OITE Review

TRAUMA

William Taylor Dodgen, MD

JPS Dept. of Orthopaedic Surgery
11/5/14
 Question 2
An 85-year-old woman with a history of poorly controlled hypertension, orally
controlled diabetes, and atrial fibrillation with controlled rate is seen on a Thursday
with an unstable intertrochanteric fracture. Evaluation reveals she is slightly
hypernatremic (sodium level 155 mEq/L) (reference range, 136-142 mEq/L). What is
the most appropriate treatment option?

1. Traction and hydration because surgical intervention puts this patient at high risk
2. One liter of normal saline and immediate (Thursday) open reduction and internal
fixation with a plate
3. Rehydration, medical evaluation, and open reduction and internal fixation with a
nail within 48 hours
4. Rehydration, cardiac stress testing, endocrine evaluation, and open reduction and
internal fixation with a plate on Monday
5. Immediate open reduction and internal fixation with a nail followed by admission to
medicine for treatment after surgery
 Question 2
An 85-year-old woman with a history of poorly controlled hypertension, orally
controlled diabetes, and atrial fibrillation with controlled rate is seen on a Thursday
with an unstable intertrochanteric fracture. Evaluation reveals she is slightly
hypernatremic (sodium level 155 mEq/L) (reference range, 136-142 mEq/L). What is
the most appropriate treatment option?

1. Traction and hydration because surgical intervention puts this patient at high risk
2. One liter of normal saline and immediate (Thursday) open reduction and internal
fixation with a plate
3. Rehydration, medical evaluation, and open reduction and internal fixation with a
nail within 48 hours
4. Rehydration, cardiac stress testing, endocrine evaluation, and open reduction and
internal fixation with a plate on Monday
5. Immediate open reduction and internal fixation with a nail followed by admission to
medicine for treatment after surgery
• Switzer JA, Layman MD, Bogoch ER. Perioperative and
postoperative considerations in the geriatric patient.
In: Schmidt AH, Teague DC, eds. Orthopaedic
Knowledge Update: Trauma 4. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2010:535-544.
• Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G,
Frankel VH. Postoperative complications and mortality
associated with operative delay in older patients who
have a fracture of the hip. J Bone Joint Surg Am. 1995
Oct;77(10):1551-6. PubMed PMID: 7593064.
 Question 6
What is the most important determinant of the
energy imparted to the soft tissues as a result of a
gunshot wound?

1. Yaw
2. Mass
3. Range
4. Caliber
5. Velocity
 Question 6
What is the most important determinant of the
energy imparted to the soft tissues as a result of a
gunshot wound?

1. Yaw
2. Mass
3. Range
4. Caliber
5. Velocity
• Bartlett CS, Helfet DL, Hausman MR, Strauss E.
Ballistics and gunshot wounds: effects on
musculoskeletal tissues. J Am Acad Orthop Surg.
2000 Jan-Feb;8(1):21-36. Review. PubMed PMID:
10666650.
• Dougherty PJ, Najibi S, Silverton C, Vaidya R.
Gunshot wounds: epidemiology, wound ballistics,
and soft-tissue treatment. Instr Course Lect.
2009;58:131-9. PubMed PMID: 19385526.
 Question 10
Figure 10 is the radiograph of an 18-year-
old man who sustained an isolated
gunshot wound to his right thigh. After
appropriate evaluation and resuscitation,
the fracture is repaired with a reamed
intramedullary nail. What is the most
commonly encountered complication in
this scenario?

1. Infection
2. Malunion
3. Nonunion
4. Fat embolism
5. Pulmonary embolism
 Question 10
Figure 10 is the radiograph of an 18-year-
old man who sustained an isolated
gunshot wound to his right thigh. After
appropriate evaluation and resuscitation,
the fracture is repaired with a reamed
intramedullary nail. What is the most
commonly encountered complication in
this scenario?

1. Infection
2. Malunion
3. Nonunion
4. Fat embolism
5. Pulmonary embolism
• Lindsey JD, Krieg JC. Femoral malrotation
following intramedullary nail fixation. J Am
Acad Orthop Surg. 2011 Jan;19(1):17-26.
PubMed PMID: 21205764.
• Ricci WM, Gallagher B, Haidukewych GJ.
Intramedullary nailing of femoral shaft
fractures: current concepts. J Am Acad Orthop
Surg. 2009 May;17(5):296-305. Review.
PubMed PMID: 19411641.
 Question 14
A 25-year-old thin man sustained a bimalleolar left ankle fracture, a
comminuted spiral midshaft left humeral fracture, and a grade IV splenic
laceration during a motor vehicle collision. His left radial nerve function is
intact. He underwent splenectomy immediately and his fractures were
splinted. In counseling the patient regarding surgical vs nonsurgical treatment
of the humerus fracture, you would advise that

1. the risk for radial nerve palsy is higher in spiral humeral shaft fractures that
are treated nonsurgically.
2. the patient may bear weight through the plated humeral fracture for the
purpose of using ambulatory aids.
3. a functional fracture brace will not adequately maintain humeral shaft
fracture alignment during the healing process.
4. surgical fixation of the humeral fracture will allow for earlier fracture union
than nonsurgical treatment with a functional fracture brace.
5. long-term outcomes for plated humeral shaft fractures are better than for
fractures treated nonsurgically.
 Question 14
A 25-year-old thin man sustained a bimalleolar left ankle fracture, a
comminuted spiral midshaft left humeral fracture, and a grade IV splenic
laceration during a motor vehicle collision. His left radial nerve function is
intact. He underwent splenectomy immediately and his fractures were
splinted. In counseling the patient regarding surgical vs nonsurgical treatment
of the humerus fracture, you would advise that

1. the risk for radial nerve palsy is higher in spiral humeral shaft fractures that
are treated nonsurgically.
2. the patient may bear weight through the plated humeral fracture for the
purpose of using ambulatory aids.
3. a functional fracture brace will not adequately maintain humeral shaft
fracture alignment during the healing process.
4. surgical fixation of the humeral fracture will allow for earlier fracture union
than nonsurgical treatment with a functional fracture brace.
5. long-term outcomes for plated humeral shaft fractures are better than for
fractures treated nonsurgically.
• Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate
weightbearing on plated fractures of the humeral shaft. J Trauma.
2000 Aug;49(2):278-80. PubMed PMID: 10963539.
• Ekholm R, Tidermark J, Törnkvist H, Adami J, Ponzer S. Outcome
after closed functional treatment of humeral shaft fractures. J
Orthop Trauma. 2006 Oct;20(9):591-6. PubMed PMID: 17088659.
• Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve
palsy associated with fractures of the shaft of the humerus: a
systematic review. J Bone Joint Surg Br. 2005 Dec;87(12):1647-52.
Review. PubMed PMID: 16326879.
• Hak DJ. Radial nerve palsy associated with humeral shaft fractures.
Orthopedics. 2009 Feb;32(2):111. Review. PubMed PMID:
19301795.
 Question 32
Figures 32a through 32c are the radiographs of a 31-year-old
man who was involved in a motor vehicle collision. He has
severe foot pain, marked swelling, and is unable to ambulate.
What is the most appropriate definitive treatment step?

1. External fixation
2. Closed reduction and casting
3. Closed reduction and percutaneous pinning
4. Open reduction and internal fixation with rigid fixation of
the first to fifth tarsometatarsal joints
5. Open reduction and internal fixation with rigid fixation of
the first to third tarsometatarsal joints and Kirschner wire
fixation of the fourth and fifth tarsometatarsal joints
 Question 32
Figures 32a through 32c are the radiographs of a 31-year-old
man who was involved in a motor vehicle collision. He has
severe foot pain, marked swelling, and is unable to ambulate.
What is the most appropriate definitive treatment step?

