5 mmol/Liter

5) Urine output of 40ml/hour

Figure A demonstrates an unstable pelvic fracture and subtrochanteric femur fracture and Figure B shows a scapular body and mutliple rib fractures. These high-energy fractures, along with the patient's initial hypotension and tacchycardia indicate a multiply injured patient in shock. Serum markers such as lactate (normal
An 80-year-old female falls and sustains the fracture seen in Figure A. She is treated with an antegrade cephalomedullary nail. Which of the following led to the complication seen in Figure B?
1) Nail with a lesser radius of curvature

2) Nail with a greater radius of curvature

3) Piriformis entry portal

4) Trochanteric entry portal

5) Lateral decubitus patient position

The image in Figure A shows an unstable intertrochanteric fracture and the image in Figure B shows perforation of the anterior cortex of the femur by the intramedullary implant. This complication is due to a mismatch of the curvature of the nail with the anterior bow of the femur, and was likely caused by a nail of a greater radius of curvature (eg, straighter than the femur).
Egol et al measured the radius of curvature for 474 matched cadaveric femurs and found the average anterior radius of curvature to be 120cm (+/- 36cm). In contrast, the radii of curvature for the measured intramedullary nails ranged from 186cm to 300cm, demonstrating that the nails were straighter than the femurs. The authors advocate for a decreased radius of curvature (more curve) for intramedullary nails, especially larger diameter implants designed for fractures about the hip
Ostrum and Levy present a case series of 3 patients with subtrochanteric
fractures who had anterior penetration of the femoral cortex. They state that the mismatch in femoral bow between the bone and the implant is a contributing factor to distal femoral anterior cortex penetration in intramedullary nailing of subtrochanteric fractures.
Simonian et al present 4 iatrogenic femoral neck fractures that occured during a series of 315 femoral nails. The authors attempted to reproduce the iatrogenic fractures with cadaveric femurs and felt that the iatrogenic fractures may be due to a combination of a valgus femoral neck and impingement from the AO insertion jig used at the time.
Harper and Carson examined 14 cadaveric femurs and intramedullary implants at the time. Similar to Egol et al, they found a mismatch between the radius of curvature of the femurs and the intramedullary nails.
Illustration A shows the difference between a lesser and greater radius of curvature. Illustration B demonstrates how to calculate radius of curvature based on an implant with an exaggerated bow. Illustration C shows the anterior bow of a synthetic femoral model compared with several intramedullary implants.

Bridge plating of the olecranon is MOST appropriate in which of the following clinical scenarios?

1) Fixation of an olecranon osteotomy used for distal humerus surgery in a 24-year-old male

2) Simple transverse olecranon fracture in 33-year-old female

3) Comminuted olecranon fracture in 45-year-old male

4) Severely comminuted proximal olecranon fracture in an osteoporotic 91-year-old female

5) Aphophyseal elbow fracture in 6-year-old male

Bridge plating is most appropriately used for fixation of comminuted fractures which are not able to be fixed anatomically. Of the choices listed above, this would be most appropriate in a comminuted fracture in a 45-year-old male. In contrast, literature shows that severely comminuted, osteoporotic low-demand elderly are best treated with olecranon fracture excision and triceps advancement when possible.
Bailey et al looked at the outcome of plate fixation of olecranon fractures. They concluded that plate fixation is effective for displaced olecranon fractures and leads to good functional outcome. There were low incidence of complications, although 20% did have removal of hardware due to irritation.
Hak et al reviewed the fixation options for olecranon fractures. In their review, they state that comminuted olecranon fractures can be treated by limited-contact dynamic-compression plates. They also supported the use of supplemental bone graft to support comminuted depressed articular fragments. Fragment excision and triceps advancement is appropriate in selected cases in which open reduction seems unlikely to be successful, such as in osteoporotic elderly patients with severely comminuted fractures.

A 75-year-old ambulatory male who lives independently presents with the fracture shown in Figure A. Which of the following is true regarding timing of surgical fixation and post-operative mortality?
1) 30 day mortality is decreased if surgery is delayed 4-7 days

2) 1 year mortality is increased if surgery is delayed greater than 4 days

3) Delay of surgery due to treatment of acute medical comorbidities has no effect on post-operative mortality rates

4) 90 day mortality rate is decreased if surgery is delayed greater than 7 days

5) Timing of surgical fixation has no statistically significant affect on postoperative mortality

Figure A shows a displaced femoral neck fracture.
Moran et al studied 2660 elderly patients who underwent surgical treatment of a hip fracture to determine whether a delay in surgery affects postoperative mortality. The 30-day mortality for patients for whom the surgery had been delayed for more than 4 days was 10.7%, compared to 7.3% in those delayed 1-4 days. The group delayed >4 days also had significantly increased mortality at 90 days and 1 year. Patients who had been admitted with an acute medical comorbidity that required treatment prior to the surgery had a 30-day mortality of 17%, which was nearly 2.5 times greater than that for patients without and acute comorbidity. The study concluded that patients with medical comorbidities that delayed surgery had 2.5 times the risk of death within 30 days after the surgery compared with patients without comorbidities. Mortality was not increased when the surgery was delayed up to four days for patients who were otherwise fit for hip fracture surgery, however, a delay of more than four days significantly increased mortality.
Healy et al examined 120 patients who underwent surgical treatment of 186 displaced femoral neck fractures with either internal fixation, hemiarthroplasty, or total hip arthroplasty. Arthroplasty was associated with more independent living, and was more cost-effective than internal fixation. There was no difference in rates of reoperation or mortality, but arthroplasty produced a longer interval to reoperation or death. They concluded that total hip arthroplasty was the best treatment for displaced fractures of the femoral neck in their series.
Illustration A shows a scoring system developed by Rogmark et al to aid in decision making.

A 35-year-old male suffers an anterior column acetabular fracture during a motor vehicle collision, and subsequently undergoes percutaneous acetabular fixation. Intraoperatively, fluoroscopy is positioned to obtain an obturator oblique-inlet view while placing a supraacetabular screw. Which of the following screw relationships is best evaluated with this view?

1) Intraarticular penetration of the screw

2) Position of the screw cephalad to the sciatic notch

3) Screw starting point at the anterior inferior iliac spine

4) Screw starting point at the gluteal pillar

5) Screw position between the inner and outer tables of the ilium

The obturator oblique-inlet view, as seen in Illustration A, best demonstrates the position of a supra-acetabular screw or pin relative to the tables of the ilium.
Starr et al review their initial results and technique of closed or limited open reduction and percutaneous fixation of acetabular fractures. They defined two groups of patients who may benefit from this technique; elderly patients with multiple comorbidities to facilitate early mobilization and restore hip morphology, and young patients with elementary fracture patterns and multiple associated injuries.
Starr et al describe their operative technique and outcomes for a case series of 3 patients using percutaneous acetabular fixation to augment open reduction of acetabular fractures. The authors state that, for placement of an anterior colum ramus screw, an iliac oblique-inlet (not obturator oblique-inlet) will ensure that the screw is within the medullary canal of the ramus and does not exit anterior or posterior.
Gardner and Nork describe a technique for placement of a large femoral distractor in the supra-acetabular region to compress displaced posterior pelvic ring injuries. They note that the obturator oblique-inlet view is necessary to view the entire length of the pin as well as to ensure that pin remains in bone.
Incorrect answers:
Answer 1: Relationshiop of the screw to the acetabulum is best evaluated with the obturator oblique-outlet view as well as the iliac oblique view
Answer 2: The iliac oblique view is used to ensure the trajectory of the screw is superior to the sciatic notch
Answer 3: The Obturator oblique-outlet view, otherwise known as the "teepee" or "tear drop" view, is used to identify the start for supra-acetabular implant placement
Answer 4: The gluteal pillar is not utilized as a start point when placing supraacetabular fixation, and the obturator oblique-inlet view would not be ideal to visualize this region of the pelvis

A 74-year-old man falls, sustaining the injury shown in Figures A through C. In surgical planning, what is the best surgical approach to treat this injury?
1) Kocher-Langenbeck

2) Watson-Jones

3) Extended iliofemoral

4) Ilioinguinal

5) Hardinge

Figures A through C depict and AP pelvis and Judet views of a T-type fracture of the right acetabulum. The ilioinguinal approach provides access to the anterior wall and anterior column for fracture fixation, in addition to allowing fixation of the nondisplaced posterior transverse fracture line. The lateral femoral cutaneous nerve (LFCN) is at risk in the superficial part of the dissection. Another option for the approach would be the modified Stoppa, which would also allow excellent access to the anterior column as well as the internal aspect of the iliac wing and quadrilateral plate.
Illustration A shows the five basic and 5 associated acetabular fractures. Incorrect Answers:
Answer 1. Kocher-Langenbeck: access for posterior wall and column fractures
Answer 2. Watson-Jones: anterolateral approach best for the hip, not the anterior column of the acetabulum.
Answer 3. Extended iliofemoral: visualization for both column fractures Answer 5. Hardinge approach: lateral approach for THA

A 28-year-old female is struck by a motor vehicle while crossing the street and suffers the injury seen in Figure A. What technical adjunct could have prevented the operative complication seen in Figure B?
1) Nail of a lesser radius of curvature

2) Nail with a more distal Herzog curve

3) Application of an anterior unicortical plate

4) Nailing while in a hyperflexed position

5) A more distal and medial nail entry site

The patient has a proximal tibia fracture that has been malreduced in procurvatum with anterior translation of the proximal fragment as seen in Figures A and B. Intramedullary nailing of proximal tibia fractures may result in malalignment such as valgus, procurvatum and anterior translation of the proximal fragment.Techniques such as anterior unicortical plating have been described to maintain reduction while placing a locked intramedullary implant.
Nork et al retrospectively review their results using several different intraoperative adjuncts to maintain reduction while nailing proximal tibia fractures including anterior unicortical plates and femoral distractors. They report that, despite high rates of segmental comminution (59.5%) and open fractures (35.1%), acceptable alignment and primary union were achieved in more than 90% of patients.
Dunbar et al describe their technique for application of a provisional unicortical plate through the traumatic wound to maintain reduction during intramedullary nailing of Gustilo-Anderson Type III open tibia fractures. The authors advocate that further soft tissue stripping during plate placement should be avoided, and found excellent results in terms of coronal and sagittal plane alignment for fractures treated with this technique.
Matthews et al review their experience with unicortical plating to maintain reduction during intramedullary nailing of tibia fractures. Similar to the other referenced studies, the authors found the technique assisted with maintaining reduction intraoperatively.
Illustrations A and B demonstrate maintenance of reduction of a proximal tibia fracture using an anterior unicortical plate as a reduction tool during intramedullary nailing.
Incorrect Answers:
Answer 1: Nail of a lesser radius of curvature. Unlike femoral nails, tibial nails are straight to match the coronal/sagittal axis of the tibia and therefore a nail with a lesser radius of curvature (more bend) would not match the anatomy and likely lead to malalignment
Answer 2: Nail with a more distal Herzog curve. The proximal bend for tibial IM nails, known as the Herzog curve, may cause malalignment in proximal tibia fractures due to a phenomenon known as the "wedge effect". Nails with more distal Herzog curves have been implicated in anterior translation of the proximal fragment.
Answer 4: Nailing in a hyperflexed position would cause extension of the proximal fragment due to tension on the extensor mechanism
Answer 5: A more distal and medial entry site would likely lead to further deformity and possible nail cut out through the anterior cortex. A more proximal and lateral entry site is preferred for nailing proximal tibia fractures

A 32-year-old male sustains an APC-III pelvic ring disruption after a motor vehicle collision. Which of the following imaging techniques best describes the correct utilization of intraoperative flouroscopy for percutaneous iliosacral screw placement across S1?

