Trauma (2008-2019)

Question 1

1. 8 Parameters to consider in a trauma patient for DCO vs Early total care (2010, 2011, 2013)

Answer 1

• Shock Factors
  
  • Systolic BP < 90mm Hg and MAP less than 60
  • Dependency on vasopressors to maintain BP
  • Urine output less than 0.5cc/hr/kg
  • Massive transfusion requirements (6 or more units in 2 hours)
  • Lactate greater than 2.5mmol/L: this is the most sensitive indicator as to whether tissues are under perfused
  • Base deficit greater than 6 mmol/L. normal range for deficit is -2 to +2
  • Ph less than 7.2
  • More recent research = BASE DEFICIT most sensitive indicator of tissue perfusion
• Coagulation parameters (i.e. things that indicate the patient is coagulopathic)
  
  • Platelet count less than 90 000
  • Elevated d-dimer
  • Fibrinogen less than 1
  • Elevated PTT (i.e. decreased factor II and V)
• Temperature
  
  • Core temp less than 35 (some say 33) degrees C
• Soft tissue injury to extremity, lungs or abdomen
  
  • Lung function: PaO2/FiO2 ratio of less than 250-300
  • Pulmonary contusions bilaterally on initial chest xray
  • Severe chest trauma as indicated by AIS score of 2 or more
  • Mangled extremity or severe crush injury to extremity
  • Bilateral femoral shaft fractures or multiple long bone fractures
  • Severe abdominal trauma (Moore III or greater) in polytrauma patient
  • Severe Pelvic fracture (AO class B or C pelvic fracture) in poly trauma patient
• Other factors
  
  • Head injured patient with AIS of 3 or more
  • ISS score greater than 20 with chest trauma
  • ISS score greater than 40 w/o chest trauma
  • Presumed OR time greater than 6 hours in a borderline patient
  • IL-6 values above 500pg/dL at the time of surgery and development of multiple organ failure (Second hit).

Question 2

2. What are 8 radiographic features of acute traumatic aortic rupture? (2011, 2013, 2015)

Answer 2

• ATLS Manual:
• Loss of Aortic Arch:
  
  • Widened mediastinum (>8mm)
  • Obliteration of the aortic knob
  • Loss of Aorto-pulmonary window
  • Widened paraspinal interfaces
• Trachea and Esophageal Findings:
  
  • Tracheal deviation to the right
  • Deviation of esophagus/NG to right
  • Widened paratracheal stripe
• Intra-pulmonary and chest wall findings
  
  • Left apical cap (apical pleural hematoma)
  • Left hemothorax
  • Depression of left mainstem bronchus
  • Elevation of right mainstem bronchus
  • Fractures of first or second rib, scapula

Question 3

3. List the 4 major and 4 minor criteria of fat embolism syndrome (2014)

Answer 3

Gurd and Wilson Criteria: (1 major with 4 minor)

• Major Criteria:
  
  • Hypoxemia
  • CNS depression/change in mental status
  • Petechial Rash
  • Pulmonary Edema
• Minor Criteria:
  
  • Tachycardia
  • Pyrexia
  • Retinal emboli
  • Fat in urine/sputum
  • Thrombocytopenia
  • Decreased hematocrit

Question 4

4. List signs of class 4 hypovolemic shock. (2011, 2014)

Answer 4

ATLS Manual:

• Heart Rate > 140bpm
• Decreased blood pressure
• Decreased pulse pressure
• Respiratory rate > 35
• Negligible urine output
• Lethargic/comatose

Question 5

5. Young female with polytrauma. Shown an xray with bilateral inf and sup ramus # but perfect SI joints. Been to OR for slenectomy and found a large retroperitoneal hematoma. Still hypotense 95/50 and 90bpm. What to do next?
6. Angio with embolization
7. “External fixator or C – clamp” (For sure this answer was as written)
8. Return to OR for re-exloration and packing
9. Pelvic binder

Answer 5

ANSWER: A

2013

Eastern Association for the Surgery of Trauma Practice Management Guidelines for Hemorrhage in Pelvic Fracture—Update and Systematic Review (J Trauma. 2011;71: 1850–1868) 

• Angiography
  
  • There is level 1 evidence that patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out should have pelvic angiography/embolization. 
• External Pelvic Fixation
  
  • Sadri et al.[11] found that blood loss was not statistically different before/after placement of the pelvic C-clamp or Ex fix.
  • In addition, there is evidence that pelvic binders are more effective at decreasing transfusion requirements because they are faster to apply, and are as effective as external fixators in decreasing pelvic volume. 
  • Temporary Pelvic Binders:
  • TPBs may limit pelvic hemorrhage, but reports on this are mixed in the literature. They do not seem to affect mortality.
  • TPBs work as well or better than emergent EPF in controlling hemorrhage.  
• Retroperitoneal Packing:
  
  • This is effective at controlling hemorrhage from an intrapelvic bleeding source if done in conjunction with either an ex fix or pelvic binder to close the pelvic volume.
  • Colorado trial**2017 - RPP faster and saves lives (charles) do packing and ex fix first, then consider embolizing
  • But was with true pelvic fractures (unstable), vs this is no unstable pelvis or disruption of posterior SI lig

Question 6

6.23 yo woman in a MVC. Presents with C7 complete cord lesion and a closed femur fracture. She has received 2 L of crystalloid. Heart rate is 110 and BP is 86/55. The cause of her hypotension is

1. Hypovolemia due to unrecognized abdominal bleeding
2. Hypovolemia due to her femur fracture
3. Spinal shock
4. Neurogenic shock

Answer 6

ANSWER: A

2013

• Obviously on-going hypotension due to bleeding. Disagreement on source –> some say femur fracture should respond to crystalloid and therefore given the mechanism the abdomen is likely bleeding
• Student Course Manual ATLS 10th edition (Charles)

Question 7

7.Regarding compartment syndrome which will NOT help treat acute compartment syndrome:

1. Transfusing to keep HGB greater than 100
2. fixing hypotension
3. Giving O2 by mask
4. Cutting all circumferential dressings and casts

Answer 7

ANSWER: A

2013

• Correction of hypotension and removal of dressings are common sense answers
• JAAOS - Acute Compartment Syndrome of the Lower Extremity
  
  • Casts or occlusive dressings should be split completely. Cast padding or circumferential dressings should be released around their entire circumference. The affected limb should not be elevated higher than the patient’s heart in order to maximize perfusion while minimizing swelling
  • Talk about perfusion gradient that might be inadequate with systemic hypotension and that hypotension should be avoided (anesthesia methods of hypotension to decrease blood loss can create/exacerbate ACS)
  • No mention of transfusion or transfusion above 100
• Hyperbaric oxygen therapy useful Fitzpatrick et al. 1998. Adjunctive treatment of compartment syndrome with hyperbaric oxygen.

Question 8

8.A 24yo male is found 24 hours after a single vehicle collision/rollover. He has a closed head injury (GCS12), a pneumothorax, and an open tibia fracture with a 10cm wound over the anteromedial tibia. Both of his legs have been lying in ditch water for 24 hours. You are shown x-rays which demonstrate a comminuted midshaft tibia fracture. Optimal treatment includes irrigation & debridement and what else?

1. Reamed IM nail
2. Unreamed IM nail
3. Ex-fix
4. Cast with conversion to an IM nail when soft tissues improve

Answer 8

ANSWER: C

2014

Argument:

• Delayed presentation + head injury (weak) + lung injury = indication for DCO
• Best stabilization without definitive hardware is external fixation

Question 9

9. Motorcycle crash 2 hours ago with hypotension, unstable. Tibia fracture with large soft tissue defect, 12cm bone on road (in paper bag with EMS), vascular injury with no pulses, insensate foot. Ipsilateral femur and acetabular fractures. How will you treat the leg?
10. I+D, Vascular repair, replace extruded tibia and unreamed nail
11. I+D, Vascular repair, discard extruded tibia and unreamed nail
12. I+D, Vascular repair, discard extruded tibia and ring fixator
13. Below knee amputation

Answer 9

ANSWER: D **

2013, 2016

Difficult question to find evidence for

• Very sick, unstable patient
• Reconstruction would take many hours
• Would consider vascular repair + ex-fix of femur and tibia but this is not an option
• LEAP trial - patient cannot survive recon, vasc, large ST injury, insensate foot not indication (usually comes back) but overall disvascular limb with large ST injury = amp

Question 10

10. Which of the following is a reason NOT to put O2 on an old person in trauma
11. Chronic lung disease with increased PaCO2
12. Chronic lung disease with decrease PaCO2
13. Heart disease
14. No reason to not put O2 on

Answer 10

ANSWER: D

2013

Callaway DW, Wolfe R Geriatric trauma. Emerg Med Clin North Am. 2007 Aug;25(3):837-60