1. External fixation
2. Closed reduction and casting
3. Closed reduction and percutaneous pinning
4. Open reduction and internal fixation with rigid fixation of
the first to fifth tarsometatarsal joints
5. Open reduction and internal fixation with rigid fixation of
the first to third tarsometatarsal joints and Kirschner wire
fixation of the fourth and fifth tarsometatarsal joints
• Watson TS, Shurnas PS, Denker J. Treatment of
Lisfranc joint injury: current concepts. J Am Acad
Orthop Surg. 2010 Dec;18(12):718-28. Review.
PubMed PMID: 21119138.
• Rammelt S, Schneiders W, Schikore H, Holch M,
Heineck J, Zwipp H. Primary open reduction and
fixation compared with delayed corrective
arthrodesis in the treatment of tarsometatarsal
(Lisfranc) fracture dislocation. J Bone Joint Surg
Br. 2008 Nov;90(11):1499-506. PubMed PMID:
18978273.
 Question 57
Advantages of a locking plate implant over a 95-degree
angled blade plate for fixation of supracondylar
femur fractures include
1. a higher union rate.
2. a lower implant cost.
3. a lower overall complication rate.
4. a lower rate of prominent hardware requiring removal.
5. improved ability to use with associated coronal
fractures.
 Question 57
Advantages of a locking plate implant over a 95-degree
angled blade plate for fixation of supracondylar
femur fractures include
1. a higher union rate.
2. a lower implant cost.
3. a lower overall complication rate.
4. a lower rate of prominent hardware requiring removal.
5. improved ability to use with associated coronal
fractures.
• Vallier HA, Immler W. Comparison of the 95-
degree angled blade plate and the locking
condylar plate for the treatment of distal femoral
fractures. J Orthop Trauma. 2012 Jun;26(6):327-
32. PubMed PMID: 22183200.
• Gwathmey FW Jr, Jones-Quaidoo SM, Kahler D,
Hurwitz S, Cui Q. Distal femoral fractures: current
concepts. J Am Acad Orthop Surg. 2010
Oct;18(10):597-607. Review. PubMed PMID:
20889949.
 Question 63
A 55-year-old man has a draining wound at the end of his transfemoral
amputation residual limb. He reports that he sustained a “compound fracture” of
his thigh bone approximately 30 years ago, requiring amputation and rodding of a
fracture near his hip. His wound drains intermittently and has done so since his
amputation. Intermittent administration of oral antibiotics temporarily ceases
wound drainage, but the drainage returns after antibiotics are stopped. Wound
culture reveals Pseudomonas aeruginosa, which is sensitive to fluoroquinolones,
carbapenems, aminoglycosides, and cephalosporins. Radiographs of the residual
limb are seen in Figures 63a and 63b. What is the recommended treatment?
1. Administration of oral ciprofloxacin for 3 months
2. Administration of oral ciprofloxacin for the rest of his life
3. Surgical debridement and irrigation with implant removal and postsurgical
ciprofloxacin for 3 months
4. Surgical debridement and irrigation with implant removal, placement of a
gentamicin-impregnated polymethylmethacrylate medullary rod, and postsurgical
ciprofloxacin for 3 months
5. Surgical debridement and irrigation with implant removal, sinus tract biopsy,
placement of a gentamicin-impregnated polymethylmethacrylate medullary rod,
and postsurgical ciprofloxacin for 3 months
 Question 63
A 55-year-old man has a draining wound at the end of his transfemoral
amputation residual limb. He reports that he sustained a “compound fracture” of
his thigh bone approximately 30 years ago, requiring amputation and rodding of a
fracture near his hip. His wound drains intermittently and has done so since his
amputation. Intermittent administration of oral antibiotics temporarily ceases
wound drainage, but the drainage returns after antibiotics are stopped. Wound
culture reveals Pseudomonas aeruginosa, which is sensitive to fluoroquinolones,
carbapenems, aminoglycosides, and cephalosporins. Radiographs of the residual
limb are seen in Figures 63a and 63b. What is the recommended treatment?
1. Administration of oral ciprofloxacin for 3 months
2. Administration of oral ciprofloxacin for the rest of his life
3. Surgical debridement and irrigation with implant removal and postsurgical
ciprofloxacin for 3 months
4. Surgical debridement and irrigation with implant removal, placement of a
gentamicin-impregnated polymethylmethacrylate medullary rod, and postsurgical
ciprofloxacin for 3 months
5. Surgical debridement and irrigation with implant removal, sinus tract biopsy,
placement of a gentamicin-impregnated polymethylmethacrylate medullary rod,
and postsurgical ciprofloxacin for 3 months
• McGrory JE, Pritchard DJ, Unni KK, Ilstrup D, Rowland
CM. Malignant lesions arising in chronic osteomyelitis.
Clin Orthop Relat Res. 1999 May;(362):181-9. PubMed
PMID: 10335297.
• Paley D, Herzenberg JE. Intramedullary infections
treated with antibiotic cement rods: preliminary results
in nine cases. J Orthop Trauma. 2002 Nov-
Dec;16(10):723-9. PubMed PMID: 12439196.
• Riel RU, Gladden PB. A simple method for fashioning
an antibiotic cement-coated interlocking
intramedullary nail. Am J Orthop (Belle Mead NJ). 2010
Jan;39(1):18-21. PubMed PMID: 20305835.
 Question 73
Figures 73a through 73c are the current radiographs of a 35-year-old woman
who fractured her ankle 3 years ago. Her course after surgery was
complicated by wound dehiscence over her fibula plate. She had hardware
removed and saucerization of her fibula at 9 months. She is now experiencing
pain reproduced with dorsiflexion/plantar flexion that limits all of her daily
living activities. She is unable to obtain a plantigrade foot with knee
extension, has no pain with inversion/eversion, and has well-healed wounds.
Laboratory studies show that her erythrocyte sedimentation rate and C-
reactive protein levels are within defined limits. What is the best treatment
option?

1. Total ankle replacement

2. Tibiotalar arthrodesis
3. Tibiotalar and subtalar arthrodesis
4. Tibiotalar arthrodesis with gastrocnemius recession
5. Tibiotalar and subtalar arthrodesis with gastrocnemius recession
 Question 73
Figures 73a through 73c are the current radiographs of a 35-year-old woman
who fractured her ankle 3 years ago. Her course after surgery was
complicated by wound dehiscence over her fibula plate. She had hardware
removed and saucerization of her fibula at 9 months. She is now experiencing
pain reproduced with dorsiflexion/plantar flexion that limits all of her daily
living activities. She is unable to obtain a plantigrade foot with knee
extension, has no pain with inversion/eversion, and has well-healed wounds.
Laboratory studies show that her erythrocyte sedimentation rate and C-
reactive protein levels are within defined limits. What is the best treatment
option?

1. Total ankle replacement

2. Tibiotalar arthrodesis
3. Tibiotalar and subtalar arthrodesis
4. Tibiotalar arthrodesis with gastrocnemius recession
5. Tibiotalar and subtalar arthrodesis with gastrocnemius recession
• Hendrickx RP, Stufkens SA, de Bruijn EE, Sierevelt
IN, van Dijk CN, Kerkhoffs GM. Medium- to
longterm outcome of ankle arthrodesis. Foot
Ankle Int. 2011 Oct;32(10):940-7. PubMed PMID:
22224322.
• Bai LB, Lee KB, Song EK, Yoon TR, Seon JK. Total
ankle arthroplasty outcome comparison for post-
traumatic and primary osteoarthritis. Foot Ankle
Int. 2010 Dec;31(12):1048-56. PubMed PMID:
21189204.
 Question 82
The fracture shown in Figure 82 is scheduled to be
fixed with a retrograde nail. An arthrotomy should
be performed during the procedure because it

1. ensures proper nail depth.

2. provides control of the distal fragment.
3. allows assessment for occult infection.
4. allows protection of the polyethylene liner.
5. allows assessment of the loosening component
requiring revision.
 Question 82
The fracture shown in Figure 82 is scheduled to be
fixed with a retrograde nail. An arthrotomy should
be performed during the procedure because it

1. ensures proper nail depth.

2. provides control of the distal fragment.
3. allows assessment for occult infection.
4. allows protection of the polyethylene liner.
5. allows assessment of the loosening component
requiring revision.
• Ellis TJ, White RR, Lhowe DW. Periprosthetic fractures. In:
Schmidt AH, Teague DC, eds. Orthopaedic Knowledge
Update: Trauma 4. Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2010:569- 577.
• McLaren AC, Dupont JA, Schroeber DC. Open reduction
internal fixation of supracondylar fractures above total
knee arthroplasties using the intramedullary supracondylar
rod. Clin Orthop Relat Res. 1994 May;(302):194-8. PubMed
PMID: 8168300.
• Haidukewych GJ. Periprosthetic distal femur fracture: plate
versus nail fixation. Opinion: open reduction internal
fixation. J Orthop Trauma. 2007 Mar;21(3):219-20. PubMed
PMID: 17473762.
 Question 87
A 52-year-old woman sustained a closed bimalleolar ankle
fracture. She was treated with open reductionand internal
fixation. A syndesmotic screw was added; however, there is
persistent asymmetry of the ankle mortise as shown in Figures
87a and 87b. What is the most likely reason for this finding?

1. The syndesmosis is malreduced.

2. The lateral malleolus is malreduced.
3. The posterior tibial tendon is entrapped in the medial joint.
4. The deltoid ligament is interposed in the medial joint space.
5. An osteochondral fragment is entrapped in the joint.
 Question 87
A 52-year-old woman sustained a closed bimalleolar ankle
fracture. She was treated with open reductionand internal
fixation. A syndesmotic screw was added; however, there is
persistent asymmetry of the ankle mortise as shown in Figures
87a and 87b. What is the most likely reason for this finding?

1. The syndesmosis is malreduced.

2. The lateral malleolus is malreduced.
3. The posterior tibial tendon is entrapped in the medial joint.
4. The deltoid ligament is interposed in the medial joint space.
5. An osteochondral fragment is entrapped in the joint.
• Weber BG, Simpson LA: Corrective
lengthening osteotomy of the fibula. Clin
Orthop Relat Res 1985; 199:61-67. PubMed
PMID: 4042497.
• Chu A, Weiner L. Distal fibula malunions. J Am
Acad Ortho Surg April 2009;17:220-230.
PubMed PMID: 19307671.
 Question 90
The World Health Organization Fracture Risk
Assessment Tool (FRAX) calculates which fracture
risk?