1) Inlet view helps best guide superior-inferior orientation

2) AP pelvis best guides anterior-posterior screw orientation

3) AP pelvis best guides superior-inferior screw orientation

4) Outlet view best guides anterior-posterior screw orientation

5) Outlet view best guides superior-inferior screw orientation

The outlet view best guides superior-inferior screw orientation during percutaneous S1 screw placement. This is due to the relative forward flexion of the sacrum and pelvis due to pelvic incidence. A lateral sacral view and an inlet pelvis view would best guide anterior-posterior screw orientation.
Routt et al did a review of percutaneous techniques of pelvic surgery. Although anterior pelvic external fixation remains the most common form of percutaneous pelvic fixation, iliosacral screws have the advantage of stabilizing pelvic disruptions directly while diminishing operative blood loss and operative time. They stress importance of a thorough knowledge of pelvic osseous anatomy, injury patterns, deformities, and their fluoroscopic correlations for surgical success.
Routt et al also looked at the complications that can result from percutaneous iliosacral screw placement. Complications ranged from inability for adequate imaging due to patient obesity, L5 nerve root injuries, fixation failure, and sacral nonunions. They support quality triplanar fluoroscopic imaging during iliosacral screw insertions to help accurately reduce injured posterior pelvic rings.
Illustration A is an example of an outlet view image status post anterior pelvic ring plating and percutaneous iliosacral screw. This outlet view allows superior S1 neural foramen visualization to help guide screw placement and avoid nerve injury.

Which of the following methods accurately describes the measurement of tip-apex-distance as it relates to placement of a lag screw in the femoral head?

1) Summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs

2) Distance from the acetabular teardrop to the tip of the screw on an AP radiograph of the hip

3) Multiplication of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs

4) Distance from the center of the lesser trochanter to the tip of the screw on an AP hip radiograph

5) Summation of the distance between the tip of the greater trochanter and end of the screw on AP and lateral hip radiographs

Tip-apex distance (TAD) as it relates to a lag screw in the femoral head is the summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs, corrected for radiographic magnification of the image. This is shown in Illustration A.
TAD is a useful intraoperative indicator of deep and central placement of the lag screw in the femoral head, regardless of whether a nail or a plate is chosen to fix a fracture. A TAD of 25mm as well as with increasing fracture severity. They concluded that TAD is a valuable consideration for intramedullary devices as well.
Illustrations B and C show a lag screw with an excessive TAD, and subsequent failure of fixation.
Incorrect Answers:
Answers 2-5: TAD is defined as the sum of the distance between the end of the lag screw and the apex of the femoral head on the AP and lateral radiographs, corrected for radiographic magnification of the image.

A 25-year-old man presents one year after undergoing open reduction and internal fixation of the fracture seen in Figure A. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. Physical exam is notable for ambulation on the lateral border of the right foot with hindfoot varus, midfoot supination and diminished subtalar motion compared with the contralateral side. Which of the following is an option for reconstruction of this patient's deformity?
1) Total ankle arthroplasty

2) Lateral calcaneus closing wedge osteotomy

3) Calcaneal neck opening wedge osteotomy

4) Talar neck opening medial wedge osteotomy

5) Triple arthrodesis

The most common position of talar neck malunion is varus and this deformity can lock the subtalar and transverse tarsal joints leading to diminished motion and ultimately subtalar arthrosis. Medial opening wedge osteotomy of the talar neck has been described to restore the anatomy of the talus and preserve hindfoot motion.
Daniels et al performed a biomechanical study of hindfoot motion following medial osteotomy and varus malalignment of the talar neck. The authors found a direct correlation between the degree of varus malalignment and diminished forefoot and subtalar motion, and caution against compressive fixation of the medial talus in the presence of comminution.
Monroe and Manoli present a case report of talar neck malunion and describe their technique for osteotomy of the talar neck with insertion of a tricortical iliac crest bone graft to correct the deformity. They found a significant improvement in the AOFAS ankle-hindfoot score and no evidence of
osteonecrosis with follow-up greater than 4 years.
Huang and Cheng retrospectively review their results with anatomic reconstruction of the talar neck in 9 patients who presented a minimum of four weeks after the initial injury with a malreduced or neglected talar neck fracture. They found favorable outcomes with delayed reconstruction as determined by the AOFAS ankle-hindfoot score at an average follow up of 53 months, however note that six patients subsequently developed radiographic hindfoot arthrosis.
Figure A demonstrates a lateral radiograph of a comminuted talar neck fracture with subluxation of the subtalar joint.
Incorrect Answers:
Answer 1: Total ankle arthroplasty is reserved for patients with end-stage tibiotalar arthritis. This patient has an intact and functional tibiotalar joint Answer 2: Lateral calcaneus closing wedge osteotomy would correct some hindfoot varus, however would not address the talar neck deformity leading to diminished motion.
Answer 3: Calcaneal neck opening wedge osteotomy would exacerbate the patient's deformity
Answer 5: Triple arthrodesis would be not be a viable option in a patient with a preserved tibiotalar and subtalar joint.

Which of the following descriptions is true regarding APC-II (anterior-posterior compression) pelvic injuries as classified by Young and Burgess?

1) Pubic symphysis diastasis, intact anterior sacroiliac ligaments, intact sacrotuberous ligament, intact posterior sacroiliac ligaments

2) Pubic symphysis diastasis, torn anterior sacroiliac ligaments, intact sacrotuberous ligament intact posterior sacroiliac ligaments

3) Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, intact posterior sacroiliac ligaments

4) Pubic symphysis diastasis, torn anterior sacroiliac ligaments, torn sacrotuberous ligament, intact posterior sacroiliac ligaments

5) Pubic symphysis diastasis, intact anterior sacroiliac ligaments, torn sacrotuberous ligament, torn posterior sacroiliac ligaments

APC II injuries are unstable injuries and occur as a result of high-energy trauma. Anatomic structures which are injured or torn include the pubic symphysis, anterior iliosacral ligaments, and the sacrotuberous ligaments. The posterior sacroiliac ligaments are spared in APC-II injuries, and differentiate an APC-II injury from an APC-III injury, in which the posterior ligaments are also torn.
Burgess et al review the classifications of pelvic ring disruptions and their association with mortality. They concluded that APC injuries required more blood replacement and were related to death more often than lateral compression, vertical shear, or combined mechanism pelvic injuries.
Tile studied the anatomy of anterior to posterior pelvic ring injuries. Although the anterior structures, the symphysis pubis and the pubic rami, contribute to 40% to the stiffness of the pelvis, clinical and biomechanical studies have shown that the posterior sacroiliac complex is more important to pelvic-ring stability. The posterior sacroiliac ligamentous complex is more important to pelvic-ring stability than the anterior structures and therefore, the classification of pelvic fractures is based on the stability of the posterior lesion.
Illustration A shows the APC classification.

Which of the following deformities is most likely to occur with dynamic hip screw fixation of unstable left sided standard obliquity hip fractures?

1) Posterior spike displacement of the proximal fragment

2) Anterior spike displacement of the proximal fragment

3) Lateral displacement of the proximal fragment relative to the distal fragment

4) Shortening of the proximal fragment relative to the distal fragment

5) Medial displacement of the proximal fragment in relation to the distal fragment

Left-sided unstable intertrochanteric hip fractures are at increased risk of malreduction compared to unstable right-sided fractures fixed with dynamic hip screws. In left-sided fractures the rotational torque imparted to the proximal head and neck fragment can cause loss of reduction leading to potential failures of fixation. With these left sided injuries, the rotational torque can cause an anterior spike, whereas with right-sided injuries the rotational torque causes compression and reduction of the fracture. In addition, if a nail is used for these injuries and the proximal fracture fragment is not being held by the nail itself, this phenomenon can be seen as well.
Mohan et al conducted a study to assess the effect of clockwise rotational torque onto the fracture configuration in unstable and stable intertrochanteric fractures fixed with a dynamic hip screw construct. They found that 11 out of 30 unstable fractures showed an anterior spike (flexion malreduction) in left-sided fixations due to clockwise torque. This malreduction was not present in right-sided or stable fractures.
Illustrations A and B are images from Mohan et al's study showing the rotational affect on the fracture with placement of a dynamic hip screw.

A 45-year-old male sustains a proximal third tibia fracture as an isolated injury and elects to undergo operative treatment with intramedullary nailing. Post-operative radiographs show excessive procurvatum deformity. Which of the following operative techniques would have helped to best avoid the procurvatum deformity?

1) Tibial nailing with increased knee flexion

2) Lateral blocking screw in the proximal fragment

3) Medial blocking screw in the proximal fragment

4) Anterior blocking screw in the proximal fragment

5) Posterior blocking screw in the proximal fragment

Posterior blocking screws in the proximal tibial segement help to avoid tibial procurvatum deformity and malunion. Proximal third tibia fractures are often times difficult to reduce anatomically due to the tendency for both valgus and flexion deformity at the fracture site. The posterior blocking screw helps to eliminate the tendency for the nail to be too posterior and cause the fracture to flex. Blocking screws should be placed on the concavity of the deformity to minimize the procurvatum and valgus deformities of this fracture pattern.
Krettek et al looked at the importance of using blocking screws during intramedullary nailing of metaphyseal fractures using small diameter nails. They found less procurvatum deformity and malunions associated with using of blocking screws and found no complication with their utilization.
Ricci et al reviewed fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. Their results supported that blocking screws were effective in maintaining alignment of fractures of the proximal third of the tibial shaft treated by intramedullary nailing.
Hiesterman et al review different reduction techniques to avoid malalignment, including the use of a proper starting point and insertion angle, blocking screws, unicortical plates, and a universal distractor.
Illustration A shows a radiograph utilizing posterior proximal and distal blocking screws to prevent procurvatum deformity.
Incorrect Answers:

Lateral compression type II fractures (as described by the Young-Burgess Classification System) are associated with a crescent fracture of the iliac wing located on the side of impact. A representative CT scan image and illustration of this injury are shown in Illustrations A and B respectively. A table describing each pelvic injury and their associated complications is shown in Illustration C. Illustration D shows each Young-Burgess pelvic injury type.
Burgess et al discuss the effectiveness of a treatment protocol as determined by their pelvic injury classification and hemodynamic status. The injury classification system was based on lateral compression, anteroposterior compression, vertical shear, and combined mechanical injury types. They found that their classification-based treatment protocols reduce the morbidity and mortality related to pelvic ring disruption.
Tile discusses acute pelvic trauma and his classification system for pelvic injuries (ie. Types A, B, and C). He states that any classification system must be seen only as a general guide to treatment, and that the management of each patient requires careful, individualized decision making.
Incorrect Answers:

: This describes an APC-II injury Answer 3: This describes an APC-III injury Answer 4: This describes and LC-I injury
Answer 5: This describes an LC-III injury (ie. "wind-swept pelvis")

A 65-year-old male presents with continued left hip and thigh pain, and inability to bear full weight after undergoing ORIF of a left proximal femur fracture 3 months ago. Current radiographs are shown in Figure A. The patient denies any fevers, or other systemic signs of illness. Which of the following would have potentially decreased the risk of excess fracture collapse and implant failure in this patient?
1) Use of a six-hole 135 degree compression plate

2) Addition of iliac crest autograft to the fracture site

3) Application of long strut allografts around the fracture site

4) Placement of a cephalomedullary nail

5) Addition of an 7.3mm de-rotation screw in the femoral head

The patient is presenting with a reverse obliquity peritrochanteric fracture nonunion, as shown in Figure A. 135-degree compression plate implants (such as the one used in this patient) are designed to stabilize intertrochanteric femoral fractures, and they may be unable to resist the deforming forces inherent in subtrochanteric fractures. When this device is used, the distal fragment often displaces medially and proximally as the fracture settles. The proximal fragment also may rotate on the compression screw because the plate design allows only for one screw in the proximal fragment.
Cephalomedullary nails, such as that shown in Illustration A, have been shown to offer biomechanical superiority and diminished risk of implant failure when compared to plating of these injuries.
Lundy provides a review article on the evaluation and treatment of subtrochanteric femur fractures. He states that these fractures can be effectively stabilized with 95° plates, femoral reconstruction nails, or trochanteric femoral nails with interlocking options. With regards to plates, he states that a 135° hip screw-plate is not suitable in the treatment of subtrochanteric femoral fractures, and that use of these implants may result in loss of fixation and fracture displacement.
Menezes et al reviewed 155 consecutive patients who were treated with a proximal femoral nail from 1997 to 2001 to determine the rate of implant specific complications. They concluded that low rates of femoral shaft fractures and failure of fixation support the use of the proximal femoral nail for treatment of unstable trochanteric and subtrochanteric fractures.
Robinson et al used the long Gamma nail to treat a consecutive series of 302 local patients who had sustained a subtrochanteric fracture during low-energy trauma over an 8 year period. They found that trochanteric-entry cephalomedullary nails are associated with an acceptable rate of perioperative complications and favorable functional outcomes.
Incorrect Answers:

The semiextended position for intramedullay nailing of proximal tibia shaft fractures has shown to cause less complications of flexion deformity and malunion. Proximal third tibia fractures are often times difficult to reduce anatomically due to the tendency for both valgus and flexion deformity at the fracture site. The semiextended position helps to eliminate the tendency for
the fracture to flex, due to the avoidance of excessive knee flexion during the reduction. Illustration A is an example of semiextended positioning for tibial nailing. Illustration B shows radiograph utilizing posterior blocking screws to prevent procurvatum deformity.
Tornetta et al looked at the semiextended intramedullary nailing of proximal tibia fractures. Of the 24 patients nailed using this technique, 19 had no anterior angulation, while only 5 had less than 5 degrees of flexion deformity.
In their study, Kubiak et al also advocate the semiextended position for tibial nailing. They note better control of fracture alignment and stabilization especially in the sagittal plane, and better ability to obtain imaging and maintenance of reduction during nail insertion and locking.
Incorrect answers:

would help to avoid valgus deformity. Answer 3 would worsen the flexion deformity.
Answer 4 would worsen the flexion deformity and drive the nail posterior in distal segment.
Answer 5 would not affect flexion deformity.

