AAOS Trauma 2018

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Question 1 of 100
A 36-year-old man has right shoulder pain after a fall from a bicycle. What is the most
likely complication of nonsurgical treatment of the injury shown in Figure 1?
1. Nonunion
2. Symptomatic malunion
3. Skin breakdown
4. Acromioclavicular joint arthrosis
Discussion
The patient has a Neer type II distal clavicle fracture with radiographic evidence of
coracoclavicular ligament disruption. With non-surgical treatment, the most commonly reported
complication is nonunion, with rates reported to be as high as 44%. However, many patients with
distal clavicular nonunion remain asymptomatic. Symptomatic malunion and skin breakdown
over the fracture site are certainly possible, but are less common than nonunion. Because the
fracture does not extend into the acromioclavicular joint, post-traumatic arthrosis would not be
expected.
 1. Nonunion
Question 2 of 100
A 99-year-old woman sustains the injury shown in Figure 1 after falling from a standing
position. What is the most cost-effective treatment?
1. Three cannulated screws

2. Long intramedullary nail
3. Sliding hip screw
4. Short intramedullary nail
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Discussion
Intertrochanteric hip fractures remain a common injury that orthopaedic surgeons manage. The
optimal form of surgical stabilization for these injuries has been a topic of debate over the years.
Recent studies have demonstrated equivalent outcomes between the use of sliding hip screws
and intramedullary nails for stable fracture patterns. Recent guidelines have suggested that the
use of sliding hip screws for stable fracture patterns can have a significant reduction in cost per
case.
 3 Sliding hip screw
Question 3 of 100
CLINICAL SITUATION
Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain
in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision.
On examination, she has well-healed scars and a well-healed flap on the medial aspect at
the level of the fracture. She reports having an infection after the initial surgery, which
resulted in debridement of the soft tissue and need for the local rotational flap. There are
no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is
healthy and has no comorbidities.
What is the best next step in the patient’s evaluation?
1. Complete metabolic workup

2. Advanced imaging with a CT scan
3. Laboratory studies for CBC, ESR and CRP
4. Nuclear medicine studi
Discussion
The patient had an open fracture that was initially treated with what appears to be appropriate
irrigation and debridement and intramedullary nail placement. The post-operative infection and
need for rotational flap is worrisome, but she has not had any issues since the flap. She has
abundant callus formation but the fracture line is still visible and unchanged on 2 sets of
radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is
no underlying infection with laboratory studies, including a complete blood count (CBC),
erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have
questionable utility, but may be helpful if the inflammatory markers from laboratory studies come
back elevated. A CT scan is not warranted because the sequential radiographs show persistent
fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had
appropriate treatment and has shown the ability to make callus, thus her biologic capacity
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appears to be intact and bone
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grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs
more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing.
Based on successive radiographs and the lack of healing, observation is probably just delaying
the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone nonunions,
especially in the femur.
 3. Laboratory studies for CBC, ESR and CRP
Question 4 of 100
CLINICAL SITUATION
Based on the radiographs shown in Figures 1 and 2, her tibia is a
1. pseudarthrosis.
2. hypertrophic nonunion.
3. healed fracture.
4. atrophic nonunion.
Discussion
appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture
nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion
of the tibia is exchange nailing. Based on successive radiographs and the lack of healing,
observation is probably just delaying the
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inevitable. Plating with retention of the nail can be useful in recalcitrant long bone nonunions,
especially in the femur.
 2. hypertrophic nonunion.
Question 5 of 100
CLINICAL SITUATION
Assuming her workup is negative for any other causes, what is the best treatment option?
1. Observation for a month

2. Plate the tibia after removing the nail
3. Autogenous bone graft to the tibia
4. Exchange nailing of the tibia
Discussion
appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture
nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion
of the tibia is exchange nailing. Based on successive radiographs and the lack of healing,
observation is probably just delaying the inevitable. Plating with retention of the nail can be
useful in recalcitrant long bone nonunions, especially in the femur.
 4. Exchange nailing of the tibia
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Question 6 of 100
A 32-year-old man has a closed mid-shaft spiral humeral fracture after a fall. After a
discussion of his treatment options, he wants to proceed with surgical management. When
counseling him about open reduction internal fixation (ORIF) versus intramedullary
nailing (IMN), what is the primary difference in outcomes between the two procedures?
1. Lower rate of iatrogenic radial nerve injury with ORIF
2. Lower rate of shoulder complications with ORIF
3. Higher rate of union with ORIF
4. Higher rate of infection with ORIF
Discussion
There has been an abundance of studies designed to compare ORIF with IMN of humeral shaft
fractures. When the most well-designed and rigorous studies are pooled and reviewed, the only
consistent difference that can be found is a higher incidence of shoulder complications with IMN
compared with ORIF. No significant differences have been shown with regard to nerve injury,
union, or infection.
 2. Lower rate of shoulder complications with ORIF
Question 7 of 100
The use of the Masquelet induced membrane technique for long bone infected nonunion involves
two stages. The first stage consists of debridement of all involved soft tissue and bone, and
1. external fixation, insertion of an antibiotic cement spacer, and culture specific antibiotics.
2. placement of an antibiotic nail, immediate bone grafting of the defect, and culture specific
antibiotics.
3. insertion of an antibiotic nail, place nothing in the bone void, and culture specific antibiotics.
4. placement of an antibiotic cement spacer, insertion of an antibiotic nail, and non-culture
specific antibiotics.
Discussion
Mauffrey and associates describe their technique for the twostage treatment of long bone osteo
myelitis. The first stage involves aradical debridement, stabilization of the bone with either extern
al fixation or an antibioticcoated intramedullary nail, placement of apolymethyl methacrylate spa
cer, and culture specific antibiotics. The second stage includes excision of the spacer and placeme
nt ofautologous bone graft.
 1. external fixation, insertion of an antibiotic cement spacer, and culture specific antibiotics.
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Question 8 of 100
Figure 1 is the injury anteroposterior pelvic radiograph, Figure 2 is the post-reduction
anteroposterior hip radiograph, and Figures 3 and 4 are the axial and coronal CT scans of a 34-year-
old woman involved in a motor vehicle collision. What is the most appropriate treatment option for
this patient?
1. Operative fixation of femoral head and posterior wall

2. Operative fixation of posterior wall and acute total hip arthroplasty
3. Protected weight bearing for six weeks
4. Resection of the femoral head fragment
Discussion
This patient has sustained an Pipkin IV femoral head/posterior wall acetabular fracture dislocation
and would benefit from operative fixation. While resection of some small femoral head fracture
fragments can be considered, this fragment is nearly half of the femoral head and should not be
excised. Similarly, the fragment is not completely reduced or stable and, therefore, non-operative
treatment with protected weight bearing is not appropriate.
Although the outcomes of such injuries with primary fixation are not consistently excellent, there
is no role for acute total hip arthroplasty in this patient. Considerable debate remains about
whether patients with Pipkin IV injuries should be treated from anterior or posterior approaches.
Advocates for the anterior approach cite less morbid exposure and direct access to the anterior
portion of the femoral head with likely stable hip examination as enough of the posterior rim
needed to be intact and present to cause the injury to the femoral head during the dislocation.
Advocates of primary fixation of both injuries from a posterior approach with surgical hip
dislocation cite access to both injuries through a single and verified safe approach and can also
address remaining osseous debris and muscle and labral damage at the same time. Regardless,
both treatment approaches include fixation of the femoral head and this should be pursued for
this patient.
 1. Operative fixation of femoral head and posterior wall
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Question 9 of 100
#527841
A 58-year-old man has a painful, warm, erythematous and fluctuant area over his left
olecranon. An aspiration would be most likely to reveal
1. Staphylococcus aureus.
Discussion
2. Streptococcus pyogenes.
Staphylococcus aureus isfaecalis.

3. Enterococcus the most common causative organism in septic bursitis, making up 80%
or more of cases of culture-proven septic bursitis (https://www.uptodate.com/contents/septic-
4. Psuedomonas aurigonosa.
bursitis). Staphylococcus aureus was the most frequent pathogen (217 out of 256 or 85%),
followed by Streptococcus pyogenes (16), other streptococci (15), Enterococcus faecalis (4) and
coagulase- negative staphylococci (2).
 1. Staphylococcus aureus
Question 10 of 100
#527899
CLINICAL SITUATION
A 56-year-old woman has a closed left elbow injury after she fell onto her outstretched
upper extremity. The injury and post-reduction radiographs are shown in Figures 1 through
4. She is neurovascularly intact.
What is the most likely pattern of instability?
1. Varus
2. Valgus
3. Varus posteromedial rotatory
4. Valgus posterolateral rotatory
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Discussion
The patient sustained a radial head/neck fracture, a coronoid tip fracture, and an elbow
dislocation, a constellation of injuries termed a “terrible triad.” These are most often the result of
a valgus posterolateral rotatory instability pattern, as evidenced by a comminuted radial head
fracture and a small coronoid tip fracture. Varus posteromedial injuries most often have an intact
radial head and a large anteromedial coronoid facet fracture. Pure varus or valgus injuries to the
elbow are rare.
 4. Valgus posterolateral rotatory
Question 11 of 100
#527900
CLINICAL SITUATION
upper extremity. The injury and post-reduction radiographs are shown in Figures 1
through
In the operating room, a lateral approach is selected. A clinical photograph of the
exposure is shown in Figure 5. What is the primary benefit of choosing the deep interval
marked with [a], rather than [b]?
*Figure 5 - Used with permission from Cheung EV, Steinmann SP. Surgical approaches to the elbow. J Am
Acad Orthop Surg. 2009 May;17(5):325-33. Review. PubMed PMID: 19411644.
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1. Increased distance to the posterior interosseous nerve (PIN)

2. Decreased risk of damage to the lateral ulnar collateral ligament (LUCL)
3. Improved visualization of the coronoid fracture
4. Dissection through an internervous plane
Discussion
Figure 5 shows two lateral approaches to the elbow, the Kaplan and the Kocher approach. The
Kaplan approach (a) is a more anterior approach between the extensor carpi radialis brevis (ECRB)
and extensor digitorum communis (EDC), or alternatively a split in the EDC. The primary benefit of
the Kaplan approach is to avoid iatrogenic injury to the lateral collateral ligament (LUCL), which
lies more posterior to the approach. However, it does bring the dissection closer to the posterior
interosseous nerve (PIN). The Kocher interval (b) is more posterior between extensor carpi ulnaris
(ECU) and anconeus. In this case, the coronoid can be approached through the radial neck
fracture, and the choice between Kaplan and Kocher approaches would not significantly impact
this. The Kocher approach is in an internervous plane between the radial nerve (anconeus) and
PIN (ECU), while the Kaplan approach may be variable depending on if the EDC is split and the
innervation of the ECRB (radial vs PIN).
The coronoid tip fracture repair with suture can be performed as an anterior capsular repair. If the
tip fracture is small, there is little bony contribution to stabilize the elbow. The brachialis would
insert distal to the tip of the coronoid, and the anterior band of the medial collateral longus
(MCL) would insert on the sublime tubercle more medially. Neither would be affected by the
fracture in this example. At this time, it is controversial whether small coronoid tip fractures
should be repaired in this setting.
This patient has a comminuted radial head and neck fracture with >3 fragments. In this setting,
arthroplasty is the recommended treatment because studies have shown poor results with
attempts at open reduction internal fixation. Radial head excision alone in the presence of a
complex instability pattern is also not recommended as the radial head provides secondary
stability with ligamentous injury. Closed treatment of the radial head would not be acceptable
given its position dislocated posteriorly in the elbow joint.
 2. Decreased risk of damage to the lateral ulnar collateral ligament (LUCL)
Question 12 of 100
#527901
CLINICAL SITUATION
A suture repair of the coronoid is performed through bone tunnels. What is the main
contribution to elbow stability provided by repair of this coronoid fracture?
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1. Repair the anterior capsule

2. Repair the brachialis insertion
3. Repair the medial collateral ligament insertion
4. Restore the ulnohumeral articulation
Discussion
The coronoid tip fracture repair with suture can be performed as an anterior capsular repair. If the
tip fracture is small, there is little bony contribution to stabilize the elbow. The brachialis would
insert distal to the tip of the coronoid, and the anterior band of the medial collateral longus
(MCL) would insert on the sublime tubercle more medially. Neither would be affected by the
fracture in this example. At this time, it is controversial whether small coronoid tip fractures
should be repaired in this setting.
 1. Repair the anterior capsule
Question 13 of 100
#527902
CLINICAL SITUATION
Intra-operatively, the radial head is noted to have 3 separate fragments in addition to a
radial neck fracture. What is the best next step?
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1. Closed treatment of the fracture

2. Radial head excision
3. Open reduction internal fixation
4. Radial head arthroplasty
Discussion
This patient has a comminuted radial head and neck fracture with >3 fragments. In this setting,
arthroplasty is the recommended treatment because studies have shown poor results with
attempts at open reduction internal fixation. Radial head excision alone in the presence of a
complex instability pattern is also not recommended as the radial head provides secondary
stability with ligamentous injury. Closed treatment of the radial head would not be acceptable
given its position dislocated posteriorly in the elbow joint.
 4. Radial head arthroplasty
Question 14 of 100
#527790
As compared to hemiarthroplasty, results of total hip arthroplasty after displaced femoral
neck fracture in an active elderly patient (older than 65 years) show
1. better functional outcomes.