1. 5-year risk for hip fracture

2. 5-year risk for distal radius fracture
3. 5-year risk for any fragility fracture
4. 10-year risk for hip fracture
5. 10-year risk for distal radius fracture
 Question 90
The World Health Organization Fracture Risk
Assessment Tool (FRAX) calculates which fracture
risk?

1. 5-year risk for hip fracture

2. 5-year risk for distal radius fracture
3. 5-year risk for any fragility fracture
4. 10-year risk for hip fracture
5. 10-year risk for distal radius fracture
• Unnanuntana A, Gladnick BP, Donnelly E, Lane
JM. The assessment of fracture risk. J Bone
Joint Surg Am. 2010 Mar;92(3):743-53.
Review. PubMed PMID: 20194335.
• Ekman EF. The role of the orthopaedic surgeon
in minimizing mortality and morbidity
associated with fragility fractures. J Am Acad
Orthop Surg. 2010 May;18(5):278-85. Review.
PubMed PMID: 20435878.
 Question 102
Figure 102 is an intraoperative figure taken during
fixation of a right lateral tibial plateau fracture
luxation. Which structure is indicated by the arrow?

1. Iliotibial band
2. Popliteus tendon
3. Medial meniscus
4. Lateral meniscus
5. Lateral collateral ligament
 Question 102
Figure 102 is an intraoperative figure taken during
fixation of a right lateral tibial plateau fracture
luxation. Which structure is indicated by the arrow?

1. Iliotibial band
2. Popliteus tendon
3. Medial meniscus
4. Lateral meniscus
5. Lateral collateral ligament
• Higgins TF, Severson EP. Tibial plateau fractures.
In: Schmidt AH, Teague DC, eds. Orthopaedic
Knowledge Update: Trauma 4. Rosemont, IL:
American Academy of Orthopaedic Surgeons;
2010:475- 486.
• Gardner MJ, Yacoubian S, Geller D, Pode M, Mintz
D, Helfet DL, Lorich DG. Prediction of soft-tissue
injuries in Schatzker II tibial plateau fractures
based on measurements of plain radiographs. J
Trauma. 2006 Feb;60(2):319-23; discussion 324.
PubMed PMID: 16508489.
 Question 107
If a physician elects to shorten a femur by 4 cm for
traumatic bone loss treatment and places an
intramedullary nail for fixation, which deformity will
be created in the lower extremity?

1. Patella alta
2. Medial mechanical axis deviation
3. Lateral mechanical axis deviation
4. Increased anatomic tibiofemoral angle
5. Translation of the anatomical axis of the femur
 Question 107
If a physician elects to shorten a femur by 4 cm for
traumatic bone loss treatment and places an
intramedullary nail for fixation, which deformity will
be created in the lower extremity?

1. Patella alta
2. Medial mechanical axis deviation
3. Lateral mechanical axis deviation
4. Increased anatomic tibiofemoral angle
5. Translation of the anatomical axis of the femur
• Paley DP. Principles of Deformity Correction.
New York, NY: Springer-Verlag; 2002:1-17.
• Kasis AG, Stockley I, Saleh M. External fixator-
assisted acute shortening with internal
fixation for leg length discrepancy after total
hip replacement. Strategies Trauma Limb
Reconstr. 2008 Apr;3(1):35-8. Epub 2008 Apr
4. PubMed PMID: 18427922.
 Question 112
The vessel ligated during the Stoppa approach for
acetabular fracture fixation (Video 112) is an
anastomosis of which structures?

1. Femoral and obturator

2. Internal iliac and obturator
3. Internal and external obturator
4. External iliac and obturator
5. Superior gluteal and obturator
 Question 112
The vessel ligated during the Stoppa approach for
acetabular fracture fixation (Video 112) is an
anastomosis of which structures?

1. Femoral and obturator

2. Internal iliac and obturator
3. Internal and external obturator
4. External iliac and obturator
5. Superior gluteal and obturator
• Tornetta P III, Hochwald N, Levine R. Corona
mortis. Incidence and location. Clin Orthop
Relat Res. 1996 Aug;(329):97-101. PubMed
PMID: 8769440.
• Archdeacon MT, Kazemi N, Guy P, Sagi HC. The
modified Stoppa approach for acetabular
fracture. J Am Acad Orthop Surg. 2011
Mar;19(3):170-5. PubMed PMID: 21368098.
 Question 117
The radiograph seen in Figure 117 reveals a
submuscular plate placement with locking screws
for fixation. The biomechanics of the construct can
be best described as

1. stiff and axially stable.

2. stiff and axially unstable.
3. flexible and axially stable.
4. flexible and axially unstable.
5. flexible and rotationally unstable.
 Question 117
The radiograph seen in Figure 117 reveals a
submuscular plate placement with locking screws
for fixation. The biomechanics of the construct can
be best described as

1. stiff and axially stable.

2. stiff and axially unstable.
3. flexible and axially stable.
4. flexible and axially unstable.
5. flexible and rotationally unstable.
• Graves M, Nork SE. Fractures of the humerus.
In: Schmidt AH, Teague DC, eds. Orthopaedic
Knowledge Update: Trauma 4. Rosemont, IL:
American Academy of Orthopaedic Surgeons;
2010:201-224.
• Livani B, Belangero WD. Bridging plate
osteosynthesis of humeral shaft fractures.
Injury. 2004 Jun;35(6):587-95. PubMed PMID:
15135278.
 Question 120
A 22-year-old man was an unrestrained driver who was ejected from
his car during a rollover motor vehicle crash. He sustained a closed
head injury, multiple closed right rib fractures with an ipsilateral
pneumothorax, and an open midshaft right tibia fracture. The tibia
wound measures approximately 3 mm in length and is free of gross
contamination. What is the most important factor shown to minimize
risk for infection at the site of an open tibia fracture?

1. Transfer to a Level I trauma center within 3 hours

2. Intravenous antibiotic administration within 3 hours
3. Irrigation and debridement of the open fracture wound within 6
hours
4. Open reduction with plate-and-screw fixation at the index tip within
6 hours
5. Tibia wound irrigation within 3 hours with a solution containing
bacitracin
 Question 120
A 22-year-old man was an unrestrained driver who was ejected from
his car during a rollover motor vehicle crash. He sustained a closed
head injury, multiple closed right rib fractures with an ipsilateral
pneumothorax, and an open midshaft right tibia fracture. The tibia
wound measures approximately 3 mm in length and is free of gross
contamination. What is the most important factor shown to minimize
risk for infection at the site of an open tibia fracture?

1. Transfer to a Level I trauma center within 3 hours

2. Intravenous antibiotic administration within 3 hours
3. Irrigation and debridement of the open fracture wound within 6
hours
4. Open reduction with plate-and-screw fixation at the index tip within
6 hours
5. Tibia wound irrigation within 3 hours with a solution containing
bacitracin
• Pollak AN, Jones AL, Castillo RC, Bosse MJ,
MacKenzie EJ; LEAP Study Group. The
relationship between time to surgical
debridement and incidence of infection after
open high-energy lower extremity trauma. J Bone
Joint Surg Am. 2010 Jan;92(1):7-15. PubMed
PMID: 20048090.
• Patzakis MJ, Wilkins J. Factors influencing
infection rate in open fracture wounds. Clin
Orthop Relat Res. 1989 Jun;(243):36-40. PubMed
PMID: 2721073.
 Question 123
A 68-year-old woman fell and sustained a displaced
femoral neck fracture. She is a community ambulator and
enjoys playing tennis weekly. Which treatment will
provide her with the best hip function?

1. Hip resurfacing
2. Hemiarthroplasty
3. Total hip arthroplasty
4. Internal fixation with cannulated screws
5. Internal fixation with a sliding hip screw and an
antirotation screw
 Question 123
A 68-year-old woman fell and sustained a displaced
femoral neck fracture. She is a community ambulator and
enjoys playing tennis weekly. Which treatment will
provide her with the best hip function?

1. Hip resurfacing
2. Hemiarthroplasty
3. Total hip arthroplasty
4. Internal fixation with cannulated screws
5. Internal fixation with a sliding hip screw and an
antirotation screw
• Avery PP, Baker RP, Walton MJ, Rooker JC, Squires B, Gargan
MF, Bannister GC. Total hip replacement and
hemiarthroplasty in mobile, independent patients with a
displaced intracapsular fracture of the femoral neck: a
seven- to ten-year follow-up report of a prospective
randomised controlled trial. J Bone Joint Surg Br. 2011
Aug;93(8):1045-8. PubMed PMID: 21768626.

• Hedbeck CJ, Enocson A, Lapidus G, Blomfeldt R, Törnkvist H,

Ponzer S, Tidermark J. Comparison of bipolar
hemiarthroplasty with total hip arthroplasty for displaced
femoral neck fractures: a concise fouryear follow-up of a
randomized trial. J Bone Joint Surg Am. 2011 Mar
2;93(5):445-50. PubMed PMID: 21368076.
 Question 128
A 23-year-old man was tackled while playing football. He felt a
“pop” in his knee and noted significant deformity.
Examination reveals a closed posterior knee dislocation that is
irreducible despite adequate sedation. He is unable to
dorsiflex his toes or ankle. His ankle-brachial index is 0.6.
What is the next most appropriate treatment step?