Which of the following cannulated screw configurations used in the treatment of subcapital femoral neck fractures is optimal?

1) Inverted triangle pattern with the inferior screw posterior to midline and adjacent to the calcar

2) Inverted triangle pattern with the inferior screw anterior to midline and adjacent to the calcar

3) Triangle pattern with the superior screw posterior to midline and adjacent to the calcar

4) Inverted triangle pattern with the inferior screw posterior to midline and central in the femoral neck

5) Inverted triangle pattern with the inferior screw anterior to midline and central in the femoral neck

The strongest portion of the femoral neck is the posterior inferior neck in the region of the femoral calcar. The optimal biomechanical configuration includes an inverted triangle pattern with the single screw in the inferior aspect of the femoral neck adjacent to the calcar.
Booth et al performed a cadaveric study comparing central versus calcar (cortical-adjacent) fixation. The results demonstrated significant improved stability, load, stiffness, and displacement in all tested parameters for the group with calcar-adjacent screw fixation.
Lindequist and Törnkvist performed a Level 4 study of 72 femoral neck fractures. They found that all 5 of their nonunions had screws placed greater than 3mm from the femoral calcar. Additionally, 16 of 18 fractures healed in the group of displaced fractures where both the fixating screws were placed within 3 mm from the femoral neck cortex.
Gurusamy et al performed a Level 4 study of 395 patients undergoing femoral neck fixation. They found a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.
Illustration A depicts the optimal configuration of an inverted triangle with the single screw being inferior and all of the screws being cortical adjacent.

A 63-year-old female sustained a distal radius and associated ulnar styloid fracture 3 months ago after being involved in a motor vehicle collision. Radiographs obtained at the time of injury are shown in Figure A. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. At the time of the index operation, there was no distal radioulnar joint instability after plating of the radius. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture?
1) Worse outcomes on the Mayo wrist score are expected without fixation

2) Chronic distal radioulnar joint instability can be expected to occur without fixation

3) Wrist function depends on the level of ulnar styloid fracture and initial displacement

4) Grip strength and wrist range of motion are improved with fixation

5) There is no adverse effect on wrist function or stability without fixation

An accompanying ulnar styloid fracture in patients with stable fixation of a distal radial fracture has no apparent adverse effect on wrist function or stability of the distal radioulnar joint.
Kim et al evaluated 138 patients who underwent surgical treatment of an unstable distal radial fracture, without fixation of an associated ulnar styloid fracture if present. Postoperative evaluation included measurement of grip strength and wrist range of motion; calculation of the modified Mayo wrist score; as well as testing for instability of the distal radioulnar joint at a mean of 19 postoperatively. They did not find a significant relationship between wrist functional outcomes and ulnar styloid fracture level or the amount of displacement.
af Ekenstam et al performed prospective and randomized study of two different treatments of extraarticular Colles' fracture with a fractured ulnar styloid. In one group, the ulnar styloid was left alone, and in the other group it was transfixed and/or the triangular ligament was repaired after closed reduction of the fractured radius. They concluded that repair of the ulnar styloid complex in extraarticular fractures of the distal radius is not better than conventional treatment.

Each of the following are guidelines for management of a domestic violence victim EXCEPT:

1) Socioeconomic status should not preclude evaluation for domestic violence

2) Interview the patient outside the presence of other non-medical personnel

3) Federal law mandates photographs be taken of injuries

4) Document your opinion if the patient’s injuries are not consistent with the offered explanation

5) Physicians should check requirements to see if there is mandatory reporting statute in their state

It is important to fully document the abuse as it has been described to you, however there is no federal law mandating photographic documentation of domestic violence injuries. Photographs may be taken but only with the patient's permission. Disclosure of a diagnosis of abuse to any third party and reporting it to the authorities should be done only with the abused patient’s knowledge and consent, unless there is a mandatory reporting statue in the particular state of practice. Being a female, age 19-29, pregnant, or of a low
socioeconomic status (
An otherwise healthy 34-year-old female undergoes an elective L5-S1 microdiscectomy. At her 4 week followup, she is noted to have drainage from her wound. Labs reveal a CRP of 30 mg/L (normal
1) CRP 20 mg/L, ESR 40 mm/hr

2) CRP 15 mg/L, ESR 20 mm/hr

3) CRP 6 mg/L, ESR 10 mm/hr

4) CRP 1 mg/L, ESR 25 mm/hr

5) CRP 8 mg/L, ESR 5 mm/hr

A normalized C-reactive protein (CRP) value (60 years, smoking, diabetes, previous surgical infection, increased body mass index, and alcohol abuse were all statistically significant preoperative risk factors for developing a post-op wound infection.. The most likely procedure to be complicated by an infection was a combined anterior/posterior spinal fusion performed in a staged manner under separate anesthesia. Infections were primarily monomicrobial and the most common organism cultured from the wounds was Staphylococcus aureus.
Illustration A shows the CRP trends in the study by Khan et al. with postoperative wound infections after spinal surgery treated with IV antibiotics. ER refers to early responder while LR refers to late responder. At the 4-week time point, 16 patients have shown clinical improvement with no fevers, wound drainage, erythema, or need for wound packing. The other 5 patients, referred to as late responders, have shown one or more clinical signs of infection in addition to having an elevated CRP. At 20 weeks, both early and late responders both have shown normalized CRP levels and no clinical evidence of infection. Illustration B shows the ESR trends in the those which demonstrated incomplete normalization of ESR values despite resolution of infection.
Incorrect Answers:
Answer 1, 2, 3, 5: CRP levels > 3 mg/L are elevated and indicate incomplete response to infection

A 25-year-old man is struck by car while crossing the street. His injuries include the closed left tibial shaft fracture shown in Figure A. He is a smoker, but is otherwise healthy. Intramedullary nailing is performed without initial complications. Which of the following puts this patient at greatest risk for tibial nonunion?
1) Use of anti-inflammatories post-operatively

2) Post-operative gapping at the fracture site

3) Presence of an associated fibular fracture

4) History of smoking

5) Mechanism of injury

Post-operative gapping at the fracture site significantly increased the risk of reoperation due to nonunion or malunion.
Bhandari et al performed a retrospective study to identify which prognostic factors were associated with an increased risk of reoperation for nonunion in surgically treated tibial shaft fractures. They examined over 200 fractures, and found the presence of an open fracture wound (RR 4.32), lack of cortical continuity between the fracture ends following fixation (RR 8.33), and the presence of a transverse fracture (RR 20.0) were the three variables most predicitive of reoperation.
Audige et al analyzed 416 patients with operatively treated tibial shaft fractures who were followed for at least 6 months. They found that the greatest risk for delayed healing or nonunion was the presence of an open injury, fractures of the distal 1/3 of the tibia, and postoperative gapping at the
fracture site (The risk of healing problems was doubled for fractures of the distal shaft and for fractures showing a postoperative diastasis).

Figure A is a radiograph of a healthy, independent 51-year-old male. He is treated with immediate open reduction internal fixation to prevent which of the following complications?
1) Fracture non-union

2) Avascular necrosis

3) Skin necrosis

4) Plantar flexion weakness

5) Ankle stiffness

Figure A shows an avulsion fracture of the calcaneal tuberosity. Immediate open reduction and internal fixation is required to prevent wound complications.
Displaced avulsion fractures of the calcaneal tuberosity should be managed urgently to prevent necrosis of the soft tissues overlying the heel. In these injuries, the Achilles tendon is securely attached to the fractured tuberosity. Urgent closed reduction and casting is usually not possible due to the power and proximal pull of the triceps surae. Surgical fixation is required. The best treatment modality is open reduction and bone-to-bone fixation with screws. Closed reduction and percutaneous pinning fixation is not strong enough to provide a stable fixation of the tuberosity.
Lui reported on avulsion fractures of the bony insertion of the Achilles tendon at the calcaneus. He stated that screw fixation alone is not sufficient for repair of these injuries. His technique involved two suture anchors used capture the small bone fragment to the calcaneus. This allowed for the pull of the triceps surae to be neutralized and early physical therapy.
Hess et al. looked at a case series of calcaneal tuberosity avulsion fractures that were treated in a delayed fashion. All three patients with posterior tuberosity calcaneal avulsion fractures developed skin necrosis because of a delay in treatment.
Figure A shows a displaced posterior tuberosity calcaneal avulsion fracture. Illustration A shows skin breakdown overlying the posterior tuberosity calcaneal avulsion fracture.
Incorrect Answers:
Answer 1: The amount of displacement is an indication for fixation, however urgent treatment does not improve union rates with these fractures.
Answer 2: Tuberosity calcaneal avulsion fractures rarely disrupt the blood supply to the avulsion fragment and are not associated with avascular necrosis.
Answer 3: Plantar flexion weakness is a known complication of these injuries despite many treatment options.
Answer 4: Ankle stiffness is most commonly related to surgical fixation methods and post-operative immobilization and delayed rehabilitation.

A 22-year-old male presents 4 weeks following open reduction and internal fixation of his unstable ankle fracture. He has had three days of increasing pain, swelling and the new onset of purulent drainage from the mid-portion of the lateral incision. Laboratory values, including white blood cell count, sedimentation rate, and C-reactive protein are elevated. Current radiographs are seen in Figures A and B. On examination the wound probes deep and likely involves the lateral plate. What is the best step in management at this time?
1) Suppression with broad spectrum oral antibiotics until fracture healing

2) Suppression with broad spectrum intravenous antibiotics until fracture healing

3) Surgical debridement, removal of internal fixation, culture specific antibiotics, casting until fracture healing

4) Surgical debridement, maintenance of internal fixation, culture specific antibiotics until fracture healing

5) Wound culture in the office and suppression with culture specific antibiotics until fracture healing

The patient is presenting with an acute deep infection following open reduction and internal fixation of an unstable ankle fracture. Recent studies have shown that a protocol of early aggressive surgical debridement, maintenance of internal fixation and culture specific antibiotics can be effective at achieving fracture healing.
Management of early postoperative infection following open reduction and internal fixation can be challenging. Effective treatment typically involves a combination of surgical debridement and culture specific antibiotics. Removing internal fixation prior to fracture healing can lead to additional insult to the soft tissue and ongoing inflammation secondary to fracture instability. Recently published protocols have shown effective treatment with maintenance of implants and culture specific antibiotics following early, aggressive surgical debridement.
Berkes et al. performed a multi-center retrospective study of 121 patients with acute postoperative infection (defined as less than 6 weeks from surgery) following internal fracture fixation. The authors demonstrated a 71% rate of success (defined by maintenance of implants until fracture healing) with a protocol of debridement and suppression with culture specific antibiotics. Risk factors for failure of this technique include open fractures and the use of an intramedullary nail for fracture fixation.
Figures A and B show an ankle status post open reduction and internal fixation of a lateral malleolus fracture. There are no signs of loosening of fixation or cortical erosions concerning for osteomyelitis.
Illustrations A and B are weight bearing X-rays that demonstrate the same fracture, now healed, after debridement and culture specific antibiotics.
Illustrations C and D demonstrate the same fracture after elective removal of implants at 10 months following the index procedure. Intraoperative cultures at the time of hardware removal were negative for recurrent infection.
Incorrect answers:
Answers 1 and 2: Broad spectrum antibiotics without surgical debridement would not be effective in dealing with the infection in this clinical scenario with purulence tracking to the level of the plate
Answer 3: Surgical debridement and antibiotics would control the infection adequately, however removal of fracture fixation in an unstable fracture would lead to instability, soft tissue inflammation and likely malunion or nonunion that would require complex revision
Answer 5: Although culture specific antibiotics are an improvement over broad spectrum, again surgical debridement in conjunction with antibiotics is the most appropriate choice in this scenario. Intraoperative deep cultures in a sterile environment are preferred over cultures obtained in the office.