2. lower dislocation rates.
3. worse functional outcomes.
Discussion
Multiple prospective
4. similar randomized studies have demonstrated that healthy, active elderly patients
outcomes.
had better outcomes at 7 to 10 year follow ups after total hip arthroplasty for displaced femoral
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neck fractures. There were higher dislocation rates but improved function with no difference in
othercomplications.
 1. better functional outcomes
Question 15 of 100
#527840
When compared to limb salvage patients, who required free flaps and/or an ankle
arthrodesis, patients treated with standard below knee amputation had
1. significantly worse two-year outcomes.

Discussion
2. significantly better two-year outcomes.
When 3. compared to patients

a trend toward treated
worse with standard
outcomes that werebelow knee amputation, salvage patients who
not significant.
required free flaps and/or ankle arthrodesis had significantly worse two-year outcomes. They had
4. a trend toward better outcomes that were not significant.
overall sickness impact profile (SIP) scores that were 2.5 points higher and psychosocial SIP scores
that were 8.4 points higher at 24 months (p = 0.014 and p = 0.013, respectively). Physical SIP
scores were 3.7 points higher in the free flap and/or arthrodesis group but only approached
statistical significance (p = 0.10). After adjusting for the need for free flap and/or arthrodesis, the
salvage pathway had clinically, but not statistically, significantly better overall and psychosocial
SIP scores than the patients with standard below knee amputation (p = 0.34 and p = 0.20,
respectively).
 2. significantly better two-year outcomes
Question 16 of 100
#527616
Post-traumatic stress disorder (PTSD) is increasingly being recognized as a problem
following orthopaedic trauma. To improve the patient’s outcome, it is important for the
orthopedist to recognize which patients might be at risk for PTSD. Which patient is most
likely to have PTSD?
1. A male with a both bone forearm fracture

2. A female with a femur fracture
3. A male with multiple injuries
4. A female with a both bone forearm fracture
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Discussion
In reviewing the literature, it appears that females are four times more likely to develop PTSD
than males. Furthermore, PTSD often lasts longer in females. Patients with a lower extremity
fracture, including a pelvic fracture, are twice as likely to develop PTSD as compared to upper
extremity fractures. It does not seem to make a difference if the patient has multiple injuries or
has an isolated fracture.
 2. A female with a femur fracture
Question 17 of 100
#528019
Suprapatellar intramedullary nailing for tibia fractures when compared to infrapatellar
nailing is associated with
1. decreased knee range of motion.

Discussion
2. increased incidence of malalignment.
Suprapatellar nailing knee

3. less anterior has been
pain. very useful in the management of proximal tibia fractures,
allowing a better reduction. Both arthroscopy and MRI have been utilized after suprapatellar
4. changes in the patellofemoral joint.
nailing to evaluate for changes in the patellofemoral joints, and no significant changes can be
attributed to this technique. In a comparative study between suprapatellar nailing and standard
(infrapatellar) nailing, both techniques showed excellent range of motion and no significant
differences between the methods. In a separate study, it was noted that patients who underwent
suprapatellar nailing did not complain of anterior knee pain that is often seen with standard
nailing.
 3. less anterior knee pain
Question 18 of 100
#527644
CLINICAL SITUATION
Figures 1 and 2 are the radiographs of a 35-year-old man who is brought into the
emergency department after a motor vehicle collision. He is complaining of isolated knee
pain. Examination reveals swelling, blood filled blisters, popliteal ecchymosis, joint line
pain, and limited knee joint motion. His pulses and sensation are normal.
This knee injury is best described as a
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1. posterior partial articular tibial plateau fracture.

Discussion
2. lateral split depression tibial plateau fracture.
Posterior partial
3. knee articular tibial
dislocation with plateau fractures
a posterior are ligament
cruciate rare. Failure to recognize this pattern can
avulsion.
lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic
4. bicondylar tibial plateau fracture.
findings on the lateral radiograph include maintenance of continuity between the anterior
articular surface and tibial shaft along with subluxation of the knee joint with excessively anterior
tibial station (the femoral condyles remain with the fractured posterior articular pieces while the
remainder of the tibia subluxes anteriorly).
 1. posterior partial articular tibial plateau fracture
Question 19 of 100
#527646
CLINICAL SITUATION
Initial surgical management should consist of
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1. closed reduction and percutaneous screw placement.

Discussion
2. open reduction internal fixation through an anterior midline approach.
Initial3. management of axially

spanning external unstable
fixation andtibial plateau
closed fractures realignment.
manipulative with soft tissue swelling should
consist of spanning external fixation and closed manipulative realignment. This allows for soft
ring fixation.
tissue4. recovery with the knee joint provisionally stabilized in reduced station. It also provides time
for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the
pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT
scan will clarify the misconception and allow for better surgical decision making.
 3. spanning external fixation and closed manipulative realignment
Question 20 of 100
#527647
CLINICAL SITUATION
Figures 3 through 8 are the axial and sagittal CT scan sections of the injury. Intra-
operative patient positioning for definitive fixation should be
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1. prone.
Discussion
2. lateral.
Attempting to visualize, reduce, and stabilize a posterior partial articular pattern in the supine
3. supine.
position from an anterior approach is fraught with difficulties. Prone positioning is preferred for
4. sloppy lateral.
definitive fixation. Surgical approaches vary, but typically incorporate a posteromedial interval
deep to the popliteus and soleus to provide buttress plating to the posterior column of the tibia.
 1. prone
Question 21 of 100
#527651
CLINICAL SITUATION
The surgical approach for definitive reduction and stabilization of this pattern is
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1. anterior midline.
Discussion
2. anterolateral.
Attempting
3. medialto visualize, reduce, and stabilize a posterior partial articular pattern in the supine
parapatellar.
position from an anterior approach is fraught with difficulties. Prone positioning is preferred for
4. posteromedial.
definitive fixation. Surgical approaches vary, but typically incorporate a posteromedial interval
deep to the popliteus and soleus to provide buttress plating to the posterior column of the tibia.
 4. posteromedial
Question 22 of 100
#527863
Figures 1 and 2 are the anteroposterior and lateral radiographs of a 61-year-old woman
after 6 months of non-operative treatment of a closed humerus fracture. She complains of
persistent pain in her arm but is neurovascularly intact. Examination reveals gross motion
at the fracture site. A pre-operative work-up reveals no evidence of infection. What is the
best next step?
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1. Sarmiento brace with low-intensity pulsed ultrasound

Discussion
2. Intramedullary nailing
The history
3. Openandreduction
radiographs show fixation
internal an established atrophic nonunion. Given the complete lack of
healing and stability, further non-operative treatment with a brace and ultrasound is unlikely to
4. Open reduction internal fixation with bone grafting
succeed. Although both intramedullary nailing and open reduction internal fixation would
provide a more stable construct, they may not adequately address the lack of biologic response
at the fracture site. The addition of some type of bone graft is indicated for this atrophic
nonunion.
 4. Open reduction internal fixation with bone grafting
Question 23 of 100
#527995
A 36-year-old man is involved in a motor vehicle collision and sustains a right posterior
wall acetabular fracture. There is no reported history of dislocation and he has no prior
history of hip trauma. Figure 1 is the anteroposterior pelvic radiograph and Figure 2 is the
CT scan at the level where the fracture fragment is the largest. Based on this information,
what is the best next step?
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1. Nonoperative treatment with protected weight bearing

Discussion
2. Examination under anesthesia to determine hip stability
Operative indications
3. Operative for posterior
treatment due towall
the acetabular
size of thefractures include a fracture involving more
wall fragment
than 50% of the posterior wall, incongruent hip joint, and intra-articular debris. The presence of a
4. Operative treatment due to a roof arc angle less than 45 degrees
dislocation was previously thought to infer instability, however, this is not accurate. Roof arc
angles do not apply to posterior wall fractures. Traditionally, fractures involving 20% to 50% of
the posterior wall were thought to be indeterminate. And fractures involving less than 20% of the
posterior wall were thought to be stable. Unfortunately, a large number of posterior wall fractures
involved less than 50% of the posterior wall and the joint appears congruent under static views
using any one of multiple published measuring techniques. Being able to determine the presence
of stability in these patients is challenging, and misdiagnosing a patient with a stable hip in the
setting of a posterior wall acetabular fracture can lead to a poor outcome.
Contemporary treatment proposes that all patients with a fracture involving less than 50% of the
posterior wall undergo an examination under anesthesia to conduct dynamic stress testing as
static views do not provide enough information. There are numerous reports of fractures that are
less than 20% of the posterior wall that are unstable. If there is any question of hip stability, a
stress examination is indicated. While the size of the posterior wall may not always correlate with
instability, the location of the cranial exit may. Recent investigations also demonstrated that
posterior wall fractures exiting within 5 mm of the acetabular dome are at high risk for instability.
 2. Examination under anesthesia to determine hip stability
Question 24 of 100
#527850
A 65-year-old woman with type II diabetes mellitus (most recent Hgb A1C was 8.2) has
had 3 days of left knee pain. Physical examination of the left knee reveals erythema,
warmth and a large effusion. Range of motion is painful and limited to 30 degrees of
flexion. She is found to be hypotensive and not responding to volume resuscitation. She
requires phenylephrine to maintain Mean Arterial Pressure (MAP) of 70. ESR and CRP
are elevated and Lactate is 3.1 mmol/L. What is the next best intervention for this
patient’s treatment?
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1. Administration of broad spectrum IV antibiotics

2. Irrigation and debridement in OR followed by broad spectrum IV antibiotics
3. NSAIDS and observation with repeat ESR and CRP in 24 hours
4. Joint aspiration and blood cultures
Discussion
The patient is demonstrating signs of septic shock. Administration of antibiotics should not be
delayed. Aspirating the knee joint and obtaining blood cultures can be rapidly accomplished to
obtain accurate specimens. This should be followed immediately by administration of broad
spectrum IV antibiotics. Patients with septic shock can be identified with a clinical construct of
sepsis with persisting hypotension requiring vasopressors to maintain mean arterial pressure
(MAP)
≥ 65 mmHg and having a serum lactate level > 2mmol/L (18 mg/dL) despite adequate volume
resuscitation. With these criteria, hospital mortality is in excess of 40%.
 4. Joint aspiration and blood cultures
Question 25 of 100
#527823
A 41-year-old man arrives at the trauma bay 45 minutes after a high-speed motor vehicle
collision. Per EMS, the patient was restrained, the airbags deployed, and the extrication
was prolonged. Upon arrival, he is intubated and his blood pressure is 60/21 and heart
rate is 159. Figure 1 is the patient’s radiograph during trauma evaluation. What would be
the most appropriate initial management of this injury in the trauma bay?
1. External fixation of his pelvis

2. Circumferential wrap placed around greater trochanters
3. Placement of a C-clamp
4. Open reduction internal fixation of his pelvis
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Discussion
A polytrauma patient creates a challenging situation for any care provider, but specifically the
orthopaedic surgeon. During the initial workup of a polytrauma patient, the typical radiographic
series includes a chest radiograph, AP pelvis, and lateral c-spine. Due to the significant morbidity
associated with pelvic ring injuries, it is critical to temporarily address these injuries during the
resuscitative process. Circumferential wrapping of the pelvis can easily be performed in the
trauma bay and allow for pelvic volume containment and aid in the resuscitative process.
Additionally, it is not uncommon to miss less obvious injuries. A thorough and expeditious
secondary survey can be performed in the trauma bay and any concerned areas should be
imaged. It is important to decide whether to temporize versus definitively manage the patient’s
orthopaedic injuries. And the status of the patient is critical when making these decisions. In the
initial management of an unstable patient, temporizing measures should be employed. Once the
patient is fully resuscitated and outside the window of a “second hit,” definitive management can
occur. Measuring serum lactate has been found to be the most accurate measurement of
someone’s resuscitation.
 2. Circumferential wrap placed around greater trochanters
Question 26 of 100
#527608
CLINICAL SITUATION
Figure 1 is the radiograph and Figure 2 is the CT image of a 45-year-old woman who fell
about 20 feet off her balcony. These images show an isolated, open injury with a 3-cm
open medial wound.
The best delayed definitive surgical fixation plan would include
1. lateral plating of the fibula and a percutaneous medial column plate.

