aaos 2015 trauma
TRANSCRIPT
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Figure 1a Figure 1b
CLINICAL SITUATION FOR QUESTIONS 1 THROUGH 3
Figures 1a and 1b are the radiographs of a 70-year-old retired man who falls
while skiing and injures his right hip. He had no preceding hip pain. After
the fall, he is unable to ambulate and is transferred down the mountain by
the ski patrol and taken to a hospital.
Question 1 of 101
The major blood supply to the femoral head comes from which vessel?
1 - Lateral femoral circumflex artery
2 - Medial femoral circumflex artery
3 - Artery of the ligamentum teres
4 - Inferior gluteal artery
PREFERRED RESPONSE: 2 - Medial femoral circumflex artery
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Question 2 of 101
A formal multidisciplinary team approach to the comanagement of geriatric
patients with hip fracture has been shown to lead to
1 - decreased intraoperative blood loss.
2 - decreased surgical time.
3 - decreased inpatient mortality.
4 - decreased per-patient costs.
PREFERRED RESPONSE: 4 - decreased per-patient costs.
Question 3 of 101
Which factor is a potential disadvantage of total hip arthroplasty compared
to hemiarthroplasty for treatment of displaced femoral neck fracture in older
patients with higher functional demands?
1 - Increased long-term overall costs
2 - Increased risk for dislocation
3 - Increased risk for revision surgery
4 - Decreased postsurgical function
PREFERRED RESPONSE: 2 - Increased risk for dislocation
DISCUSSION
The main source of blood supply to the femoral head is the deep branch of
the medial femoral circumflex artery. The lateral femoral circumflex artery
and artery of the ligamentum teres contribute to a lesser degree, while the
inferior gluteal artery has a minimal contribution. This vascular supply is
compromised with displaced femoral neck fractures and results in a high rate
of osteonecrosis. This is a reason to consider arthroplasty for older patientswho may not be able to tolerate multiple procedures.
Studies evaluating comanagement protocols for the treatment of hip
fractures in patients older than age 60 have demonstrated significant
improvements in mortality, length of stay, complication and readmission
rates, and ambulatory status at time of discharge while decreasing costs.
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Surgical time, blood loss, time to surgery, and inpatient mortality have not
been altered.
Total hip arthroplasty is more frequently recommended for primary
treatment of displaced femoral neck fractures in older, active patients whowould have otherwise been treated with hemiarthroplasty. Risk for
acetabular erosion is alleviated, implant survival is longer, and revision
surgery rates are lower, as are overall long-term costs. Postsurgical function
is not compromised and may actually be better. Dislocation rates are
increased (up to 10%), although these rates may be lessened with recent
improvements in component design that allow for use of larger femoral
heads.
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Figure 4a Figure 4b Figure 4c
Question 4 of 101
A 30-year-old man was involved in a high-speed motorcycle collision and
sustained the injury shown in Figure 4a. Hypotension ensued shortly after
arrival in the emergency department. Figure 4b is the initial contrast pelvic
CT image with an unrecognized blush consistent with arterial bleeding.
During surgical repair, the patient was noted to have active bleeding and an
angiogram was obtained (Figure 4c). Which structure is the likely cause of
his bleeding?
1 - Superior gluteal artery2 - Branch of the external iliac artery
3 - Branch of the pudendal artery
4 - Branch of the femoral artery
PREFERRED RESPONSE: 3 - Branch of the pudendal artery
DISCUSSION
Pelvic bleeding occurs predominantly from disruption of the posterior
venous plexus and bleeding from the fractured bone. Occasionally arterial bleeding is seen, with injury to the superior gluteal artery most common.
Anterior pelvic bleeding occurs from injury to the obturator artery
(commonly from a pubic bone fracture laceration) and less frequently from
the pudendal artery near the symphysis. The location of the bleeding on CT
and angiography images does not correspond to the superior gluteal, external
iliac, or femoral arteries.
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Figure 5a Figure 5b
RESPONSES FOR QUESTIONS 5 THROUGH 8
1 - Avascular necrosis, head collapse, and screw penetration
2 - Fixation failure and varus collapse
3 - Humeral stem loosening
4 - Glenoid component loosening
5 - Hardware failure (breakage of plate or screws)
6 - Shoulder dislocation
Please choose from the responses to identify the most likely complication in
each scenario.
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Question 5 of 101
An active 79-year-old woman with the radiograph and intraoperative image
shown in Figures 5a and 5b undergoes open reduction and internal fixation
(ORIF) of her proximal humerus fracture.
1 - Avascular necrosis, head collapse, and screw penetration
2 - Fixation failure and varus collapse
3 - Humeral stem loosening
4 - Glenoid component loosening
5 - Hardware failure (breakage of plate or screws)
6 - Shoulder dislocation
PREFERRED RESPONSE: 1 - Avascular necrosis, head collapse, and
screw penetration
Question 6 of 101
A 73-year-old woman sustains a displaced 3-part proximal humerus fracture.
At the time of surgery, she has a massive rotator cuff tear in addition to the
proximal humerus fracture. She is treated with total shoulder arthroplasty
(TSA).
1 - Avascular necrosis, head collapse, and screw penetration
2 - Fixation failure and varus collapse3 - Humeral stem loosening
4 - Glenoid component loosening
5 - Hardware failure (breakage of plate or screws)
6 - Shoulder dislocation
PREFERRED RESPONSE: 4 - Glenoid component loosening
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Question 7 of 101
An 82-year-old woman with osteoporosis has increased pain and difficulty
using her arm 3 weeks after undergoing ORIF of her 4-part proximal
humerus fracture.
1 - Avascular necrosis, head collapse, and screw penetration
2 - Fixation failure and varus collapse
3 - Humeral stem loosening
4 - Glenoid component loosening
5 - Hardware failure (breakage of plate or screws)
6 - Shoulder dislocation
PREFERRED RESPONSE: 2 - Fixation failure and varus collapse
Question 8 of 101
A 79-year-old woman with a massive rotator cuff tear presents to the
emergency department with pain and difficulty moving her arm 7 weeks
after undergoing reverse TSA for a displaced 4-part proximal humerus
fracture.
1 - Avascular necrosis, head collapse, and screw penetration2 - Fixation failure and varus collapse
3 - Humeral stem loosening
4 - Glenoid component loosening
5 - Hardware failure (breakage of plate or screws)
6 - Shoulder dislocation
PREFERRED RESPONSE: 6 - Shoulder dislocation
DISCUSSION
The complication rate is high after surgical treatment of proximal humerus
fractures, particularly in elderly patients with osteoporotic bone. In patients
treated with ORIF, common complications include varus malunion (16%),
avascular necrosis (10%), screw penetration (8%), and infection (4%). In
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cases involving a dislocation of the humeral head, avascular necrosis is more
common. In patients treated with hemiarthroplasty or TSA, complications
include component loosening, infection, and dislocation. TSA is associated
with glenoid loosening in patients with rotator cuff incompetence and should
be avoided in these patients. Reverse TSA is a potential solution for this population. Dislocation and postoperative infection are potential
complications after reverse TSA.