1. Surgical intervention
2. Splint and monitor peripheral pulse oximetry
3. Magnetic resonance angiography
4. Computed tomography angiography
5. Standard angiography
 Question 128
A 23-year-old man was tackled while playing football. He felt a
“pop” in his knee and noted significant deformity.
Examination reveals a closed posterior knee dislocation that is
irreducible despite adequate sedation. He is unable to
dorsiflex his toes or ankle. His ankle-brachial index is 0.6.
What is the next most appropriate treatment step?

1. Surgical intervention
2. Splint and monitor peripheral pulse oximetry
3. Magnetic resonance angiography
4. Computed tomography angiography
5. Standard angiography
• Rihn JA, Groff YJ, Harner CD, Cha PS. The acutely
dislocated knee: evaluation and management. J
Am Acad Orthop Surg. 2004 Sep-Oct;12(5):334-
46. Review. PubMed PMID: 15469228.
• Patterson BM, Agel J, Swiontkowski MF,
Mackenzie EJ, Bosse MJ; LEAP Study Group. Knee
dislocations with vascular injury: outcomes in the
Lower Extremity Assessment Project (LEAP)
Study. J Trauma. 2007 Oct;63(4):855-8. PubMed
PMID: 18090017.
 Question 132
A 24-year-old man sustained a medial tibial plateau
fracture (Schatzker type IV) after being involved in a
motor vehicle-pedestrian collision. What is the best next
step?

1. An MRI scan
2. Ankle brachial index
3. Immediate open reduction and internal fixation
4. Closed reduction and percutaneous screw fixation
5. Definitive treatment with a hybrid external fixator
 Question 132
A 24-year-old man sustained a medial tibial plateau
fracture (Schatzker type IV) after being involved in a
motor vehicle-pedestrian collision. What is the best next
step?

1. An MRI scan
2. Ankle brachial index
3. Immediate open reduction and internal fixation
4. Closed reduction and percutaneous screw fixation
5. Definitive treatment with a hybrid external fixator
• Berkson EM, Virkus WW. High-energy tibial
plateau fractures. J Am Acad Orthop Surg. 2006
Jan;14(1):20-31. Review. PubMed PMID:
16394164.
• Gardner MJ, Yacoubian S, Geller D, Suk M, Mintz
D, Potter H, Helfet DL, Lorich DG. The incidence of
soft tissue injury in operative tibial plateau
fractures: a magnetic resonance imaging analysis
of 103 patients. J Orthop Trauma. 2005
Feb;19(2):79-84. PubMed PMID: 15677922.
 Question 135
A 45-year-old woman sustained a fall from height and has the
injury shown in Figures 135a and 135b. A 3-dimensional
reconstruction CT scan is shown in Figure 135c. Joint-spanning
external fixation is applied on the day of injury. Ten days later,
her skin is acceptable for definitive fixation. What is the most
appropriate type of fixation for her fracture?

1. Percutaneous screws and cast

2. Conversion to a circular fixator
3. Medial and anterolateral locked plates
4. Medial and anterolateral nonlocked plates
5. Lateral locked plate and medial malleolus screws
 Question 135
A 45-year-old woman sustained a fall from height and has the
injury shown in Figures 135a and 135b. A 3-dimensional
reconstruction CT scan is shown in Figure 135c. Joint-spanning
external fixation is applied on the day of injury. Ten days later,
her skin is acceptable for definitive fixation. What is the most
appropriate type of fixation for her fracture?

1. Percutaneous screws and cast

2. Conversion to a circular fixator
3. Medial and anterolateral locked plates
4. Medial and anterolateral nonlocked plates
5. Lateral locked plate and medial malleolus screws
• Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr.
A staged protocol for soft tissue management in
the treatment of complex pilon fractures. J
Orthop Trauma. 2004 Sep;18(8 Suppl):S32-8.
PubMed PMID: 15472563.
• Collinge C, Prayson M. Open reduction and
internal fixation of pilon fractures. In: Tornetta P,
Williams GR, Ramsey ML, Hunt TR, Wiesel SW,
eds. Operative Techniques in Orthopaedic Trauma
Surgery. Philadelphia, PA: Lippincott Williams &
Wilkins; 2011:483-498.
 Question 137
The fracture seen in Figure 137 was most likely
caused by what type of mechanism?

1. Direct impact to the fibula

2. Abduction of the foot relative to the tibia
3. Adduction of the foot relative to the tibia
4. Internal rotation of the foot relative to the tibia
5. External rotation of the foot relative to the tibia
 Question 137
The fracture seen in Figure 137 was most likely
caused by what type of mechanism?

1. Direct impact to the fibula

2. Abduction of the foot relative to the tibia
3. Adduction of the foot relative to the tibia
4. Internal rotation of the foot relative to the tibia
5. External rotation of the foot relative to the tibia
• Barei DP Crist BD. Fractures of the ankle and
distal tibial pilon. In: Schmidt AH, Teague DC, eds.
Orthopaedic Knowledge Update: Trauma 4.
Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2010:499-518.
• Lauge-Hansen N. Fractures of the ankle. II.
Combined experimental-surgical and
experimentalroentgenologic investigations. Arch
Surg. 1950 May;60(5):957-85. PubMed PMID:
15411319.
 Question 139
The best way to avoid sentinel event errors is
through better

1. training.
2. staffing ratios.
3. communication.
4. patient assessment.
5. availability of information.
 Question 139
The best way to avoid sentinel event errors is
through better

1. training.
2. staffing ratios.
3. communication.
4. patient assessment.
5. availability of information.
• The Joint Commission. 2007 National Patient Safety Goals.
The Joint Commission, 2007. Viewed 27 October 2009.
http://www.pharmacytimes.com/publications/issue/2007/
2007-02/2007-02-6294 (Accessed 7/10/2012)
• Leonard M, Graham S, Bonacum D. The human factor: the
critical importance of effective teamwork and
communication in providing safe care. Qual Saf Health
Care. 2004 Oct;13 Suppl 1:i85-90. PubMed PMID:
15465961.
• VA National Center for Patient Safety Executive Summary,
2007. Joint Commission Sentinel Event Alert Issue 12
http://www.patientsafety.gov/ (Accessed 7/10/2012)
 Question 144
A 22-year-old man wants a second opinion 3 weeks after intramedullary
nailing of a comminuted diaphyseal femoral shaft fracture. Examination
reveals his injured leg has 26 degrees’ more external rotation than the
contralateral limb and is 3 cm shorter based on a block measurement. He
should be advised to

1. let the fracture unite as is because there is sufficient hip rotation to

accommodate the external
rotation deformity, and a small shoe lift can accommodate for the limb length
discrepancy.
2. let the fracture unite, and if he later finds it bothersome, consider a
corrective osteotomy of the injured femur for correction of the deformity.
3. let the fracture unite because there is sufficient hip rotation to
accommodate the external rotation deformity; if he later finds the leg length
discrepancy bothersome, he should consider contralateral closed femoral
shortening.
4. consider revision surgery to correct the rotational deformity but not alter
length because this may impair fracture union if performed at this time.
5. consider revision surgery to correct both the rotational deformity and leg
length discrepancy.
 Question 144
A 22-year-old man wants a second opinion 3 weeks after intramedullary
nailing of a comminuted diaphyseal femoral shaft fracture. Examination
reveals his injured leg has 26 degrees’ more external rotation than the
contralateral limb and is 3 cm shorter based on a block measurement. He
should be advised to

1. let the fracture unite as is because there is sufficient hip rotation to

accommodate the external
rotation deformity, and a small shoe lift can accommodate for the limb length
discrepancy.
2. let the fracture unite, and if he later finds it bothersome, consider a
corrective osteotomy of the injured femur for correction of the deformity.
3. let the fracture unite because there is sufficient hip rotation to
accommodate the external rotation deformity; if he later finds the leg length
discrepancy bothersome, he should consider contralateral closed femoral
shortening.
4. consider revision surgery to correct the rotational deformity but not alter
length because this may impair fracture union if performed at this time.
5. consider revision surgery to correct both the rotational deformity and leg
length discrepancy.
• Lindsey JD, Krieg JC. Femoral malrotation
following intramedullary nail fixation. J Am
Acad Orthop Surg. 2011 Jan;19(1):17-26.
PubMed PMID: 21205764.
• Jaarsma RL, Pakvis DF, Verdonschot N, Biert J,
van Kampen A. Rotational malalignment after
intramedullary nailing of femoral fractures. J
Orthop Trauma. 2004 Aug;18(7):403-9.
PubMed PMID: 15289684.
 Question 149
On an anteroposteriorly directed fluoroscopic radiograph, the
appropriate entry point for an intramedullary tibia nail being
used for fixation of a proximal third diaphyseal tibial fracture
is ideally positioned

1. centered between the medial and lateral tibial eminences.