2. intramedullary fixation of the fibula and an anterolateral tibial plate.
3. open medial column plating, percutaneous screw fixation of the joint, and
lateral fibular plating.
4. screw fixation of the medial column with an anterolateral tibial plate and
lateral fibular plating.
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Discussion
The timely administration of antibiotics has been shown to be the best initial treatment to reduce
the incidence of infection following an open fracture. Life threatening injuries must first be
addressed. But in this isolated open pilon fracture, antibiotics should be initiated early along with
tetanus prophylaxis. Reduction and splinting would stabilize the fracture but these interventions
should follow antibiotic coverage. Emergency department irrigation is controversial. Closed
reduction and splinting, external fixation, CT scan, and delayed open reduction internal fixation
would be the preferred sequence of management. External fixation to provide provisional limb
stabilization would be indicated in this length unstable C type injury to provide soft tissue
stabilization and prevent further chondral injury. Splinting alone would not prevent shortening and
would not allow soft tissue recovery. CT scans prior to limb stabilization are not warranted because
the patterns make more sense after the restoration of gross length, rotation and alignment in the
external fixator. Initial fibular fixation is also not recommended in this case because the location of
incisions could affect the definitive surgical tactic. In this multi-fragmentary fibular injury, anatomic
reduction would be challenging and malreduction could occur and influence subsequent
reconstructions. Delayed open reduction internal fixation is ideal after the resolution of soft tissue
swelling.
Anterolateral buttress plating of the tibial component and lateral plating of the fibula would best
resist the valgus compression failure of the lateral column. The medial side failed in tension and
plating in this location would not biomechanically resist the valgus displacement. Articular reduction
could also be carried out from the anterolateral side with joint reconstruction building back to the
posterolateral fragment. Secondary to the central articular impaction, isolated screw fixation would
not provide stability to the metaphyseal comminution. Medial columnar screws could be used to
secure the medial tension failure and would limit surface implants in the location of the open
wounds.
Failure to attain a high school diploma has been related to poorer outcomes following treatment of
high-energy pilon fractures. Quality of reduction does lead to better overall results but still has a
drastic impact on functional outcomes. The complexity of the initial fracture also does not lead to
differing outcomes at long-term follow up.
 4. screw fixation of the medial column with an anterolateral tibial plate and
lateral fibular plating
Question 27 of 100
#527609
CLINICAL SITUATION
Figure 1 is the radiograph and Figure 2 is the CT image of a 45-year-old woman who fell
about 20 feet off her balcony. These images show an isolated, open injury with a 3-cm
open medial wound.
Three years following surgery, which parameter will most likely predict a poor clinical
outcome and failure to return to work?
2
OT-UNHAS-
1. Accuracy of joint line restoration

2. Amount of comminution
3. Lower level of education
Discussion
The timely
4. Openadministration
fracture of antibiotics has been shown to be the best initial treatment to reduce
the incidence of infection following an open fracture. Life threatening injuries must first be
addressed. But in this isolated open pilon fracture, antibiotics should be initiated early along with
tetanus prophylaxis. Reduction and splinting would stabilize the fracture but these interventions
should follow antibiotic coverage. Emergency department irrigation is controversial. Closed
reduction and splinting, external fixation, CT scan, and delayed open reduction internal fixation
would be the preferred sequence of management. External fixation to provide provisional limb
stabilization would be indicated in this length unstable C type injury to provide soft tissue
stabilization and prevent further chondral injury. Splinting alone would not prevent shortening and
would not allow soft tissue recovery. CT scans prior to limb stabilization are not warranted because
the patterns make more sense after the restoration of gross length, rotation and alignment in the
external fixator. Initial fibular fixation is also not recommended in this case because the location of
incisions could affect the definitive surgical tactic. In this multi-fragmentary fibular injury, anatomic
reduction would be challenging and malreduction could occur and influence subsequent
reconstructions. Delayed open reduction internal fixation is ideal after the resolution of soft tissue
swelling.
Anterolateral buttress plating of the tibial component and lateral plating of the fibula would best
resist the valgus compression failure of the lateral column. The medial side failed in tension and
plating in this location would not biomechanically resist the valgus displacement. Articular reduction
could also be carried out from the anterolateral side with joint reconstruction building back to the
posterolateral fragment. Secondary to the central articular impaction, isolated screw fixation would
not provide stability to the metaphyseal comminution. Medial columnar screws could be used to
secure the medial tension failure and would limit surface implants in the location of the open
wounds.
Failure to attain a high school diploma has been related to poorer outcomes following treatment of
high-energy pilon fractures. Quality of reduction does lead to better overall results but still has a
2
OT-UNHAS-
drastic impact on functional outcomes. The complexity of the initial fracture also does not lead to
differing outcomes at long-term follow up.
 3. Lower level of education
Question 28 of 100
#527884
A 23-year-old man sustains a closed mid-shaft fracture of the left clavicle after a fall from
a bicycle. The fracture is completely displaced with mild comminution, but there is no
tenting of the skin. When discussing treatment options with the patient, what is the
primary benefit of open reduction internal fixation (ORIF) versus non-operative
treatment?
1. Improved cosmesis with ORIF

Discussion
2. Decreased cost with ORIF
Multiple 3.
randomized,
Reduced controlled trials have
rate of secondary demonstrated
surgery a benefit to operative management of
with ORIF
displaced mid-shaft clavicle fractures. However, much of the functional benefit of surgery seems
4. Reduced rate of nonunion with ORIF
to come from preventing nonunions and symptomatic malunions, rather than general
improvement across all operative patients.
ORIF can improve cosmesis, but is not the primary benefit of ORIF. The most common
complication after surgical management is hardware irritation/prominence and rates of removal
have been reported as high as 25 to 30%. ORIF has also been shown to be a more expensive
option than nonoperative treatment.
 4. Reduced rate of nonunion with ORIF
Question 29 of 100
#527845
A 58-year-old man with a 50-year history of osteomyelitis of the left tibia has a painful
ulceration of the anterior lower limb. Figure 1 is the clinical photograph of the wound,
which had purulent discharge and an unpleasant odor. Figures 2 and 3 are radiographs of
the left tibia. A biopsy reveals malignant degeneration. What are the most likely findings?
2
OT-UNHAS-
1. Reticulosarcoma
Discussion
2. Squamous cell carcinoma
Squamous cell carcinoma is the most common type of malignant tumor deriving from chronic
3. Fibrosarcoma
osteomyelitis. The most frequently affected site is the tibia, followed by the femur. When the
4. Malignant fibrous histiocytoma
neoplasm invades the bone, there is either osteolytic erosion or a pathological fracture. Diagnosis
is confirmed by biopsy at all suspicious wound sites. The malignant transformation most often
results in squamous cell carcinoma and much more rarely in fibrosarcoma, osteosarcoma,
reticulosarcoma, malignant fibrous histiocytoma or angiosarcoma. Many experts accept
amputation as the best treatment option for carcinomatous transformation of chronic bone
infections.
 2. Squamous cell carcinoma
Question 30 of 100
#527856
Figure 1 is the radiograph of a 49-year-old man who sustained a closed injury to his left
shoulder in a motor vehicle collision. He underwent uncomplicated ORIF (see Figure 2),
but at his first post-operative visit he had persistent pain and deformity (see Figure 3).
What is the primary factor contributing to this complication?
2
OT-UNHAS-
1. Excessive working length of the construct

Discussion
2. Lack of inferomedial calcar support
The 3.fixation construct reduction

Unsatisfactory most likely failed
of the due to a lack of inferomedial calcar support.
fracture
Biomechanical and clinical studies have emphasized the importance of medial calcar support in
4. Plate length is insufficient
preventing varus collapse. This can be accomplished in a number of ways, including anatomic
reduction of the medial calcar, long locking screws that engage the inferomedial humeral head,
or medial cortical reconstruction with a fibular strut.
The working length of the construct is not excessively long, and the plate length is sufficient.
Though there remains a gap at the fracture site, the overall reduction is satisfactory and not the
primary cause for fixation failure.
 2. Lack of inferomedial calcar support
Question 31 of 100
#528021_1
There are many bone graft substitutes and fracture healing adjuncts available. Please match
the biologic property most associated with allograft cancellous bone.
1. Osteoinductive
2. Osteoconductive
3. Osteogenic
4. Osteogenic and osteoconductive
5. Osteogenic and osteoinductive
6. Osteoconductive and osteoinductive
7. Osteogenic, osteoconductive and osteoinductive
2
OT-UNHAS-
Discussion
Autogenous bone graft remains the gold standard for grafting procedures because of its
osteogenic, osteoinductive and osteoconductive properties. This is true for either iliac crest bone
grafts or bone obtained from the intramedullary canal via the reamer irrigator aspirator system.
Although bone marrow aspirate is from the patient, its lack of “structure” makes it osteogenic
and osteoinductive only. Demineralized bone matrix obtained from cadaveric sources is “dead”
bone but contains small amounts of bone morphogenic proteins (BMPs) that are osteoinductive.
Furthermore, demineralized bone matrix has structure to it, adding osteoconductive capabilities
as well. Although carriers are used in the implantation of BMPs, the BMPs are purely
osteoinductive. Ceramics are synthetic bone substitutes/graft extenders and only provide a
scaffold and are considered osteoconductive. Allograft bone is dead bone and, thus, is
osteoconductive.
 2. Osteoconductive
Question 32 of 100
the biologic property most associated with autogenous iliac crest bone graft.
1. Osteoinductive
2. Osteoconductive
Discussion
3. Osteogenic
5. Osteogenic
Although andaspirate
bone marrow osteoinductive
is from the patient, its lack of “structure” makes it osteogenic
7. Osteogenic,
Furthermore, osteoconductive
demineralized bone matrixand
hasosteoinductive
structure to it, adding osteoconductive capabilities
osteoconductive.
 7. Osteogenic, osteoconductive and osteoinductive
2
OT-UNHAS-
Question 33 of 100
#528021_3
the biologic property most associated with demineralized bone matrix.
1. Osteoinductive
2. Osteoconductive
Discussion
3. Osteogenic
5. Osteogenic
7. Osteogenic,
hasosteoinductive
osteoconductive.
 6. Osteoconductive and osteoinductive
Question 34 of 100
#528021_4
the biologic property most associated with ceramics.
1. Osteoinductive
2. Osteoconductive
3. Osteogenic
3
OT-UNHAS-

Discussion
osteoconductive
 2. Osteoconductive
Question 35 of 100
#528021_5
the biologic property most associated with bone marrow aspirate.
1. Osteoinductive
Discussion
2. Osteoconductive
3. Osteogenic
5. Osteogenic
7. Osteogenic,
hasosteoinductive
osteoinductive.
3
OT-UNHAS-
Ceramics are synthetic bone substitutes/graft extenders and only provide a scaffold and are
considered osteoconductive. Allograft bone is dead bone and, thus, is osteoconductive
 5. Osteogenic and osteoinductive
Question 36 of 100
#528021_6
the biologic property most associated with bone morphogenic protein.
1. Osteoinductive
Discussion
2. Osteoconductive
3. Osteogenic
grafts4. orOsteogenic andfrom
bone obtained osteoconductive
the intramedullary canal via the reamer irrigator aspirator system.
Although bone marrow
5. Osteogenic andaspirate is from the patient, its lack of “structure” makes it osteogenic
osteoinductive
bone6.butOsteoconductive and osteoinductive
contains small amounts of bone morphogenic proteins (BMPs) that are osteoinductive.
Furthermore, demineralized
7. Osteogenic, bone matrixand
osteoconductive hasosteoinductive
osteoconductive
 1. Osteoinductive
Question 37 of 100
#528021_7
the biologic property most associated with platelet rich plasma.
1. Osteoinductive
2. Osteoconductive
3. Osteogenic
3
OT-UNHAS-

Discussion
osteoconductive
 1. Osteoinductive
Question 38 of 100
#528021_8
the biologic property most associated with reamer irrigator aspirator bone graft.
1. Osteoinductive
Discussion
2. Osteoconductive
3. Osteogenic
5. Osteogenic
7. Osteogenic,
hasosteoinductive
as
3
OT-UNHAS-
well. Although carriers are used in the implantation of BMPs, the BMPs are purely osteoinductive.
Ceramics are synthetic bone substitutes/graft extenders and only provide a scaffold and are
considered osteoconductive. Allograft bone is dead bone and, thus, is osteoconductive
 7. Osteogenic, osteoconductive and osteoinductive
Question 39 of 100
#528000
Figure 1 is the radiograph of a 19-year-old man who is involved in a rollover motor
vehicle collision. Distal femoral skeletal traction and circumferential pelvic sheet is
applied, with the resultant alignment seen in Figure 2. He undergoes an exploratory
laparotomy and has a splenectomy. Pelvic angiography shows no embolizable source of
bleeding. Resuscitation continues and the remainder of his trauma workup is negative.
Over the next 36 hours, he becomes hemodynamically unstable again. What is the best
next step?
1. Repeat CT head scan

Discussion
2. Repeat exploratory laparotomy
The patient has a surgical

3. Perform completefixation
disruption
of of the symphysis
pelvic ring injurypubis and right complete sacral fracture
with vertical displacement of the right hemi-pelvis. Appropriate initial orthopaedic intervention
4. Repeat pelvic angiography
includes circumferential pelvic sheeting and distal femoral skeletal traction. This reapproximates
normal anatomy, decreases the pelvic volume, and provides some initial temporary stability that
maintains any initial clots that occurred at the site of osseous and/or vascular injury. The
remainder of the patient’s initial evaluation was negative except for the intra-abdominal injuries
that were initially addressed during the exploratory laparotomy.
Multiple treatment algorithms exist, however, in patients with continued, hemodynamic

instability, the source of continued bleeding needs to be identified. Thus, the need for repeat
angiography should not be discarded. There is a small subset of patients who will require repeat
angiography with a previously identified site bleeding, a new site of bleeding, or a combination
of both. Beyond identifying patients in need of possible angiography, risk factors to help identify
the patients who are at higher risk of requiring repeat angiography include the following:
 Continued hypotension
 Need for greater than 2 units of packed red blood cells prior to angiography or greater than 6
units of packed red blood cells after angiography
3
OT-UNHAS-
 Multiple vessels requiring embolization or super selective embolization performed during the
initial procedure
 4. Repeat pelvic angiography
Question 40 of 100
#527796
You receive a call from the trauma team leader about a patient with a mangled extremity.
He asks you what is the best scoring system to use to decide between amputation and
limb salvage, and what score predicts the need for amputation so he can get informed
consent. What should you tell him?
1. A mangled extremity severity score (MESS) of 5 predicts amputation with

high specificity and low sensitivity
Discussion
2. A predictive salvage index (PSI) of 6 predicts amputation with low sensitivity
The performance of the indices in all of the injury-pattern groups indicates that these lower
and specificity
extremity injury severity scoring systems
A limb salvage Index (LSI) of 4 predicts amputation with high sensitivity and
have limited usefulness and cannot be used as the sole criterion by which amputation decisions
3.
low
are made. specificity
Scores at or above theamputation threshold should be used cautiously by a surgeon, w
ho must decide the fate of a lower extremity with a high-energy injury.
4. Scoring systems cannot be used because they are not predictive of
 4.functional recoverycannot be used because they are not predictive of functional
Scoring systems
recovery
Question 41 of 100
#527636
CLINICAL SITUATION
Figures 1 and 2 are the radiographs of a 35-year-old man who has elbow pain after falling
from a ladder onto an outstretched hand. Examination reveals elbow pain, swelling,
limited motion, and normal neurologic function.
A pathognomonic radiographic feature of this injury is a
3
OT-UNHAS-
1. radiocapitellar joint dislocation.