“Supplemental oxygen should be placed on all elderly trauma patients. This practice provides the needed oxygen reserves if rapid sequence intubation is needed and contributes to cellular oxygenation”

Question 11

11. A patient presents to ER with C5/6 jumped facets and complete quadriplegia following an MVC (or some other similar trauma). It is an isolated injury. The patient is bradycardic (HR 60?) and hypotensive (80/45 mmHg). So far the patient has been given 6L of crystalloid. What should you do now?
12. Slow IV to maintenance rate
13. Start transfusing blood
14. Give albumin
15. Rapid bolus with IV crystalloid

Answer 11

ANSWER: A

2014

JAAOS 1999 - Acute Management of Spinal Cord Injury

Patients in neurogenic shock typically have a heart rate between 50 and 70 beats per minute and a systolic pressure 30-50mm Hg below normal

Treatment of neurogenic shock includes an initial fluid challenge, Trendelenberg positioning, vasopressors after central line insertion and atropine for treatment of bradyarrhythmias

Question 12

12. What is the best predictor of resuscitation in polytrauma?
    a. base deficit
    b. urine output
    c. blood pressure
    d. heart rate

Answer 12

 ANSWER: A

2015

Crowl AC (J Trauma 2000)

Patients with ISS > 18 and IMN within 24 hours

Compensated shock (normal BP, HR, U/O)

Pt with lactate > 2.5 had higher pulmonary and infectious complications

Question 13

13. Patient presents with a femur fracture and a pulmonary contusion. Hemodynamically stable. What is the most appropriate treatment?
14. Subcutaneous plate
15. External fixation
16. Unreamed IM nail
17. Reamed IM nail

Answer 13

ANSWER: D

2016

• Pape (Ann Surg 2007) RCT of IMN vs DCO
• Exclusion AIS thorax > 2, body weight > 250lb
• Stable patients –> IMN associated with decreased ventilator time
• Borderline patients –> acute IMN associated with increased acute lung injury
• JAAOS - Damage Control Orthopedics
• Borderline Patients:
• ISS > 20 + thoracic injury
• ISS > 40
• Bilateral pulmonary contusion
• Polytrauma with abdominal/pelvic trauma and hemodynamic shock
• Elevated pulmonary arterial pressure > 24 mmHg
• Pulmonary arterial pressure increase of 6mmHg during procedure
• Hypothermia
• ? Severe abdominal injury (AIS > 3)
• Morshed (JBJS 2009)
• 50% relative risk reduction in mortality in patients treated after 12 hours
• Significant abdominal injury benefitted most from delay
• ? Bilateral femur fractures
• ? Head Injury
• O’Toole RV (J Trauma 2009)
• Retrospective review of protocol for treatment of femur fractures
• ISS > 17, 229 patients
• 88% had reamed IM nailing, 12% DCO
• “normalizing lactate” parameter for adequate resuscitation
• Mean time to nail 14 hours
• 1.5% ARDS, 2.0% ARDS with pulmonary injury, 3.3% with pulm injury and ISS > 28
• COTS (J Trauma 2006)
• 322 femur fractures
• IMN within 24 hours
• No significant differences
• Reamed 3/63
• Unreamed 2/46
• 40000 patients needed for appropriate power
• Bosse MJ (JBJS 1997)
• No difference in patients treated with nails vs plates

Question 14

14. List 5 factors that increase the 30 day morbidity of a patient with a hip fracture (2012, 2014)

Answer 14

Nottingham Hip Fracture Score:

• Age
• Male
• Hemoglobin < 100
• MMSE < 6
• Institutionalized
• > 2 Comorbidities
• Malignancy

HIM MAC M

Question 15

15. Describe the Leadbetter maneuver. (2010, 2015)

Answer 15

• Flex hip to 45-90, slight adduction
• Inline traction
• Internal rotation to 45o
• Maintain traction and IR, then abduction and extension

Question 16

16. What are three radiographic factors indicate adequate reduction of a displaced femoral neck? (2010, 2013, 2015)

Answer 16

Question 17

17. List 3 strategies while antegrade nailing a subtrochanteric femur fracture to assist with reduction and avoid varus malunion. (2013)

Answer 17

• Lateral positioning for nail
• Limb positioning with flexion, abduction, traction
• Crutch/Cobb/Mallet/F-tool
• Open Reduction with clamp/uni-cortical plate/cerclage wire
• Blocking screws
• Medial start point on nail

Question 18

18. Give 2 advantages of doing a piriformis starting point vs. a trochanteric starting point for an antegrade femoral nail. (2011)

Answer 18

• JAAOS - Intramedullary Nailing of femoral shaft fractures
• Piriformis Advantage:
  
  • Straight trajectory with shaft
  • Decreased risk of varus malreduction
  • Decreased risk of iatrogenic fracture comminution
  • Decreased risk of GT fracture
• Disadvantages:
  
  • More difficult start point
  • Sensitive to anterior/posterior misplacement
  • Increased theoretical risk of blood supply disruption
  • Risk of femoral neck fracture
• Trochanteric Start Point:
• Advantage:
  
  • Easier start point
  • Less hoop stresses in GT, more forgiving to AP mistakes with start point
  • Less soft tissue damage

Question 19

19. Given an x-ray of a varus malunited femoral neck fracture. List 4 clinical findings found on physical exam other than decreased ROM. (2011)

Answer 19

• Prominent GT
• Impingement with ROM
• Leg length discrepancy
• Obligate external rotation with flexion
• Trendelenberg Sign/Abductor Weakness

PILOT

Question 20

20. In an adult femur supracondylar fracture, intraarticular and metaphyseal comminution what are 3 advantages over a distal femoral locking plate over a 95 degree sliding dynamic condylar screw. (2013)

Answer 20

• Preserves more distal bone stock
• Ability to control multiple fracture fragments
• Better fixation in osteoporotic/comminuted bone (multiple points of fixation)
• Less soft tissue stripping
• Anatomic contour helps with reduction of joint
• Biomechanically superior in cyclic load and ultimate strength

PAB LAB

JAAOS 1997 Supracondylar Fractures of the Femur. Albert.

Gwathmey FWF, Jones-Quaidoo SMS, Kahler DD, Hurwitz SS, Cui QQ. Distal femoral fractures: current concepts. J Am Acad Orthop Surg. 2010;18(10):597–607

Question 21

21. List 3 radiographic strategies to properly determine the rotation of the distal femur when nailing a femoral shaft fracture. (2014, 2015, 2016)

Answer 21

• Tornetta Technique (1995): anteversion determined off c-arm angles for perfect lateral of proximal and knee of non-injured limb, recreate with rotation of distal femur to match.
  
  • Results in rotational discrepancy under 8 degrees
• Lateral-only imaging (2000): true lateral knee, measure anteversion on screen, recreate this
  
  • Results in rotational discrepancy under 10 degrees
• Lesser-trochanter profile: true lateral of knee, then 90 degrees to this take AP of lesser trochanter, use as template
  
  • Results in <10 degrees of malrotation

Question 22

22. List 5 intra-operative techniques to aid in reduction of a proximal tibial shaft fracture (2012,2015)

Answer 22

• Unicortical plate
• Poller Screws
• Semi-extended positioning/supra-patellar start point
• Lateralize start point
• Femoral Distractor
• More Proximal Herzog Angle

UPS LFP

Question 23

23. 4 principles of managing a Pilon excluding soft tissue (2012)

Answer 23

JAAOS 2011 - Pilon Fractures

• Reduce and fix fibula fracture to re-establish length
• Correct varus/valgus deformity
• Anatomic Reduction of articular surface
• Back fill metaphyseal defect
• Fix articular block to tibial shaft

Question 24

24. 3 radiographic findings suggesting syndesmotic injury (2012)

Answer 24

JAAOS 2007 Ankle Syndesmotic Injury

• Increased medial clear space on mortise >4mm
• Decreased tibio-fibular overlap (<6mm AP, <1mm on mortise)
• Increased TibFib clear space (>6mm on AP and mortise)
• Avulsion fracture off posterior mal
• Proximal spiral fibular fracture with no tibia fracture

Question 25

25. List 3 complications of doing an ankle ORIF in a patient with DM (2010, 2011)

Answer 25

JAAOS 2008 - Complications of Ankle Fractures in Patients with Diabetes

• Increased risk of infection
• Delayed wound healing
• Delayed time to union
• Non-union
• Mal-union/loss of reduction
• Increased hardware failure
• Charcot neuroarthropathy
• CRPS
• Amputation

Question 26

26. For an isolated posterior wall acetabular fracture, all of the following are indications for ORIF EXCEPT:
27. Intra-articular fragment
28. Roof arc less than 20
29. Positive stress test
30. 40% wall involvement