2. in line with the lateral border of the lateral tibial eminence.
3. in line with the medial border of the lateral tibial eminence.
4. in line with the lateral border of the medial tibial eminence.
5. in line with the medial border of the medial tibial
eminence.
 Question 149
On an anteroposteriorly directed fluoroscopic radiograph, the
appropriate entry point for an intramedullary tibia nail being
used for fixation of a proximal third diaphyseal tibial fracture
is ideally positioned

1. centered between the medial and lateral tibial eminences.

2. in line with the lateral border of the lateral tibial eminence.
3. in line with the medial border of the lateral tibial
eminence.
4. in line with the lateral border of the medial tibial eminence.
5. in line with the medial border of the medial tibial
eminence.
• McConnell T, Tornetta P III, Tilzey J, Casey D. Tibial
portal placement: the radiographic correlate of
the anatomic safe zone. J Orthop Trauma.
2001Mar-Apr;15(3):207-9. PubMed PMID:
11265012.
• Song SJ, Jeong BO. Three-dimensional analysis of
the intramedullary canal axis of tibia: clinical
relevance to tibia intramedullary nailing. Arch
Orthop Trauma Surg. 2010 Jul;130(7):903-7. Epub
2009 Nov 3. PubMed PMID: 19885665.
 Question 156
Figures 156a and 156b are the radiographs of a 38-year-old man with
diabetes mellitus who fell 8 feet from a ladder and sustained an
isolated closed injury of his leg. Examination revealed swollen but soft
compartments. His neurovascular examination was unremarkable. A
damage-control fixator was initially applied, and his soft-tissue
envelope is now amenable to further intervention. What is the most
appropriate treatment?

1. Conversion to a peri-articular hybrid frame

2. Open reduction and internal fixation with a lateral locking plate
3. Open reduction and internal fixation with a lateral nonlocking plate
4. Open reduction and internal fixation with medial and lateral plates
5. Open reduction and internal fixation with posteromedial and lateral
plates
 Question 156
Figures 156a and 156b are the radiographs of a 38-year-old man with
diabetes mellitus who fell 8 feet from a ladder and sustained an
isolated closed injury of his leg. Examination revealed swollen but soft
compartments. His neurovascular examination was unremarkable. A
damage-control fixator was initially applied, and his soft-tissue
envelope is now amenable to further intervention. What is the most
appropriate treatment?

1. Conversion to a peri-articular hybrid frame

2. Open reduction and internal fixation with a lateral locking plate
3. Open reduction and internal fixation with a lateral nonlocking plate
4. Open reduction and internal fixation with medial and lateral plates
5. Open reduction and internal fixation with posteromedial and
lateral plates
• Barei DP, O'Mara TJ, Taitsman LA, Dunbar RP,
Nork SE. Frequency and fracture morphology of
the posteromedial fragment in bicondylar tibial
plateau fracture patterns. J Orthop Trauma. 2008
Mar;22(3):176-82. PubMed PMID: 18317051.
• Barei DP, Nork SE, Mills WJ, Coles CP, Henley MB,
Benirschke SK. Functional outcomes of severe
bicondylar tibial plateau fractures treated with
dual incisions and medial and lateral plates. J
Bone Joint Surg Am. 2006 Aug;88(8):1713-21.
PubMed PMID: 16882892.
 Question 160
Figure 160 is the intrasurgical photo of a 35-year-old woman
with an open tibial fracture. Examination reveals no Doppler
signal of the peroneal artery or anterior tibial artery. However,
flow in her posterior tibial artery is detected by Doppler.
According to the Gustilo-Anderson classification system, the
fracture should be classified as

1. type I.
2. type II.
3. type IIIA.
4. type IIIB.
5. type IIIC.
 Question 160
Figure 160 is the intrasurgical photo of a 35-year-old woman
with an open tibial fracture. Examination reveals no Doppler
signal of the peroneal artery or anterior tibial artery. However,
flow in her posterior tibial artery is detected by Doppler.
According to the Gustilo-Anderson classification system, the
fracture should be classified as

1. type I.
2. type II.
3. type IIIA.
4. type IIIB.
5. type IIIC.
• Gustilo RB, Anderson JT. Prevention of infection in
the treatment of one thousand and twenty-five
open fractures of long bones: retrospective and
prospective analyses. J Bone Joint Surg Am. 1976
Jun;58(4):453-8. PubMed PMID: 773941.
• Gustilo RB, Mendoza RM, Williams DN. Problems
in the management of type III (severe) open
fractures: a new classification of type III open
fractures. J Trauma. 1984 Aug;24(8):742-6.
PubMed PMID: 6471139.
 Question 163
To minimize complications and to maximize the likelihood of
successful outcomes after percutaneous fixation of displaced
extension-type supracondylar humeral fractures in children,
the physician should

1. use a divergent wire technique with wires placed medially.

2. use a divergent wire technique with wires placed laterally.
3. use a crossed-wire technique with wires placed laterally
and medially.
4. apply a postsurgical circumferential cast with the elbow
fully extended to prevent postsurgical displacement.
5. apply a postsurgical circumferential cast with the elbow
flexed past 90 degrees to prevent postsurgical displacement.
 Question 163
To minimize complications and to maximize the likelihood of
successful outcomes after percutaneous fixation of displaced
extension-type supracondylar humeral fractures in children,
the physician should

1. use a divergent wire technique with wires placed medially.

2. use a divergent wire technique with wires placed laterally.
3. use a crossed-wire technique with wires placed laterally
and medially.
4. apply a postsurgical circumferential cast with the elbow
fully extended to prevent postsurgical displacement.
5. apply a postsurgical circumferential cast with the elbow
flexed past 90 degrees to prevent postsurgical displacement.
• Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic
ulnar nerve injury after
• the surgical treatment of displaced supracondylar fractures of the
humerus: number needed to harm, a systematic review. J Pediatr Orthop.
2010 Jul-Aug;30(5):430-6. Review. PubMed PMID: 20574258.
• Woratanarat P, Angsanuntsukh C, Rattanasiri S, Attia J, Woratanarat T,
Thakkinstian A. Meta-analysis of pinning in supracondylar fracture of the
humerus in children. J Orthop Trauma. 2012 Jan;26(1):48-53. PubMed
PMID: 21909033.
• Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J
Bone Joint Surg Am. 2008 May;90(5):1121-32. Review. PubMed PMID:
18451407.
• McKeon KE, O'Donnell JC, Bashyal R, Hou CC, Luhmann SJ, Dobbs MB,
Gordon JE. Immobilization after pinning of supracondylar distal humerus
fractures in children: use of the A-frame cast. J Pediatr Orthop. 2012 Jan-
Feb;32(1):e1-5. PubMed PMID: 22173398.
 Question 167
A 24-year-old football player sustained an injury to his left
foot when another player fell directly on his= heel. He is
unable to bear weight, but radiograph findings were
negative. He is exquisitely tender at the midfoot. What is
the best next diagnostic study?

1. A CT scan
2. A bone scan
3. Weight-bearing views
4. Contralateral foot radiographs
5. Repeat radiograph in 2 weeks
 Question 167
A 24-year-old football player sustained an injury to his left
foot when another player fell directly on his= heel. He is
unable to bear weight, but radiograph findings were
negative. He is exquisitely tender at the midfoot. What is
the best next diagnostic study?

1. A CT scan
2. A bone scan
3. Weight-bearing views
4. Contralateral foot radiographs
5. Repeat radiograph in 2 weeks
• Nunley JA, Vertullo CJ. Classification,
investigation, and management of midfoot
sprains: Lisfranc injuries in the athlete. Am J
Sports Med. 2002 Nov-Dec;30(6):871-8.
PubMed PMID: 12435655.
• Watson TS, Shurnas PS, Denker J. Treatment of
Lisfranc joint injury: current concepts. J Am
Acad Orthop Surg. 2010 Dec;18(12):718-28.
Review. PubMed PMID: 21119138.
 Question 172
What is the most common nerve injury seen in
Figures 172a and 172b?

1. Ulnar
2. Radial
3. Median
4. Anterior interosseous
5. Lateral antebrachial cutaneous
 Question 172
What is the most common nerve injury seen in
Figures 172a and 172b?

1. Ulnar
2. Radial
3. Median
4. Anterior interosseous
5. Lateral antebrachial cutaneous
• Abzug JM, Herman MJ. Management of
supracondylar humerus fractures in children:
current concepts. J Am Acad Orthop Surg. 2012
Feb;20(2):69-77. Review. PubMed PMID:
22302444.
• Babal JC, Mehlman CT, Klein G. Nerve injuries
associated with pediatric supracondylar humeral
fractures: a meta-analysis. J Pediatr Orthop. 2010
Apr-May;30(3):253-63. PubMed PMID:
20357592.
 Question 176
The risk for developing complex regional pain
syndrome after surgery to the foot and ankle or the
wrist can be decreased through the use of

1. capsaicin.
2. vitamin C.
3. vitamin D and calcium.
4. dexamethasone block.
5. multimodal pain therapy.
 Question 176
The risk for developing complex regional pain
syndrome after surgery to the foot and ankle or the
wrist can be decreased through the use of

1. capsaicin.
2. vitamin C.
3. vitamin D and calcium.
4. dexamethasone block.
5. multimodal pain therapy.
• Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis
RW. Can vitamin C prevent complex regional pain
syndrome in patients with wrist fractures? A
randomized, controlled, multicenter dose-response
study. J
• Bone Joint Surg Am. 2007 Jul;89(7):1424-31. PubMed
PMID: 17606778. Besse JL, Gadeyne S, Galand-Desmé
S, Lerat JL, Moyen B. Effect of vitamin C on prevention
of complex regional pain syndrome type I in foot and
ankle surgery. Foot Ankle Surg. 2009;15(4):179-82.
Epub 2009 Apr 5. PubMed PMID: 19840748.
 Question 186
What is the most common complication seen after
patellar fracture open reduction and internal
fixation?