Discussion
2. fat pad sign.
Coronal
3. shear fractures
proximal of the distal
radioulnar joint end of the humerus are rare. Failure to recognize the fracture
dislocation.
pattern can lead to poor patient outcomes secondary to poor surgical decision making. The
4. double arc sign.
double arc sign is considered a pathognomonic finding on the lateral elbow radiograph seen in
Figure 2. This is created by the subchondral bone of the capitellum and lateral trochlear ridge.
Excessive internal rotation of the fracture fragment or a subpar lateral radiograph can make
recognition of this sign difficult.
Ideal visualization of the fragment during surgery is provided through a laterally based elbow
approach (Kaplan or Kocher) with the patient in the supine position. Extension of the approach
can be accomplished by releasing the lateral collateral ligament origin, which must be repaired to
prevent post-operative instability. Posterior comminution and lateral column impaction are
occasionally seen. When present, a posterior approach with an olecranon osteotomy is
considered an alternative, but still does not allow ideal visualization of the anterior articular
cartilage or safe angles for anterior to posterior screw placement. Therefore, the posterior
approach not the preferred approach.
Headless screws are useful because this is typically a partial articular injury and screw orientation
is ideally from anterior to posterior. The anterior entry of the screw should be buried beneath the
articular cartilage margin.
 4 double arc sign
Question 42 of 100
#527637
CLINICAL SITUATION
What is the typical intra-operative patient position for treatment of this injury?
3
OT-UNHAS-
1. Supine
Discussion
2. Lateral
Coronal
3. shear
Pronefractures of the distal end of the humerus are rare. Failure to recognize the fracture
4. Beach chair
articular cartilage margin.
 1. supine
3
OT-UNHAS-
Question 43 of 100
#527638
CLINICAL SITUATION
The surgical exposure that provides optimal visualization to treat this injury is
1. medial approach to the elbow.

Discussion
2. anterior approach to the cubital fossa.
Coronal
3. shear fractures
posterior of theto
approach distal end of the humerus are rare. Failure to recognize the fracture
the elbow.
4. lateral approach to the elbow.
articular cartilage margin
 4. lateral approach to the elbow
3
OT-UNHAS-
Question 44 of 100
#529639
CLINICAL SITUATION
What type of screws should be available for stabilization of this injury?
1. Headless
Discussion
2. Cannulated
Coronal
3. shear fractures of the distal end of the humerus are rare. Failure to recognize the fracture
Titanium
4. Dual core
articular cartilage margin
 1. Headless
3
OT-UNHAS-
Question 45 of 100
#527814
Figure 1 is the radiograph and Figure 2 is the clinical photograph of an 89-year-old
woman who fell down a flight of steps. The most effective way to decrease the likelihood
of infection in this patient is to immediately?
1. Go to the operating room for irrigation and debridement

Discussion
2. Administer antibiotics
Open3. fractures
Performcan be challenging
skeletal for an orthopaedic surgeon to treat. One of the biggest
stabilization
challenges is to prevent infection after gross contamination and exposure to the surrounding
4. Irrigate the open wound in the emergency department
environment. Multiple studies have demonstrated that the most reliable way to reduce the risk of
infection is to administer antibiotics as soon as possible after the injury occurred. Although
important, the timing to surgical debridement and skeletal stabilization seem to have much less
of an impact compared with the immediate administration of antibiotics. However, surgical
debridement should be done within 24 hours of injury and perhaps earlier for high-risk injuries
such as this one.
 2. Administer antibiotics
4
OT-UNHAS-
Question 46 of 100
#527958
Figure 1 is a 3-D CT surface rendered outlet image of a patient with pelvic fracture. What
makes a safe S1 iliosacral screw placement most challenging?
1. Mammillary bodies
Discussion
2. Steep alar slope
The CT
3. surface rendered
Residual image reveals many findings present with sacral dysmorphism, including
S1 disk
the upper sacral body relatively collinear with the iliac crests; steep alar slope; mammillary bodies;
Large, S1
large,4. irregular irregular
neural S1 neural and
foramina; foramina
a residual S1 disk. The other notable characteristics of
tongue-in-groove sacroiliac joint and cortical indentation of the sacral ala are not visualized on
this image. A patient is diagnosed with sacral dysmorphism if any of these characteristics are
present in any degree, ranging from subtle to obvious, but not all characteristics are required.
Out of all the possible criteria, the steep alar slope is the most clinically relevant. This altered
osseous corridor is now smaller and angled more acutely in both the anterior-posterior and the
caudal-cranial directions. The dysmorphic alar osteology does not permit a transiliac transsacral
style screw at the S1 level but does allow an iliosacral style screw. If this altered osteology is not
identified pre-operatively, an extraosseous screw can be placed with potential neurologic or
vascular injury.
The remainder of the criteria for sacral dysmorphism are listed in choices A, C, and D. Although
these criteria are present in the CT surfaced rendered image, they do not directly impact clinical
practice. Instead, when viewed on standard radiographs or CT imaging, they help the surgeon
recognize the presence of sacral dysmorphism. Once recognized, the altered S1 osteology can be
fully appreciated and appropriate templating and intra-operative execution can occur without
incident.
 2. Steep alar slope
4
OT-UNHAS-
Question 47 of 100
#527624
CLINICAL SITUATION
Figures 1 through 4 are the radiographs of a 38-year-old man who is involved in a motor
vehicle collision. He is stable and his injuries are isolated to the extremity shown in
Figures 1 through 4 with no other non-musculoskeletal injury. He has no neurological or
vascular dysfunction in the extremity.
What is the most devastating complication from this type of injury?
1. Osteonecrosis of the femoral head

Discussion
2. Nonunion of the femoral neck fracture
Osteonecrosis of the
3. Nonunion of femoral head infracture
the diaphyseal a young person is not salvageable unless by total hip
arthroplasty or vascularized fibular grafting. Nonunion of either fracture is treatable with either
4. Infection of the femoral fracture
valgus osteotomy of the neck and revision fixation and grafting of the shaft. Infection is a
problem but is treatable with a good result
An anatomical reduction of the femoral neck fracture usually guarantees the best result for this
fracture. This is best achieved through an open reduction. However, if the surgeon can assure
that the neck is anatomically reduced closed then it would be acceptable. Fixation of the neck is
best done using some form of compression to achieve stability and prevent collapse. Femoral
shaft fixation is best done by a separate implant usually a retro grade nail.
It is taught that the neck is the priority so that it will reestablish the blood supply. However, what
is important is the adequacy of the neck reduction and this can be difficult with the femur
unstabilized. The most important aspect is what will get the best result for the femoral neck
fracture.
4
OT-UNHAS-
The patient has a nonunion of the femoral neck. A valgus osteotomy is a very successful
procedure for this condition even in the face of osteonecrosis of the head. There is enough room
to do the osteotomy above the nail and get the plate screw around the nail.
 1. Osteonecrosis of the femoral head
Question 48 of 100
#527626
CLINICAL SITUATION
Figures 1 through 4 are the radiographs of a 38-year-old man who is involved in a motor
vehicle collision. He is stable and his injuries are isolated to the extremity shown in
Figures 1 through 4 with no other non-musculoskeletal injury. He has no neurological or
vascular dysfunction in the extremity.
The patient has done well but returns in 6 months, complaining of groin pain, without
thigh pain, when walking and during the night. In addition, the leg seems to be shorter
(see Figures 5 and 6). Infection is ruled out and the patient has a normal erythrocyte
sedimentation rate, C-reactive protein, and vitamin D levels. What is the best next step?
1. Non weight bearing and follow up in 3 to 6 months
4
OT-UNHAS-
2. Total hip arthroplasty

3. Valgus osteotomy
4. Revision fixation of the neck with bone graft
Discussion
Osteonecrosis of the femoral head in a young person is not salvageable unless by total hip
arthroplasty or vascularized fibular grafting. Nonunion of either fracture is treatable with either
valgus osteotomy of the neck and revision fixation and grafting of the shaft. Infection is a
problem but is treatable with a good result
An anatomical reduction of the femoral neck fracture usually guarantees the best result for this
fracture. This is best achieved through an open reduction. However, if the surgeon can assure
that the neck is anatomically reduced closed then it would be acceptable. Fixation of the neck is
best done using some form of compression to achieve stability and prevent collapse. Femoral
shaft fixation is best done by a separate implant usually a retro grade nail.
It is taught that the neck is the priority so that it will reestablish the blood supply. However, what
is important is the adequacy of the neck reduction and this can be difficult with the femur
unstabilized. The most important aspect is what will get the best result for the femoral neck
fracture.
The patient has a nonunion of the femoral neck. A valgus osteotomy is a very successful
procedure for this condition even in the face of osteonecrosis of the head. There is enough room
to do the osteotomy above the nail and get the plate screw around the nail.
 3 Valgus osteotomy
Question 49 of 100
#527860
Figures 1 and 2 are the radiographs of a 52-year-old man who fell from his height. He
sustained a closed injury to his left elbow. He is neurovascularly intact. What is the best
approach to address the coronoid fracture?
1. Olecranon osteotomy
4
OT-UNHAS-
2. Through the radial head excision

3. Flexor carpi ulnaris (FCU) split
4. Medial epicondyle osteotomy
Discussion
The radiographs reveal a large medial coronoid fracture associated with an elbow dislocation. The
radial head appears intact. This constellation of injuries represents a varus posteromedial rotatory
instability pattern. Given the size of the fragment and the injury pattern, the coronoid warrants a
direct approach and buttress plate fixation, which is best accomplished through a medial flexor
carpi ulnaris splitting approach.
An olecranon osteotomy would be unnecessary and would still not allow buttress plating of the
coronoid. The radial head is intact and should not be excised in this pattern. A medial epicondylar
osteotomy could provide good visualization of the coronoid, but is unnecessarily invasive and
risks further destabilizing the medial collateral ligament complex. Alternatively, a medial
Hotchkiss over- the-top approach could also provide visualization of the fracture.
 3. Flexor carpi ulnaris (FCU) split
Question 50 of 100
#527623
Figures 1 and 2 are the radiographs of a 19-year-old woman who sustained a femoral
shaft fracture in a motor vehicle collision. She was treated with a closed static locked
reamed nail. At 8 months, she is still complaining of pain in the thigh with activity, has
no limb length discrepancy and no rotational deformity. An infection and metabolic
workup are normal. The CT scan is shown in Figure 3. What is the best next treatment?
1. Ultrasound
4
OT-UNHAS-
2. Exchange nailing
3. Continued observation with weight bearing
4. Adjunctive plate fixation with bone graft
Discussion
This appears to be either a hypertrophic or oligotrophic nonunion with cortical contact. By

enhancing the stability with a larger nail and stimulating blood flow by reaming, this nonunion
will probably heal. Exchange nailing is not a 100% cure so the use of a bone graft or adjunctive
plate fixation may also be considered.
 2, Exchange nailing
Question 51 of 100
#527844
A 56-year-old man with poorly controlled diabetes mellitus has rapidly developing and
advancing erythema, warmth and swelling with bullae formation on the left lower
extremity. These findings appear to be advancing proximally several millimeters per
hour. Culture results are most likely to reveal
1. group A Streptococcus.
Discussion
2. Methicillin-resistant staphylococcus aureus.
Necrotizing fasciitis (NF) results in the death of the body's soft tissue. It is a severe disease of
3. Clostridium.
sudden onset that spreads rapidly. Symptoms include red or purple skin in the affected area, with
4. polymicrobial infection.
severe pain, fever, and vomiting. The most commonly affected areas are the limbs and perineum.
Early diagnosis is difficult as the disease often looks like a simple superficial skin infection in the
early stages. While a number of laboratory and imaging modalities can raise the suspicion for
necrotizing fasciitis, the gold standard for diagnosis is a surgical exploration in the setting of high
suspicion. When in doubt, a small "keyhole" incision can be made into the affected tissue. If a
finger easily separates the tissue along the fascial plane, the diagnosis is confirmed and an
extensive debridement should be performed. The Laboratory Risk Indicator for Necrotizing
Fasciitis (LRINEC) score can be utilized to risk stratify people who have signs of cellulitis and
determine the likelihood of necrotizing fasciitis being present. It uses six serologic measures,
including C-reactive protein, total white blood cell count, hemoglobin, sodium, creatinine and
glucose.
Polymicrobial synergistic infection was the most common cause of necrotizing fasciitis (48
patients; 53.9%) with streptococci and enterobacteriaceae being the most common isolates.
Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The
most common associated comorbidity was diabetes mellitus (63 patients; 70.8%).
4
OT-UNHAS-
 4. polymicrobial infection
Question 52 of 100
#527959
During the process of placing an iliosacral screw with fluoroscopic assistance, Figure 1
shows the outlet view, Figure 2 shows the inlet view, and Figure 3 shows the lateral view.
At this point, the surgeon notes that the drill tip is above the iliac cortical density (ICD).
This finding indicates the drill is
1. intraosseous and safe from neurovascular injury.