Answer 26

ANSWER: B

Repeat 2013, 2015

JAAOS 2001 Displaced Acetabular Fractures

• JOT 1996 The Effect of Variable Size Posterior Wall Acetabular Fractures on the Contact Characteristics of the Hip Joint
• “Articular incongruity is one indication for open reduction and internal fixation of these fractures. For fractures of the posterior wall, the indications for operative treatment also include instability of the hip, incarcerated or impacted osteochondral fragments, and irreducible fracture-dislocation of the hip.”
• From the OTA powerpoint slides:
• Cannot use roof arc measurements for wall fractures since these can only be treated non-operatively if hip joint remains completely stable and congruent

Question 27

27. What type of acetabular fracture can you not use a roof angle in?
28. Associated two column (worded this way)
29. Transverse posterior wall
30. Posterior column
31. T type

Answer 27

ANSWER:A

2012

• From the OTA powerpoint slides:
• Cannot use roof arc measurements for associated both column since there is no intact portion of the acetabulum to measure

Question 28

28. Posterior wall fractures (2nd question) all are true EXCEPT
29. 5 of Letournels lines are intact
30. > 50% of posterior wall involvement requires fixation
31. Marginal impaction requires disimpaction and bone grafting.
32. Intra-articular split requires fixation

Answer 28

ANSWER: D

2013

• Isolated posterior wall fractures have all other lines intact - YES
• Posterior wall fractures >40% are associated with hip instability –> should go on to fixation
• Articular steps associated with poor outcomes –> therefore should be disimpacted
• All posterior wall fractures are intra-articular, those <20% and stable are not an indication for fixation

Question 29

29. What is the best approach to fix an associated both column acetabular fracture:
30. Iliofemoral
31. Triradiate
32. Kocher-Langenbach
33. Ilioinguinal/Stoppa

Answer 29

ANSWER: D

2015

• From Chapt 36 of Core 2 - Stoppa is appropriate for associated both column fractures, and it is similar to the middle window of the ilioinguinal approach (which also has associated both column listed as an indication)

Question 30

30. When utilizing the Kocher-Langenbeck approach for acetabular fractures, everything is true about positioning EXCEPT? 
31. Lateral: useful for transverse fractures
32. Lateral: useful for ipsilateral pubic symphysis fractures
33. Prone: useful to decrease sciatic nerve tension
34. Prone: useful to palpate the quadrilateral plate

Answer 30

ANSWER: A

2016

Question 31

31. Elderly acetabular fracture, which of the following is true?
32. Most need posterior approach
33. Gull sign is representative of interposed fragment
34. Most have an anatomic reduction
35. 20% or more go on to total hip with long term outcome

Answer 31

ANSWER: D

2016

Archdeacon (JOT 2013) Treatment of protrusio fractures of the acetabulum in patients 80 years and older

• 26 patients at 1 years
• 19% underwent THA
• 26% died at average of 20 months

Question 32

32. Which approach gives best access for reduction and fixation to quadrilateral plate?
33. Medial window ilioinguinal
34. Stoppa
35. Kocher-langenbeck
36. Hardinge

Answer 32

ANSWER: B

2016

• JAAOS 2011 - Modified Stoppa Approach for Acetabular Fracture
• Subperiosteal dissection performed along the pubis, superior pubic ramus, posterior surface of the ramus and pelvic brim into the internal iliac fossa
• Ligate the corona mortis between obturator and external iliac over superior ramus
• Additional exposure:
• Detach the iliopectineal fascia, place deaver under iliopsoas to protect vessels
• Next quadrilateral surface and medial aspect of posterior column exposed
• JAAOS 2015 - Surgical Approaches to the Acetabulum
• Lateral Window - inner table of ilium, anterior SI, pelvic brim
• Middle Window - quad plate, pelvic brim (anterior Si to pectineal eminence)
• Medial Window - superior pubic ramus and pubic symphysis
• JOT 2014 - Quantification of bony pelvic exposure through the modified Stoppa approach
• The modified Stoppa approach allows for exposure of most (79%) of the inner true bony pelvis including the entire pelvic brim and 80% of the quadrilateral surface. On average, visualization is possible 2 cm above the pelvic brim and 5 cm below the pelvic brim along the quadrilateral surface, providing adequate anterior exposure for clamp and implant placement

Question 33

33. A 50yo male falls from a horse. You are shown an x-ray which demonstrates 2-3cm pubic diastasis and slight right SI joint widening but no vertical instability. What was the mechanism?
34. Vertical shear
35. Anterior posterior compression
36. Lateral compression
37. Open book

Answer 33

ANSWER: B

2014

Question 34

34. What is true about SI screw placement? *VERSION OF A REPEAT
35. To place an S2 screw 1 cm distance between the S1 and S2 foramens is required
36. You cannot place an S2 screw if there is sacral dysmorphism
37. Displacement in the AP plane of 1.5cm
38. Displacement in the cranial-caudal plane of 1.5cm

Answer 34

ANSWER: A

Question 35

35. A guy comes in with a posterior hip dislocation that is not reducible by closed reduction attempts. What is the block to reduction?
36. Sciatic nerve
37. Psoas tendon
38. Posterior labrum
39. Obturator Internus

Answer 35

ANSWER: C

 2016

JAAOS 2015 – Hip Dislocation: Evaluation and Management

“irreducible dislocations may be the result of bony or soft-tissue interposition and several structures have the potential to impede successful reduction including labrum, capsule, iliopsoas, rectus femoris, piriformis, gluteus maximus, ligamentum teres or bone fragments”

Slatis (Injury 1974)

Hunter 1969  posterior capsule button-hole

Funk 1962  capsular interposition

2x case report = piriformis muscle/bone fragments, obturator internus

Uzel (Chin J Traumatol?? 2011)

Capsular entrapment

Canale ST (JBJS 1979)

Review of 54 dislocations

Button-holed through capsule, piriformis in acetabulum

“Non-concentric” reduction  inverted limbus, osseous fragment

McKee (JOT 1998)

Block to reduction  13 x acetabular fragment, 4x capsule, 3x piriformis tendon, 1x obturator muscle, 1x sciatic nerve, 6x femoral head fragments, 3x femoral neck fragments

 

Question 36

36. 75 year old female suffers a subtrochanteric fracture and is treated with a blade plate as seen in the XR. (This XR is nearly identical to what we were shown). What is true?
37. It will fail because it is not anatomically fixed with absolute stability of the cortical fragments.
38. It will not fail because the load is spread over a long length of plate
39. It will fail because it was not bone grafted
40. It will fail because of osteoporosis and delayed fracture healing.

Answer 36

ANSWER: B

2012, 2013 

I don’t know how to reference this question:

A - diaphyseal fracture –> length, alignment and rotation

B - yay for working length

C - don’t need primary bone grafting

D - osteoporosis does not delay fracture healing

Question 37

37. Elderly person suffers a Garden 3-4 fracture of the femoral neck. Concerning all arthroplasty (Hemi and THA) compared to fixation which of the following is NOT true?
38. Functional outcomes are better for arthroplasty
39. Mortality is greater for fixation
40. Revision is greater for fixation
41. Blood loss is less for fixation

Answer 37

ANSWER: B

• 2012, 2013
• Mortality lower for fixation than arthroplasty*
• JAAOS 2008 - Surgical Management of Hip Fractures
• • Bhandari (JBJS 2003)
• ORIF vs arthroplasty (bipolar and THA)
• Similar results for pain relief, overall function and 1 year mortality
• Increased early mortality for THA (first 4 months)

Question 38

38. In a severely displaced femoral neck fracture, what blood supply to the femoral head is likely preserved?
    a. Medial femoral circumflex
    b. Lateral femoral circumflex
    c. Retinacular vessels
    d. Obturator

Answer 38

ANSWER: D

2015

Supplies the artery of the ligamentum teres, has minimal blood supply to the head in adults, but the vessels running up the neck are disrupted in displaced femoral neck fractures

Question 39

39. CMN vs DHS, for all intertroch fractures:
40. Transfusion rates are similar
41. Mortality higher at 1 year for DHS
42. CMN have a lower failure rate
43. Functional outcomes better for CMN at 1 year 

Answer 39

ANSWER: A

2012

• Parker, M. (Cochrane 2010). Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults.
• When including ALL TYPES of IM nails:
•  No difference
• Length of surgery
• Screw cutout
• Union
• Infection
• Pain
• Mortality
• Return to residence
• Transfusion
•  
• Difference
• Intraoperative femur fracture – More in IM nail group
• Postoperative femur fracture – more in IM nail group
• Reoperation (all reasons) – more in IM nail group

Question 40

40. Regarding a DHS placement. Which of the following is NOT true:
41. Peripheral placement makes no difference
42. Tip apex is D(ap) x D(lat) (Yup, it was X, not plus)
43. Screws placed in the superior aspect of the head are more likely to cut out

Answer 40

ANSWER: B

2013

• Baumgartner M (JBJS 1995) The value of the tip-apex distance in predicting failure of fixation of peri-trochanteric fractures of the hip
• Placement in the centre-centre position with a tip-apex distance of less than or equal to 25 is the safest (zero cut-outs in the study). Anterosuperior and posteroinferior had the highest cut-out rates, but when they controlled for TAD, screw position was not independently associated with screw cut out. TAD was the best predictor of cut out.
• Other factors influencing cutout: Patient age (older), Fracture stability (unstable), Quality of reduction (poor quality), and 150 degree DHS.
•  
• Hsueh, K.-K. (IO 2009) Risk factors in cutout of sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients. 
• TAD is most important predictor of cut out.
• Screw position (middle middle or inferior middle had lowest cut out)
• fracture pattern (unstable = increased cut out)
• Fracture reduction (bad reduction = increased cut out)
• patient age (increasing age = increased cut out)
•  
• De Bruijn (JBJS 2012). Reliability of Predictors for Screw Cutout in Intertrochanteric Hip Fractures. 
• Tip apex distance found to be the biggest risk factor for cut out (greater than 25mm)
• Unstable fractures had higher risk
• Anterior inferior and central inferior screw positions had lower cut out.