1. Loss of reduction
2. Knee extensor lag
3. Symptomatic implants
4. Flexion contracture exceeding 5 degrees
5. Extension contracture exceeding 15 degrees
 Question 186
What is the most common complication seen after
patellar fracture open reduction and internal
fixation?

1. Loss of reduction
2. Knee extensor lag
3. Symptomatic implants
4. Flexion contracture exceeding 5 degrees
5. Extension contracture exceeding 15 degrees
• Lebrun CT, Langford JR, Sagi HC. Functional
outcomes after operatively treated patella
fractures. J Orthop Trauma. 2012
Jul;26(7):422-6. PubMed PMID: 22183197.
• Melvin JS, Mehta S. Patellar fractures in
adults. J Am Acad Orthop Surg. 2011
Apr;19(4):198-207. Review. PubMed PMID:
21464213.
 Question 188
An athletic 30-year-old sustained multiple injuries in a high-
speed motor vehicle collision that resulted in a loss of
approximately 30% of blood volume. On arrival to the
emergency department, the heart rate is 100 and blood
pressure is 104/62. The best means with which to evaluate
true hemodynamic status is

1. hematocrit.
2. serial heart rate.
3. serial blood pressure with a manual cuff.
4. serial blood pressure with an arterial line.
5. lactate and base deficit levels.
 Question 188
An athletic 30-year-old sustained multiple injuries in a high-
speed motor vehicle collision that resulted in a loss of
approximately 30% of blood volume. On arrival to the
emergency department, the heart rate is 100 and blood
pressure is 104/62. The best means with which to evaluate
true hemodynamic status is

1. hematocrit.
2. serial heart rate.
3. serial blood pressure with a manual cuff.
4. serial blood pressure with an arterial line.
5. lactate and base deficit levels.
• Hak DJ, Stahel PF, Giannoudis P. Pathophysiology
of the polytrauma patient. In: Schmidt AH,
Teague DC, eds. Orthopaedic Knowledge Update:
Trauma 4. Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2010:117–131.
• Rossaint R, Cerny V, Coats TJ, Duranteau J,
Fernández-Mondéjar E, Gordini G, Stahel PF, Hunt
BJ, Neugebauer E, Spahn DR. Key issues in
advanced bleeding care in trauma. Shock. 2006
Oct;26(4):322- 31. Review. PubMed PMID:
16980877.
 Question 196
Which virtual hinge shown in Figure 196 will gain
the most length with the least amount of
translation and angulation at the end of deformity
correction?

1. A
2. B
3. C
4. D
5. E
 Question 196
Which virtual hinge shown in Figure 196 will gain
the most length with the least amount of
translation and angulation at the end of deformity
correction?

1. A
2. B
3. C
4. D
5. E
• Paley DP, ed. Principles of Deformity
Correction. New York, NY: Springer-Verlag;
2002:99-154.
• Feldman DS, Shin SS, Madan S, Koval KJ.
Correction of tibial malunion and nonunion
with six-axis analysis deformity correction
using the Taylor Spatial Frame. J Orthop
Trauma. 2003 Sep;17(8):549-54. PubMed
PMID: 14504575.
 Question 200
Figures 200a and 200b are the radiographs of an 82-year-
old woman who fell on a flexed knee. She has no other
injuries and was able to ambulate without assistance
before her fall. The recommended treatment to optimize
her quality of life consists of

1. external fixation.
2. revision arthroplasty.
3. open reduction and internal fixation.
4. closed reduction and casting.
5. closed reduction and fracture bracing.
 Question 200
Figures 200a and 200b are the radiographs of an 82-year-
old woman who fell on a flexed knee. She has no other
injuries and was able to ambulate without assistance
before her fall. The recommended treatment to optimize
her quality of life consists of

1. external fixation.
2. revision arthroplasty.
3. open reduction and internal fixation.
4. closed reduction and casting.
5. closed reduction and fracture bracing.
• Ricci WM, Bolhofner BR, Loftus T, Cox C, Mitchell S,
Borrelli J Jr. Indirect reduction and plate fixation,
without grafting, for periprosthetic femoral shaft
fractures about a stable intramedullary implant. J Bone
Joint Surg Am. 2005 Oct;87(10):2240-5. PubMed PMID:
16203889.
• Streubel PN, Gardner MJ, Morshed S, Collinge CA,
Gallagher B, Ricci WM. Are extreme distal
periprosthetic supracondylar fractures of the femur too
distal to fix using a lateral locked plate? J Bone Joint
Surg Br. 2010 Apr;92(4):527-34. PubMed PMID:
20357329.
 Question 201
Figure 201a is the radiograph of a patient with an open femur fracture
who had debridement and nailing with antibiotic beads as shown in
Figure 201b. The patient notices leg deformity while lying in bed.
Subsequent CT scans are shown in Figures 201c and 201d. In addition
to being fixed short, what other malalignment, if any, is seen?

1. Fixed with approximately 24 degrees’ internal rotation deformity

2. Fixed with approximately 24 degrees’ external rotation deformity
3. Fixed with approximately 31 degrees’ internal rotation deformity
4. Fixed with approximately 31 degrees’ external rotation deformity
5. No malalignment; deformity is attributable to postsurgical pain and
reflex relaxation
 Question 201
Figure 201a is the radiograph of a patient with an open femur fracture
who had debridement and nailing with antibiotic beads as shown in
Figure 201b. The patient notices leg deformity while lying in bed.
Subsequent CT scans are shown in Figures 201c and 201d. In addition
to being fixed short, what other malalignment, if any, is seen?

1. Fixed with approximately 24 degrees’ internal rotation deformity

2. Fixed with approximately 24 degrees’ external rotation deformity
3. Fixed with approximately 31 degrees’ internal rotation deformity
4. Fixed with approximately 31 degrees’ external rotation deformity
5. No malalignment; deformity is attributable to postsurgical pain and
reflex relaxation
• Ricci WM, Gruen GS, Summers H, Siska PA.
Fractures of the femoral diaphysis. In: Schmidt
AH, Teague DC, eds. Orthopaedic Knowledge
Update: Trauma 4. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2010:431-
444.
• Jaarsma RL, van Kampen A. Rotational
malalignment after fractures of the femur. J Bone
Joint Surg Br. 2004 Nov;86(8):1100-4. Review.
PubMed PMID: 15568519.
 Question 204
A 23-year-old man had a laparotomy and splenectomy with packing of the abdomen
after a motorcycle collision. Laboratory studies show a hemoglobin level of 7.1 g/dL
(reference range [rr], 14.0-17.5 g/ dL) and a lactate level of 8.0 mmol/L (rr, 0.6-1.7
mmol/L). He also has a left humeral fracture, an anteroposterior compression I pelvic
fracture, bilateral distal third femur fractures, and an open Gustilo type IIIA tibial
diaphysis fracture with moderate contamination. What is the most appropriate
treatment to administer before leaving the operating room?

1. Saline lavage and splinting of the tibia and knee immobilizers of both femurs
2. Betadine dressing and splinting of the tibia with unlocked retrograde nailing of both
femurs
3. Betadine dressing and external fixation of the tibia and knee immobilizers of both
femurs
4. Irrigation and debridement and external fixation of the tibia and external fixation of
both femurs
5. Irrigation and debridement and external fixation of the tibia and unlocked
retrograde nailing of both femurs
 Question 204
A 23-year-old man had a laparotomy and splenectomy with packing of the abdomen
after a motorcycle collision. Laboratory studies show a hemoglobin level of 7.1 g/dL
(reference range [rr], 14.0-17.5 g/ dL) and a lactate level of 8.0 mmol/L (rr, 0.6-1.7
mmol/L). He also has a left humeral fracture, an anteroposterior compression I pelvic
fracture, bilateral distal third femur fractures, and an open Gustilo type IIIA tibial
diaphysis fracture with moderate contamination. What is the most appropriate
treatment to administer before leaving the operating room?