A 28-year-old male sustained an ankle injury 3 months ago, and was treated with closed management and splinting; a current x-ray is shown in Figure A. Which of the following is the most important factor in deciding between a joint sacrificing and a joint preserving operation for this patient at this time?
1) Workers' Compensation involvement

2) Gender

3) Date of injury

4) Degree of tibiotalar arthritis

5) Degree of deformity

This patient presents with malunion after sustaining a bimalleolar ankle fracture. Surgical treatment options consist of osteotomy for deformity correction with internal fixation (joint preserving) versus fusion (joint sacrificing) with the primary determinant being the amount of ankle arthritis present.
When treating ankle malunions, the decision to perform deformity correction and preserve the joint versus fusing the joint is dependent on signs of progressive, advanced tibiotalar arthritis on radiographs.
Yablon and Leach followed 26 patients following corrective fibular osteotomy following malunion and noted excellent results at a mean follow-up of 7 years. All but 3 returned to preinjury level of activity and had desired outcomes following deformity correction.
Reidsma et al. prospectively followed 57 patients with a minimum follow-up of 10 years following corrective osteotomy and fixation for ankle fracture malunions. Good to excellent results were obtained for 85% of the cohort. The authors concluded that those ankle fracture malunions with none to minimal arthritic changes should still receive corrective osteotomy to prevent further progression of arthritis.
Yablon et al. following 53 patients for 6-9 months, reported on the importance of anatomic restoration of the lateral malleolus when fixing bimalleolar ankle fractures. With anatomic reduction and fixation, no progression of arthritis was noted with return to function.
Figure A is an AP radiograph of a right ankle fracture malunion. Incorrect answers:
Answers 1-3, 5: Factors such as age, gender, and degree of deformity are not
as important as the presence of advanced arthritis that may suggest requiring a joint sacrificing fusion procedure. The date of injury may portend a poor outcome (the longer from the date of injury/subsequent malunion), but is not the most important factor in deciding between corrective osteotomy versus fusion.

A 45-year-old male presents after falling off of a ladder. Radiograph is shown in Figure A. Which of the following is the appropriate sequence in management?
1) Closed reduction, splint application, computed tomography (CT) scan, delayed open reduction and internal fixation

2) Closed reduction, cast application, close observation

3) Splint application, CT scan, application external fixator, delayed open reduction and internal fixation

4) Splint application, application external fixator, CT scan, delayed open reduction and internal fixation

5) Splint application, acute open reduction and internal fixation

This patient has sustained a pilon fracture, with severe comminution and impaction at the articular surface.
The correct sequence of management includes (1) immediate splinting, (2) application of an external fixator, (3) restoration of length alignment and rotation with temporizing external fixation, (4) computed tomography, followed by (5) definitive fixation once soft tissues are amenable.
Tornetta and Gorup analyzed the use of preoperative CT scans in comparison to radiographs in preparation for fixing pilon fractures. The authors noted increased recognition of intra-articular fragments, comminution and noted a high percentage of operative planning changes following CT analysis.
Furthermore, the authors recommended CT scans AFTER external fixation, for even better fragment characterization.
Marsh et al. in their instructional course lecture provide tips and tricks in successful management of pilon fractures. One of the highlighted points include staged, delayed treatment of pilon fractures via spanning external fixator as well as highlighting the importance of obtaining the CT after restoring length and alignment.
Figure A exhibits a radiograph of a comminuted, impacted, shortened pilon fracture.
Incorrect answers:
Answer 1: With such a short, impacted fracture, external fixation as a temporizing measure is recommended to help calm the soft tissue envelope. Answer 2: Closed treatment is not accepted in this type of fracture, due to the high incidence of arthritis and malunion.
Answer 3: CT scan should be obtained AFTER external fixation, not before. Answer 5: This high-energy injury likely has severe soft tissue injury, which is not amenable to acute fixation.

A 45-year-old male with long-standing diabetes sustains the injury shown in Figure A. He has a BMI of 38, established peripheral neuropathy, and his most recent HbA1c is 8.8. What is the most appropriate definitive management option of Figures B through F?
1) Figure B

2) Figure C

3) Figure D

4) Figure E

5) Figure F

Open reduction and internal fixation (ORIF) remains the mainstay of treatment for ankle fractures in patients with diabetes.
ORIF for ankle fractures in diabetics can be augmented with increased density of fixation to account for notable, pathologic bone. Specifically, multiple quadricortical syndesmotic screws, bicortical medial malleolar screws, and stiffer plates are all viable options. Furthermore, due to delayed healing properties, prolonged immobilization may also be required to avoid fixation failure.
Guo et al. performed a cohort controlled comparison between diabetics and non-diabetic patients with operative ankle fractures. Although they hypothesized that there would be more complications in the diabetic group, there was no statistical differences in fixation failure or complications when adhering to treatment principles for diabetics (including prolonged non-weight bearing for 10-12 weeks and increased density of fixation).
Chaudhary et al. review the notable complications following ankle fracture treatment in patients with diabetes. In reviewing the literature, the authors recommend ORIF with meticulous soft tissue handling, increased density of fixation, and prolonged immobilization as the mainstay of diabetic ankle fracture treatment. External fixation and frames, while treatment options, should be reserved for salvage or infectious clinical scenarios.
Figure A depicts a bimalleolar ankle fracture. Figure B depicts a cam walker.
Figure C depicts a cast. Figure D standard fixation for ankle fracture for a patient without diabetes. Figure E exhibits definitive fixation with additional screws to increase construct stability. Figure F depicts a ring fixator.
Incorrect Answers:
Answers 1,2: Non-operative treatment is not appropriate for this fracture pattern
Answer 3: Figure D, typically used for those without diabetes is less appropriate for this patient/clinical scenario.
Answer 5: While external fixation and a ring fixator may be utilized, ORIF should be attempted first, however, as it provides stiffer fixation.

Distraction bone block arthrodesis alone would most likely help a patient suffering from a painful calcaneus fracture malunion with all of the following except:

1) Low talar declination angle

2) Hindfoot varus alignment

3) Subtalar arthritis

4) Talonavicular subluxation

5) Peroneal impingement

Distraction bone block arthrodesis in isolation would be unlikely to improve pain related to peroneal impingement. Lateral wall exostectomy would likely be needed for this, and should be concomitantly performed in most cases.
Calcaneal fracture malunions demonstrate several common patterns. Patients may manifest pain from anterior tibiotalar impingement (a result of a low talar declination angle), difficulty with shoe wear due to shortening and widening of the hindfoot, painful talonavicular subluxation, subfibular impingement, and post-traumatic subtalar osteoarthritis. The distraction bone block arthrodesis procedure was developed to eliminate the pain of subtalar arthritis while simultaneously normalizing hindfoot height by inserting a contoured structural bone graft into the subtalar joint. The procedure can correct pathologic hindfoot varus/valgus and restore a normal talocalcaneal angle, thereby improving symptomatic post-traumatic pes planus. The procedure alone does not address lateral wall blowout causing subfibular or peroneal impingement, which requires lateral wall exostectomy. Lateral wall exostectomy therefore should be done in addition to address this issue.
Carr et al. first reported the use of subtalar distraction bone block arthrodesis for salvage of post-traumatic subtalar arthritis following calcaneus fractures. In their 16 patient series, distraction of the subtalar joint with insertion of the bone block allowed for correction of talocalcaneal angle, restoration of hindfoot height, and improvement in symptoms related to tibiotalar impingement.
Clare et al. evaluated a treatment protocol for calcaneal malunions based upon the classification of Stephens and Sanders. Type II and III malunions were treated with subtalar bone-block arthrodesis and other concomitant procedures. They found that their treatment protocol was effective for pain relief, re-establishing a plantigrade foot, and improving function. The most difficult component of the case was restoration of calcaneal height.
Braley et al. evaluated isolated lateral decompression in the treatment of symptomatic calcaneal malunions without concomitant subtalar arthrodesis. These 11 patients had persistent lateral sided pain and their malunions did demonstrate subtalar involvement. The authors reported 9 of the 11 patients had a satisfactory outcome with lateral decompression alone. They concluded that a lateral decompression in management of symptomatic malunions with lateral-sided symptoms is an essential consideration.
Incorrect Answers:
Answer 1: Talar declination angle describes the relative plantar- or dorsiflexion of the talus relative to the ground.
Answer 2: Hindfoot alignment can be improved with distraction arthrodesis. Answer 3: Arthrodesis addresses painful subtalar arthritis.
Answer 4: Restoration of the normal talocalcaneal angle can be achieved, which can also normalize the talonavicular relationship.

A 31-year-old patient has had activity related lateral ankle pain for 4 months. She underwent the procedure shown in Figure A approximately 8 months ago. What surgical technique has most likely resulted in this patients pain?
1) Failure to recognize the most distal screw penetrating the joint surface

2) Low posterior plating with prominent distal screw

3) Failure to recognize an associated syndesmosis disruption

4) Fracture malreduction causing shortening of the fibula

5) Failure to use a longer plate with the lag screw positioned outside the plate

Figure A shows a low posterior plate with a prominent screw head in the most distal hole of the plate. This fixation technique is correlated with peroneal pathology, which usually presents months after fixation when the patient increases their activity level.
The two most common fixation techniques of lateral malleolus fractures are (1) lag screw plus lateral neutralizing plating and (2) posterolateral antiglide plating. The disadvantages of the lateral plating includes the risk of intraarticular screws distally, prominent lateral hardware, and poor distal screw fixation. To overcome these complications, posterolateral antiglide plating allows for bicortical distal fixation with no articular perforation. However, low placement of the plate with a prominent screw head in the most distal hole is associated with symptomatic peroneal pathology. If the most distal screw is not prominent, or absent, this is less likely to cause peroneal complications.
Weber et al. examined the effect of antiglide plate and screw positioning on peroneal tendon pathology. They showed that low posterior plating and large screw heads caused significant retromalleolar pain in most patients. To decrease peroneal pathology, they state that the distal end of the plate should stay proximal to the osteosynovial peroneal groove. Radiologically this level
corresponds to the junction of the proximal and middle thirds of the lateral malleolus.
Figure A shows a posterior positioned 5 hole 1/3 tubular plate. There is no articular screw penetration and the fracture is healed in an anatomical position. The distal aspect of the plate is is the distal third of the lateral malleolus.
Incorrect Answers:
Answer 1: The most distal screws rarely penetrates the joint with the use of fibular antiglide plates. In addition, there is no evidence of screw penetration in this patient.
Answer 3: A missed syndesmosis disruption would usually show some radiographic findings. The tibiofibular clear space is usually most sensitive, which is measured radiographically by the distance from the lateral border of the posterior malleolus in the distal tibia to the medial border of the fibula. As a general rule, it is considered normal if the measurement is less than approximately 6 mm on both AP and mortise views.
Answer 4: The fracture reduction looks anatomic. The talocrural angle, 'dime' sign and “Shenton's line” of the ankle all normal.
Answer 5: The construct used to fix this isolated lateral trans-syndesmotic fracture is acceptable. The one-third tubular plate, which is placed posterolaterally on the fibula as an antiglide plate, indirectly reduces the fracture and acts as a buttress to resist the posterior and proximal displacement of the distal fragment. Insertion of a lag screw through the plate is a described technique.

A 35-year-old painter falls from a ladder sustaining an isolated fracture of his left calcaneus. Months later at follow-up, he is noted to have pain and a catching sensation in his medial foot with active flexion of the great toe. What is the most likely initial injury leading to this complication?