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Figure 9a Figure 9b
Figure 9c Figure 9d
Question 9 of 101
Figures 9a through 9d are the radiographs of a 21-year-old woman who is
involved in a high-speed motor vehicle collision and sustains an isolated
right closed-foot injury. Before surgery, the patient is advised about the
relatively poor long-term outcomes associated with this injury. What is the
most common reason for functional limitations after surgical treatment in
this scenario?
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1 - Subtalar arthritis
2 - Osteonecrosis
3 - Nonunion
4 - Varus malunion
PREFERRED RESPONSE: 1 - Subtalar arthritis
DISCUSSION
When a displaced talar neck fracture occurs, the rate of osteonecrosis is
high; however, many revascularize the talus without collapse. A nonunion
can occur but is less common than osteonecrosis and arthritis. A varus
malunion can be debilitating and lead to subtalar arthritis. In a fracture with
the talar body dislocated posteromedially (such as in this example)
neurologic deficits in the tibial nerve distribution are common but typicallyimprove with urgent reduction. Studies show that posttraumatic subtalar
arthritis is common after this injury and is the most likely cause of long-term
functional impairment.
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Figure 10a Figure 10b Figure 10c
CLINICAL SITUATION FOR QUESTIONS 10 THROUGH 12
Figure 10a is the radiograph of a 30-year-old man who sustained an injury in
a motor vehicle collision.
Question 10 of 101
This patient underwent fixation and his radiographs (Figures 10b and 10c) at
6 weeks are shown. What was the failure mode for this implant?
1 - Varus collapse and hardware failure
2 - Screw cut out in the femoral head
3 - Failure of distal screws and loss of fixation
4 - Lack of patient compliance
PREFERRED RESPONSE: 1 - Varus collapse and hardware failure
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Question 11 of 101
The biomechanical reason for implant failure in this case is related to
1 - lack of medial cortical contact secondary to comminution.
2 - lack of friction fit of plate to bone.
3 - varus malreduction of the fracture.
4 - poor bone quality in the femoral head and diaphysis.
PREFERRED RESPONSE: 1 - lack of medial cortical contact secondary
to comminution.
Question 12 of 101
Among the options listed below, what is the best treatment for the
complication shown in Figure 10c?
1 - Removal of hardware and bone grafting
2 - Removal of hardware and total hip arthroplasty (THA)
3 - Removal of hardware and revision using a first-generation femoral nail
4 - Removal of hardware and revision using a second-generation femoral nail
PREFERRED RESPONSE: 4 - Removal of hardware and revision using
a second-generation femoral nail
DISCUSSION
Proximal femur fractures can be treated using a variety of implants including
intramedullary nails, blade plates, and locking plates (now precontoured
proximal femur plates). The comminution and lack of medial cortical
support may predispose these fractures to nonunion.
The recent popularity of locking plates for proximal femur treatment has
increased their use for this fracture; however, a disproportionately high rate
of failure of these plates, including early implant failure with plate and screw
breakage, cut out with varus collapse, and nonunion have been reported.?
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Malreduction predisposes these fractures to failure. The initial postoperative
radiographs do not reveal a varus malreduction because the tip of the greater
trochanter is below the center of the femoral head.
Once failure occurs, the best fixation method among the options detailed isan intramedullary nail (second generation with screws into the femoral head)
and restoration of alignment. THA is usually not recommended for treatment
of subtrochanteric femur fractures in young patients.
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Question 13 of 101
Which medication or supplement is recommended to promote healing of
atypical subtrochanteric fractures?
1 - Bisphosphonates
2 - Teriparatide
3 - Vitamin D
4 - Glucosamine chondroitin
PREFERRED RESPONSE: 2 - Teriparatide
DISCUSSION
Use of teriparatide in association with fracture fixation promotes healing
because these fractures are associated with delayed healing. The other
responses are not associated with healing of these fractures.
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Figure 14a Figure 14b
estion 14 of 101
An 18-year-old man was involved in an altercation during which he
sustained the injuries shown in Figures 14a and 14b. His Glasgow Coma
Scale (GCS) score is 11 (a GCS score of 9-12 indicates moderate head
injury). The neurosurgeons elect to not place an intracranial pressure (ICP)
monitor. The patient responds appropriately to stimuli and is
hemodynamically stable. What is the most appropriate initial treatment?
1 - Knee immobilizer
2 - Immediate spanning external fixation
3 - Immediate intramedullary nailing
4 - Immediate plate fixation
PREFERRED RESPONSE: 2 - Immediate spanning external fixation
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DISCUSSION
Although management of femoral shaft fractures in patients with head
injuries remains controversial, most practitioners agree that "damage-control
principles" are appropriate for patients with evolving head injuries. This patient has a subarachnoid hemorrhage and a decreased GCS but is
responding appropriately. The best treatment is a damage-control approach
for the femur that will cause minimal blood loss and allow the brain injury
(and swelling) to equilibrate. External fixation can be performed
expeditiously and with minimal blood loss, which will reduce further injury
to the brain. Special attention should be paid to maintaining cerebral
perfusion pressure higher than 70 mmHg. Admission to the intensive care
unit is recommended for monitoring of this injury. Knee immobilizers are
not tolerated well by young muscular men with femur shaft fractures. A
GCS score of 11 or higher can be observed without ICP monitoring.
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Figure 15
Question 15 of 101
The most common reason for proximal femur fracture fixation failure
(Figure 15) is secondary to which common deformity?
1 - Varus
2 - Valgus
3 - Malrotation
4 - Shortening
PREFERRED RESPONSE: 1 - Varus
DISCUSSION
Malposition of a proximal lag screw may result in cut-out similar to that
seen with a sliding hip screw. Varus malreduction also can result in implant
failure. Studies have shown no difference in complication or healing rates
when comparing short and long cephallomedullary nails.
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CLINICAL SITUATION FOR QUESTIONS 16 THROUGH 20
A 23-year-old man sustains multiple injuries in a high-speed motor vehicle
collision. Among his injuries are a right transverse-posterior wall acetabular
fracture, a left open tibia fracture with compartment syndrome, and a right
calcaneus fracture.
Question 16 of 101
After initial evaluation he is taken to the operating room urgently and
undergoes debridement of his open tibia fracture, 4-compartment
fasciotomy, and intramedullary nailing of the fracture. Negative pressurewound therapy (NPWT) is chosen for the open wound and fasciotomy sites.