Discussion
2. extraosseous and at risk for L5 nerve root injury.
The 3.
intra-operative
extraosseousviews
and show
at riskS1foriliosacral
S1 nervescrew
root placement
injury. in a patient with noted sacral
dysmorphism. The safe corridor for intraosseous screw placement proceeds from posterior to
4. extraosseous and at risk for iliac vessel injury.
anterior and caudal to cranial. When placing a screw in these patients, the surgeon must
understand the patient’s underlying osseous anatomy. The inlet view (Figure 2) shows the
anterior cortical indentation, which shows the anterior limit of the safe screw pathway. The outlet
view (Figure 1) shows the appropriate trajectory in relation to the S1 neuroforamen and the
cortical density of the neuroforaminal tunnel as it courses from cranial to caudal, medial to
lateral, and posterior to anterior.
When a lateral view (Figure 3) is checked, the drill tip is cranial to the ICD, however, it is still
intraosseous. The slope of the S1 sacral ala can be see as well. The steep alar slope alters the
normal relationship of the ICD to the sacral ala and the drill/wire/screw will appear cranial and
anterior to the ICD. In patients with sacral dysmorphism, this is a normal and expected finding.
The drill/wire/screw is intraosseous and safe at this point and is not in danger of neurovascular
structure injury. If the drill was anterior to the anterior sacral indentation, the L5 nerve root would
be at risk for injury. The drill has not passed medial enough to be into the neuroforaminal tunnel
zone so the S1 nerve root injury is not a risk. Similarly, the drill has not passed medial or cranial
enough to endanger the iliac vessels.
 1 intraosseous and safe from neurovascular injury
Question 53 of 100
#527800
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Post-traumatic stress disorder (PTSD) frequently affects orthopaedic trauma patients.

How does the timing of identifying PTSD have an effect on access to resources and the
recovery process?
1. Early identification of PTSD lengthens the time of the recovery process

Discussion
2. Early identification of PTSD does not affect the access to resources
Early3.identification can help care

Early identification teams provide
of PTSD shortensthe
theresources andrecovery
time of the support to offset the distress.
process
Several options that help trauma patients navigate their short-term recovery include holistic
4. Early identification of PTSD decreases the access to resources
approaches, pastoral care, coping skills, mindfulness, peer visitation, and educational resources.
Starr and associates showed that 51% of trauma patients met the criteria for the diagnosis of
PTSD. Patients with PTSD had significantly higher Injury Severity Scores (p = 0.04), a higher sum
of Extremity Abbreviated Injury Scores (p = 0.05), and a longer time to recovery than those
without PTSD (p < 0.01).
 3. Early identification of PTSD shortens the time of the recovery process
Question 54 of 100
#527824
CLINICAL SITUATION
Figure 1 is the anteroposterior radiograph of an 85-year-old man who fell from a standing
position and landed directly on his left hip. In the emergency department, he complains of
immediate pain and an inability to bear weight.
After the emergency department physician sees this patient, he consults cardiology. The
cardiologist orders an echocardiogram to be performed immediately. What is the likely
result of ordering this test?
1. Decreasing the patient’s length of stay

2. Increasing the patient’s time to surgery
3. Determining the type of anesthesia for surgery
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4. Determining what service the patient will get admitted to
Discussion
The treatment of hip fractures in the elderly population represents a major public health priority
and a source of ongoing debate among orthopaedic surgeons and anesthesiologists. Most of
these injuries are treated with surgery in an expedient fashion. From the surgical perspective,
there are certain special considerations in this population, including osteoporosis, pre-existing
arthritis, age, activity level, and overall health that contribute to the type of surgical fixation
performed.
Timing to surgery has been born out in the literature to be an important factor in regard to
outcomes. Studies have shown that many of the extraneous pre-operative testing that we order
rarely dictates care, but delays time to surgery. Additionally, multiple studies have demonstrated
that urgent hip surgery can safely be performed while patients are on anticoagulants. The goal of
surgical intervention is to provide a construct that can allow early mobilization and limit
complications.
Studies demonstrate that arthroplasty is considered the gold standard for elderly patients with
displaced femoral neck fractures. While there has been a recent debate about performing
hemiarthroplasty versus total hip arthroplasty (THA), the consensus still exists that THA is
complicated by a higher dislocation risk as compared to hemiarthroplasty.
Elderly patients cannot be partial weight bearing- they either are non-weight bearing or weight
bearing as tolerated (WBAT). A goal of the surgical procedure chosen should be to allow the
patient to be WBAT immediately after surgery.
 2. Increasing the patient’s time to surgery
Question 55 of 100
#527826
CLINICAL SITUATION
Compared to a total hip arthroplasty, a hemiarthroplasty is associated with a
1. decreased dislocation rate.

2. higher post-operative mortality rate.
3. lower incidence of revision surgery.
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4. increased need for skilled nursing facility.
Discussion
performed.
complications.
 1. decreased dislocation rate
Question 56 of 100
#527827
CLINICAL SITUATION
What should this patient’s post-operative weight bearing status be?
1. Non-weight bearing
2. Weight bearing as tolerated
3. Toe touch weight bearing
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4. Transfers with assistance
Discussion
performed.
complications.
 2. Weight bearing as tolerated
Question 57 of 100
#527887
Figure 1 is the trauma chest radiograph of a 35-year-old man who arrives at the
emergency department after a motorcycle collision. He was intubated and sedated in the
field, so a neurological examination cannot be obtained. The patient has a palpable, but
thready, pulse in his right upper extremity. A consultation is called for the right clavicle
fracture with a 2- cm open wound overlying the fracture site. What is the best next step?
1. Irrigation and debridement in the emergency room

2. Irrigation and debridement in the operating room
3. CT scan of the chest to assess for associated injuries
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4. Pulse examination and brachial-brachial index
Discussion
The chest radiograph reveals a distracted right clavicle fracture, which is highly concerning for
scapulothoracic dissociation. Although all the options are reasonable, the most important initial
step would be to rule out an associated vascular injury, which is common with a scapulothoracic
dissociation.
On physical examination, this can be done with a pulse examination and brachial-brachial index.
Based on the physical examination, advanced imaging can be ordered as needed. A chest CT can
be performed to evaluate lateral displacement of the right scapula compared to the left. The
open fracture will also require urgent irrigation and debridement as well.
 4 Pulse examination and brachial-brachial index
Question 58 of 100
#527842
In contrast to the findings of the Lower Extremity Assessment Project (LEAP), the Military
Extremity Trauma Amputation/Limb Salvage (METALS) study demonstrated
1. that patients with limb salvage had better outcomes.

2. that patients with amputation had better outcomes.
Discussion
After3.adjustment for covariates,

no difference in outcomespatients with an amputation
with amputation had better scores in all short
or limb salvage.
musculoskeletal function assessment (SMFA) domains compared with patients whose limbs had
4. that patients with limb salvage required fewer operations.
been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of
being engaged in vigorous sports. There were no significant differences between the groups with
regard to the percentage of patients with depressive symptoms, pain interfering with daily
activities (pain interference), or work/school status.
 2. that patients with amputation had better outcomes
Question 59 of 100
#527618
An active 80-year-old woman had operative management of an intertrochanteric fracture.
She has been taking a bisphosphonate for osteoporosis treatment for the past 6 months.
She wants to restart her bisphosphonate. What is the most appropriate recommendation?
1. Do nothing because it is not your expertise
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2. Start on a bone forming therapy as the bisphosphonate failed

3. Restart her bisphosphonate within 1 week of surgery
4. Restart her bisphosphonate within 3 months of surgery
Discussion
She needs to restart medication therapy to prevent worsening of her osteoporosis. A case can be
made for changing to a bone-forming agent but these require self-administration and are
expensive. Because she wishes to remain on the bisphosphonate she may start within one week
of surgery. It appears that there is no effect in fracture healing by starting bisphosphonates
within one week of surgery.
 1 Restart her bisphosphonate within 1 week of surgery
Question 60 of 100
#527606
Figure 1 is the clinical photograph and Figure 2 is the radiograph of a 47-year-old woman
who has foot pain and swelling after a fall. Her past medical history includes diabetes
mellitus and a current smoker. What is the next step?.What is the next step?
1. Splinting with delayed open reduction internal fixation (ORIF)

Discussion
2. Splinting with nonoperative management secondary to comorbidities
The radiograph
3. Splinting and clinical
with photograph
emergent showreduction
operative a displaced
andcalcaneal
fixation tuberosity with impending
posterior soft tissue compromise. This represents a surgical urgency, requiring prompt diagnosis
4. Emergent casting with equinus foot position
and treatment. If treatment is delayed, the posterior skin will suffer necrosis and will likely require
soft tissue reconstruction.
Although the patient has associated comorbidities, delayed ORIF would be inappropriate as the
posterior soft tissues will deteriorate unless treatment is initiated. Nonoperative management is
not an option because the displaced tuberosity will not improve with time. Although equinus
splinting can temporary relieve the pressure on the posterior soft tissues, this would not
definitively relieve the posterior skin pressure or reduce the tuberosity displacement.
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 3.. Splinting with emergent operative reduction and fixation
Question 61 of 100
#527656
CLINICAL SITUATION
Figures 1 through 3 are the radiographs of a 25-year-old man who is brought to the
emergency department after a motorcycle collision. He is complaining of isolated knee
pain. Examination reveals swelling, popliteal ecchymosis, joint line pain, and limited
knee joint motion. His pulses and sensation are normal.
This knee injury is best described as a
1. posterior partial articular tibial plateau fracture.

Discussion
2. lateral split depression tibial plateau fracture.
Medial
3. plateau
medial fracture
plateau dislocations are rare. Failure to recognize this pattern can lead to poor
fracture dislocation.
patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the
4. knee dislocation with lateral collateral ligament tear.
anteroposterior radiograph include an intact lateral column (lateral articular surface still in
continuity with tibial shaft), centrolateral articular impaction, shortening, and condylar widening.
The medial femoral condyle stays with the fractured medial tibial plateau segment.
 3. medial plateau fracture dislocation
Question 62 of 100
#527657
CLINICAL SITUATION
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Initial surgical management should consist of
1. closed reduction and percutaneous screw placement.

Discussion
2. open reduction internal fixation through an anterior midline approach.
Initial3. management of axially

spanning external unstable
fixation andtibial plateau
closed fractures realignment.
manipulative with soft tissue swelling should
consist of spanning external fixation and closed manipulative realignment. This allows for soft
4. ring fixation.
tissue recovery with the knee joint provisionally stabilized in reduced station. It also provides time
for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the
pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT
scan will clarify the misconception and allow for better surgical decision making.
 3. spanning external fixation and closed manipulative realignment
Question 63 of 100
#527658
CLINICAL SITUATION
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Figures 4 through 8 are the axial and coronal CT scan sections of the injury. Intra-
operative patient positioning for definitive fixation should be
1. prone.
Discussion.
2. lateral.
Supine
3. positioning
supine. is preferred for definitive fixation, but surgical approaches vary. Attempting to
stabilize a medial partial articular pattern in the supine position from a lateral utility approach is
4. sloppy lateral.
fraught with difficulties. Lateral locked plating is not designed for this indication. The lateral utility
approach allows for visualization of the centrolateral impaction and lateral meniscal peripheral
capsular avulsion repair, but when used alone leads to biomechanically unsound implant
placement. The primary plate should be on the medial side of the tibia rather than the intact
lateral column.
 3. supine
Question 64 of 100
#527663
CLINICAL SITUATION
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The surgical approach for definitive reduction and stabilization of this pattern is
1. direct posterior.
Discussion
2. direct lateral.
Supine
3. positioning is preferred for definitive fixation, but surgical approaches vary. Attempting to
posterolateral.
stabilize a medial partial articular pattern in the supine position from a lateral utility approach is
4. posteromedial.
fraught with difficulties. Lateral locked plating is not designed for this indication. The lateral utility
approach allows for visualization of the centrolateral impaction and lateral meniscal peripheral
capsular avulsion repair, but when used alone leads to biomechanically unsound implant
placement. The primary plate should be on the medial side of the tibia rather than the intact
lateral column.
 4, posteromedial
Question 65 of 100
#527791
Surgical treatment of hip fractures in patients on clopidogrel should be delayed
1. for at least five days.