1) Displaced calcaneal beak fracture

2) Displaced fracture of the calcaneal tuberosity

3) Comminuted posterior facet fracture

4) Fracture of the sustentaculum tali

5) Lateral wall blowout fracture

A known complication of fractures of the sustentaculum tali is stenosis (delayed) or injury (acute) of the flexor hallucis longus (FHL) tendon. Stenosis
can cause pain and popping with great toe flexion.
Fractures of the calcaneus often occur after falls from height, and in addition, may be associated with vertebral fractures due to the high-impact mechanism. The FHL tendon runs directly underneath the sustentaculum tali on the medial calcaneus and can be injured causing frank tears or delayed stenosis. These fractures may be missed on ankle or foot plain films alone, and advanced imaging should be ordered if clinical suspicion for calcaneus fractures exists given mechanism and location of pain/swelling.
Komiya et al. present a case report of direct impalement of the FHL tendon in the tunnel under the sustentaculum tali. Though this particular complication is quite rare, such a report highlights the relevant anatomy and structures at risk as well as demonstrates the need for a good clinical exam as the injury was not noted on imaging but the concern was raised on physical exam of FHL involvement.
Della Rocca et al. report their 19-patient series on operatively managed isolated sustentaculum tali fractures. They report a high rate of associated ipsilateral foot injuries (14 patients) and describe fixation using a medial approach and retracting the flexor tendons and neurovascular bundle.
Illustration A is an axial CT image from Della Rocca (2009) et al. showing a representative sustentaculum tali fracture
Incorrect Answers:
Answer 1 - beak fractures are posterior, anatomically related to the Achilles tendon insertion, not the FHL tendon.
Answer 2 - FHL tendon is not associated with the tuberosity.
Answer 3 - FHL tendon runs anterior to the posterior facet and would unlikely be involved in that injury.
Answer 5 - FHL tendon runs medially, not laterally.

A 30-year-old male patient involved in a hang-gliding accident sustains a knee dislocation with multiligamentous knee injury and transection of his peroneal nerve. He undergoes multiple reconstructive surgeries. Two years later, he continues to have a foot drop and dynamic tendon transfer is recommended. This treatment most commonly involves transferring a tendon from which native insertion point to which new insertion point?

1) Plantar distal phalanges to medial navicular

2) Medial navicular to dorsal lateral cuneiform

3) Plantar 1st metatarsal to dorsal lateral cuneiform

4) 5th metatarsal base to dorsal medial cuneiform

5) Plantar distal phalanx of the hallux to dorsal distal phalanx of hallux

Dynamic tendon transfer to restore active dorsiflexion of the foot involves transferring the posterior tibial tendon (PTT) insertion on the medial navicular to the dorsal lateral cuneiform.
Common peroneal nerve (CPN) injuries following traumatic knee dislocation are common, with an incidence of 25-40%. CPN palsy is characterized by foot drop
due to loss of ankle dorsiflexors with a steppage gait and eventual development of a supinated equinovarus foot secondary to the unopposed pull of the PTT. Nonsurgical management involves use of an ankle-foot orthosis and physical therapy. Surgical options include acute primary repair, nerve grafting with either autologous sural nerve or nerve conduits and dynamic tendon transfer. The PTT is harvested from its insertion at the navicular, passed through the interosseous membrane (IOM) and anchored to the lateral cuneiform (see Illustration A). The classic bridle procedure involves concomitant anastamosis of the PTT to the tibialis anterior (TA) and peroneus longus (PL) tendons.
Garozzo et al reported a case series of 62 patients with post-traumatic CPN palsy who underwent a one-stage procedure consisting of nerve repair and PTT transfer. Nerve repair combined with PTT transfer improved postoperative outcomes compared to nerve repair alone. At 2-year follow up, neural regeneration was demonstrated in 90% of patients. The authors hypothesized that poor outcomes following nerve repair alone are due to force imbalance between the functioning flexors and paralyzed extensors, which is somewhat equalized by performing a PTT transfer at time of repair.
Niall et al reviewed 55 patients with traumatic knee dislocation and reported a 41% incidence of CPN injury, exclusively associated with dislocations involving disruption of the posterior cruciate ligament (PCL) and posterolateral corner (PLC). Complete neurologic recovery was found in only 21% of patients. The best prognosis was found with lesions in continuity, less than 7cm of nerve involvement, and short conduction block and muscle activity on nerve conduction and EMG studies.
Vigasio et al described a dynamic tendon transfer technique for traumatic complete CPN injury, involving transfer of the PTT to the TA rerouted to a new origin at the lateral cuneiform to restore ankle dorsiflexion and flexor digitorum longus (FDL) to the extensor digitorum longus (EDL) and extensor hallucis longus (EHL) to restore digit dorsiflexion. Rerouting the TA towards the transferred PTT ensures the PTT harvest length is sufficient. This avoids excessive tensioning of the PTT, which may limit tendon excursion and result in a static tenodesis rather than dynamic function, as well as the need for PTT lengthening which may decrease strength of the transfer
Illustration A is a series of intraoperative photographs demonstrating PTT transfer from Garg et al. An incision is made distal to the medial malleolus and the PTT is harvested subperiosteally (A). The PTT is delivered through a second incision ~15cm proximal to the medial malleolus (B-C). The PTT is then passed through the interosseous membrane and out a third incision over the anterior
fibula (D). Lastly, the PTT is passed through a fourth incision over the dorsal midfoot and anchored to the lateral cuneiform (E).
Incorrect Responses:
Answer 1: Transferring the FDL (insertion = plantar distal phalanges) to the medial navicular is used for correction of flexible flatfoot deformity arising from PTT insufficiency. Some surgeons transfer the FDL to the medial navicular at the time of PTT transfer to the dorsum of the foot, to compensate for loss of PTT function and minimize risk of flatfoot development.
Answers 3: Transferring the PL (insertion = plantar 1st metatarsal) is not recommended, as this muscle is innervated by the CPN via the superficial peroneal nerve and therefore would not be functional.
Answer 4: Transferring the peroneus brevis (PB; insertion = 5th metatarsal base) is not recommended, this muscle is innervated by the CPN via the superficial peroneal nerve and therefore would not be functional.
Answer 5: Transferring the flexor hallucis longus (FHL; insertion = plantar distal phalanx of the hallux) to the insertion of the EHL (dorsal distal phalanx of hallux) is recommended for correction of claw toe deformity and would not help restore foot dorsiflexion in this patient.

Which of the following represents the most common complication following operative treatment of the injury shown in Figure A?
1) Figure B

2) Figure C

3) Figure D

4) Figure E

5) Figure F

This patient has a displaced talar neck fracture. The most common complication is post-traumatic arthritis.
Complications after treatment of displaced talar neck fractures are common. Both tibiotalar and subtalar arthritis occur, with subtalar arthritis being the most common. Osteonecrosis is also common, but post-traumatic arthritis is the most common.
Lindvall et al. reviewed 26 displaced talar fractures treated with internal fixation and found that post-traumatic arthritis was the most common complication, occurring in 100% of patients. Osteonecrosis was found in 13 of 26 patients (50%).
Vallier et al. reviewed patients presenting with talar neck fractures and found post-traumatic arthritis in 21 of 39 patients (54%). Osteonecrosis was found in 19 of 39 patients (49%).
Figure A shows a displaced talar neck fracture. Figure B shows talar neck nonunion (arrow) and osteonecrosis of the talar body. Figure C is an AP of the same patient shown in Figure B and again shows osteonecrosis of the talar body. Figure D shows subtalar arthritis after internal fixation of a talar neck fracture via medial malleolar osteotomy. Figure E shows a clinical photo of a patient with a varus malunion after talar neck fracture. Figure F shows a wound dehiscence.
Incorrect answers:
Answers 1, 2, 4, 5. These are all known complications of surgical treatment of displaced talar neck fractures but occur less frequently than post-traumatic arthritis.

A 25-year-old woman began training for a marathon and she reports a 2-week history of heel pain. She has pain throughout the day that worsens with prolonged weight-bearing. On exam, the location of
maximal tenderness is indicated by the white arrow in Figure A. The patient denies point tenderness at the location of the yellow arrow in Figure A. Which of the following MRI images (Figures B to F) would you expect to find in this patient?
1) Figure B

2) Figure C

3) Figure D

4) Figure E

5) Figure F

The clinical presentation is consistent with a stress fracture of the calcaneus. The T1 MRI shows a fracture line within the calcaneus which is consistent with
a calcaneal stress fracture.
Calcaneal stress fractures most commonly occur in long-distance runners and military recruits. Usually, they are caused by overload and inability of bone formation to match resorption. Patients usually begin a rapid increase of activity level from a prior sedentary lifestyle. Patients complain of heel pain that persists throughout the day. The pain is located along the medial and lateral walls of the calcaneus. Diagnosis can be made with radiographs 2-3 weeks after symptom onset by the appearance of a sclerotic line. If the diagnosis is uncertain, MRI may be obtained.
Gehrmann et al. performed a review of stress fractures in the foot. They report that most studies of calcaneal stress fractures are from military recruits.
Primary treatment includes rest, avoidance of weight-bearing, and physical therapy. Patients usually return to full duty between 8 and 10 weeks. Recruits with inadequate treatment had a recurrence of symptoms. They conclude that most studies are from the 1940’s and 1950’s and lack any significant detail into specific treatment protocols.
Sormaala et al. performed a retrospective study in which they reviewed MRIs in all military recruits who had exercise-induced heel pain, over an eight-year period. They report that only 15% of injuries were visible on radiographs and a portion of patients had stress fractures of another tarsal bone. They conclude that a majority of calcaneal stress fractures occur in the posterior part of the bone, but some fractures may be found in the middle and anterior parts. They recommend obtaining an MRI if a radiograph is negative in a patient with exercise-induced foot or heel pain.
Figure A demonstrates the most common area of tenderness and pain of a calcaneal stress fracture, indicated by the white arrow, while the yellow arrow points to the area of tenderness consistent with plantar fasciitis. Figure B is a sagittal T2-weighted MRI demonstrating plantar fasciitis. Figure C is a sagittal T1-weighted MRI demonstrating a calcaneal stress fracture. Figure D is an axial T1-weighted MRI demonstrating a mass on the medial aspect of the calcaneus consistent with a ganglion cyst. Figure E is a sagittal T1-weighted MRI of the foot demonstrating an intraosseous lipoma within the calcaneus. Figure F is a sagittal T2-weighted MRI demonstrating insertional Achilles tendinopathy.
Illustration A demonstrates the most common etiologies of plantar foot pain.
Incorrect Answers:
Answer 1: Figure B, a sagittal T2-weighted MRI, demonstrates plantar fasciitis. Symptoms of plantar fasciitis are sharp heel pain, usually worse in the morning. Tenderness is usually found on the plantar aspect of the foot.
Answer 3: Figure D, an axial T1-weighted MRI, demonstrates a ganglion cyst in the tarsal tunnel. Symptoms of tarsal tunnel syndrome include sharp burning pains in the foot and parasthesias and numbness in the plantar foot.
Answer 4: Figure E, a sagittal T1-weighted MRI, demonstrates an intraosseous lipoma. Intraosseous lipomas are usually incidental findings.
Answer 5: Figure F, a sagittal T2-weighted MRI, demonstrates insertional Achilles tendinitis. This usually presents with pain over the insertion of the Achilles. It may have a relapsing and remitting course, which worsens with activity.