NPWT in this scenario will
1 - remove bacteria from the wound and decrease risk for infection.
2 - promote wound contraction, making primary closure less likely.
3 - promote local wound perfusion.
4 - decrease compartment pressures.
PREFERRED RESPONSE: 3 - promote local wound perfusion.
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Question 17 of 101
Nine hours after surgery you are contacted because the patient has continued
tachycardia and ongoing resuscitation needs. The NPWT canister has been
emptied 3 times in the last 8 hours and contains sanguinous fluid. In additionto continued resuscitation, what is the most appropriate next step??
1 - Order the NPWT applied to wall suction to allow less frequent emptying
of the canister.
2 - Clamp off the suction device and return to the operating room for wound
exploration.
3 - Turn the suction down from -125 mm Hg to -50 mm Hg.
4 - Take the patient for angiography and possible embolization.
PREFERRED RESPONSE: 2 - Clamp off the suction device and return tothe operating room for wound exploration.
Question 18 of 101
On postinjury day 3 the patient undergoes open reduction and internal
fixation of his right acetabular fracture via a Kocher-Langenbeck approach.
On postoperative day 5 he is noted to have persistent serous drainage
without any localized signs of infection. Incisional NPWT used in this
setting would likely result in
1. infection.
2. a sealed wound (more rapidly than sealing would occur with a
compressive dressing).
3. hematoma formation.
4. it can electively delay flap coverage for 3 to 4 weeks.
PREFERRED RESPONSE: 2 - a sealed wound (more rapidly than sealing
would occur with a compressive dressing).
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Question 19 of 101
The patient undergoes repeat debridements for the open tibia fracture and
associated compartment syndrome. It becomes apparent that the medial open
fracture wound is not amenable to primary closure. NPWT is useful in thissetting because
1 - it will stabilize the soft-tissue environment while the patient awaits
flap coverage.
2 - it will promote granulation of the wound over the exposed fracture site
to prevent flap coverage.
3 - it will promote fracture healing.
4 - it can electively delay flap coverage for 3 to 4 weeks.
PREFERRED RESPONSE: 1 - it will stabilize the soft-tissue environment
while the patient awaits flap coverage.
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Question 20 of 101
The patient subsequently requires split-thickness skin grafting over his
lateral fasciotomy wound during soft-tissue reconstruction. In this setting,
NPWT
1 - will likely improve incorporation of the graft.
2 - will provide an inconsistent bolster to the graft.
3 - should be used directly over the skin graft.
4 - should be used at the donor site to promote faster healing.
PREFERRED RESPONSE: 1 - will likely improve incorporation of the
graft.
DISCUSSION
NPWT increases wound perfusion. The dressing may help decrease risk for
wound infection, but will not do so by removing bacteria. It also helps to
prevent wound contracture to improve the likelihood of primary wound
closure. NPWT can help to improve tissue edema and will not elevate
compartment pressure.
Hemorrhage is the most common major complication associated with NPWT. This risk is highest when NPWT is used in areas of major vessels
and vessels that have been ligated and for patients undergoing
anticoagulation therapy. Specialized white polyvinyl alcohol sponges are
available to prevent adherence to vessels, exposed nerves, or exposed bone.
NPWT should not be used directly over exposed major vessels. If major
bleeding occurs, a return to the operating room for wound exploration is
recommended.
Incisional NPWT is an effective treatment for persistent serous drainage.
Wounds that drain persistently seal more quickly and pose lower risk for
infection when incisional NPWT is used vs compressive dressings.
Incisional NPWT has also demonstrated benefit when used on high-risk
postsurgical wounds of the tibial plateau, pilon, and calcaneus. It has not
been shown to contribute to increased risk for wound dehiscence or
hematoma.
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NPWT stabilizes the soft-tissue environment and does not necessitate
frequent dressing changes. Despite this benefit, a delay of flap coverage after
NPWT still poses higher risk for infection than early coverage.
Consequently, flaps should not be delayed for long. NPWT promotes the
formation of granulation tissue and can be used over exposed bone, but itwould not be expected to form granulation tissue over an exposed fracture
site or hardware or promote fracture healing.
NPWT provides an excellent bolster for a skin graft and improves skin graft
incorporation. It needs to be applied with nonadherent dressings to prevent
adherence to the skin graft. NPWT is generally not used at skin grafting
donor sites.
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Question 21 of 101
Preventing "missed" femoral neck fractures associated with ipsilateral
femoral shaft fractures is best achieved with
1 - an examination.
2 - dedicated anteroposterior and lateral hip radiographs.
3 - thin-cut pelvic CT images with coronal and sagittal reconstructions.
4 - MRI.
PREFERRED RESPONSE: 3 - thin-cut pelvic CT images with coronal
and sagittal reconstructions.
DISCUSSION
Ipsilateral femoral neck and shaft fractures occur in up to 6% of femur
fractures. A femoral neck fracture is often vertical and nondisplaced. A high
degree of suspicion is necessary to avoid "missed" femoral neck fractures in
patients with this condition. Although an examination and dedicated hip
radiographs help to avoid missed injuries, a significant decrease in missedinjuries has been described with the use of thin-cut pelvic CT images. In
patients who undergo trauma, a pelvic CT scan is often performed to assess
for associated injuries and is easily reviewed to examine the femoral neck.
Although MRI is advocated to identify isolated occult femoral neck
fractures, CT has been described as the method of choice with which to
identify ipsilateral femoral neck and shaft fractures in the trauma population.
Currently, no literature supports the use of MRI in this population.
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Figure 22
CLINICAL SITUATION FOR QUESTIONS 22 THROUGH 25
Figure 22 is the anteroposterior radiograph of a 44-year-old firefighter who
falls from his road bike and sustains a closed midshaft clavicle fracture. He
chooses surgical treatment with open reduction and internal fixation (ORIF).
Question 22 of 101
What is the most common complication of nonsurgical treatment for this
injury?
1 - Anterior chest wall numbness
2 - Symptomatic malunion
3 - Nonunion
4 - Pneumothorax
PREFERRED RESPONSE: 3 - Nonunion
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Question 23 of 101
Which variable is a risk factor for nonunion of displaced clavicle fractures?
1 - Adolescence
2 - Displacement exceeding 100%
3 - Transverse fracture
4 - Male gender
PREFERRED RESPONSE: 2 - Displacement exceeding 100%
Question 24 of 101
The patient decides to undergo surgery with open reduction and plate
fixation. What is the most common reason for revision surgery after plate
fixation of a clavicle fracture?