1. Saline lavage and splinting of the tibia and knee immobilizers of both femurs
2. Betadine dressing and splinting of the tibia with unlocked retrograde nailing of both
femurs
3. Betadine dressing and external fixation of the tibia and knee immobilizers of both
femurs
4. Irrigation and debridement and external fixation of the tibia and external fixation
of both femurs
5. Irrigation and debridement and external fixation of the tibia and unlocked
retrograde nailing of both femurs
• Hak DJ, Stahel PF, Giannoudis P. Pathophysiology
of the polytrauma patients. In. Schmidt AH,
Teague DC, eds. Orthopaedic Knowledge Update:
Trauma 4. Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2010:117-131.
• Ricci WM, Gruen GS, Summers H, Siska PA.
Fractures of the femoral diaphysis. In: Schmidt
AH, Teague DC, eds. Orthopaedic Knowledge
Update: Trauma 4. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2010:431-
444.
 Question 207
Which nerve identified by the arrow seen in Figure
207 is encountered during fixation of a tibial pilon
fracture?

1. Sural
2. Saphenous
3. Lateral cutaneous
4. Deep peroneal
5. Superficial peroneal
 Question 207
Which nerve identified by the arrow seen in Figure 207 is
encountered during fixation of a tibial pilon fracture?

1. Sural
2. Saphenous
3. Lateral cutaneous
4. Deep peroneal
5. Superficial peroneal

****This question was excluded from scoring

• Mehta S, Gardner MJ, Barei DP, Benirschke SK,
Nork SE. Reduction strategies through the
anterolateral exposure for fixation of type B and C
pilon fractures. J Orthop Trauma. 2011
Feb;25(2):116-22. PubMed PMID: 21245716.
• Crist BD, Khazzam M, Murtha YM, Della Rocca GJ.
Pilon fractures: advances in surgical
management. J Am Acad Orthop Surg. 2011
Oct;19(10):612-22. Review. PubMed PMID:
21980026.
 Question 208
What is the mechanism of action of tranexamic acid
in controlling traumatic hemorrhage?

1. Inhibition of vitamin K reductase

2. Inhibition of topoisomerase II and IV
3. Antithrombin-III selective inhibition of Factor Xa
4. Competitive inhibition of plasminogen activation
5. Stimulation of integrin-mediated platelet
adhesion and activation
 Question 208
What is the mechanism of action of tranexamic acid
in controlling traumatic hemorrhage?

1. Inhibition of vitamin K reductase

2. Inhibition of topoisomerase II and IV
3. Antithrombin-III selective inhibition of Factor Xa
4. Competitive inhibition of plasminogen
activation
5. Stimulation of integrin-mediated platelet
adhesion and activation
• Godier A, Roberts I, Hunt BJ. Tranexamic acid: less
bleeding and less thrombosis? Crit Care. 2012 Jun
29;16(3):135. [Epub ahead of print] PubMed
PMID: 22748073.
• Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter
MJ. Military Application of Tranexamic Acid in
Trauma Emergency Resuscitation (MATTERs)
Study. Arch Surg. 2012 Feb;147(2):113-9. Epub
2011 Oct 17. PubMed PMID: 22006852.
 Question 211
Figures 211a and 211b are the radiographs of a 41-year-
old construction worker who sustained a twisting injury
to his right leg. Which injury in the ipsilateral extremity is
most commonly associated with this type of fracture?

1. Lisfranc injury
2. Anterior cruciate ligament injury
3. Proximal tibiofibular joint dislocation
4. Tibial plateau fracture
5. Posterior malleolus fracture
 Question 211
Figures 211a and 211b are the radiographs of a 41-year-
old construction worker who sustained a twisting injury
to his right leg. Which injury in the ipsilateral extremity is
most commonly associated with this type of fracture?

1. Lisfranc injury
2. Anterior cruciate ligament injury
3. Proximal tibiofibular joint dislocation
4. Tibial plateau fracture
5. Posterior malleolus fracture
• Boraiah S, Gardner MJ, Helfet DL, Lorich DG.
High association of posterior malleolus
fractures with spiral distal tibial fractures. Clin
Orthop Relat Res. 2008 Jul;466(7):1692-8.
Epub 2008 Mar 18. PubMed PMID: 18347885.
• Stuermer EK, Stuermer KM. Tibial shaft
fracture and ankle joint injury. J Orthop
Trauma. 2008 Feb;22(2):107-12. PubMed
PMID: 18349778.
 Question 216
A 25-year-old man sustained a closed right knee dislocation in a motor
vehicle collision. His pedal pulses are symmetrical in the emergency
department, both before and after reduction of the dislocation.
Angiography can be avoided if

1. his ipsilateral ankle-brachial index is 0.78.

2. he had an absent ipsilateral pedal pulse in the field before arriving at
the hospital.
3. he has a slightly cool right foot that becomes warm again over the
course of 3 hours.
4. he has normal color and warmth of the right foot with normal pedal
pulses for 48 hours.
5. he has a large hematoma that has increased in size during the first 3
hours after admission.
 Question 216
A 25-year-old man sustained a closed right knee dislocation in a motor
vehicle collision. His pedal pulses are symmetrical in the emergency
department, both before and after reduction of the dislocation.
Angiography can be avoided if

1. his ipsilateral ankle-brachial index is 0.78.

2. he had an absent ipsilateral pedal pulse in the field before arriving at
the hospital.
3. he has a slightly cool right foot that becomes warm again over the
course of 3 hours.
4. he has normal color and warmth of the right foot with normal
pedal pulses for 48 hours.
5. he has a large hematoma that has increased in size during the first 3
hours after admission.
• Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G Jr,
Robinson JT, Volgas DA. Vascular injuries in knee
dislocations: the role of physical examination in
determining the need for arteriography. J Bone Joint Surg
Am. 2004 May;86-A(5):910-5. PubMed PMID: 15118031.
• Mills WJ, Barei DP, McNair P. The value of the ankle-brachial
index for diagnosing arterial injury after knee dislocation: a
prospective study. J Trauma. 2004 Jun;56(6):1261-5.
PubMed PMID: 15211135.
• Nicandri GT, Chamberlain AM, Wahl CJ. Practical
management of knee dislocations: a selective angiography
protocol to detect limb-threatening vascular injuries. Clin J
Sport Med. 2009 Mar;19(2):125- 9. Review. PubMed PMID:
19451767.
 Question 221
A 24-year-old man had multisystem injuries, including an open
left femoral shaft fracture he sustained after a motorcycle
collision. He received 3 liters of crystalloid and 2 units of
packed red blood cells. Urgent debridement and irrigation of
his open left femur fracture is planned. Which finding would
support proceeding with definitive fixation of the fracture at
the time of debridement?

1. Lactate level of 2.2 mg/dL

2. Platelet count of 70,000
3. Urine output of 20 cc/hour
4. Systolic blood pressure of 90
5. Body temperature of 34.5°C
 Question 221
A 24-year-old man had multisystem injuries, including an open
left femoral shaft fracture he sustained after a motorcycle
collision. He received 3 liters of crystalloid and 2 units of
packed red blood cells. Urgent debridement and irrigation of
his open left femur fracture is planned. Which finding would
support proceeding with definitive fixation of the fracture at
the time of debridement?

1. Lactate level of 2.2 mg/dL

2. Platelet count of 70,000
3. Urine output of 20 cc/hour
4. Systolic blood pressure of 90
5. Body temperature of 34.5°C
• Pape HC, Tornetta P 3rd, Tarkin I, Tzioupis C,
Sabeson V, Olson SA. Timing of fracture fixation in
multitrauma patients: the role of early total care
and damage control surgery. J Am Acad Orthop
Surg September 2009; 17:541-549. PubMed
PMID: 19726738.
• Pape HC, Giannoudis PV, Krettek C, Trentz O.
Timing of fixation of major fractures in blunt
polytrauma role of conventional indicators in
clinical decision making. J Orthop Trauma Sep
2005;19(8):551-562. PubMed PMID: 16118563.
 Question 223
The World Health Organization Safe Surgery Guidelines
Checklist requires that when prophylactic antibiotics are
indicated, they should be administered

1. within 30 minutes prior to incision.

2. within 60 minutes prior to incision.
3. within 30 minutes prior to or after incision.
4. within 60 minutes prior to or after incision.
5. only in the operating room once the patient’s allergies,
if any, have been confirmed by the anesthesiologist and
circulating nurse.
 Question 223
The World Health Organization Safe Surgery Guidelines
Checklist requires that when prophylactic antibiotics are
indicated, they should be administered

1. within 30 minutes prior to incision.