A 35-year-old male fell and sustained an open talar neck fracture. He underwent operative fixation of his fracture. He presents at 2 months after surgery. He denies any constitutional symptoms and his pain is well controlled. On exam, his wounds are well healed with no erythema. Imaging is shown in Figure A. What can the patient be told about his condition?
1) Hawkins sign is positive. The likelihood of developing osteonecrosis is high

2) Hawkins sign is positive. The likelihood of developing osteonecrosis is low

3) Hawkins sign is negative. The likelihood of developing osteonecrosis is high

4) Hawkins sign is negative. The likelihood of developing osteonecrosis is low

5) He has developed chondrolysis

This patient has a positive Hawkins sign, which signifies that he is unlikely to develop osteonecrosis.
A subchondral radiolucency of the talar dome after a talar neck fracture is known as the Hawkins sign. It is an indication that the talar body is viable. It usually appears by 6-8 weeks after injury and is best seen on the mortise view. If the Hawkins sign is present, it is unlikely that the patient will develop osteonecrosis.
Early writes a review on talus fracture management. He reports that talar neck fractures occur through the extra-articular portion of the talus and represent nearly half of talus fractures. The mechanism of injury is a combined ankle dorsiflexion followed by axial compression of the tibiotalar joint. He concludes that anatomic reduction gives the patient the best chance of a good outcome.
Leduc et al. wrote a review on posttraumatic avascular necrosis of the talus. They note that AVN is diagnosed on plain radiography by the absence of the Hawkins sign. They report that CT can also reveal characteristic talar AVN patterns and can be used to confirm radiographic findings. CT helps to assess subtle depression, collapse, fragmentation, and arthritic changes. MRI remains the most sensitive technique for detecting osteonecrosis of the talus, especially in the early stages. They conclude that although there are many published treatments of AVN of the talus, outcome studies are still lacking.
Tezval et al. performed a retrospective review to determine the prognostic reliability, sensitivity, and specificity of the Hawkins sign. They found that in all patients who developed osteonecrosis, none had the Hawkins sign present. In all patients that exhibited a Hawkins sign, none developed osteonecrosis. They determined the sensitivity of the Hawkins sign to be 100% while the specificity was 57.5%. They conclude that if a full or partial positive Hawkins sign is detected, it is unlikely that AVN will develop.
Figure A demonstrates the Hawkins sign with subchondral radiolucency which is noted by arrows in Illustration A.
Incorrect Answers:
Answers 1, 3, 4: The patient has a positive Hawkins sign, therefore the chance of developing osteonecrosis is low.
Answer 5: Chondrolysis is characterized by rapid destruction of articular cartilage on both sides of the joint which leads to loss of joint space

A 25-year-old male presents to the emergency department after a lawnmower accident with traumatic loss of his great toe. On examination, his wound is grossly contaminated with soil. In addition to a cephalosporin and an aminoglycoside, penicillin is given. Which of the following is true with regards to the organism that penicillin is targeting in this injury?

1) It is an Aerobic, Gram-positive rod

2) It is an Anaerobic, Gram-positive coccus

3) It is an Anaerobic, Gram-negative rod

4) It is Catalase positive

5) It may cause botulism

The organism being covered with penicillin is Clostridia spp. Clostridium botulinum is a Gram Positive Bacilli that is the cause of botulism.
Clostridia spp, is a Gram-positive, obligate anaerobic spore-forming rod that is found in soil and gut flora. It produces gas by the fermentation of glucose and
may cause gas gangrene. Common bacteria of this genus are C. perfringens (most common), C. tetani (causes tetanus), C. difficile, and C. botulinum (causes botulism). If wounds are grossly contaminated with soil, penicillin is given to cover against Clostridia.
Decoster et al. performed a review of traumatic foot wounds. They report that lawnmower injuries to the foot are relatively common. IV antibiotic therapy should be initiated with a broad-spectrum cephalosporin and an aminoglycoside to provide coverage against Gram-negative organisms.
Penicillin should be given to protect against Clostridial infection. They conclude that irrigation and debridement is indicated initially followed by packing of open wounds. Repeat debridements are necessary as nonviable tissue demarcates. If major reconstructive procedures are necessary, they should be delayed as they have a high rate of failure if performed too soon.
Cross et al. wrote a review on treatment principles in the management of open fractures and they note that in open fractures with soil contamination, additional coverage should be added for anaerobic bacteria, typically Clostridia. Another member of the genus Clostridia is C. tetani, the causative agent of tetanus. Vaccine status for tetanus must also be assessed in these situations as well.
Illustration A is a radiograph demonstrating soft tissue swelling and subcutaneous emphysema, consistent with gas gangrene. Illustration B is a clinical photograph of gas gangrene evidenced by edema, discoloration, ecchymosis, and hemorrhagic bullae. Illustration C is a pathology slide of C. perfringens, a Gram-positive rod.
Incorrect Answers:
Answers 1, 2, 3: Clostridia are Gram-positive, obligate anaerobes. Answer 4: Clostridia are catalase negative.

All of the following are ways that a negative pressure dressing is beneficial to wound healing EXCEPT:

1) Accelerated granulation tissue formation

2) Removes excess proteins and electrolytes from wound

3) Reducing anaerobic colonization

4) Causes cells to release vascular endothelial growth factor by mechanical force

5) Causes an increase in capillary afterload

Negative pressure dressings or vacuum-assisted wound closures (VAC) apply a negative pressure to the wound bed which allows a decrease in capillary afterload which produces a better inflow of blood.
VAC dressings exert their positive effects on wound healing in multiple ways. Firstly, they remove interstitial fluids, which have been found to contain inhibitory factors that suppress the formation of fibroblasts, vascular endothelial cells, and keratinocytes. This also eliminates the formation of any superficial purulence or slime which also reduces the potential for anaerobic colonization. Removal of excess fluid also pulls out excess proteins and electrolytes to help maintain and osmotic and oncotic gradient. VACs allow arterioles to dilate which produces a proliferation of granular tissue. Also, there is a decrease in capillary afterload, (the pressure against which the heart must overcome to eject blood), which promotes better inflow of blood. Lastly, applying a mechanical force to the surrounding soft tissues allows the edges of the wound to be drawn towards the center, uniformly. This decreases the size of the wound over time. The micromechanical forces exerted on individual cells causes a release in local growth factors, such as vascular endothelial growth factor (VEGF), which stimulate wound healing.
Herscovici et al. applied VAC dressings to 21 consecutive patients with open, high-energy soft tissue injuries. They found that wounds averaged 4.1 sponge changes and the device was used for an average of 19.3 days. 12 wounds avoided the need for further treatment. Only 9 patients required free tissue transfer. They concluded that the VAC is a viable treatment adjunct for the treatment of open, high-energy injuries.
Clare et al. reported their experience with the VAC dressing in the treatment of non-healing, diabetic and dysvascular wounds. They retrospectively reviewed 17 patients with non-healing wounds of the lower extremity. 9 had diabetes and 8 had severe peripheral vascular disease. The average length of treatment
was 8.2 weeks and 14/17 wounds successfully healed, and only 3 failed VAC treatment. They concluded that the VAC dressing is an acceptable option for wound care of the lower extremity.
Illustration A is a photo of an open wound being treated with a VAC dressing. Incorrect Answers:
Answers 1, 2, 3, and 4 are all ways that VAC dressings are beneficial to wound
healing.

Which of the following is true regarding anterior sternoclavicular joint dislocations?

1) Reduction may result in tracheal injury

2) They are usually stable following closed reduction

3) They require fusion to hold the reduction

4) They are rarely symptomatic when left unreduced

5) They should be treated acutely with medial clavicle excision

From the Bicos article, “Anterior SC joint instability should primarily be treated conservatively. The patients should be informed that there is a high risk of persistent instability with nonoperative or operative care, but that the persistent instability will be well tolerated and have little functional impact in the vast majority. Therefore, operative intervention for anterior SC joint instability is mainly cosmetic in nature."

An otherwise healthy 45-year-old female slips and falls with immediate right ankle pain. Stress examination of the right ankle is shown in Figure A. Which of the following is the most important for achieving a satisfactory outcome following open reduction internal fixation for this injury?
1) Weight-bearing before 3 weeks.

2) Medial clear space >5mm

3) Talocrural angle of 83 degrees

4) Tibiofibular clear space of >6mm

5) Talar tilt of >5 degrees

Anatomic reduction of a rotational ankle fracture is considered the most important factor in achieving a satisfactory outcome. A talocrural angle of 83 degrees suggests an anatomic reduction has been achieved.
Unstable rotational ankle fractures should be treated surgically in order to achieve anatomic reduction (if the fracture is not overly comminuted) as well as restore length, rotation, and alignment. Satisfactory outcomes can be best achieved when these surgical goals are achieved. Postoperative protocols
regarding immobilization and weight bearing may be somewhat variable depending on surgeon preference, fracture pattern, modifiable patient factors, and non-modifiable patient factors.
Lin et al. performed a systematic review of randomized studies looking at postoperative immobilization and rehabilitation following ankle fractures. They found that after surgical fixation, starting exercise in a removable brace improved pain, ankle range of motion, and improved activity limitations but led to a higher rate of adverse events. Early weight-bearing improved ankle range of motion as well. They concluded that there is limited evidence to support removable braces, early weight-bearing, and no immobilization following surgical fixation of ankle fractures.
Reidsma et al. retrospectively reviewed 57 malunited ankle fractures treated with revision osteotomy with a minimum of 10 years of follow-up. They found that 85% of patients had good or excellent outcomes and that prolonged time to reconstructive surgery led to a worse outcome. They concluded that reconstructive surgery should be performed early in the setting of a malunited ankle fracture even with early arthritic changes.
Figure A shows a displaced Weber B fibula fracture with medial joint space widening on stress examination. Illustration A shows intraoperative imaging following open reduction internal fixation of the same patient. Illustration B demonstrates the talocrural angle and medial clear space parameters in an anatomically reduced ankle.
Incorrect Answers:
Answer 1: Nonweightbearing for at least 6 weeks is common; however, some studies have shown improved outcomes in range of motion if weight-bearing is started early in the immobilization period.
Answer 2, 4, and 5: Postoperatively the parameters of the medial clear space

Which of the following arteries supplies the surgical flap in the extensile open treatment of the injury shown in Figure A?
1) Lateral calcaneal branch of the anterior tibial artery

2) Lateral calcaneal branch of the peroneal artery

3) Lateral malleolar branch of the peroneal artery

4) Lateral malleolar branch of the dorsalis pedis artery

5) Lateral malleolar branch of the anterior tibial artery

This patient has a displaced calcaneal fracture that is commonly treated through a lateral extensile approach. The flap of the lateral extensile approach is supplied by the lateral calcaneal branch of the peroneal artery.
Intraarticular fractures of the calcaneus represent approximately 2% of all fractures and are commonly the result of high-energy trauma such as motor vehicle accidents and falls. Successful operative treatment of these injuries depends on the anatomic reduction of the articular surface; restoration of the alignment, height, and length of the calcaneus; and avoidance of complications. These fractures are usually treated with a lateral extensile approach. The artery which provides blood supply to this flap is the lateral calcaneal branch of the peroneal artery. It is critical to maintain the integrity of this vessel in order to avoid complications.
Borrelli et al. performed a study to describe the arterial blood supply of the subcutaneous tissues of the lateral hindfoot and to define the relationships between these arteries and the lateral extensile incision. The lateral calcaneal artery appeared to be responsible for the blood supply to the corner of the flap.
Figure A demonstrates a displaced fracture of the calcaneus. Illustration A depicts the arteries on the lateral foot (PA: peroneal artery, LCA: lateral calcaneal artery, LMA: lateral malleolar artery, LTA: lateral tarsal artery). Illustration B (Borrelli et al.) is a lateral radiograph of the hindfoot and ankle that demonstrates skin staples placed along the surgical incision and vascular clips placed along the path of each artery. Illustration C is a clinical photograph of the lateral extensile approach.
Incorrect Answers:
Answer 1: The lateral calcaneal artery is a branch of the peroneal artery, not the anterior tibial artery.
Answers 3-5: The lateral malleolar artery is a branch of the anterior tibial artery. It does not supply the flap of the lateral extensile approach.

A 25-year-old male presents following a motor vehicle collision with a Glasgow Coma Scale of 7. Subsequent imaging in the trauma bay demonstrates a bifrontal cerebral contusion, an L4 burst fracture, multiple rib fractures, an LC-1 type pelvic ring injury, a femoral shaft fracture, and an open ipsilateral tibial shaft fracture. He is intubated and an intracranial pressure monitor is placed which consistently measures 30mm Hg. He is normotensive with a lactate of 1.5 after 2 liters of crystalloid and 1 unit of packed red blood cells. Which of his injuries would most dictate a temporizing approach with external
fixation of his femoral shaft fracture instead of reamed intramedullary nailing?