2. for at least three days.
3. until medical optimization.
4. until international normalized ratio (INR) is < 1.5.
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Discussion
While the effect of clopidogrel on platelets is irreversible and may take 7 to 10 days to be
completely reversed, there is no significant difference in bleeding or need for blood transfusions
when comparing surgeries done after 1 to 2 days off clopidogrel or after 5 days and later. Since
delay in treating hip fractures may result in worse outcomes, it has been recommended that
surgery should not be delayed for patients on clopidogrel. The medication should be stopped on
admission and the patient taken to the operating room once medically optimized. Clopidogrel
has no effect on INR levels.
 3. until medical optimization
Question 66 of 100
#527960
During the process of placing an S2 transiliac transsacral style screw with fluoroscopic
assistance, Figure 1 shows the outlet view, Figure 2 shows the inlet view, and Figure 3
shows the lateral view. At this point during the procedure, the drill tip is
1. intraosseous and safe from neurovascular injury.

Discussion
2. extraosseous and at risk for S1 nerve root injury.
The intra-operative
3. extraosseous views
andshow placement
at risk of an root
for S2 nerve S2 transiliac
injury. transsacral style screw in a patient
with sacral dysmorphism. This is most notably shown by the anterior sacral indentations seen on
4. extraosseous and at risk for iliac vessel injury.
the inlet view (Figure 2). In these patients, the S1 corridor does not allow for a transiliac
transsacral style screw. Instead, these patients typically have a larger S2 osseous corridor which
will accommodate the transiliac transsacral style screw. At this point in the procedure, the drill is
in the sacral ala and has not reached the neuroforaminal tunnel. The inlet view (Figure 2) shows
the drill to be traversing the S1 anterior sacral indentations, which would be concerning if the
screw is at the S1 level. Instead, the screw is at the S2 level and the lateral view (Figure 3)
confirms the drill is intraosseous. Although the S1 or S2 nerve roots could be damaged during
screw placement at this level, none of the structures listed above are at risk with the current
position of the drill.
 1. intraosseous and safe from neurovascular injury
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Question 67 of 100
#527621
Preventing heterotopic ossification (HO) following fracture surgery of an injured joint
using non-steroidal anti-inflammatory drugs (NSAIDs) or radiation is associated with
1. better results from NSAIDs.

Discussion
2. nonunion of the fracture.
The only fact that appears

3. expected fractureconsistent between most studies and reviews is that either radiation or
union rates.
NSAIDs will cause nonunion of the fracture in the injured joint to prevent HO. The effectiveness
4. better results from radiation.
of either radiation and/or NSAIDs in the prevention of HO is debatable with no real evidence that
either of them work consistently.
 2. nonunion of the fracture
Question 68 of 100
#527809
Figure 1 is radiograph of a 96-year-old woman who fell down two steps and comes to the
emergency department with an inability to bear weight and right hip pain. Figure 2 is
the post-traction radiograph. What intra-operative event would increase the rate of failure
when using a sliding hip screw (SHS) to treat this fracture pattern?
1. Penetration of the femoral head with the guide wire

2. Obtaining a tip apex distance of less than 25mm
3. Fracture of the lateral wall
4. Using a 2-hole SHS instead of a 4-hole SHS
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Discussion
The integrity of the lateral wall of the proximal femur when treating intertrochanteric femur
fractures has been identified as a predictor of successful outcomes. Multiple studies have
identified that a thin or “incompetent” lateral wall increases the likelihood of intra-operative
lateral wall blowout. This intra-operative complication has been shown to significantly increase
the likelihood of post-operative hardware failure and the need for reoperation. Therefore, most
identify the integrity of the lateral wall as a predictor of fracture pattern stability and a
radiographic sign to guide implant choices. Hsu and associates reference the determination of
the competency of the lateral wall.
 3. Fracture of the lateral wall
Question 69 of 100
#527890
Figures 1 and 2 are the radiographs of a 46-year-old man with left shoulder pain and
limited range of motion two years after a proximal humerus fracture, which was treated
non- operatively. He has forward elevation to 100 degrees with pain at the terminal arc of
motion. A subsequent MRI reveals no soft tissue abnormality. After a failed course of
nonoperative treatment, what is the most appropriate surgical treatment?
1. Arthroscopic tuberoplasty
Discussion
2. Valgus-producing osteotomy
The patient has a varus

3. Humeral malunion of his left proximal humerus. There are no signs of advanced
hemiarthroplasty
glenohumeral arthrosis or osteonecrosis. After failed non-surgical treatment, the surgery most
4. Reverse total shoulder arthroplasty
likely to improve his symptoms is a valgus-producing osteotomy of the proximal humerus.
Arthroscopic tuberoplasty addresses massive rotator cuff tears or greater tuberosity malunions,
but does not address the varus alignment of the articular surface. Humeral hemiarthroplasty can
address the deformity but would sacrifice an otherwise normal humeral head in a relatively young
patient. Reverse total shoulder arthroplasty would not be indicated in a patient this age with an
intact rotator cuff.
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 2 Valgus-producing osteotomy
Question 70 of 100
#528004
CLINICAL SITUATION
Figure 1 is the radiograph of a 67-year-old woman who is involved in a motor vehicle
collision and sustains an isolated injury to her left hip. She is a community ambulatory
who does not use any assistive devices.
She undergoes a closed reduction in the emergency department. Figures 2 through 5 are
post-reduction CT images. What is the ideal surgical approach to address this fracture?
1. Kocher-Langenbeck
Discussion
2. Ilioinguinal
The patient sustained

3. Extended a posterior wall fracture dislocation. For acetabular fractures, the position
iliofemoral
of the limb in space at the time of impact (in terms of the amount of flexion/extension,
4. Anterior intrapelvic
internal/external rotation, and adduction/abduction) will dictate the fracture pattern. For
posterior wall fracture patterns, the limb is in some degree of flexion, adduction, and internal
rotation. Other combinations are possible to contribute to an acetabular fracture but not likely to
contribute to a posterior wall pattern.
This posterior wall fracture pattern can be addressed from a standard Kocher-Langenbeck
approach for both fixation and arthroplasty. There is no significant cranial or anterior extension of
the fracture that would necessitate a modified posterior approach or greater trochanteric
osteotomy. The other listed approaches would not be appropriate
 1. Kocher-Langenbeck
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Question 71 of 100
#528005
CLINICAL SITUATION
Which factors will lead a surgeon to pursue fracture fixation and acute total hip
arthroplasty instead of fixation alone?
1. Age > 50 years, marginal impaction, posterior wall comminution

Discussion
2. BMI > 50, femoral head damage, prior hip surgery
Indications for total

3. Posterior hipcomminution,
wall arthroplasty are continuing
worker’s to evolve and
compensation many
injury, patient-specific
femoral head and
fracture damage
specific variables are involved. Several studies have investigated this issue and the
common variables that influence the success of primary fixation are related to the age of the
patient, greater than 50 years as well as associated bone quality and how these are affected with
the fracture. The presence of marginal impaction suggests significant insult to the cartilage. In the
presence of pre- existing cartilage wear, the likelihood of success with primary fixation is
decreased. The presence of significant comminution of the fracture (greater than 3 fragments)
also suggests decreased success with primary fixation. The other factors listed can contribute to
perioperative morbidity but not as clearly when compared to the three listed in answer A. In the
clinical setting of a patient older than 50 years old with a comminuted fracture, marginal
impaction, and femoral head damage, there should be serious consideration for combined
fracture fixation and acute total hip arthroplasty. Delayed arthroplasty can be an option in some
patients, but clinical outcomes have not been as favorable as acute combined treatment.
 1. Age > 50 years, marginal impaction, posterior wall comminution
Question 72 of 100
#528006
CLINICAL SITUATION
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In this patient, what other potential injury can be associated with this fracture pattern and
is commonly overlooked?
1. Urethral tear
Discussion.
2. Ipsilateral knee
Although
3. Riburethral tears, rib fractures, and subdural hematoma are commonly involved with high-
fractures
energy accidents and are routinely investigated through advanced trauma life support (ATLS)
4. Subdural hematoma
protocols, the ipsilateral knee has not received such focus. In a recent multi-center study, 15% of
patients were found to have ipsilateral knee symptoms within a period of 1 year from the date of
injury. The patterns of knee injury included 56 fractures (29%), 49 ligamentous lesions (25%), and
88 miscellaneous (46%) causes, including bone bruises, wounds, and swelling. Multi-ligamentous
knee injuries can be occult and a detailed examination of the knee should be standard in these
patients upon secondary and tertiary surveys.
 4 Subdural hematoma
Question 73 of 100
#527843
Six weeks after open reduction internal fixation of a closed tibial pilon fracture, a patient
has a draining wound with surrounding erythema and swelling. Radiographs show
lucency around screws. What is the most appropriate treatment sequence?
1. Start IV antibiotics, obtain wound swab for culture, perform irrigation and
debridement and retain hardware
2. Start IV antibiotics, obtain deep soft tissue and bone cultures in OR,
perform irrigation and debridement and remove hardware
3. Obtain wound swab for culture, start IV antibiotics, perform irrigation and
debridement and remove hardware
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4. Obtain deep bone and soft tissue cultures in OR, start IV antibiotics,
perform irrigation and debridement and remove hardware
Discussion
Management of acutely infected wounds is primarily surgical. Osteomyelitis frequently involves

orthopaedic hardware, which would ideally be removed or replaced given biofilm involvement.
Multiple operative cultures of fluid collections, soft tissues and bone should routinely be
obtained. Culture yield is highest if cultures are obtained before empiric antibiotic treatment is
started. Tissue samples are greatly preferred to swabs, which are notoriously inaccurate.
 4 Obtain deep bone and soft tissue cultures in OR, start IV antibiotics, perform
irrigation and debridement and remove hardware
Question 74 of 100
#527607
Figure 1 shows a patient with an open tibia fracture who presents to the emergency
department after a propeller injury in brackish water (river water and sea water). What is
the most appropriate antibiotic coverage for this patient?
1. Gentamicin and penicillin

Discussion
2. Cefazolin and penicillin
The clinical photo shows

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

commonly added in barnyard injuries for extended coverage of soil-borne pathogens (clostridial
species). Vancomycin is not indicated for coverage in marine environments, rather it is more
commonly used for populations with a high prevalence of nosocomial infections.
Sulfamethoxazole-trimethoprim is not used for open fracture coverage.
 3 Doxycycline and ceftazidime
Question 75 of 100
#527893
Figures 1 and 2 are the radiographs of a 44-year-old man who comes to the emergency
department after a fall from a ladder with pain and a closed injury to his left shoulder. He
undergoes open reduction internal fixation (ORIF) of his left proximal humerus fracture.
A postoperative radiograph is shown in Figure 3. What best describes the function of the
intramedullary fibular allograft?
1. Provides additional purchase for proximal articular screws

Discussion
2. Provides additional purchase for diaphyseal screws
The patient has a surgical

3. Decreases neck across
union time fracturethe
with medial
zone calcar comminution. In patients where this
of comminution
cannot be anatomically reconstructed to provide cortical support, a fibular allograft can be used
4. Restores medial cortical support to prevent varus collapse
to prevent varus collapse. A “push” screw can be seen in Figure 3, which was used to medialize
the graft into a biomechanically favorable position for this fracture pattern. Although the allograft
theoretically provides the other benefits listed, they are not the primary indication for this injury.
 Restores medial cortical support to prevent varus collapse
Question 76 of 100
#528007
Figure 1 is the radiograph of a 32-year-old man who is involved in a motor vehicle
collision and sustains an injury to his right hip. Physical examination reveals that the right
limb is
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significantly shorter than the left and is positioned in slight flexion and in neutral rotation.
The decision is made to perform a closed reduction and conscious sedation with fentanyl
and versed is given. During the attempted reduction, the limb is notably immobile with
moderate force. What is the best next step?
1. Skeletal traction
Discussion
2. Re-attempt closed reduction
The 3.
clinical scenario
Urgent depicted
CT scan here isreduction
and surgical consistent with an irreducible femoral head fracture
dislocation. The standard posterior hip fracture dislocations has the leg notably flexed, internally
4. Knee immobilizer
rotated, and rather mobile with reduction attempts. In contrast, the irreducible variant has the
limb in slight flexion, neutral rotation, and the limb is relatively immobile in comparison.
The anteroposterior radiograph shows a subtle difference with the femoral head closed opposed
to the supra-acetabular iliac bone. With the constellation of these findings, the diagnosis of an
irreducible femoral head fracture dislocation is made and no further reduction attempts should
be made. More forceful movements may cause an iatrogenic femoral neck fracture. Instead,
appropriate advanced imaging should be obtained for pre-operative planning, appropriate
advanced trauma life support (ATLS) protocol and resuscitation should occur, and the patient
should be brought to the operating room for a formal open reduction internal fixation of the
fracture.
 3. Urgent CT scan and surgical reduction
Question 77 of 100
#527801
Figure 1 is the radiograph of a 25-year-old man who injured his left lower extremity. He
is intubated and sedated for other injuries sustained. At 1:00 am his nurse calls with
the
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concern that his leg “feels tight.” What is the most accurate way to diagnose compartment
syndrome?
1. Palpating his left lower extremity compartments