1 - Supraclavicular nerve entrapment
2 - Symptomatic malunion
3 - Nonunion
4 - Hardware irritation/prominence
PREFERRED RESPONSE: 4 - Hardware irritation/prominence
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Question 25 of 101
Which structure(s) is/are most at risk with surgical treatment of displacedclavicle fractures with ORIF?
1 - Subclavian artery
2 - Subclavian vein
3 - Brachial plexus
4 - Supraclavicular nerves
PREFERRED RESPONSE: 4 - Supraclavicular nerves
DISCUSSION
Complications associated with nonsurgical treatment of displaced midshaft
clavicle fractures are uncommon. Although intrathoracic and local vascular
complications have been reported with clavicle fracture, subclavian artery
aneurysm and pneumothorax are rare. Malunion to some degree is inevitable
with nonsurgical treatment of displaced clavicle fractures, but only about 9%
of patients develop symptomatic malunion. Nonunion occurs in about 15%
of patients.
Previously identified risk factors for nonunion of clavicle fractures include
female gender, displacement exceeding 100%, comminution, and advanced
age. Research demonstrates the strongest risk factors are smoking,
comminution, and fracture displacement. Rate of nonunion in 1 study was
approximately 13%. Murray and associates showed that by estimating the
risk of nonunion using their model and operating only on fractures with at
least a 40% chance of nonunion, they would only need to operate on 1.7
patients to prevent 1 nonunion (decreased from 7.5 procedures per nonunion
if operating on all displaced midshaft fractures). This data could potentially
be used to limit unnecessary procedures and decrease costs associated with
treatment of clavicle fractures.
Hardware removal is the most common reason for revision surgery.
Symptomatic malunion and supraclavicular nerve entrapment are rare after
surgery. Nonunion is uncommon (in fewer than 2% of cases). The main
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reason for revision surgery is hardware removal to address local
irritation/prominent hardware or infection.
An anatomical study demonstrated that in 97% of clavicles, 2 to 3 branches
of the supraclavicular nerve were crossing the clavicle with wide locationvariability in the zone in which most clavicle fractures occur and surgery
would take place. The subclavian vein and artery and brachial are rarely
injured, although there are case reports of injury to all either by the displaced
fracture fragments or errant hardware.
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Figure 26a Figure 26b Figure 26c Figure 27
CLINICAL SITUATION FOR QUESTIONS 26 AND 27
Figures 26a through 26c are the radiographs of a 50-year-old athlete who
sustained an injury to his right foot; the foot was plantar flexed and another player landed on the posterior aspect of his heel. After sustaining the injury
he was unable to bear weight, and 3 days later he was seen in the emergency
department because of persistent pain and tenderness over his midfoot.
Question 26 of 101
CT images reveal a purely ligamentous injury. Which treatment produces the
best results?
1 - Open reduction and internal fixation (ORIF) of the fracture2 - Early fusion of the first and second tarsometatarsal joints
3 - Nonweight-bearing activity for 6 weeks
4 - Weight bearing with a camwalker
PREFERRED RESPONSE: 2 - Early fusion of the first and second
tarsometatarsal joints
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Question 27 of 101
ORIF of the injury was chosen (as illustrated in Figure 27). Long-term
results may include
1 - improved American Orthopaedic Foot & Ankle Society (AOFAS) scores
as compared to scores obtained following fusion.
2 - pes planovalgus.
3 - persistent pain and arthritis.
4 - hindfoot pain.
PREFERRED RESPONSE: 3 - persistent pain and arthritis.
DISCUSSION
The injury mechanism describes axial loading to a plantar-flexed foot and is
classic for Lisfranc injury. If the initial films are not diagnostic as in this
case, weight-bearing films are a reasonable next step. Radiographic
widening of 2 mm or more between the second metatarsal base and medial
cuneiform (as compared to the other side) is diagnostic; occasionally, a
"fleck" sign (a small bony fragment noted in the Lisfranc joint) may indicate
an avulsion fracture. Clinical signs include plantar ecchymosis, tenderness
over the Lisfranc joint, and an inability to bear weight. Anatomic ORIF orfusion are the options for treatment, and results for ligamentous injuries are
better when fusion is performed. Better AOFAS scores have been
demonstrated with fusion, and a higher incidence of pain and arthritis have
been noted with fixation. No significant difference has been seen regarding
hardware failure, and hindfoot pain is not a consideration.
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Question 28 of 101
A 67-year-old right-hand-dominant man who is an avid golfer sustains an
unstable distal radius fracture on his right side. He undergoes a closed
reduction with acceptable alignment. After discussing surgical vs
nonsurgical management and recovery, the patient decides to have surgery.
He made this decision because he was told that his
1 - functional outcome at 1 year would be worse with nonsurgical
management.
2 - radiographs will look better after surgery.
3 - grip strength will be better with surgical intervention.4 - overall long-term outcome can improve with formal occupational therapy
after surgery.
PREFERRED RESPONSE: 3 - grip strength will be better with surgical
intervention.
DISCUSSION
The optimal treatment of distal radius fractures in elderly patients remains
controversial. Both surgical and nonsurgical management of distal radius
fractures produce identical functional outcomes at 1 year. Although many
patients have better motion early with surgery, only grip strength has been
shown to be significantly better at 1 year. Radiographic outcome has not
been correlated with functional outcome, and complications are also
equivalent. Independent prescribed therapy has been better than formal
occupational therapy for range of motion, but no differences in functional
outcome were seen as assessed by Disabilities of the Arm, Shoulder and
Hand scores.
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Figure 29
Question 29 of 101
Figure 29 is the anteroposterior radiograph of a 60-year-old man who is
involved in a motorcycle collision and airlifted to a trauma center. The
patient is hypotensive and tachycardic upon arrival and fluid resuscitation is
underway. He has a scrotal hematoma and his bilateral lower extremities are
externally rotated. What is the first step in managing this scenario?
1 - Obtain CT images of the pelvis
2 - Angiography
3 - Place external fixation
4 - Apply a pelvic binder
PREFERRED RESPONSE: 4 - Apply a pelvic binder
DISCUSSION
A pelvic binder or sheet can be applied right away to reduce and stabilize the pelvis more quickly than is possible with an external fixator. Pelvic ring
injuries are associated with a high incidence of mortality mainly because of
the potential for retroperitoneal hemorrhage. A pelvic circumferential
compression device allows for force-controlled circumferential compression.
It can effectively reduce pelvic ring injuries and poses minimal risk for
overcompression and complications. Reduction of external rotation injuries
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is comparable to definitive fixation reduction and does not cause significant
overcompression of internal rotation injuries. Angiography is used to assess
persistent hemodynamic instability after initial stabilization of the pelvic
ring with the binder or sheet. CT images should be obtained after initial
resuscitation.