Question 41

41. Tip-to-Apex distance when using a DHS. Which of the following does not lead to a poor result.
42. Using a 150° instead of a 135° blade plate
43. Gender
44. Using this device in an unstable fracture pattern
45. TAD of 35cm

Answer 41

ANSWER: B

2012

Difficult depending on exact answers

• Baumgartner M (JBJS 1995) The value of the tip-apex distance in predicting failure of fixation of peri-trochanteric fractures of the hip
• Hsueh, K.-K. (IO 2009) Risk factors in cutout of sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients. 
• De Bruijn (JBJS 2012). Reliability of Predictors for Screw Cutout in Intertrochanteric Hip Fractures. 
• Pervez H (Injury 2004) Prediction of fixation failure after sliding hip screw fixation
• Associated with Cutout:
• Tip Apex Distance > 25mm
• Unstable fracture pattern
• Poor reduction
• 150 degree DHS
• Superior and anterior/posterior screw placements
• Older patient age (not associated in some)
• NOT Associated with:
• Gender
• BMI
• ASA Class

Question 42

42. 65 yr F , non-pathological, with transverse fracture at the level of the Lesser Trochanteric. How do you treat it?
43. Blade plate
44. Centromedullary nail (interlocking)
45. Cephalomedullary nail (recon)
46. Retrograde nail

Answer 42

ANSWER: C

2011, 2012

• Inter-locking nail is designed to bring the nail medial in the canal as second screw is placed
• May medialize the femur in a transverse pattern
• Bhandari (JOT 2009) Intramedullary vs extramedullary fixation for subtrochnateric femur fractures
• Blade plate and DCS most quoted extramedullary devices
• Grade B evidence that operative time is reduced and fixation failure is reduced with intra-medullary implants for subtrochanteric fractures
• Cochrane Review:
• Transverse and reverse obliquity fractures did better with IM nail as compared to extramedullary devices

Question 43

43. A 25yo male is involved in a MVC. You are shown an x-ray of a basicervical fracture, fairly horizontal pattern, displaced. GT is intact. What is the optimal treatment?
44. Cephalomedullary nail
45. Sliding hip screw with anti-rotation screw
46. Short threaded screws with 1 superior and 2 inferior
47. Short threaded screws with 2 superior and 1 inferior

Answer 43

ANSWER: D

2014

• Optimal Internal Fixation for Femoral Neck Fractures: Multiple Screws or Sliding Hip Screws? Bhandari, et al. J Orthop Trauma. 2009
• A meta-analysis by Parker and Blundell evaluated 28 trials (N = 5547 patients) and reported no advantage of any internal fixation technique over any other.
• The pooled estimate for displaced fractures revealed a trend in favor of the sliding hip screw in reducing the need for revision surgery.
• In summary, both indirect and direct comparisons suggest a possible benefit for a sliding hip screw over multiple cancellous screws in reducing the need for revision surgery
• JBJS 2008 –> Fixation with multiple cancellous lag screws is recommended for most femoral neck fractures. Three cancellous lag screws placed parallel to one another and perpendicular to the fracture line provide optimal compression at the fracture. Pauwels Type-I and II fracture variants are most amenable to this type of fixation. These three cancellous lag screws should be in an inverted triangle configuration (Fig. 4-B) because there is less risk of a subtrochanteric fracture with this apex-distal screw orientation than there is with the apex-proximal orientation. The most inferior screw should rest on the medial aspect of the distal femoral neck fragment to resist varus displacement. A fourth screw does not increase mechanical strength enough in most femoral neck fractures to justify its use, but if there is posterior comminution, a fourth screw is recommended. Two cannulated screws are inadequate for fixation of a displaced femoral neck fracture.
• Basicervical femoral neck fractures with comminution are a variant in which a sliding hip screw provides more stable fixation than three cancellous screws. Blair et al. recommended sliding-hip-screw fixation on the basis of their biomechanical cadaver study in which they evaluated three different fixation techniques for the treatment of a basicervical femoral neck fracture. They found that a derotational screw located superior to the sliding hip screw does not enhance fixation. However, we still use a derotational screw to prevent rotation of the femoral head during insertion of the compression screw.
• Others use a sliding hip screw for more vertically oriented femoral neck fractures (Pauwels Type III). Baitner et al. found that fixation with this device resulted in less inferior femoral head displacement, less shearing displacement, and a greater load to failure when compared with the findings following fixation with three cannulated cancellous screws44. Bonnaire and Weber 45 evaluated four different methods of fixation of Pauwels Type-III femoral neck fractures in cadavers; these methods included a sliding hip screw with a derotational screw, a sliding hip screw without a derotational screw, cancellous screws, and a 130_-angled blade-plate. They concluded that the sliding hip screw with the derotational screw is the best implant for this fracture pattern.

Question 44

44. Regarding a hip fracture patient on Plavix (clopidogrel), which of the following is true?
45. The effects can be reversed with vitamin K and plasma transfusion
46. Multiple transfusions will be required if the patient goes to the OR within 48 hours
47. There will be no major complications if the patient is taken to the OR before 24-48 hours
48. It is safer to wait 3-5 days before operative intervention to avoid perioperative complications

Answer 44

ANSWER - C

2014

• Doleman B (Injury 2015) Is early hip fracture surgery safe for patients on clopidogrel? Systematic review, meta-analysis and meta-regression
• For patients taking clopidogrel undergoing early surgery, there was no associated increase in overall mortality or 30-day mortality. However, there was an associated increase in blood transfusion. There was an associated decreased length of stay in the early surgery versus delayed surgery group.
• The effect of clopidogrel and aspirin on blood loss in hip fracture surgery. Chechik et. al. Injury. 2011
• The use of anti-platelet drugs was the strongest predictor for increased blood loss, followed by early surgery and prolonged surgery.
• Our study demonstrated that perioperative blood loss amongst patients, who were chronically treated with clopidogrel and not taken off the medication, was, indeed, greater than for matched patients, who were not taking anti-platelets, and even further increased amongst patients on combined clopidogrel and aspirin.
• Nydick et al.
• retrospectively compared 29 patients on clopidogrel (28 of whom had been operated within 5 days of admission) to a matched 32- patient control group, and found no serious complications or increased transfusion requirements with early surgical fracture fixation.  
• The Effects of Clopidogrel (Plavix) and Other Oral Anticoagulants on Early Hip Fracture Surgery. Collinge et. al. JOT. 2012
• Clopidogrel is different from other anticoagulants because no physiologic method of reversing the antithrombotic effect of this medication is known. Platelet transfusions have been attempted but have not been effective in reversing the effect of clopidogrel. The effects of clopidogrel on platelet aggregation are thought only to be completely reversed within 7 days of the last dose by production of new platelets.
• No significant increase in bleeding parameters or complications was observed in patients taking clopidogrel compared with those not on clopidogrel.
• The present investigation suggests that patients on clopidogrel who underwent early open operative treatment of a hip fracture did not have increased clinically significant risk for blood loss, transfusion requirement or perioperative complications compared with those patients not taking the medication.