Discussion
2. Increasing paresthesia in his foot
The diagnosis of acute

3. Diastolic bloodcompartment syndrome
pressure minus is a challenge. The
intracompartmental clinical diagnosis
pressure can30be made
is less than
mmHG
using specific clinical findings. In this scenario, however, the patient is intubated and sedated and
the only clinical examination available is palpation of the lower extremity compartments and
pulse examination. The published literature suggests that these clinical signs are unreliable. Given
the lack of diagnostic certainty due to a limited clinical exam, the use of objective evidence
makes sense. Compartment pressure monitoring has been advocated for the past four decades.
The use of perfusion pressure instead of absolute pressure has been shown to be more
physiologically relevant. As the literature supports, fasciotomies can be avoided if the perfusion
pressure (diastolic blood pressure minus compartment pressure) is greater than 30 mmHg.
 3 Diastolic blood pressure minus intracompartmental pressure is less than 30

mmHG
Question 78 of 100
#527610_1
Which treatment option listed is best for each patient described?
Figure 1 is the radiograph of a 72-year-old woman who fell while hiking
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1. In situ percutaneous screws

Discussion
2. Open reduction and percutaneous screws
Figure
3. 1Compression
shows a reverse obliquity intertrochanteric fracture with displacement of the lesser
hip screw
trochanter. Cephalomedullary nail fixation is indicated in this pattern secondary to the obliquity
4. Cephalomedullary nail
of the fracture line.
5. Hemiarthroplasty
 4 Cephalomedullary nail
6. Total Hip arthroplasty
Question 79 of 100
#527610_2
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Figure 2 is the radiograph of an 80-year-old who is limited to household ambulation with
a cane and fell from ground level.

Discussion
Figure
3. 2Compression
shows a displaced transcervical femoral neck fracture in a low-demand patient.
hip screw
Hemiarthroplasty is an effective treatment modality to allow early weight bearing and
mobilization in this patient. Early mobilization reduces perioperative morbidity. Percutaneous
Hemiarthroplasty
screw5. fixation and open reduction internal fixation is associated with up to 40% failure rates in
this patient population. Although total hip arthroplasty is an option, it is not indicated for this
low-demand patient with no radiographic evidence of hip osteoarthritis.
 5. Hemiarthroplasty
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Question 80 of 100
#527610_3
Figure 3 is the radiograph of a 78-year-old who fell from ground level.

Discussion
Figure
3. 3 Compression
shows a stable hip
valgus impacted femoral neck fracture. This stable pattern is amenable to
screw
percutaneous screw fixation. This would allow early weight bearing and would prevent further
fracture displacement. Open reduction is not indicated because the fracture does not need a
5. Hemiarthroplasty
reduction
6. 1.Total
 Hippercutaneous
In situ arthroplasty screws
Question 81 of 100
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#527610_4
Figure 4 is the radiograph of a 65-year-old after a motorcycle collision.

Discussion
Figure
3. 4Compression
shows a traction radiograph showing a high-energy 2-part standard obliquity
hip screw
intertrochanteric femur fracture. This would be amenable to open reduction internal fixation with
a compression hip screw. Open reduction would likely be indicated secondary to the fracture
5. Hemiarthroplasty
displacement and failure of realignment with traction.
6. 3.Total
 Hip arthroplasty
Compression hip screw
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Question 82 of 100
#527610_5
Figure 5 is the radiograph of a 69-year-old active man with pre-existing hip pain who fell
from a ladder.

Discussion
Figure3. 5 Compression
shows a displaced basicervical femoral neck/intertrochanteric fracture with pre-existing
hip screw
hip osteoarthritis. In an active patient with existing osteoarthritis, total hip arthroplasty is
indicated to restore hip function. A calcar replacing type of arthroplasty might be needed
5. Hemiarthroplasty
secondary to the fracture pattern. Open reduction internal fixation is also an option, but would
likely require implant removal and conversion to total hip arthroplasty after fracture healing,
which would subject the patient to a second surgery and the associated morbidity.
 6. Total Hip arthroplasty
Question 83 of 100
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#527874
CLINICAL SITUATION
Figures 1 and 2 are the radiographs of a 19-year-old man with a closed right humeral
shaft fracture as well as a right femoral shaft fracture and a left ankle fracture-dislocation
after a motor vehicle collision. On initial examination, he is noted to have a complete
radial nerve palsy of his right upper extremity.
After a discussion with the patient, surgery is chosen for the right humerus. A posterior
triceps-reflecting approach is selected. What structure marks the most proximal extent of
the humerus that can be exposed through this approach?
1. Axillary nerve
Discussion
2. Radical nerve
The 3.patient sustained

Origin a comminuted
of the medial head of theextra-articular
triceps distal humeral diaphyseal fracture. In
isolation, this fracture would still be amenable to an attempt at closed treatment. His radial nerve
4. Anatomic neck of the proximal humerus
palsy alone does not warrant open management, as early exploration has not shown a significant
benefit in a closed fracture. In addition, despite the comminution and distal extent of the fracture,
it is still amenable to closed treatment, though it may be at higher risk for malunion. However, in
this patient with multiple lower extremity injuries, fixation of the humerus can facilitate early
mobilization and weight-bearing with his right upper extremity, representing a relative indication
for surgical management.
The posterior triceps-reflecting approach described can be extended proximally to the level of
the axillary nerve. The radial nerve must be found and protected, but the dissection can be
carried well proximal to it and the medial triceps origin. The anatomic neck of the humerus
cannot be visualized through this approach.
 1. Axillary nerve
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Question 84 of 100
#527873
CLINICAL SITUATION
What represents the best indication for surgical management of the humeral shaft fracture
in this patient?
Discussion
1. Radial nerve palsy
The 2.patient sustained

Extensive a comminuted
fracture comminution extra-articular distal humeral diaphyseal fracture. In
isolation, this fracture would still be amenable to an attempt at closed treatment. His radial nerve
palsy3.alonePolytraumatized
does not warrantpatient
open management, as early exploration has not shown a significant
benefit in a closed fracture.
4. Distal third diaphyseal In addition, despite the comminution and distal extent of the fracture,
fracture
it is still amenable to closed treatment, though it may be at higher risk for malunion. However, in
this patient with multiple lower extremity injuries, fixation of the humerus can facilitate early
mobilization and weight-bearing with his right upper extremity, representing a relative indication
for surgical management.
 3. Polytraumatized patient
Question 85 of 100
#527876
CLINICAL SITUATION
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Postoperative radiographs are shown in Figures 3 and 4. How does the plate function?
1. Neutralization
Discussion
2. Compression
The plate functions as a neutralization plate, as multiple lag screws are seen placed outside of the
3. Bridging
plate, suggesting anatomic reduction and fixation of the fracture prior to applying the plate.
4. Buttressing
 1 Neutralization
Question 86 of 100
#527877
CLINICAL SITUATION
The working length of the plate is best described as the length
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1. of the plate.
2. of screw purchase in bone.
3. between the screws closest to the fracture.
4. between the screws furthest from the fracture.
Discussion
The working length of the plate is the distance between the proximal and distal screws closest to
the fracture. The length of screw purchase in bone represents the working length of the screw,
not the plate. The other answer choices describe dimensions of the plate and the fixation
construct, not its working length.
 3 between the screws closest to the fracture
Question 87 of 100
#527852
A 56-year-old woman sustains a type IIIB open tibial shaft fracture. She undergoes
irrigation and debridement and intramedullary nailing with flap coverage 24 hours later.
Cultures are taken pre-debridement and post-debridement. She develops a surgical site
infection at 6 weeks, which requires removing the hardware and placing an external
fixator. Deep cultures are most likely to show pathogens found in
1. pre-debridement cultures.
Discussion
2. post-debridement cultures.
One 3.
study founddebridement
neither only 8% of organisms
culture. grown on pre-debridement cultures eventually caused
infection; 7% of cases with negative pre-debridement cultures became infected. Of cases that did
4. anaerobic specimens.
become infected, pre-debridement cultures grew the infecting organism only 22% of the time.
Post-debridement cultures were more accurate in predicting infection. However, of cases that
became infected, the infecting organism was present on post-debridement cultures only 42% of
the time. It is concluded that pre-debridement and post-debridement bacterial cultures from
open fracture wounds are of essentially no value. It is recommended that they not be done.
In another study, before any interventions were performed, initial aerobic and anaerobic cultures
of the wounds of 117 consecutive open extremity fractures grades I through III were obtained.
The results of these cultures were correlated with the development of a wound infection. If an
infection occurred, the organism grown from the infected wound was compared with any
organism grown from the primary wound cultures. Of the initial cultures, 76% (89/117) did not
demonstrate any growth, while the other 24% (28/117) only grew skin flora. There were only 7
(6%) wound infections, and 71% (5/7) initially did not grow any organisms. Of the isolates
that grew from the initial
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cultures, none were the organisms that eventually led to wound infections. The use of primary
wound cultures in open extremity injuries has no value in the management of patients suffering
from infections after long bone open extremity fractures.
 3. neither debridement culture
Question 88 of 100
#527792
Deep vein thrombosis (DVT) prophylaxis is recommended for what fracture after surgery?
1. Hip fractures
Discussion
2. Olecranon fractures
DVT 3.prophylaxis for hip

Distal radius fractures requires 10 to 14 days of pharmacological anticoagulation.
fractures
However, the American College of Chest Physicians recommends a longer period (up to 35 days)
4. Lisfranc injuries
for hip fractures.
The Pentasaccharide in Hip-Fracture Surgery (PENTHIFRA) study compared fondaparinux, a

synthetic inhibitor of factor Xa, with enoxaparin. This was a large, multi-center, randomized,
double-blind trial of 1,711 patients with hip fractures. Despite no differences in clinically relevant
bleeding rates, the incidence of total venous thromboembolism was significantly lower in the
fondaparinux study group (8% vs 19%, p <.001). Based on the PENTHIFRA study, the total
recommended duration of fondaparinux was 4 weeks after surgery.
Injuries below the knee or in the upper extremity do not need any prophylaxis, unless the patient
has other risk factors. Overall, the risk of DVT for olecranon and wrist fractures are extremely low.
Therefore, olecranon and wrist injuries, if isolated, do not merit DVT prophylaxis.
 1. Hip fractures
Question 89 of 100
#527758
CLINICAL SITUATION
Figures 1 and 2 are the radiographs of a 68-year-old woman who comes to the emergency
department after stepping into a hole and twisting her ankle. She is complaining of
isolated ankle pain and is unable to bear weight.
After closed manipulative reduction and splint placement, she is scheduled for operative
treatment. The stability of the syndesmosis should be evaluated after
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1. fixation of the lateral malleolus.