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Question 30 of 101
An 82-year-old woman falls from a standing height and sustains a proximal
humerus fracture. Which factor is the best predictor of ischemia of the
humeral head?
1 - Fracture pattern involving 4 parts
2 - Humeral head angulation exceeding 45 degrees
3 - Posteromedial calcar length of less than 8 mm attached to the humeral
head
4 - Glenohumeral dislocation
PREFERRED RESPONSE: 3 - Posteromedial calcar length of less than 8
mm attached to the humeral head
DISCUSSION
Humeral head ischemia that occurs following proximal humerus fractures is
closely associated with the amount of posteromedial calcar bone attached to
the humeral head. Fractures that exit within 8 mm of the posteromedial edgeof the head more commonly are ischemic (compared to fractures that have
more than 8 mm of posteromedial calcar still attached). Four-part fracture
patterns are a moderate predictor of humeral head ischemia, with an
accuracy of 0.67. Angulation of the humeral head exceeding 45 degrees also
is a moderate predictor of humeral head perfusion, with an accuracy of 0.62.
Glenohumeral dislocation is a poor predictor of humeral head ischemia.
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Question 31 of 101
An atypical bisphosphonate-associated femur fracture would show which
features?
1. Lateral cortical thickening at the subtrochanteric region with a
fracture line extending to the medial side.
2. Lateral cortical thickening at the supracondylar region with a fracture
line extending to the medial side.
3. Stress fracture of the femoral neck.
4. Reverse obliquity intertrochanteric femur fracture.
PREFERRED RESPONSE: 1 - Lateral cortical thickening at the
subtrochanteric region with a fracture line extending to the medial side
DISCUSSION
Patients sustaining atypical femur fractures have classic radiographic
findings including medial beaking, lateral cortical thickening, and transverse
or short oblique proximal (subtrochanteric) femur fracture.
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RESPONSES FOR QUESTIONS 32 THROUGH 35
1. Open reduction and internal fixation with a proximal humerus locking
plate.
2. Nonsurgical treatment.
3. Arthroplasty
Match the appropriate treatment listed with the clinical scenario described.
Question 32 of 101
A 78-year-old right-hand-dominant woman who lives independently falls
down the stairs at her home. She has an isolated injury to her left shoulderand a history of hypertension and atrial fibrillation. Imaging reveals a
proximal humerus fracture with a displaced fracture splitting the humeral
head and a large displaced greater tuberosity fragment.
1. Open reduction and internal fixation with a proximal humerus
locking plate.
2. Nonsurgical treatment.
3. Arthroplasty
PREFERRED RESPONSE: 3 - Arthroplasty
Question 33 of 101
A 72-year-old right-hand-dominant woman sustains an isolated injury to her
right shoulder after a fall while walking her dog. She lives independently
and has a history of hypercholesterolemia. Her activities include walking,
aerobics, and yoga. Imaging reveals a proximal humerus fracture with
fracture of the surgical neck that is displaced 2 cm.
1 - Open reduction and internal fixation with a proximal humerus locking plate2 - Nonsurgical treatment
3 - Arthroplasty
PREFERRED RESPONSE: 1 - Open reduction and internal fixation with a
proximal humerus locking plate
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Question 34 of 101
An 81-year-old left-hand-dominant woman who lives independently has a
slip-and-fall accident while shopping. She has an isolated injury to her left
shoulder and a history of coronary artery disease and hypertension. Imagingreveals a proximal humerus fracture with 50% translation at the surgical
neck.
1 - Open reduction and internal fixation with a proximal humerus locking
plate
2 - Nonsurgical treatment
3 - Arthroplasty
PREFERRED RESPONSE: 2 - Nonsurgical treatment
Question 35 of 101
An 80-year-old right-hand-dominant woman who lives independently falls
in her home. She has an isolated injury to her right shoulder and a history of
a total hip replacement for a femoral neck fracture (3 years prior). She has
had a prior failed rotator cuff repair. Her daily activities include volunteering
at her church and caring for her grandchildren. Imaging reveals a displaced
proximal humerus fracture with comminution and 50% translation withvarus angulation at the surgical neck. She also has displacement and
comminution of the greater tuberosity.
1 - Open reduction and internal fixation with a proximal humerus locking
plate
2 - Nonsurgical treatment
3 - Arthroplasty
PREFERRED RESPONSE: 3 - Arthroplasty
DISCUSSION
Treatment of proximal humerus fractures in elderly patients is controversial
and requires consideration of the patient's functional demands and fracture
characteristics. The majority of fractures can be treated nonsurgically.
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Nonsurgically treated fractures should be briefly immobilized before
beginning pendulum exercises and elbow range of motion.
Some patients are surgical candidates based upon functional demands and
degree of displacement. Fractures that are reconstructible can besuccessfully treated with reduction and fixation or intramedullary nailing. If
there is tuberosity involvement, plate fixation is preferable to intramedullary
nailing. Factors that make fixation challenging and vulnerable to failure
include poor bone quality and significant varus alignment. Relative
indications for arthroplasty, especially in patients with poor bone quality,
include initial varus alignment, head-splitting fractures, and 4-part fractures.
Traditionally, hemiarthroplasty has produced reliable pain relief and
unreliable function because of the difficulty associated with reconstruction
of the tuberosities to restore rotator cuff function. Reverse shoulder
arthroplasty may be a better option for patients who are arthroplastycandidates who have tuberosities that will not be reliably reconstructed or
for those who have a pre-existing rotator cuff deficiency.
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Figure 36
Question 36 of 101
Two femoral shaft fractures are shown in Figure 36. Each is fixed identically
with the same intramedullary nail and interlocking screws. The fracture gapstrain is higher in
1 - A.
2 - B.
3 - neither; the strain is identical in A and B.
4 - neither; the strain is dependent on femur length.
PREFERRED RESPONSE: 1 - A.
DISCUSSION
Fracture gap strain is defined as deformation of granulation tissue within the
fracture gap when a given force is applied. Normal strain is the change in
length (? l) divided by the original length (l) when a given load is applied.
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The amount of deformation that a tissue can tolerate while functioning varies
greatly. Intact bone has a normal strain tolerance of 2% (before it fractures),
whereas granulation tissue has a strain tolerance of 100%. Bony bridging
between the distal and proximal callus can only occur when local strain (ie,
deformation) is less severe than the forming bone can tolerate. Therefore,treatment of fractures must optimize the strain environment to enable
healing.
Comminution, as shown in B, results in distribution of the motion between
multiple fracture fragments. As a result, each fracture gap experiences less
motion and strain is decreased. In simple fracture patterns as shown in A,
small amounts of motion or even a small fracture gap results in a high-strain
environment. Strain is dependent upon the length of the fracture gap but not
on the length of the bone.