Question 45

45. When performing a valgus intertrochanteric osteotomy and bone grafting for a nonunion of a femoral neck fracture in a 40 year old, all of the following are true, except?
46. Need to medialize the shaft as much as possible
47. It is best to leave at least 2 cm between entry point of blade plate and osteotomy
48. Aiming for angulation of fracture line to horizontal of 20-30 degrees
49. There is a high union rate but a limp persists

Answer 45

ANSWER: A

2012

JAAOS 2005 - Salvage of Failed Treatment of Hip Fractures

• Valgus intertrochanteric osteotomy converts shear forces to compressive forces
• The non-union should be transitioned to about 20-30o from horizontal
• The osteotomy is performed, taking care to leave at least 2cm between inferior aspect of the blade tract and the osteotomy
• Mathews (JBJS Br 1986)
• 15 patients –> all had union but persistent limp is common due to loss of offset and abductor moment

Question 46

46. What is a described complication of antegrade nailing a proximal femur fracture using a lateral entry nail
47. varus malunion
48. valgus malunion
49. increased disruption of femoral head blood supply
50. Increased hoop stresses and fracture

Answer 46

ANSWER: A

2015

• Millers = varus and apex anterior angulation with IM nail
• Management of Subtrochanteric Proximal Femur Fractures: A Review of Recent Literature 2018
• http://downloads.hindawi.com/journals/aorth/2018/1326701.pdf
• The second starting point is the trochanteric start point. Advantages include protecting more of the sof tissue structures around the hip and easier placement [19]. However there is a greater concern for varus malreduction and vast changes in the “ideal” start point based on patient anatomy

Question 47

47. Transverse femur fracture treated with a femoral nail that is statically locked. It will heal by:
48. Primary bone healing because it is absolute stability
49. Secondary bone healing because it is absolute stability
50. Primary bone healing because it is relative stability
51. Secondary bone healing because it is relative stability

Answer 47

ANSWER: D

2012

AO Manual

Question 48

48. Open femur fracture with 3cm bone loss. I+D and ex-fix are done. What is the next step?
49. Convert to IM nail and shorten
50. IM nail then wait 16-20 weeks and bone graft if no union
51. Bone graft 2 weeks later when you IM nail
52. Bone transport at 8 weeks once soft tissue envelope is optimized

Answer 48

ANSWER: B

2014

• JAAOS 2015 - Management of Segmental Bone Defects:
• Autologous bone grafting an option up to 5cm
• Bone transport a good option for infected defects, but usually only used in longer defects
• Acute shortening an option up to 3-5cm (vascular kinking after this), but more common in upper extremity
• • UK study – JBJS The treatment of open femoral fractures with bone loss 2010
• A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing.
•  

Question 49

49. You are shown an x-ray of a periprosthetic oblique distal femur fracture just above a well fixed TKA. Bone quality is good. The patient is otherwise healthy. What is the best treatment?
50. Cast
51. Revision with long stems
52. ORIF
53. Distal femur-replacing prosthesis and revision of the tibial component

Answer 49

ANSWER: C

2014

Stable implant + can tolerate OR –> ORIF

Question 50

50. For a 95 degree distal femoral locking plate, where should the first guidewire go?
51. Parallel to the joint line, proximal to Blumensaat’s line
52. Parallel to the joint line, distal to Blumensaat’s line
53. Perpendicular to the femoral shaft, proximal to Blumensaat’s line
54. Perpendicular to the femoral shaft, distal to Blumensaat’s line

Answer 50

ANSWER - A

2014

Guide referenced is old 7.3 mm screw plates, but concept is the same with distal femoral locking plates, you want the central screw to be above Blumensaats and advance into the medial femoral condyle.

Question 51

51. A patient presents with a distal pole patella fracture with displacement and comminution. The patient has a large hemarthrosis and extensor mechanism disruption. What is the best treatment option?
52. Complete patellectomy
53. ORIF maintaining all fragments
54. Partial patellectomy with repair to posterior patella
55. Inferior pole patellectomy with repair to anterior patella

Answer 51

ANSWER: B (changed from D - depends on amount of comminution)

• Vaselko M (JBJS 2005) Inferior Patellar Pole Avulsion Fractures: Osteosynthesis Compared with Pole Resection
• Retrospective review of 14 vs 11 fractures
• Average patellofemoral score better in internal fixation group than resection with patellar ligament repair (94 vs 81)
• Normal patellar height in 10/11 ORIFs, 3/13 tendon advancements
•  
• JAAOS 2011 - Patellar Fractures in Adults
• Partial Patellectomy and Inferior Pole Fracture
• Saltzman et al, Marder et all found that reattachment of the patellar tendon to the anterior surface of the remaining patella - which most resembles the native anatomy-substantially minimized contact stresses
• Saltzman –> 40 patients with partial patellectomy
• 78% good or excellent, quads strength 85%
• Bostman –> poor outcomes if >40% of patella removed
• Marder –> increased PF contact forces with patellectomy 

Question 52

52. You are given a coronal CT slice mid joint of a Schatzker II split depression lateral plateau fracture. The arrow points to the impacted joint depression fragment. What is the best way to reduce this fragment at the time of the operation?
53. Ligamentotaxis with X-Fix
54. Direct visualization and manipulation of fragment
55. Indirect reduction using raft screws
56. Indirect reduction using k-wires

Answer 52

ANSWER: B

2012

Buckley - Sub-meniscal arthrotomy vs fluoroscopy

• A sub-meniscal arthrotomy improves the medium-term patient outcome of tibial plateau fractures 2018
• ORIF with a sub-meniscal arthrotomy provides better quality reductions and better medium-term results as compared to CRIF for tibial plateau fractures. This may provide more long-term benefit from osteoarthritic symptoms in this patient group

Question 53

53. 45yo male sustains a bicondylar tibial plateau fracture. What is the most important part of management?

articular reduction

early ROM

use of a locking plate

Alignment

Answer 53

ANSWER: D

2015

ANSWER: D

2015

• Marsh JL (JBJS 2002) Articular Fractures: Does an Anatomic Reduction Really Change the Result
• “There is little rationale, one the bases of the evidence available in the literature, for the assertion that accurate articular reduction of tibial plateau fractures, particularly to tolerances of <2mm, is critical to the attainment of a good clinical outcome”
• JAAOS 2009 - Locking plates for Extremity Fractures
• There were no statistically significant differences between locking plates and non-locking plates for patient-oriented outcomes, adverse events or complications
• Scott CE (BJJ 2015) TKA following tibial plateau fracture: a matched cohort study
• Patients with instability or non-union needed TKA earlier (14 months) than those with intra-articular malunion (50 months)
• • Open Reduction and Internal Fixation Compared with Circular Fixator Application for Bicondylar Tibial Plateau Fractures: Results of a Multicenter, Prospective, Randomized Clinical Trial
• The Canadian Orthopaedic Trauma Society
• The Journal of Bone & Joint Surgery, 2006-12, Vol.88 (12), p.2613-2623
• All three are critical, especially in the young patient, but there is some evidence that limb alignment and knee stability are most crucial, whereas non-anatomical reduction is less important regarding functional results.

Question 54

54. Regarding fixation of a tibial plateau fracture, which is true?
    a. Locking plates have better outcomes and less complications than non-locking plates
    b. Locking plates have better outcomes and more complications than non-locking plates
    c. Locking plates have equal outcomes and less complications than non-locking plates
    d. Locking plates have equal outcomes and equal complications as non-locking plates

Answer 54

ANSWER: D

2011, 2015

• JAAOS 2009 - Locking plates for Extremity Fractures
• There were no statistically significant differences between locking plates and non-locking plates for patient-oriented outcomes, adverse events or complications
• Jiang R,(Knee 2008) A comparative study of Less Invasive Stabilization System (LISS) fixation and two-incision double plating for the treatment of bicondylar tibial plateau fractures
• Unilateral LISS plate vs double plating
• No difference in outcomes, complications in either group
• Higher rates of post-operative malalignment and trend towards symptomatic hardware with locking plates

Question 55

55. Proximal tibia fracture. Where do you place your blocking screws to prevent deformity?
56. Anterior and medial
57. Anterior and lateral
58. Posterior and medial
59. Posterior and lateral

Answer 55

ANSWER: D

2016

on the CONCAVE part of the deformity - prox tib = apex anterior (procurvatum) and valgus

Question 56

56. Proximal tibia fracture. What has the lowest rate of ligament injury
57. Bicondylar
58. Lateral joint depression
59. Lateral joint split
60. Lateral joint split depression

Answer 56

ANSWER: B

2013

• Bennett WF, Browner B. Tibial plateau fractures: a study of associated soft tissue injuries. J Orthop Trauma. 1994;8:183–188.
• 56% of fractures had soft tissue injuries
• Schatzker type IV and II associated with highest frequency of soft tissue injuries
• MCL most commonly associated with Schatzker II
• Menisci with Schatzker IV
•  
• •  
• Gardner MJ (JOT 2005) Incidence of Soft Tissue Injury in Operative Tibial Plateau Fractures: A MRI Imaging Analysis of 103 Patients
• 77% complete tear or avulsion of one or more cruciate or collateral ligaments
• 91% lateral meniscal pathology
• 44% medial meniscal pathology
• Tibial Plateau Types
• 60% Schatzker II (most common) - no Schatzker III fractures in study
• Shepherd L (JOT 2002) Prevalence of soft tissue injuries in non-operative tibial plateau fractures as determined by MRI
• 90% of undisplaced fractures treated non-operatively had significant soft tissue injuries
• 80% meniscal tears, 40% complete ligament disruptions (primarily MCL)
• Associated conditions
• meniscal tears
• lateral meniscal tear
• more common than medial
• associated with Schatzker II fracture pattern
• associated with >10mm articular depression
• medial meniscal tear
• most commonly associated with Schatzker IV fracture
• ACL injuries
• more common in type IV and VI fractures (25%)