1) L4 burst fracture

2) Bifrontal cerebral contusion

3) Open ipsilateral tibia fracture

4) LC1 pelvic ring injury

5) Rib fractures

In the setting of a severe closed head injury such as a bifrontal cerebral contusion with elevated intracranial pressures, external fixation of a femoral shaft fracture is indicated to limit the risk of intraoperative hypotension and decreased cerebral perfusion pressure.
Immediate reamed nailing remains the standard treatment for the vast majority of femoral shaft fractures, however patients with multiple injuries with incomplete resuscitation and patients with severe intracranial trauma may benefit from a damage control approach with external fixation.
Anglen et al retrospectively reviewed the intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients undergoing femoral nailing. The authors found a significant decrease in intraoperative CPP, especially in those patient undergoing femoral nailing in the first 24 hours, however they were unable to demonstrate a link between the decreased CPP and poor patient outcomes.
Pietropaoli et al examined the effects of intraoperative hypotension on patients with blunt head trauma. The authors found that 32% of patients experienced intraoperative hypotension (systolic blood pressure less than 90mm Hg) and those patients with a hypotensive episode had an 82% mortality and significantly worse outcomes on the Glasgow Outcomes Scale.
McKee et al conducted a retrospective cohort study comparing matched groups of patients with femoral shaft fractures with and without a closed head injury. In contrast to previous studies, the authors found no significant difference in outcome between the groups including mortality, hospital length of stay or neuropsychologic testing.
Illustration A shows a femoral shaft fracture treated with external fixation. Incorrect Answers:
Answer 1, 3-5: Immediate reamed nailing would not change the outcome of any of these injuries

A 22-year-old left hand dominant laborer sustains the injury shown in Figures A and B as the result of a fall from a ladder. Which of the following has been shown to be true regarding operative versus nonoperative treatment of this injury?
1) Decreased chance of nonunion with nonoperative treatment

2) Improved Constant and DASH scores with operative treatment at all time points

3) Increased symptomatic malunion rate with operative treatment

4) No change in shoulder abduction strength

5) Increased time to union with operative treatment

Surgical management of displaced, shortened clavicle fractures is associated with a decreased rate of nonunion and malunion. General recommendations for surgical treatment include shortening of greater than 2 centimeters.
Kim et al. review clavicle fracture treatment history and current indications. They report that although previous thought was that nearly all clavicle fractures should be treated nonoperatively, outcomes can be improved with fixation of certain clavicle fracture patterns.
COTS et al. performed a multicenter, randomized controlled trial of 132 patients with a displaced midshaft fracture of the clavicle. They found that Constant and DASH scores were improved in the operative fixation group at all points in time, with union time being 28 weeks in the nonoperative group and
16 weeks in the operative group. Malunion was higher in the nonoperative group as well.
McKee et al. reviewed 30 patients who underwent closed treatment of a displaced midshaft clavicle fracture. They found that range of motion of the shoulder was maintained but the strength of the shoulder was decreased to 81% for flexion, 82% for maximum abduction, 81% for maximum external rotation, and 85% for maximum internal rotation. Endurance for these movements was also significantly decreased as compared to the contralateral side.
Figure A shows a clinical photo of a patient with a clavicle fracture. Figure B shows a displaced, comminuted clavicle fracture.
Incorrect Answers:
Answer 1: Operative treatment increases the union rate.
Answer 3: Operative treatment decreases the rate of symptomatic malunion. Answer 4: Operative treatment increases shoulder abduction strength.
Answer 5: Time to union is decreased with operative treatment.

A 45-year-old female presents to the office wearing a right upper arm splint with radiographs shown in Figure A and B. She sustained an isolated closed injury to the right arm 9 days ago. Her soft-tissues and neurological examination are normal. What would be the most appropriate treatment for this injury?
1) Continue current splint for 6 weeks

2) Continue current splint for 3 weeks and transition to hanging arm sling for additional 3 weeks

3) Transition to functional brace for additional 6-8 weeks

4) Open reduction internal fixation with compression plating

5) Staged procedure with humeral external fixator, then open reduction internal fixation with compression plating

Figures A and B show radiographs on a minimally displaced humeral shaft fracture. The most appropriate treatment for this injury would be functional bracing (Sarmiento) for an additional 6-8 weeks or until healed.
Commonly accepted parameters for closed treatment include less than 30 degrees of varus angulation, 20 degrees of anterior/posterior angulation, and 3 cm of shortening. Functional bracing has become the gold standard for humeral shaft fractures as it consistently shows excellent healing results as well as preventing the complication of shoulder +/- elbow stiffness associated with joint spanning splints or slings.
Sarmiento et al. treated 922 patients with humeral diaphysis fractures with a prefabricated brace. They found a 97% rate of union with the use of the brace. In addition, only 2% of the patients had lost more than 25 degrees of shoulder motion at the time of brace removal.
Koch et al. reviewed 67 humeral shaft fractures that were treated by Sarmiento bracing in a 15-year period. Fifty-eight cases (87%) had healed clinically at a mean of 10 weeks. Among 9 patients with delayed or nonunion leading to operative intervention, there were 6 cases with transverse fractures
Figures A and B show a moderately displaced right humeral shaft fracture with 13 degrees of AP angulation, 10 degrees of varus/valgus angulation and no shortening, treated in a coaptation splint. A nondisplaced proximal humeral fracture is also seen. Illustration A shows an image taken of a patient wearing the sarmiento brace.
Incorrect Answers:
Answer 1,2: Joint spanning splints or slings have not shown to be superior to functional bracing. They are associated with joint stiffness post removal.
Answer 4: Operative indications are: associated vascular injuries, bilateral humeral shaft fractures, polytrauma patient (including paraplegia), injury to the brachial plexus, pathological fractures, floating elbow, and floating shoulder.
Answer 5: Staged operative procedure would be indicated in open fractures or significant deformity with soft-tissue swelling.

Which of the following is an appropriate initial step in the management of a multiply injured patient with an unstable pelvic ring fracture and hemodynamic instability?

1) Application of an external fixator

2) Pelvic angiography

3) Pelvic packing

4) Application of a pelvic binder

5) Percutaneous Iliosacral screws

Patients with multiple injuries including a pelvic ring fracture who present with hemodynamic instability should have a pelvic binder or circumferential pelvic sheet placed as part of their initial resuscitation.
A systematic approach to search for sources of bleeding and control ongoing hemorrhage is necessary for patients who present with hemodynamic changes in the setting of a pelvic ring fracture. Management of continued hypotension after pelvic binder placement is controversial and varies among trauma centers.
Krieg et al. prospectively evaluated 16 patients with unstable pelvic ring injuries initially managed with a novel circumferential compression device. The authors found substantial reduction in pelvic width with the use of this
compressive device in patients with volume expanding pelvic ring fractures.
Croce et al. retrospectively compared patients with unstable pelvic ring injuries who were treated with either emergent pelvic fixation (EPF) or a pelvic orthotic device (POD). The authors found that those patients treated with POD had decreased transfusion requirements and shorter length of hospital stay.
Routt et al describe their technique for circumferential pelvic antishock sheeting (CPAS). The authors provide an illustrative case and discuss the potential advantages of sheet application versus other techniques of pelvic stabilization.
Illustration A is the initial AP radiograph of a patient with a pelvic fracture and hemodynamic instability. The pelvic binder was placed in the field prior to arrival. Illustration B demonstrates the same patient in the angiography suite after removal of the pelvic binder. Note the increased widening of bilateral SI joints, greater on the left than the right.
Incorrect Answers:
Answer 1: External fixation of pelvic ring fractures can be used to assist with resuscitation but pelvic binder application should be attempted first
Answer 2: The use of pelvic angiography is controversial and institution specific however some centers utilize pelvic angiography as part of the algorithm for management of ongoing hemorrhage.
Answer 3: Pelvic packing is utilized in some centers to control ongoing pelvic hemorrhage however it is not used as initial management of patients with hemodynamic instability
Answer 5: Percutaneous iliosacral screws can also be utilized as a form of resuscitation however they should not be used as as first line of management

A 19-year-old female sustains the injury shown in Figures A thru C as the result of a motor vehicle collision. Which of the following is the most common cause of death with this type of pelvic injury pattern?
1) Hypovolemic shock

2) Spinal injury

3) Solid organ rupture

4) Acute respiratory distress syndrome

5) Closed head injury

The injury pattern described in the question and images is a lateral compression pelvic ring injury. Of the choices provided, the most common associated cause of death is a closed head injury.
Pelvic ring disruptions are the result of high energy blunt trauma and are associated with other significant injuries in greater than 50% of the cases. These injuries may involve neurovascular structures and other organ systems.
Burgess et al. retrospectively reviewed their pelvic ring injuries and reported their classification system based upon the vector of force involved and the quantification of disruption from that force, i.e., lateral compression, anteroposterior compression, vertical shear, and combined mechanical injury. Overall blood replacement was highest in anterior-posterior patterns. Mortality was also highest in anteroposterior patterns. The most common identifiable cause of death in patients with lateral compression fractures is closed head injury. In contrast, the identifiable cause of death in patients with anteroposterior compression injuries is combined pelvic and visceral injury.
Watnik et al. reviewed lower urinary tract injuries and noted that they occur in as much as 25% of patients with pelvic ring disruptions. They also report that early repair of bladder injury can facilitate the placement anterior pelvic fixation, in efforts to minimize infection.
Smith et al. reviewed hemodynamically unstable pelvic ring fracture patients and found that there is a positive association of blood replacement requirements and mortality. They also reported that death within the first 24 hours after admission was most often a result of acute blood loss while death after the first day was most often caused by multi-organ failure.
Figure A shows an AP pelvic radiograph with evident anterior pelvic ring fractures. Figure B and C are axial CT cuts showing the posterior and anterior ring fractures, respectively. This fracture pattern is consistent with a lateracl compression mechanism.
Incorrect Answers:
Answer 1-4: These options are less commonly reported as causes of death than closed head injury in a lateral pelvic ring injury mechanism.

A 67-year-old male is involved in a motor vehicle accident and presents with the closed orthopedic injuries shown in Figures A and B. He is also noted to have a grade 1 splenic laceration and lung contusion. He is cleared by the trauma team, and undergoes early total care with reamed femoral and tibial nailing. A tourniquet is used for the tibial nailing portion of the case, and the tibial isthmus is over reamed to accept a larger nail. The use of a tourniquet in this case has been most clearly shown to be associated with which of the following?
1) Tibia shaft necrosis post-operatively

2) Increased pulmonary morbidity post-operatively

3) Increased cortical bone temperature during reaming

4) Increased nonunion rates

5) Decreased pain post-operatively

In patients with multitrauma, combining reamed femoral nailing with fracture fixation (ie. tibial shaft) under tourniquet control has been shown to increase pulmonary morbidity.
Limb reperfusion after tourniquet ischemia causes pulmonary microvascular injury. Similarly, microembolization, like that associated with reamed femoral nailing, can induce pulmonary microvascular injury. Both processes result in increased pulmonary capillary membrane permeability and edema, and ultimately increased pulmonary morbidity.
Karunakar et al showed in a canine model that there is no significant difference in the heat generated during reaming with and without a tourniquet. The factor that made the most difference was related to the size of the reamer used compared with the diameter of the isthmus. They concluded that the risk of
thermal necrosis appears to be related more to the process of intramedullary reaming than to the tourniquet.
Giannoudis and associates performed a prospective randomized trial on 34 patients to measure the rise of temperature during reaming of the tibia before intramedullary nailing with and without the use of a tourniquet. The factor that generated the most heat was using large reamers (11 mm to 12 mm) in a patient with a small isthmus (8 mm to 9 mm). Use of a tourniquet, steroid use, and knee flexion during reaming were not shown to be associated with diaphyseal necrosis after reamed tibial nailing.
Pollak et al evaluated the association between femoral nailing followed by tourniquet ischemia and clinical lung injury. They reviewed 72 patients with femoral shaft fractures and tibial or ankle fractures requiring internal fixation over a six year period. All femoral shaft fractures were treated with reamed intramedullary nails, and the patients were divided into groups, based on whether the tibial or ankle injury was managed surgically with or without a tourniquet. They noted increased pulmonary morbidity in the group where a tourniquet was used.
Figure A shows a femoral shaft fracture at the junction of the middle and proximal one-third of the femoral shaft. Figure B shows a contralateral tibial shaft fracture.
Incorrect Answers:
1-Tourniquet use has not been shown to lead to thermal necrosis of the bone during reaming of the tibial shaft.