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Figure 37
Question 37 of 101
Figure 37 is the radiograph of a 31-year-old woman who has acute right hip
pain after a fall. The treatment variables that are most important to maximize
clinical outcome are
1 - timing of fixation and capsulotomy.
2 - timing of fixation and choice of implants.3 - quality of reduction and fixation.
4 - choice of open reduction and capsulotomy.
PREFERRED RESPONSE: 3 - quality of reduction and fixation.
DISCUSSION
Femoral neck fractures are potentially devastating injuries for physiologically
young patients. Studies have demonstrated that the timing of fixation is not as
critical to outcome or to avascular necrosis prevention as other factors.
Experimental evidence supports capsulotomy to improve femoral head blood flow.
Relative biomechanical advantages are associated with different implants;
however, a surgeon can obtain good fixation with a variety of devices. For a
physiologically young patient, an open reduction is often required to obtain the
desired anatomic reduction; however, if the desired result can be achieved with
closed reduction, open reduction is not required. Anatomic reduction of the
fracture and biomechanically sound fixation consistently yield optimal results.
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Figure 38a Figure 38b Figure 38c
Question 38 of 101
A 55-year-old man fell off a bicycle and sustained the injury shown in
Figures 38a through 38c. Which fracture pattern best describes this injury?
1 - Anterior column posterior hemitransverse2 - Anterior column
3 - Anterior wall
4 - Associated both-column
PREFERRED RESPONSE: 2 - Anterior column
DISCUSSION
This is an anterior column fracture with dome impaction. The obturator
oblique view and both CT images show disruption of the anterior column.
Both CT images also reveal an intact posterior column, which eliminates
anterior column posterior hemitransverse and associated both-column
fracture types as correct responses. An anterior wall fracture would not
extend up into the ilium.
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Figure 39
CLINICAL SITUATION FOR QUESTIONS 39 THROUGH 41
Figure 39 is the standing radiograph of a 20-year-old college student who
injures his foot while playing intramural football. Initial radiograph findings
are reportedly normal, but 1 week after injury he still cannot bear weight.
You see him in the clinic and note swelling of his foot and plantar
ecchymosis.
Question 39 of 101
What is the strongest structure supporting the tarsometatarsal (TMT)
complex of the midfoot?
1 - Oblique interosseous ligament
2 - Deep band of the plantar oblique ligament
3 - Dorsal oblique ligament
4 - First TMT ligament
PREFERRED RESPONSE: 1 - Oblique interosseous ligament
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Question 40 of 101
What radiographic finding is consistent with a Lisfranc injury?
1 - Dorsal and plantar aspects of the metatarsals (MTs) correspond with thecuneiforms and cuboid on the lateral view.
2 - The medial border of the second MT is aligned with the medial border of
the middle cuneiform on the anteroposterior view.
3 - The medial border of the fourth MT is aligned with the medial border of
the cuboid on the oblique view.
4 - Diastasis between the first and second MT is 3.5 mm.
PREFERRED RESPONSE: 4 - Diastasis between the first and second MT
is 3.5 mm.
Question 41 of 101
Primary arthrodesis is associated with which outcome when compared to
outcomes associated with open reduction and internal fixation (ORIF)
without arthrodesis?
1 - Decreased secondary surgeries
2 - Increased pain3 - Increased risk for infection
4 - Poorer function at 2-year follow-up
PREFERRED RESPONSE: 1 - Decreased secondary surgeries
DISCUSSION
There are longitudinal, oblique, and transverse ligaments at the TMTcomplex that are further defined by their location as dorsal, interosseous, or
plantar. There are 3 ligaments between the medial cuneiform and the second
MT base, the most important of which is the oblique interosseous ligament,
which is also known as the Lisfranc ligament. Plantar and dorsal oblique
ligaments contribute to stability to a lesser degree. The dorsal ligaments are
weakest and may be the first to fail in a Lisfranc injury.
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The second MT base should be aligned with the middle cuneiform at the
medial borders, and the fourth MT base should be aligned with the cuboid at
the medial borders on the oblique view. The dorsal and plantar aspects of the
MTs should align with the cuneiforms/cuboid on the lateral view. Any
malalignment should raise the suspicion of a Lisfranc injury. Diastasis between the second MT and the first MT/medial cuneiform complex of more
than 2 mm indicates injury, as does TMT joint subluxation of 2 mm more
than seen on the uninjured contralateral side. Diastasis between the first and
second MT up to 2.7 mm can be normal. Another radiographic sign of injury
includes avulsion fracture of the second MT base or medial cuneiform.
Additional imaging studies that may be helpful in identifying subtle injuries
include weight-bearing radiographs and CT or MRI images.
Two prospective randomized studies compared primary fusion with ORIF
Lisfranc injuries. The second study included fracture-dislocations, whereasthe first looked at primarily ligamentous injuries. Results conflicted with an
earlier study demonstrating improved results (less pain, better function) with
primary fusion, while a more recent study showed no difference. Neither
study showed worse results with primary fusion, and the rate of secondary
surgery was more common in the ORIF group (salvage arthrodesis or
hardware removal).
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Figure 42a Figure 42b
Question 42 of 101
Which ligament attaches to the bony fragment identified by the CT image
arrows in Figures 42a and 42b?
1 - Posterior tibiotalar ligament
2 - Posterior-inferior tibiofibular ligament (PITFL)
3 - Interosseous ligament (IOL)
4 - Anterior-inferior tibiofibular ligament (AITFL) ?
PREFERRED RESPONSE: 2 - Posterior-inferior tibiofibular ligament
(PITFL)
DISCUSSION
The distal tibiofibular syndesmosis is a ligamentous complex that consists of the
AITFL, PITFL, intertransverse ligament (ITL), and IOL. The PITFL originates on
the posterior inferior aspect of the tibia (Volkmann tubercle) and inserts on the
lateral malleolus. The AITFL originates on the anterolateral aspect of the tibia
(Chaput tubercle) and inserts on the distal anterior aspect of the fibula (Wagstaffe
tubercle). The ITL is a group of fibers running transversely just inferior to the
PITFL. As a group, these structures maintain the appropriate tibial plafond and
talus relationship throughout physiologic range of motion.
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Figure 43a Figure 43b
CLINICAL SITUATION FOR QUESTIONS 43 THROUGH 46
A 46-year-old healthy right-hand-dominant man falls and sustains the injury
shown in Figures 43a and 43b.
Question 43 of 101
What is the treatment of choice?