Question 57

57. In a grade IIIA open tibia fracture, which of the following is true?
    a. Delayed closure results in decreased wound complications
    b. Delayed closure results in increased wound complications
    c. Delayed closure results in decreased infection
    d. Delayed closure results in increased infection

Answer 57

ANSWER: D

2013, 2015

• (JBJS 2014) Delayed Wound Closure Increases Deep Infection Rates Associated with Lower-Grade Open Fracture
• Matched control
• Primary Closure - 3% infection
• Delayed Closure - 17% infection
• Bhattacharyya (Plast Reconstr Surg 2008)
• 12.5% infection for <7 days, 57% > 7 days

Question 58

58. Obese patient with large open tibia fracture. Severe diabetes for 20 years. Heavy smoker. Which factor reduces the risk of infection the most?
59. Poor diabetic sugar control
60. Smoking history
61. Administering antibiotics in < 1 hour
62. Early operative debridement

Answer 58

ANSWER: C

2016

JAAOS 2010 - Open Tibial Fracture

• Early antibiotics shown to reduce infection (<3 hours)
• Smoking and diabetes are risk factors for infection
• Quality of debridement is important for infection risk, but no evidence for timing of debridement

Question 59

59. “Type II” open tibia treated with bmp 2 at definitive procedure. What is NOT true? (These are the answers we were given; absolutely they meant type II open)
60. Lower rate of subsequent bone grafting procedures
61. Lower rate of subsequent soft tissue procedures
62. Higher infection
63. Lower infection

Answer 59

ANSWER: C

2012, 2013

• Govender S (JBJS 2002) Recombinant human BMP-2 for treatment of open tibial fracture
• 94% follow up at 2 years (unreamed nail)
• BMP-2 group:
• 44% reduction in risk of failure
• secondary intervention because of delayed union
• Fewer intervention
• Faster fracture healing
• Fewer hardware failures
• Fewer infections (type IIIA/B injuries)
• Faster wound healing
• Swiontkowski MF (JBJS 2006) Recombinant Human BMP 2 in Open tibial fractures
• Sub-analysis of 2 RCT
• Type IIA/B fractures
• Fewer bone grafting procedures
• Fewer secondary procedures
• Lower rate of infection
• Reamed IM nailing
• No differences between groups
• Aro (JBJS 2011) Recombinant Human BMP2 (reamed nail)
• No difference in healing time with reamed nails (there is a trend though)
• Fewer “most invasive” procedures
• No difference in infection
• Garrison KR (Cochrane Review 2010) BMP for fracture healing in adults
• Fewer secondary procedures with BMP
• Adverse Events:
• Infection
• Hardware failure
• Pain
• Donor site morbidity
• HO
• Immunogenic reaction
• “Considerable industry involvement in current available evidence”

Question 60

60. Tibial external fixator is placed. In converting to definitive treatment all of the following are acceptable EXCEPT: *REPEAT
61. 2 weeks convert to IM nail
62. 2 weeks convert to plate
63. 5 weeks, curettage pin sites, IM nail
64. 5 weeks, curettage pin sites, delayed IM nail

Answer 60

ANSWER: C

2016

Bhandari M (JOT 2005) IM Nailing following external fixation in femoral and tibial shaft fractures

• “Increased rate of infection with external fixation > 28 days, requires pin holiday to decrease risk”
• Pin holiday of > 14 days has increased infection risk vs < 14 days

Question 61

61. All are true regarding fixation of distal tibial fracture, EXCEPT?
62. Fixation of fibula is associated with higher nonunion rate
63. Open fractures have higher rates of malunion and nonunion
64. Plate fixation is associated with higher rate of malunion
65. No difference in union rates between plate and IM nail fixation

Answer 61

ANSWER - C

2014, 2015

• Radiographic and Clinical Comparisons of Distal Tibia Shaft Fractures (4 to 11 cm Proximal to the Plafond): Plating Versus Intramedullary Nailing. Vallier, Le and Bedi. JOT. 2008
• Deficient healing was not related to age, fracture pattern, or the presence of a fibula fracture.
• Nonunion was more common in patients who had concurrent fixation of their fibula fracture (14% versus 2.6%, P = 0.04) regardless treating the tibia with a plate or a nail….
• A higher rate of infection occurred after open fracture (P = 0.03)…. Malunions occurred in more open fractures (13 of 34, 38%) than closed fractures (P = 0.006).
• There was no association of malunion with the fracture pattern, presence of a fibula fracture, or fixation of the fibula
• Malunions were more common after treatment with a nail (n = 22, 29%) versus a plate (n = 2, 5.4%; P = 0.003). All of these fractures were initially stabilized in a malaligned position.

Question 62

62. A patient suffers an open pilon fracture. You are shown an x-ray with a huge piece of the medial malleolus and distal articular surface. They tell you it is devoid of soft tissue attachment. How do you manage this patient?
63. Autoclave and reimplant
64. Send to the bone bank for later reimplantation
65. Discard
66. Clean thoroughly and reimplant

Answer 62

ANSWER - D

 2014

• Extruded Osteoarticular Distal Tibia: Success at 18-Month Follow-Up With Reimplantation. Meininger et. al. JOT. 2010 
• In the management of open fractures, validated algorithms are the standard of care, although there are few guidelines for the treatment of extruded bone segments. Kumar described thermal decontamination with success, although steam autoclave results in denaturation of bone. Van Winkle, on the other hand, advocated chlorhexidene lavage and antibiotic emersion as a 100% effective method of clearing microbial contamination. Case reports of total talar extrusion have succeeded with reimplantation through various techniques. Assal et al reported no infection with use of pulsatile normal saline lavage and emergent reimplantation. Smith reported on 27 cases of talar extrusion, all with use of Bacitracin baths and reimplantation. They averaged 6.7 hours before operative debridement and had one infection.
•  
• Reimplantation of an Extruded Osteoarticular Segment of the Distal Tibia in a 14-Year-Old Girl. Case Report and Review of the Literature. Farrelly et. al. JOT. 2012
• In most of the case reports available in the literature, some form of heat, such as boiling or autoclave, was used to achieve sterilization. This was not considered as an attractive option in the case presented here because of the desire to preserve chondrocytes at the articular surface.

Question 63

63. Ankle ORIF with medial malleolus fixed and fibula plated short. 2nd XR with syndesmosis screw removed and broken screw. Syndesmosis not wide at all on 2nd. What is the primary cause of the lateral talar shift?
64. Deltoid rupture
65. Fibula short
66. Syndesmosis screw removed too early and unstable
67. Two R5s don’t make an R10 and they still can’t fix an ankle

Answer 63

ANSWER: B

2013

JAAOS 2009 - Distal Fibula Malunion

“Distal fibular malunion is associated with talar instability with or without syndesmotic injury”

Question 64

64. 30 yr dude with posterior mall and lateral mall fracture. No medial mall facture. Talus 40% subluxated posterior. Lateral Mall is oblique at the joint line. What provides the most stable fixation?
65. One lag screw and lateral plate
66. Two lag screws
67. One lag screw and posterior plate
68. Tension band Wire

Answer 64

ANSWER: C

2012

• Presumably referring to the fibula only - lateral vs posterior plating
• Ostrum RF (JOT 1996) Posterior Plating of Displaced Weber B Fibular Fractures
• Benefits of posterior plating:
• Bicortical screws –> better fixation
• Stronger and stiffer construct
• Lag screw stronger as it is done through the plate (acts as a stronger cortex)
• Schaffer JJ (JBJS 1987) The Anti-glide plate for distal fibular fixation. A biomechanical comparison with fixation with a lateral plate
• Posterolateral anti-glide plates compared to lateral plates for short oblique distal fibula fractures
• Posterior anti-glide plate biomechanically superior to lateral plating in terms of torque
• Minihane KP (JOT 2006) Comparison of lateral locking plate and anti-glide plate for fixation of distal fibular fractures in osteoporotic bone: a biomechanical study
• Posterior anti-glide plating was superior in terms of torque to failure and construct stiffness

Question 65

65. What is true about posterior malleolus fractures:
66. 5% of spiral tibia fractures extend intra-articularly
67. Posterior malleolus fixation provides more stability than syndesmosis fixation
68. 10% involvement results in posterior subluxation
69. Often starts posterolaterally and extends into the medial malleolus