Based on the radiographs shown, the patient has a comminuted trans-olecranon fracture dislocation of the elbow. Stability will be optimized with internal fixation in the form of a plating construct.
Trans-olecranon fracture dislocations often occur in the young secondary to high energy mechanisms. Direct blows often lead to high levels of comminution; the distal humerus is driven into the proximal ulna and olecranon, thereby leading to a concomitant dislocation. In this setting, the optimal treatment is use of a plate and screw fixation construct to provide mechanical stability.
Veillette et al. review the epidemiology, pathophysiology and treatment options for olecranon fractures. They highlight that because olecranon injuries involve the articular surface, fixation constructs should allow anatomic restoration of the joint surface. Additionally, fixation constructs should allow for early mobilization in order to prevent stiffness of the elbow.
Mortazavi et al. retrospectively reviewed eight patients who sustained anterior trans-olecranon fracture dislocations of the elbow. Based on their experience, they recommend use of plate fixation to optimize stability of the elbow.
Additionally, they indicate that satisfactory results can be obtained if the greater sigmoid notch is appropriately reduced.
Figures A and B show the AP and lateral radiographs of a trans-olecranon fracture dislocation of the elbow. Severe comminution of the olecranon can be seen on the lateral radiograph in Figure B.
Incorrect Answers:
Answers 1, 2, 4: K-wires alone would not provide optimal stability and allow for early motion. A tension-band construct or IM screw fixation is contraindicated with this degree of comminution.

: Use of cast immobilization would lead to high levels of stiffness and is not indicated for this patient.

A 25-year-old male sustained an isolated injury to his right foot after a fall from height. On examination, he has moderate swelling and pain over the dorsum of the foot. The overlying skin is intact. Radiographs of the foot are seen in Figures A and B. A CT scan image is seen Figures C. When consenting the patient for open reduction and internal fixation of this injury, what would you document as the most common complication?
1) Symptomatic implants

2) Subtalar arthritis

3) Tibiotalar arthritis

4) Malunion

5) Wound dehiscence

This patient has sustained a displaced talar neck fracture. The most common complication associated with this injury is post-traumatic arthritis of the subtalar and tibiotalar joint.
Talar neck fractures are the most common fracture of the talus. They occur most frequently during forced dorsiflexion of the foot with axial load. Displaced fractures are best treated with anatomic reduction and stable internal fixation.
Complications of surgery include nonunion or malunion, post-traumatic arthritis, infection, osteonecrosis, and secondary surgery. The prevalence of post-traumatic subtalar arthritis has been shown to be approximately 50-100% with these injuries.
Lindvall et al. examined a retrospective cohort of twenty-six displaced talar neck fractures that had been treated with open reduction and stable internal fixation. They reported that 26/26 fractures developed post-traumatic arthritis and pain within 48 months of follow-up after fixation. They concluded that post-traumatic arthritis is a more common complication than osteonecrosis following operative treatment.
Vallier et al retrospectively reviewed the records of 39 fractures of the talar neck treated with open reduction and internal fixation. Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p
A 23-year-old man presents with the injury seen in Figure A after a motor vehicle collision. He undergoes the treatment seen in Figure B. Which of the following statements is most accurate when comparing his treatment with open reduction and internal fixation?
1) Higher rates of radial nerve injury

2) Higher total complication rate

3) Lower rates of nonunion

4) Lower rates of shoulder impingement

5) Lower rates of malunion

Antegrade intramedullary (IM) nailing of humeral shaft fractures has been found to be associated with increased complication rates when compared with open reduction and internal fixation (ORIF).
Operative treatment of humeral shaft fractures remains controversial, with prospective randomized studies demonstrating small differences between IM nailing and ORIF.
Heineman et al. (2010) conducted a meta-analysis of prospective randomized studies comparing IM nailing with ORIF for humeral shaft fractures. The authors found no significant difference between the two treatment modalities for either their primary outcome (complications) or any of the secondary outcomes (nonunion, infection, nerve palsy, re-operation)
Heineman et al. (2012) have recently conducted an update on their meta-analysis to include more recent randomized studies. With the inclusion of these newer studies the author found a statistically significant increase in total complication rate with the use of IM nailing compared with ORIF.
Figure A demonstrates a displaced, transverse humeral shaft fracture. Figure B demonstrates antegrade IM nailing of a humeral shaft fracture
Incorrect Answers:
Answer 1: Radial nerve injury has not been shown to be different between IM nailing and ORIF
Answer 3: No difference in union rates between the two modalities in prospective studies
Answer 4: Higher rates of shoulder impingement have been seen with IM nailing in some studies
Answer 5: No difference in rates of malunion between IM nailing and ORIF

Elevated interleukin 6 (IL-6) is most closely associated to which of the following clinical outcomes in orthopedic trauma patients?

1) Decreased mortality rates

2) Increased mortality rates

3) Decreased osteomyelitis infection rates

4) Increased rhabdomyolysis rates

5) Increased compartmental syndrome rates

Elevated levels of Interleukin 6 (IL-6) is most closely associated with higher injury severity scores and increased mortality rates in polytrauma orthopaedic patients.
Hyperstimulation of the inflammatory system by major trauma is considered to be the key element in the pathogenesis of severe inflammatory response syndrome and multi-organ dysfunction syndrome. IL-6 is a complex acute-reactant cytokinase that is expressed by cells in response to tissue injury. IL-6 levels are associated with injury severity, complications, and mortality.
Patients with the most severe injuries have the highest IL-6 serum levels.
Sears et al. reviewed the markers of inflammation in major trauma. They suggest that interleukin-6 and human leukocyte antigen-DR class II molecules appear to have the greatest potential for use in predicting the clinical course and outcome in trauma patients. Early identification of traumatic patients, based on inflammatory markers and genomic predisposition, could help to guide intervention and treatment.
Pape et al measured the perioperative concentrations of interleukin-6 in sixty-eight blunt trauma patients with non-life threatening pelvic fractures. Release of proinflammatory cytokines were higher in patients undergoing surgical procedures that cause increased blood loss. The release of markers seems to be related to the type and magnitude of surgery, rather than to the duration of the procedure.
Illustration A shows a diagram of the acute inflammatory response after major trauma
Incorrect Answers:
Answer 1: Mortality rates have shown to be increased with elevated levels of IL-6 in early trauma.
Answer 3: Osteomyelitis is a complication of open fracture trauma. Elevated levels of IL-6 and CRP are seen with this infection.
Answer 4: IL-6 is not commonly measured in rhabdomyolysis. Creatine kinase is commonly elevated with musculoskeletal injury.
Answer 5: Elevated IL-6 levels are not closely correlated with incidence incidence of compartmental syndrome.

A 26-year-old female sustained a closed femoral shaft fracture which was treated as shown in Figure A. She subsequently developed a painful oligotrophic nonunion and an exchange nailing was performed 6 months later. However, she has had persistent pain in the thigh since time of revision surgery seven months ago, but denies any fevers, chills, or night sweats. Current examination reveals a mildly tender right thigh with no obvious deformity. Laboratory studies for infectious markers are normal, but her radiograph in Figure B continues to show an oligotrophic nonunion. Which of the following factors has most likely contributed to her current presentation?
1) One pack of cigarettes per day for last 8 years

2) Positive intraoperative cultures for coagulase-negative Staphylococcus at the time of nail exchange

3) Iliac crest bone grafting at the time of nail exchange

4) Exchange nail was dynamically interlocked

5) A larger diameter nail was used in the exchange

The clinical presentation and radiographs are consisted with persistent oligotrophic non-union of the femur, after reamed nail exchange. Of the following factors, cigarette smoking has been shown to have the biggest effect on non-union in this population.
Reamed intramedullary nail exchange has become widely accepted as the treatment of choice for most diaphyseal femoral nonunions. The use of reamed exchange nailing are thought to allow for more biomechanical stability via larger diameter nails and improved biologics with bone reaming. These will help to generate bone healing and bridge fracture gaps. Smoking has been shown clinically and experimentally to affect union rate and fracture callus strength. Patients with femoral shaft non-unions should be forewarned of the its effect on fracture healing in nail exchange.
Hak et al retrospectively reviewed a cohort of 23 patients treated with reamed nail exchange for symptomatic femoral shaft non-unions. 15 of the patients were smokers and only 10 (66.7 percent) went on to heal after reamed nail exchange. This was in comparison to all 8 non-smoking patients who healed without complication after exchange reamed nailing. They suggest that smokers should be referred to an appropriate smoking cessation program before revision nail exchange is considered.
Figure A shows a proximal third femoral shaft fracture that was treated with intramedullary nailing. The oblique fracture line remains evident with a small callus response at the fracture site at 8 months post-operative. Figure B shows an radiograph of the exchange femoral nail 7 months after revision sugary.
There is increased fracture callus at fracture site, however the fracture line remains evident.
Incorrect Answers:
Answer 2: Intraoperative coagulase-negative staph. cultures are likely contaminant. The patient denies infectious symptoms and inflammatory markers for infection are negative. In addition, the radiographs do not suggest infection as there is no cortex irregularity, bone lysis, or implant loosening.
Answer 3: Bone grafting at the time of nail exchange has shown to increase bone union.
Answer 4: Dynamic interlocked screws were shown to increase bone union greater than static interlocked screws at the time nail exchange.
Answer 5: Bone grafting at the time of nail exchange has shown to increase bone union.

The sacrospinous and sacrotuberous ligaments are disrupted in which of the following injury patterns?

1) Ischial tuberosity avulsion fracture

2) Type I anterior-posterior compression pelvic ring injury

3) Type II lateral compression pelvic ring injury

4) Type II anterior-posterior compression pelvic ring injury

5) Both column acetabular fracture

Type II anterior-posterior compression (APC) pelvic ring injuries have disruption of the symphysis pubis, as well as disruption of the anterior SI ligaments, sacrotuberous ligament, and sacrospinous ligament. The alternative pattern of disruption of the pelvic floor ligaments is sometimes seen as an avulsion injury from the bony attachments of these structures (sacrum or ischium).
The progression of this pattern to involve the posterior SI joint ligaments creates a type III pattern, which is vertically and rotationally unstable.
Tile published a comprehensive review of pelvic ring injuries, focusing on the
anatomy and pathology of these injuries. He noted that the posterior SI complex is the most important to pelvic ring stability, which is the reason why these are generally classified by the grade of posterior injury. He also reminds the reader that these classification systems are not a substitute for individualized treatment decision making.
Illustration A shows an APC III pelvic ring injury, with significant symphyseal diastasis and SI joint widening. Illustration B shows the ligamentous anatomy of the pelvic ring.
Incorrect Answers:
Answer 1: These injuries are generally seen in sports-related trauma, with avulsion of the hamstring(s) from the ischium.
Answer 2: This injury pattern does not have any involvement of these two ligaments by definition.
Answer 3: This injury pattern involves inward rotation of the hemipelvis, thus protecting these structures. A type III LC injury may have a contralateral rupture of these ligaments, however.
Answer 5: This injury pattern typically does not involve rupture of these ligaments unless an ipsilateral pelvic ring injury is seen.

A 34-year-old man is involved in a motorcycle accident and sustains a closed tibia fracture and multiple rib fractures. A radiograph is provided in Figure A. During surgical treatment of this fracture, which of the following techniques will help facilitate a successful reduction and intramedullary fixation?
1) Hyperflexion to help prevent apex anterior angulation

2) A medial parapatellar incision to help prevent valgus angulation

3) Starting point just lateral to the medial tibial eminence to help prevent valgus angulation

4) A medially placed blocking screw to help prevent valgus angulation

5) Suprapatellar nailing technique to help prevent apex anterior angulation

The clinical scenario and radiograph demonstrate a proximal tibia fracture amenable to intramedullary nail fixation. The suprapatellar nailing technique helps prevent apex anterior or procurvatum deformity typical of these injuries.
Proximal third tibial shaft fractures are often difficult to reduce anatomically due to the tendency for both valgus and flexion deformity at the fracture site. Many different techniques have been devised to overcome the deforming forces. These include (1) Poller blocking screws posterior and lateral to the intramedullary nail (IMN), (2) utilizing a semi-extended knee position during IMN of proximal tibia fractures, (3) use of a suprapatellar approach for IMN,