1 - Nonsurgical treatment
2 - Open reduction and internal fixation (ORIF)3 - Hemiarthroplasty
4 - Total shoulder arthroplasty (TSA)
PREFERRED RESPONSE: 2 - Open reduction and internal fixation
(ORIF)
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Question 44 of 101
If the patient undergoes ORIF, which strategy is essential to minimize
fixation failure?
1 - Use of all locking screws
2 - Use of cancellous allograft for defect management
3 - Achieving at least 3 points of fixation in the humeral head
4 - Restoration of medial cortical support
PREFERRED RESPONSE: 4 - Restoration of medial cortical support
Question 45 of 101
A similar fracture is treated with ORIF and a locking plate for an active 73-
year-old right-hand-dominant woman. Which patient characteristic is most
likely to contribute to possible fixation failure?
1 - Hand dominance
2 - Level of activity
3 - Osteoporosis
4 - Rotator cuff incompetence
PREFERRED RESPONSE: 3 - Osteoporosis
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Question 46 of 101
The 73-year-old patient undergoes shoulder hemiarthroplasty. What is a risk
factor for a poor outcome?
1 - Tuberosity nonunion
2 - Hand dominance
3 - Female gender
4 - BMI higher than 30
PREFERRED RESPONSE: 1 - Tuberosity nonunion
DISCUSSION
Surgical treatment is favored for young, active patients with displaced
proximal humerus fractures. Nonsurgical treatment is favored to treat
fractures with minimal displacement among low-demand elderly patients.
When ORIF is used, a number of strategies are employed to prevent failure,
including restoration of medial cortical support (medial calcar),
incorporation of the rotator cuff into the construct, and placement of screws
of adequate length to gain purchase in the subchondral bone of the humeral
head. Intramedullary allograft is not routinely required but is useful when
dealing with osteoporotic bone. Cancellous allograft has not been shown to prevent failure. Varus collapse and failure of fixation are more prevalent in
patients with osteoporotic bone, and, in these cases, strategies for
supplemental fixation are advisable. In cases of severe osteoporosis,
comminution, or poor bone quality, shoulder arthroplasty may be a better
choice. Without a functioning rotator cuff, as would happen with a
tuberosity nonunion, outcomes after shoulder hemiarthroplasty and TSA are
poor.
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Figure 49a Figure 49b Figure 49c
Figure 50a Figure 50b
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RESPONSES FOR QUESTIONS 47 THROUGH 50
1 - Stress distribution
2 - Stress concentration
For each pattern detailed or depicted, select the appropriate condition.
Question 47 of 101
A simple fracture pattern that is nonanatomically reduced with a 3-mm gap
and treated with an 8-hole locking plate with 4 bicortical locking screws
placed on each side of the fracture
1 - Stress distribution
2 - Stress concentration
PREFERRED RESPONSE: 2 - Stress concentration
Question 48 of 101
A multifragmentary fracture pattern that is bridge plated to restore length
and alignment and treated with a 12-hole locking plate with 4 bicortical
locking screws placed on each side of the fracture
1 - Stress distribution
2 - Stress concentration
PREFERRED RESPONSE: 1 - Stress distribution
Question 49 of 101
Figures 49a through 49c
1 - Stress distribution
2 - Stress concentration
PREFERRED RESPONSE: 2 - Stress concentration
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Question 50 of 101
Figures 50a and 50b
1 - Stress distribution2 - Stress concentration
PREFERRED RESPONSE: 1 - Stress distribution
Figure 50c Figure 50d
DISCUSSION
When comparing stress distribution and stress concentration, the focus is
primarily on the implant. Stress is equal to force divided by the area over
which that force is distributed. When the area is small, concentration ofstress occurs. When the area is large, distribution of stress occurs. The
practical importance is most easily understood via an analogy (Figures 50c
and 50d). Consider a ruler. If the goal were to break the ruler, placing your
thumbs close together would be a logical choice. This hand position
concentrates the forces over a small area (stress concentration). Now
imagine that the ruler is a bone and your thumbs are screws placed on each
side of a fracture. If a bending load is applied, the same small area of the
plate is cycled. Metal can sustain a limited number of cycles before fatigue
failure occurs. If the bone does not heal before this time, construct failure
ensues. In a scenario in which prolonged healing times are expected, leaving
a larger segment of the plate unsupported (ie, moving the center screws
further away from each other) would distribute implant stress. This must be
balanced with the goal of stability and the basic science of bone healing.
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Figure 51a Figure 51b Figure 52a
Figure 52b Figure 52c Figure 52d
CLINICAL SITUATION FOR QUESTIONS 51 THROUGH 53
Figures 51a and 51b are the radiographs of a 55-year-old man who was
involved in a motor vehicle collision. The patient has pain and deformity of
his right knee. Examination reveals crepitus and swelling about the knee
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with gross motion of the distal femur. There is an 8-cm lateral open wound
with exposed bone and gross contamination.
Question 51 of 101
Immediate surgical treatment should consist of irrigation and debridement of
the fracture and
1 - bridging external fixation.
2 - a retrograde intramedullary nail.
3 - a tibial traction pin.
4 - open reduction and internal fixation (ORIF) with plate fixation.
PREFERRED RESPONSE: 1 - bridging external fixation.
Question 52 of 101
The patient undergoes ORIF as shown in Figures 52a and 52b. Three months
later, he develops a deformity and pain. Radiographs are shown in Figures
52c and 52d. Early hardware failure in the management of distal femur
fractures has been linked to
1 - the use of nonlocking screws in the proximal fragment.
2 - the length of the plate used.
3 - distal placement of the plate.
4 - comminution of the fracture.
PREFERRED RESPONSE: 2 - the length of the plate used.
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Question 53 of 101
When applying a locking plate to the lateral aspect of the distal femur,
medial translation of the distal femur occurs with respect to the diaphysis
("golf-club deformity"). This deformity was created by
1 - placement of the plate too posterior.
2 - placement of the plate too proximal.
3 - placement of the plate too anteriorly on the shaft.
4 - placement of the plate too anteriorly on the condyles.
PREFERRED RESPONSE: 1 - placement of the plate too posterior.
DISCUSSION
This patient should undergo immediate irrigation and debridement of the
fracture. Secondary to gross contamination, there is concern for initial
definitive treatment. ?
Because of the contamination, temporary stabilization will allow for better
soft-tissue management and a second look prior to definitive internal
fixation. Tibial traction pin placement for skeletal traction is less than ideal
because it confines patients to bed rest. With external fixation, a patient canmobilize.
Obtaining CT images prior to ORIF will aid in preoperative planning.
Locked plating of supracondylar distal femur fractures has not been without
complications. In a large study of patients undergoing surgical fixation, it
was found that a key failure factor was plate length. A plate longer than 9
holes (shaft) that allows for at least 8 holes proximal to the fracture is ideal.