Answer 65

ANSWER: B

2015

• A - spiral tibia fractures 9-40% posterior mal fractures
• D - posterior mal fracture is a tension fracture (starts PM)
• Fixation of Posterior Malleolar Fractures Provides Greater Syndesmotic Stability. Gardner et. al. Clinical Orthopaedics and Related Research. 2006
• PER Stage 4 ankle fracture with a deltoid ligament tear and posterior malleolus fracture
• After fracture creation, five specimens were assigned randomly to receive posterior malleolar fixation…The remaining five specimens received trans-syndesmotic fixation.
• Each specimen first was tested intact to determine its baseline stability for later use as its own internal control.
• Specimens were tested again after fixation to determine the effect of fracture creation and fixation on syndesmotic stability.
• Posterior malleolar fixation provided better rotational stability than syndesmosis fixation.
• Specimens with posterior malleolar fixation had a decrease in stiffness of 30% compared with the intact stiffness of each specimen
• Patients who had traditional syndesmosis stabilization had a 60% (SD, 20%) decrease in stiffness compared with intact rotation (40% of intact stiffness was restored).  
• Kempegowda (JOT 2016) Posterior Malleolar Fractures Associated with Tibial Shaft Fractures and Sequence of Fixation
• 1113 tibia fractures
• 9% had concomitant posterior malleolus fractures
• Boraiah S (CORR 2008) High association of posterior malleolus fracture with spiral distal tibial fractures
• 62 patients with distal third tibial fractures
• 39% posterior malleolus fracture
• CT ankle of all patients: diagnosis 33% –> 48%
• Haraguchi JBJS 2005
• “most investigators have recommended internal fixation for posterior fragments comprising >25-30% of the tibial plafond”

Question 66

66. When fixing a syndesmotic injury with tibiofibular screws versus with an ORIF of the posterior malleolus, which of the following is true?
67. Stiffer syndesmosis with posterior malleolar fixation
68. External rotation of fibula can occur with posterior malleolar fixation
69. They both have the same rates of sural nerve injury
70. They both have the same rates of syndesmotic malreduction

Answer 66

ANSWER - A

2014

• Fixation of Posterior Malleolar Fractures Provides Greater Syndesmotic Stability. Gardner et. al. Clinical Orthopaedics and Related Research. 2006
• PER Stage 4 ankle fracture with a deltoid ligament tear and posterior malleolus fracture
• After fracture creation, five specimens were assigned randomly to receive posterior malleolar fixation…The remaining five specimens received trans-syndesmotic fixation.
• Each specimen first was tested intact to determine its baseline stability for later use as its own internal control.
• Specimens were tested again after fixation to determine the effect of fracture creation and fixation on syndesmotic stability.
• Posterior malleolar fixation provided better rotational stability than syndesmosis fixation.
• Specimens with posterior malleolar fixation had a decrease in stiffness of 30% compared with the intact stiffness of each specimen
• Patients who had traditional syndesmosis stabilization had a 60% (SD, 20%) decrease in stiffness compared with intact rotation (40% of intact stiffness was restored).  
• Injuries to the Ankle Syndesmosis. Van Heest and Lafferty. JBJS. 2014
• Recent evidence indicates that fixation of the posterior malleolus with an intact posterior inferior tibiofibular ligament adequately stabilizes the syndesmosis.

Question 67

67. 5 indications for ORIF of midshaft humerus (2012)

Answer 67

• JAAOS 2012 - Management of Humeral Shaft Fractures
• Open Fractures
• Failure of conservative management
• Floating Elbow
• Poly-trauma/early mobilization
• Brachial plexus injury/flail extremity
• Pathologic Fracture
• Vascular Injury
• High energy GSW

Question 68

68. Components of the terrible triad (2012)

Answer 68

• Elbow Dislocation
• Coronoid Fracture
• Radial Head Fracture

Question 69

69. Clavicle fracture; what is NOT indication to fix
70. Grade III open
71. Floating Shoulder
72. 5 mm displaced lateral clavicle
73. 1.5 cm shortening

Answer 69

ANSWER: C

2009, 2012, 2013

JAAOS 2007 - Acute Midshaft Clavicular Fractures

• Indications for surgical management:
• Open fractures
• Skin or neurovascular compromise
• Relative Indications:
• Poly-traumatized patients
• Floating shoulder
• Painful malunion/nonunion
• High-energy closed fractures with >15-20mm shortening
• Completely displaced
• comminuted

Question 70

70. What has the highest chance of a clavicle non union
71. Proximal 1/3 clavicle
72. Middle 1/3 clavicle
73. Distal 1/3 clavicle lateral to CC ligaments
74. Distal 1/3 medial to CC ligaments

Answer 70

ANSWER: D

2013

COTS 2007 –> 16% non-union with non-operative treatment

McKee (JBJS 2012) Meta-analysis –> 23% non-union OR symptomatic malunion

JAAOS 2010 - Distal Clavicle Fracture

• Type II fractures have non-union rates of 28-75%
• Bahk MS (JBJS 2009) AC and SC injuries and Clavicular, Glenoid and Scapular Fractures
• “there is general agreement that lateral clavicular fractures, which account for 10-15% of all clavicular fractures, with complete displacement are associated with a higher prevalence of non-unions than are midshaft clavicular fractures”

Question 71

71. What is a risk factor for mid-shaft clavicle non-union:
72. Scapula fracture
73. Male
74. Younger age
75. Degree of displacement

Answer 71

ANSWER: D

2014, 2015

JAAOS 2007 - Acute Midshaft Clavicular Fractures

• Risk Factors for Non-union:
• Women
• Fragment Displacement >1.5-2cm
• Comminution
• Advancing age (>60 years)
• Severity of Initial Trauma
• Soft tissue interposition
• Robinson (JBJS 2004)
• Risk Factors:
• Female gender
• Lack of cortical apposition
• Comminution of fracture fragments
• Advancing age

Question 72

72. When doing a hemiarthroplasty for a 4 part proximal humerus fracture, what is an important technical consideration:
73. Head should be 0.5-1.5cm above GT
74. Uncemented prosthesis should be used
75. Prosthesis should be 3.5cm above the pec insertion
76. Prosthesis should be in 50deg of retroversion

Answer 72

ANSWER: A

2013, 2015 with slight variation

JAAOS 2012 - Hemi-arthroplasty for proximal humerus fracture

• 30o retroversion ideal
• Too much anteversion = anterior dislocation
• Too much retroversion = posterior dislocation
• Humeral Head Height:
• 5.6cm off top of pectoralis major upper border
• GT –> 3-5mm below top of humerus, 10mm below articular surface
• 6mm from superior edge of GT and superior edge of humeral head

Question 73

73. What is the most common complication following use of locked plates in proximal humerus ORIF?
74. Delayed union
75. Infection
76. Neurologic complication
77. Intra-articular screw penetration
78. Prominent hardware

Answer 73

ANSWER: D

2014

• Sudkamp (JBJS 2009) ORIF of Proximal Humeral Fractures with Use of the Locking Proximal Humerus Plate
• 14% had primary screw penetration unrecognized at surgery
• Secondary screw penetration in 7% because of loss of reduction, 4% after humeral head necrosis
• Maier (JBJS 2014) Proximal Humeral Fracture Treatment in Adults
• 14% intra-operative screw perforation of the humeral head…as the most common complication
• Solberg BD (JOT 2009) Locked plating of 3- and 4-part proximal humerus fractures in older patients

Question 74

74. What is not an indication to operate on a humerus fracture
75. Open
76. Vascular injury
77. Polytrauma
78. Radial nerve injury

Answer 74

ANSWER: D

2013, 2015

• OKU Indications for Surgery:
• Multiple Injuries:
• Bilateral humerus fractures
• Lower extremity fractures that limit weight bearing
• Floating elbow
• Concomitant head injury
• Nursing care is facilitated by fixation
• Open fractures
• Burns or soft tissue injury precluding bracing
• Vascular injury
• Brachial plexus injury
• No muscular compression of fracture to provide reduction therefore non-operative treatment in splint won’t work
• Displaced pathologic fracture
• Radial nerve dysfunction following closed reduction
• Fracture characteristics and patterns:
• Significant distraction at fracture site
• Long proximal spiral fracture
• Joint extension distally
• Inability to maintain an adequate reduction with bracing
• Body habitus that precludes bracing
• Ring (JHS 2004) Radial nerve palsy associated with high energy humeral shaft fractures
• 6/18 explored fractures had transection
• However, none of the repaired nerves recovered at final follow up
• Bishop (JHS 2009) Management of radial nerve palsy associated with humeral shaft fracture
• Early surgical intervention doesn’t improve outcomes
• Except:
• Open fracture
• Concomitant forearm injury/floating elbow
• <40% recovery of nerve

Question 75

75. What is true regarding a humeral nail vs. ORIF of a humerus fracture?
76. Humeral nail associated with more shoulder pain
77. ORIF has more malunion
78. Radial nerve palsy is contraindication to humeral nail
79. Varus angulation of 15 degrees is poorly tolerated