2. within 60 minutes prior to incision.
3. within 30 minutes prior to or after incision.
4. within 60 minutes prior to or after incision.
5. only in the operating room once the patient’s allergies,
if any, have been confirmed by the anesthesiologist and
circulating nurse.
• Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH,
Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan
MC, Merry AF, Moorthy K, Reznick RK, Taylor B,
Gawande AA; Safe Surgery Saves Lives Study Group. A
surgical safety checklist to reduce morbidity and
mortality in a global population. N Engl J Med. 2009
Jan 29;360(5):491-9. Epub 2009 Jan 14. PubMed PMID:
19144931.
• World Alliance for Patient Safety. WHO guidelines for
safe surgery. Geneva, Switzerland: World Health
Organization; 2008.
 Question 226
Judet radiographs of the pelvis are shown in Figures 226a
through 226c, and an axial CT scan of the pelvis is shown
in Figure 226d. The acetabular fracture is best classified
as

1. associated T type.
2. associated both column.
3. associated transverse and posterior wall.
4. associated posterior column and posterior wall.
5. associated anterior and posterior hemitransverse.
 Question 226
Judet radiographs of the pelvis are shown in Figures 226a
through 226c, and an axial CT scan of the pelvis is shown
in Figure 226d. The acetabular fracture is best classified
as

1. associated T type.
2. associated both column.
3. associated transverse and posterior wall.
4. associated posterior column and posterior wall.
5. associated anterior and posterior hemitransverse.
• Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical
results in patients managed operatively within three weeks after the
injury. J Bone Joint Surg Am. 1996 Nov;78(11):1632-45. PubMed
• PMID: 8934477.
• Borrelli J Jr, Peelle M, McFarland E, Evanoff B, Ricci WM. Computer-
reconstructed radiographs are as good as plain radiographs for assessment
of acetabular fractures. Am J Orthop (Belle Mead NJ). 2008 Sep;37(9):455-
9; discussion 460. PubMed PMID: 18982180.
• Beaulé PE, Dorey FJ, Matta JM. Letournel classification for acetabular
fractures. Assessment of interobserver and intraobserver reliability. J Bone
Joint Surg Am. 2003 Sep;85-A(9):1704-9. PubMed PMID: 12954828.
• Letournel E. Acetabulum fractures: classification and management. Clin
Orthop Relat Res. 1980 Sep;(151):81-106. PubMed PMID: 7418327.
 Question 228
A 78-year-old woman sustained a periprosthetic
supercondylar femoral fracture. What is the
advantage of submuscular plating compared with
an extensile lateral approach?

1. Decreased rate of infection

2. Decreased risk for nonunion
3. Decreased risk for iatrogenic fracture
4. Improved functional outcome
5. Increased longevity of the component
 Question 228
A 78-year-old woman sustained a periprosthetic
supercondylar femoral fracture. What is the
advantage of submuscular plating compared with
an extensile lateral approach?

1. Decreased rate of infection

2. Decreased risk for nonunion
3. Decreased risk for iatrogenic fracture
4. Improved functional outcome
5. Increased longevity of the component
• Hou Z, Bowen TR, Irgit K, Strohecker K, Matzko
ME, Widmaier J, Smith WR. Locked plating of
periprosthetic femur fractures above total knee
arthroplasty. J Orthop Trauma. 2012
Jul;26(7):427-32. PubMed PMID: 22357080.
• Hoffmann MF, Jones CB, Sietsema DL, Koenig SJ,
Tornetta P 3rd. Outcome of periprosthetic distal
femoral fractures following knee arthroplasty.
Injury. 2012 Jul;43(7):1084-9. Epub 2012 Feb 18.
PubMed PMID: 22348954.
 Question 235
Figure 235 is the radiograph of a 75-year-old woman who
is seen in the emergency department following a low-
energy fall. What is the most appropriate treatment
based on her radiographic findings?

1. Perform a biopsy of the lesion

2. Stabilize with an intramedullary nail
3. Initiate immediate bisphosphonate therapy
4. Treat with chemotherapy followed by wide resection
5. Obtain a chest CT scan, urine protein electrophoresis,
and serum protein electrophoresis
 Question 235
Figure 235 is the radiograph of a 75-year-old woman who
is seen in the emergency department following a low-
energy fall. What is the most appropriate treatment
based on her radiographic findings?

1. Perform a biopsy of the lesion

2. Stabilize with an intramedullary nail
3. Initiate immediate bisphosphonate therapy
4. Treat with chemotherapy followed by wide resection
5. Obtain a chest CT scan, urine protein electrophoresis,
and serum protein electrophoresis
• Weil YA, Rivkin G, Safran O, Liebergall M, Foldes
AJ. The outcome of surgically treated femur
fractures associated with long-term
bisphosphonate use. J Trauma. 2011
Jul;71(1):186-90. PubMed PMID: 21610533.
• Prasam ML, Ahn J, Helfet DL, Lane JM, Lorich DG.
Bisphosphonate-associated femur fractures have
high complication rates with operative fixation.
Clin Orthop Relat Res. 2012 Aug;470(8):2295-301.
PubMed PMID: 22669553.
 Question 238
Figures 238a and 238b are the radiographs of a 60-year-old
woman who fell and sustained a right midshaft humeral
fracture 1 year ago. She was treated in a functional brace for 6
months and has used an electrical bone stimulator for the
past 6 months. She has arm pain and limited use of her left
shoulder and elbow. What is the best treatment option?

1. A reamed intramedullary nail

2. A change to an ultrasound bone stimulator
3. Continued nonsurgical treatment with both functional
bracing and electrical bone stimulator
4. Systemic administration of 1-34 teriparatide
5. Compression plating with or without bone graft
 Question 238
Figures 238a and 238b are the radiographs of a 60-year-old
woman who fell and sustained a right midshaft humeral
fracture 1 year ago. She was treated in a functional brace for 6
months and has used an electrical bone stimulator for the
past 6 months. She has arm pain and limited use of her left
shoulder and elbow. What is the best treatment option?

1. A reamed intramedullary nail

2. A change to an ultrasound bone stimulator
3. Continued nonsurgical treatment with both functional
bracing and electrical bone stimulator
4. Systemic administration of 1-34 teriparatide
5. Compression plating with or without bone graft
• Abboud JA, Boardman ND III. Shoulder
trauma: bone. In: Flynn JM, ed. Orthopaedic
Knowledge Update 10. Rosemont, IL:
American Academy of Orthopaedic Surgeons;
2011:271-284.
• Ring D, Chin K, Taghinia AH, Jupiter JB.
Nonunion after functional brace treatment of
diaphyseal humerus fractures. J Trauma. 2007
May;62(5):1157-8. PubMed PMID: 17495717.
 Question 249
A 75-year-old woman fell at home and sustained
the injury seen in Figures 249a through 249c. What
is the most appropriate treatment option?

1. Stand pivot transfer only

2. Bed rest with bathroom privileges
3. Partial weight bearing on the right
4. Weight bearing only after surgical intervention
5. Bilateral weight bearing as tolerated
 Question 249
A 75-year-old woman fell at home and sustained
the injury seen in Figures 249a through 249c. What
is the most appropriate treatment option?

1. Stand pivot transfer only

2. Bed rest with bathroom privileges
3. Partial weight bearing on the right
4. Weight bearing only after surgical intervention
5. Bilateral weight bearing as tolerated
• Sagi HC, Liporace FA. Fractures of the pelvis and
acetabulum. In: Flynn JM, ed. Orthopaedic
Knowledge Update 10. Rosemont, IL: American
Academy of Orthopaedic Surgeons; 2011:379-
397.
• Sembler Soles GL, Lien J, Tornetta P III.
Nonoperative immediate weightbearing of
minimally displaced lateral compression sacral
fractures does not result in displacement. J
Orthop Trauma. 2012 Apr 10. PubMed PMID:
22495523.
 Question 261
A 30-year-old man sustained the injury seen in
Figure 261. According to the Lauge-Hansen
Classification System, the fracture should be
classified as

1. pronation-abduction.
2. pronation-adduction.
3. pronation-external rotation.
4. supination-adduction.
5. supination-external rotation
 Question 261
A 30-year-old man sustained the injury seen in
Figure 261. According to the Lauge-Hansen
Classification System, the fracture should be
classified as

1. pronation-abduction.
2. pronation-adduction.
3. pronation-external rotation.
4. supination-adduction.
5. supination-external rotation
• Davidovitch RI, Egol KA. Fractures of the ankle.
In: Bucholz RW, Court-Brown CM, Heckman
JD, Tornetta P, eds. Fractures and Dislocations.
Philadelphia, PA: Lippincott; 2009:1975-2021.
• Graves M. Ankle fractures. In: Flynn JM, ed.
Orthopaedic Knowledge Update 10.
Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2011:493-505.
 Question 268
The condition shown in Figure 268 has been subject to 2
nailing attempts. The patient is seen 8 months after the
second surgery. What is the most appropriate treatment
method?

1. Bone stimulator with vitamin D supplementation

2. In situ noncompressive plating with a bone graft
3. In situ repeat intramedullary nailing with a bone graft
4. Corrective alignment with exchange nailing with a bone
graft
5. Corrective alignment and compression plating without a
bone graft
 Question 268
The condition shown in Figure 268 has been subject to 2
nailing attempts. The patient is seen 8 months after the
second surgery. What is the most appropriate treatment
method?

1. Bone stimulator with vitamin D supplementation

2. In situ noncompressive plating with a bone graft
3. In situ repeat intramedullary nailing with a bone graft
4. Corrective alignment with exchange nailing with a bone
graft
5. Corrective alignment and compression plating without a
bone graft
• Bolhofner BR, Finnegan M, Lundy DW. Nonunions
and malunions. In: Schmidt AH, Teague DC, eds.
Orthopaedic Knowledge Update: Trauma 4.
Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2010:145-157.
• Bellabarba C, Ricci WM, Bolhofner BR. Results of
indirect reduction and plating of femoral shaft
nonunions after intramedullary nailing. J Orthop
Trauma. 2001 May;15(4):254-63. PubMed PMID:
11371790.