Discussion
2. fixation of the medial malleolus.
The 3.radiographs
fixation ofreveal a trimalleolar
the posterior ankle fracture dislocation with an associated distal
malleolus.
tibiofibular syndesmotic disruption. Medial and lateral malleolar stabilization are consistently
4. all planned fixation is completed.
agreed upon. The decision to stabilize the posterior malleolus is more controversial. Posterior
malleolar stabilization accomplishes the following:
 Restores incisura competence thereby reducing the incidence of syndesmotic malreduction by

creating containment
 Assists in stabilizing the syndesmosis via the posterior inferior tibiofibular ligament, potentially
limiting the need for additional syndesmotic stabilization
 Maximizes the surface area for ankle joint loading
 Enhances posterior translational stability of the talus
The traditional indication for stabilization of the posterior malleolus is based on fragment size.
However, fracture orientation varies and makes evaluation of the fragment size challenging with a
lateral radiograph alone. The three primary types include the posterolateral oblique, medial
extension, and shell. Because of the additive syndesmotic stability which is gained through the
deep deltoid ligament and medial malleolar fixation, the anterior talofibular ligament and lateral
malleolar fixation, and the posterior inferior tibiofibular ligament and posterior malleolar fixation,
syndesmotic stability should only be assessed after all other points of instability that are planned
for fixation are fixed.
 4. all planned fixation is completed
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Question 90 of 100
#527759
CLINICAL SITUATION
How is syndesmotic instability best assessed intra-operatively?
1. By comparing tibiofibular overlap with population norms

Discussion
2. By comparing tibiofibular clear space with population norms
Syndesmotic instability should

3. Intra-operative be assessed
tibiofibular withtest
squeeze direct manipulation on both the anteroposterior
and lateral views with special attention to the lateral view. Syndesmotic reduction should be
4. Intra-operative radiographic stress examination
assessed either through open visualization or by comparing closed reduction parameters (clear
space, overlap, and fibular position on the lateral view) with the patient’s contralateral side
(assuming no injury). This is more effective than using population norms secondary to the two
types of syndesmotic morphologies which create different absolute values for these parameters.
 4 Intra-operative radiographic stress examination
Question 91 of 100
#527760
CLINICAL SITUATION
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How is syndesmotic reduction best assessed intra-operatively?
1. By comparing tibiofibular overlap with population norms

Discussion
2. By comparing tibiofibular clear space with population norms
Syndesmotic instability should

3. By comparing imagesbewith
assessed with direct
the patient’s manipulation
contralateral on both side
uninjured the anteroposterior
and lateral views with special attentionto the lateral view. Syndesmotic reduction should be asses
4. By measuring the talocrural angle
sed either through open visualization or by comparing closed reductionparameters (clear space,
overlap, and fibular position on the lateral view) with the patient’s contralateral side (assuming no
injury). Thisis more effective than using population norms secondary to the two types of syndes
motic morphologies which create different absolutevalues for these parameters.
 3 By comparing images with the patient’s contralateral uninjured side
Question 92 of 100
#527762
CLINICAL SITUATION
Our understanding of malreduction of the syndesmosis has changed over the years based
on changes in technique and imaging. Our current understanding is that malreduction of
the syndesmosis
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1. occurs only when the ankle is in plantarflexion.

2. never occurs and is not possible.
Discussion
3. is primarily dependent upon clamp application.
The 4.radiographs reveal
is dependent a the
upon trimalleolar
anterior ankle
width fracture dislocation with an associated distal
of the talus.
tibiofibular syndesmotic disruption. Medial and lateral malleolar stabilization are consistently
agreed upon. The decision to stabilize the posterior malleolus is more controversial. Posterior
malleolar stabilization accomplishes the following:
 Restores incisura competence thereby reducing the incidence of syndesmotic malreduction by

creating containment
 Assists in stabilizing the syndesmosis via the posterior inferior tibiofibular ligament, potentially
limiting the need for additional syndesmotic stabilization
 Maximizes the surface area for ankle joint loading
 Enhances posterior translational stability of the talus
The traditional indication for stabilization of the posterior malleolus is based on fragment size.
However, fracture orientation varies and makes evaluation of the fragment size challenging with a
lateral radiograph alone. The three primary types include the posterolateral oblique, medial
extension, and shell. Because of the additive syndesmotic stability which is gained through the
deep deltoid ligament and medial malleolar fixation, the anterior talofibular ligament and lateral
malleolar fixation, and the posterior inferior tibiofibular ligament and posterior malleolar fixation,
syndesmotic stability should only be assessed after all other points of instability that are planned
for fixation are fixed.
Syndesmotic instability should be assessed with direct manipulation on both the anteroposterior
and lateral views with special attention to the lateral view. Syndesmotic reduction should be
assessed either through open visualization or by comparing closed reduction parameters (clear
space, overlap, and fibular position on the lateral view) with the patient’s contralateral side
8
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(assuming no injury). This is more effective than using population norms secondary to the two
types of syndesmotic morphologies which create different absolute values for these parameters.
-  3 is primarily dependent upon clamp application
Question 93 of 100
#527763
CLINICAL SITUATION
Anatomic reduction and stabilization of the posterior malleolus fracture component
1. does not affect syndesmotic stability.

2. 2 restores
 restoresthe
theintegrity
integrityofof
thethe
incisura fibularis.
incisura fibularis
3. should be based only on size criteria.
4. must
Question 94 of precede
100 lateral malleolar fixation.
#527765
CLINICAL SITUATION
What is the morphology of the posterior malleolar fracture component?
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1. Always posteromedial
2. 3.Always
 Varies posterolateral
in morphology
3. Varies in morphology
4. Is95best
Question assessed on the lateral radiograph
of 100
#527903
Figures 1 and 2 are the radiographs and Figure 3 is the axial CT cut of a 47-year-old man
who has pain in his right elbow after a fall from his roof. On examination, he is noted to
have an effusion and his range of motion is limited by pain. What is the most appropriate
definitive treatment for this injury?
1. Closed treatment with early mobilization

2. Open reduction internal fixation
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3. Distal humeral hemiarthroplasty

4. Total elbow arthroplasty
Discussion
The patient presents with a coronal plane injury to his capitellum and trochlea as well as a partial
articular radial head fracture. Given his displaced, intra-articular fracture, open reduction internal
fixation is the most appropriate treatment in this case.
If his radial head were an isolated injury, then closed treatment with early mobilization would be
satisfactory. If the patient was older and had an unreconstructable fracture, then arthroplasty,
either with a distal humeral hemiarthroplasty or a total elbow arthroplasty, would be a reasonable
option.
 2 Open reduction internal fixation
Question 96 of 100
#527617
A 35-year-old woman is being resuscitated after a motor vehicle collision. She has a
major pulmonary contusion, a mild head injury, and an open femoral shaft fracture with
about a 4-cm skin laceration over the anterolateral aspect of the mid-thigh with what
appears to be viable muscle. The patient also has a lateral compression fracture of the
pelvis and a fracture of her humerus. Her blood pressure is 90mmHg systolic with a heart
rate of 120. She is receiving her second unit of packed red blood cells. Her lactate is 7
mmol/L, pH 7.3, and base excess -8.0 mmol/L. What is the best next step?
1. Traction for the femur fracture and splint for the humerus
Discussion
2. Emergent debridement and stabilization of femur and humerus fractures
The debate betweendebridement

3. Emergent early total care
andand damage
reamed control has evolved
intramedullary nailingto(IMN)
the early appropriate
fixation of
care protocol basedand
the femur on the patient’s
splinting of biochemical
the humerusresponse
fractureto resuscitation. Using the protocol of
having the lactate and a normalizing base excess and pH has shown that early fracture fixation
4. Traction for the femoral shaft fracture and immediate open reduction
within 36 hours is possible with a decreased length of stay and fewer complications.
internal fixation (ORIF) of the humeral shaft fracture
 1. Traction for the femur fracture and splint for the humerus
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Question 97 of 100
#528017
CLINICAL SITUATION
Figures 1 through 3 are the anteroposterior pelvis, hip and lateral hip radiographs of a 39-
year-old man who is involved in a motor vehicle collision and sustains an isolated injury
to his right hip and diaphyseal femur.
Femoral neck fractures in young adults are frequently comminuted. What is the most
common location for comminution to occur?
1. Superior and anterior

Discussion
2. Superior and posterior
The patient sustained

3. Inferior a high-energy femoral neck fracture. The Pauwel’s classification is made by
and anterior
evaluating the angle of the fracture. Degree I is from 0 to 30, Degree II is from 30 to 50, and
4. Inferior and posterior
Degree III is greater than 50. There is no Degree IV
Due to the muscular forces of the iliopsoas, external rotators, and abductors acting on the
fracture fragments, the common deformity associated with this fracture would be hip flexion,
external rotation, and shortening.
Due to the high energy needed to cause such an injury in a young patient with good bone
quality, there is often comminution. A recent study demonstrated that significant comminution (>
1.5 cm) was present in 96% of their patient cohort with posterior (84%) and inferior (94%) being
the most common sites.
 4. Inferior and posterior
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Question 98 of 100
#528018
CLINICAL SITUATION
Figures 1 through 3 are the anteroposterior pelvis, hip and lateral hip radiographs of a 39-
year-old man who is involved in a motor vehicle collision and sustains an isolated injury
to his right hip and diaphyseal femur.
What factor has been shown to best influence the outcome of the patient after
stabilization of their femoral neck fracture?
1. Type of implant used

Discussion
2. Quality of fracture reduction
Numerous
3. Timeoutcome studiesfixation
to surgical have been performed on patients after stabilization of femoral neck
fractures, and multiple factors can affect the outcomes identified. Out of the variables listed, the
4. Time until weight bearing allowed
quality of the surgical reduction has been shown to have the largest impact on fracture healing
and clinical outcomes. The time until surgery was historically thought to impact the rate of
osteonecrosis but this has not been found to be the case in more contemporary studies. There
are numerous implants being used to stabilize these fractures, ranging from cannulated screws to
sliding hip screw constructs and static and dynamic locking implants. At this time, there is no
clear consensus on the best implant to use.
The final intra-operative images reveal reduction and fixation with the use of 3 cannulated screws
as well as a medial femoral neck buttress plate. While reduction and fixation can occur through
the use of a Watson-Jones, it would not be possible to place the medial buttress plate in this
instance. Therefore, only the Heuter (also commonly referred to as the distal limb of the Smith-
Petersen) could provide such access.
 2 Quality of fracture reduction
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Question 99 of 100
#527811
Figures 1 and 2 are the radiographs of a 51-year-man who was shot in the right thigh. Which
factor would likely lead to fracture malrotation during definitive fixation?
1. Location of the fracture

Discussion
2. Fracture comminution
Fracture characteristics
3. Patient’s bodycan lead to difficulties when determining appropriate rotation. Studies
habitus
have shown that increased fracture comminution has led to increased malrotation rates.
4. Antegrade nailing
Appropriate use of a systematic approach to judging the rotation of the femur can decrease the
likelihood of malrotation and lead to more optimal results. Surgeon experience, patient’s body
habitus, and type of nail has not been demonstrated in the literature to significantly influence the
ability to obtain acceptable rotation.
 2 Fracture comminution
Question 100 of 100

#527605
What is the best treatment option for complex proximal humerus fractures in the low-
demand patient population?
1. Hemiarthroplasty
2. Reverse total shoulder arthroplasty
3. Locked-plate fixation
4. Nonoperative treatment
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Discussion
In the recent meta-analysis by Mao and associates, there was no evidence to support the use of
any of the operative modalities to treat 3- and 4-part fractures of the proximal humerus in low-
demand patients. Although surgeons and patients will differ in their treatment algorithms, the
recent meta-analysis showed lower complications with nonoperative treatment for these complex
fractures. New treatment modalities involving fibular strut allograft, reverse total shoulder
arthroplasty for elderly patients with an incompetent rotator cuff, and locked-plate fixation may
prove to be superior to nonoperative treatment in select patient populations. However, not one
operation has been shown to be superior to nonoperative treatment in the low-demand patient
population with complex proximal humerus fractures.
 4. Nonoperative treatment

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OT-UNHAS-MH

1. Three cannulated screws

 3 Sliding hip screw

1. Complete metabolic workup

 3. Laboratory studies for CBC, ESR and CRP

1. Observation for a month

 2. Lower rate of shoulder complications with ORIF

1. Operative fixation of femoral head and posterior wall

Staphylococcus aureus isfaecalis.

 4. Valgus posterolateral rotatory

1. Increased distance to the posterior interosseous nerve (PIN)

 2. Decreased risk of damage to the lateral ulnar collateral ligament (LUCL)

1. Repair the anterior capsule

 1. Repair the anterior capsule

1. Closed treatment of the fracture

 4. Radial head arthroplasty

1. better functional outcomes.

 1. better functional outcomes

1. significantly worse two-year outcomes.

When 3. compared to patients

 2. significantly better two-year outcomes

1. A male with a both bone forearm fracture

 2. A female with a femur fracture

1. decreased knee range of motion.

Suprapatellar nailing knee

 3. less anterior knee pain

1. posterior partial articular tibial plateau fracture.

 1. posterior partial articular tibial plateau fracture

1. closed reduction and percutaneous screw placement.

Initial3. management of axially

 3. spanning external fixation and closed manipulative realignment

1. Sarmiento brace with low-intensity pulsed ultrasound

 4. Open reduction internal fixation with bone grafting

1. Nonoperative treatment with protected weight bearing

 2. Examination under anesthesia to determine hip stability

1. Administration of broad spectrum IV antibiotics

 4. Joint aspiration and blood cultures

1. External fixation of his pelvis

 2. Circumferential wrap placed around greater trochanters

1. lateral plating of the fibula and a percutaneous medial column plate.

1. Accuracy of joint line restoration

 3. Lower level of education

1. Improved cosmesis with ORIF

 4. Reduced rate of nonunion with ORIF

 2. Squamous cell carcinoma

1. Excessive working length of the construct

The 3.fixation construct reduction

 2. Lack of inferomedial calcar support

 7. Osteogenic, osteoconductive and osteoinductive

 6. Osteoconductive and osteoinductive

6. Osteoconductive and osteoinductive

 5. Osteogenic and osteoinductive

5. Osteogenic and osteoinductive

 7. Osteogenic, osteoconductive and osteoinductive

1. Repeat CT head scan

The patient has a surgical

Multiple treatment algorithms exist, however, in patients with continued, hemodynamic

 4. Repeat pelvic angiography

1. A mangled extremity severity score (MESS) of 5 predicts amputation with

1. radiocapitellar joint dislocation.