Other risk factors that led to implant failure in this study were obesity, open
fractures, smoking, and younger age. There has not been an association with
early failure using nonlocked screws or the degree of comminution. Both
may be factors in long-term failure if there is delayed healing or nonunion
development. ?
The golf-club deformity has been a long-standing problem in the
management of distal femur fractures when a plate is applied too posteriorly.
This was true when 95-degree dynamic condylar plates or blade plates were
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used, and this still holds true for locking plates. Distal placement of the plate
also leads to this deformity because in both situations medialization of the
condyles occurs. Placing the plate too anterior on the shaft can lead to
compromised fixation and early failure, whereas placement anterior on the
condyles can lead to hardware pain or intra-articular screw penetration intothe patella-femoral joint. Proximal placement of the plate would not result in
the deformity and is not a common problem because of the contour of the
plate. If the plate were applied too proximal, the condyles would be
lateralized and/or insufficient points of fixation could occur.
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Figure 54a Figure 54b
Question 54 of 101
A 53-year-old man is involved in a motor vehicle collision and sustains the
closed distal femur fracture seen in Figures 54a and 54b. A precontoured
distal femoral locking plate is selected for fixation. A locking construct
should be used to
1 - make the construct as rigid as possible and minimize strain to promote
primary bone healing.
2 - make the construct as rigid as possible and provide a high-strain
environment to promote primary bone healing.
3 - provide a fixed-angle construct and bridge the area of comminution to
minimize strain and promote secondary bone healing.
4 - provide a fixed-angle construct and bridge the area of comminution to
provide a high-strain environment and promote secondary bone healing.
PREFERRED RESPONSE: 3 - provide a fixed-angle construct and bridge
the area of comminution to minimize strain and promote secondary bone
healing.
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DISCUSSION
This patient has a comminuted distal femur fracture. A fixed-angle device
such as a locking plate is preferred to confer angular stability to the construct
and prevent varus collapse. The strategy to promote union of the fracture isto provide a low-strain environment to allow bone healing. Strain is
determined by the amount of motion over the length of a fracture. In the case
of a noncomminuted fracture, the fracture surfaces can be compressed and
rigid fixation applied to abolish strain and promote primary bone healing
without callus. In the case of a comminuted fracture, the preferred fixation
strategy focuses on distributing motion along the length of the fracture to
provide a low-strain environment that will promote secondary bone healing
and callus formation.
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Question 55 of 101
An 83-year-old right-hand-dominant woman sustains a displaced right extra-
articular distal radius fracture and is treated with closed reduction and
casting. At her 4-week follow-up visit, radiographs demonstrate a volar tilt
of -5 degrees and 4 mm of positive ulnar variance. Which treatment is
recommended?
1 - No additional reduction and continued treatment in the cast
2 - Repeat closed reduction and cast application
3 - Closed reduction and percutaneous skeletal fixation
4 - Open reduction and internal fixation
PREFERRED RESPONSE: 1 - No additional reduction and continued
treatment in the cast
DISCUSSION
Studies demonstrate that surgical treatment of distal radius fractures in
elderly people does not result in improved outcomes. Although nonsurgicaltreatment resulted in worse radiographic findings for this patient, these
findings did not translate into worse functional outcomes.
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Figure 56
Question 56 of 101
Figure 56 is the radiograph of a 62-year-old noninsulin-dependent woman
with diabetes who twisted her ankle while walking and felt a pop. At the
emergency department she describes heel pain. What is the best course of
action?
1 - Protected weight-bearing activity for 6 weeks
2 - Closed reduction and cast application
3 - Urgent open reduction and internal fixation
4 - Excision of the calcaneal tuberosity
PREFERRED RESPONSE: 3 - Urgent open reduction and internal fixation
DISCUSSION
The radiograph reveals a displaced calcaneal tuberosity fracture.
Displacement of a large tuberosity fragment necessitates urgent fracture
reduction and stabilization. Delayed reduction results in compromise of the
skin and soft tissues at the posterior heel. This injury occurs frequently in
patients with diabetes. Protected weight-bearing activity does not address thedisplaced fragment or the threatened skin. Closed reduction, if possible, will
not maintain the tuberosity fragment in a reduced position and will likely
result in redisplacement. The fragment is large enough that it may be fixed
and not excised. The Achilles tendon inserts on the displaced tuberosity
fragment, so tuberosity reduction and fixation is necessary to achieve proper
Achilles function.
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RESPONSES FOR QUESTIONS 57 THROUGH 59
1 - High strain
2 - Low strain
For each fracture detailed, select the appropriate description.
Question 57 of 101
A simple fracture pattern that is anatomically reduced and compressed and
treated with an 8-hole conventional plate with 4 bicortical conventional
screws placed on each side of the fracture
1 - High strain
2 - Low strain
PREFERRED RESPONSE: 2 - Low strain
Question 58 of 101
A multifragmentary fracture pattern that is bridge plated, restoring length
and alignment, and treated with a 12-hole locking plate with 4 bicortical
locking screws placed on each side of the fracture
1 - High strain
2 - Low strain
PREFERRED RESPONSE: 2 - Low strain
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Question 59 of 101
A transverse humeral shaft fracture that occurs between a stiff arthritic
shoulder joint; a stiff, arthritic elbow joint is treated nonsurgically in a
hanging-arm cast
1 - High strain
2 - Low strain
PREFERRED RESPONSE: 1 - High strain
DISCUSSION
In 1977, Perren and Cordey penned a German manuscript that first described
an interpretation of mechanical influences on tissue differentiation. This
became known as the Strain Theory of Perren. In 1980, a second manuscript
by the same authors was published in English. Within this manuscript,
Perren wrote, "These thoughts about the mechanical influences on tissue
differentiation are not intended as conclusive evidence since precise data are
still not available, but we hope that they will stimulate thought and provide a
basis for discussion." More than 30 years later, these thoughts continue to
stimulate discussion and research on cell mechanotransduction. This theory
is still being manipulated in surgical theatres all around the world in anattempt to more consistently achieve fracture healing. Strain is a magnitude
of deformation. As typically defined, it is the change in dimension of a
deformed object during loading divided by its original dimension. This is
difficult to work with intraoperatively. The fraction below illustrates a
simpler way to regard this concept:
Strain = Magnitude of displacement between fragments during loading /
Total resting distance between fragments after stabilization
By remembering that low strain generally leads to bone formation and
healing, it is possible to manipulate this fraction intraoperatively to achieve
success. When a simple fracture pattern is anatomically reduced and
compressed, then the total resting distance between fragments after
stabilization approaches 0. This means the numerator must be near