Answer 75

ANSWER: A

JAAOS 2012 - Management of Humeral Shaft Fractures

• Klenerman found that deformities, including those with <20o angulation in the saggital plane, those with <30o of varus or valgus angulation or limb shortening <2-3cm are generally considered acceptable
• “IM nailing has been associated with shoulder pain and a high number of secondary procedures”

Question 76

76. Which of the following is true regarding humeral shaft fractures?
77. Approximately 5% nonunion rate
78. 15 degrees varus is poorly tolerated
79. Radial nerve palsy is a contraindication to conservative management
80. 2cm of shortening is a contraindication to non-operative treatment

Answer 76

ANSWER: A

2014

• Management of Humeral Shaft Fractures. Carroll, et al. JAAOS. 2012.
• “A certain amount of malalignment is well tolerated by patients. Klenerman found that deformities, including those with <20° degrees of angulation in the sagittal plane, those with <30° of varus or valgus angulation, or limb shortening <2 to 3 cm, are generally considered acceptable and compatible with good function.”
• “Rates of union achieved with nonsurgical management vary, but rates >90% have been reported.”
• “Bishop and Ring found that early observation was appropriate in patients with radial nerve palsy given that early surgical intervention did not appear to improve outcomes except in special circumstances, including open humeral fracture, concomitant forearm injury, or floating elbow.” 
• Treatment of Diaphyseal Fractures of the Humerus Using a Functional Brace. Rutgers and Ring. J Orthop Trauma. 2006. 
• Solid union was achieved in 44 of 49 patients (90%) (Fig. 2). Among the patients achieving union, the average follow-up was 14 months, with a range from 2 to 50 months.
• An angular deformity (measured on anteroposterior and lateral radiographs) of more than 20 degrees of varus was present in three patients (25, 30, and 35 degrees). Angular deformity did not seem to cause functional limitations in any patient.
•  JAAOS - Proximal Humeral and Humerus Shaft Nonunions
• Papasoulis E (Injury 2010) - overall nonunion rate 5.5%
• Ekholm (JOT 2006), Koch PP (JSES 2002), Rugerts (JOT 2006), Toivanen (Int Orthop 2005) –> nonunion rate of 10-23%
• Sarmiento (JBJS 2000) - 2% nonunion with functional bracing
• Healy (CORR 1987):
• Transverse fractures 47% nonunion, short oblique 27%
• Proximal diaphyseal lesions have higher risk of nonunion due to muscular forces
• Parsarn MI (Injury 2004), Rutgers (JOT 2006), Tovianen (Int Orthop 2005), Ring D (J Trauma 2007)
•  

Question 77

77. What is true about a comminuted distal humerus fracture in an elderly patient?
78. TEA has improved outcome over ORIF at 1 year
79. Patient functional outcomes for TEA are better at 1 year
80. Re-operation rates for ORIF are significantly higher at 1 yr
81. It is “almost impossible” to do a quality ORIF with poor bone

Answer 77

ANSWER: B

Repeat 2012

• McKee (JSES 2009) RCT of TEA vs ORIF for elderly patients with intra-articular distal humerus fractures
• Improved functional outcomes as measured by DASH and MEPS in TEA (at early time points, equal later)
• Decreased OR time in TEA
• No difference in re-operation rate
• No difference in ROM (trend towards TEA)
• No difference in complications

Question 78

78. Given AP x-ray of an extra-articular supracondylar elbow fracture. 65yo lady. Best treatment?
79. Olecranon osteotomy with orthogonal plating
80. Extra-articular parallel plating
81. Early ROM
82. TEA

Answer 78

ANSWER: B

2015

Rationale - don’t need olecranon osteotomy as it is not intra-articular, TEA not required for same reason

Fix it to allow ROM

Question 79

79. Shown a lateral x-ray of the elbow with a “double bubble” sign (ie fracture of the capitellum and trochlea).

Which of the following not is true?

a. It should be approached from anterior through the antecubital fossa
b. The fracture involves the capitellum
c. You must see the trochlea when reducing this fracture
d. A medial incision may be required

Answer 79

ANSWER: A

2016, 2012

• Answer: A False: lateral approach is used
• B: True and the trochleaàcalled double-arc sign. the McKee variant to the Morrey classification of capitellar fractures. Other exams say “fracture involves ONLY the capitellum” which would be false.
• C: true for anatomic reduction must see across the joint
• D: true
• McKee MD (JBJS 1996) Coronal Shear Fractures of the Distal End of the Humerus
• Fracture line was observed to extend in the coronal plane across the capitellum to include most of the lateral trochlear ridge and the lateral half of the trochlea”
• “a pathognomic radiographic feature of these injuries is the so-called double-arc sign, best seen on the lateral radiograph of the elbow for the patients in this series”
• JAAOS 2008 - Coronal Plane Partial Articular Fractures of the Distal Humerus

Question 80

80. What is the mechanism of injury in Bado I Monteggia fractures:
81. Forced supination
82. Forced pronation
83. Hyperextension
84. Fall on flexed elbow

Answer 80

ANSWER: B

2011, 2012, 2015

Lots of subtle variations in remembered questions over the years

Rockwood & Green:

Three separate mechanisms of type I lesions have been described:

1. direct trauma to posterior forearm (traditional belief, but not as common)
2. hyperpronation during FOOSH
3. hyperextension, anterior radial head dislocation, then ulna fracture

Bado (CORR 1967) The Monteggia Lesion

Very distinctly states that hyper-pronation is causative factor for type 1 lesions

Question 81

81. Old lady with an olecranon fracture tension banded. Decent reduction. Pins penetrating anterior cortex. Next image on follow-up shows the transverse olecranon piece is proximal to the construct by 5 cm or so. Why did this happen?
82. Took off splint too early
83. You physio to do Passive ROM too early
84. She didn’t stop smoking
85. The wire construct was passed superficial to the triceps

Answer 81

ANSWER: D

2012

JAAOS 2000 - Olecranon Fractures

• “if the bent end of the Kirschner wire is left superficial to the triceps fibres routine post-operative elbow extension may cause the wire to back out”
• “The most important factor in preventing wire migration is ensuring that the bent proximal end of the wire is buried beneath the fibres of the triceps”

Question 82

82. What is true regarding olecranon fractures?
83. If proximal ulna dorsal angulation is decreased, the patient will lose elbow extension
84. It is sometimes acceptable to leave an articular gap or bone loss in comminuted olecranon fractures
85. A tension band wire construct creates more compression across the joint surface compared to a pre-contoured anatomic plate
86. After excision of the olecranon fragment, advancement of the triceps to the anterior bony surface will result in better extension strength

Answer 82

ANSWER: B

2014, 2015

JAAOS 2015 - Management of Fractures of the Proximal Ulna

• Proximal Ulna Dorsal Angulation (PUDA)
• Present in 96% of population
• Averages 6o and is located 5cm distal to the tip of the olecranon
• Increased PUDA = decreased elbow terminal extension
• Comminuted - direct trauma
• Can generate intermediate fragments from the articular surface
• Need to recognize this to restore congruity of the ulnohumeral joint, avoid iatrogenic narrowing of greater sigmoid notch
• If excision required, reattach triceps as dorsally as possible to maintain strength
• 24% of strength is lost when tendon needs to be repaired to bone
• Wilson J (JBJS Br 2011) Biomechanical comparison of inter-fragmentary compression in transverse fractures of the olecranon
• Mean compression with TBW on articular side 77N
• Mean compression for plate was 343N
• “pre-contoured plates provide significantly greater compression than tension bands in the treatment of transverse fractures of the olecranon”
• Ferreira LM (JOT 2011) The effect of triceps repair techniques following olecranon excision on elbow stability and extension strength
• Posterior repair resulted in greater laxity than anterior repair
• Less than 3o, not significant
• Posterior repair resulted in greater extension strength than anterior repair for all resections
• Loss of extension strength of 24% for posterior and 30% for anterior repairs

Question 83

83. Best indication for Ex fix in a BBFA: REPEAT 
84. Grade IIIB
85. Grade IIIC
86. Comminuted
87. Segmental

Answer 83

ANSWER: B

2012

AO Surgery Reference

“In general, external fixation is only used as a temporary treatment in forearm shaft fractures. It is often indicated in the presence of severe soft-tissue injuries and in poly-trauma patients whose definitive treatment may have to be delayed”

Question 84

84. What is the best indication for external fixation in an open diaphyseal radius and ulna fracture?
85. Segmental bone loss
86. Ipsilateral wrist injury
87. Grade IIIC Injury
88. Elbow instability

Answer 84

ANSWER: C

2013

• Really difficult choice –> for a grade IIIC injury in the forearm need disruption of both ulnar and radial arteries therefore would need a big wound….however, in order to get segmental bone loss you also need a big wound
• Some argument that primary shortening is an option in the forearm
• JAAOS - Adult Diaphyseal Forearm Fractures
• The use of external fixation for forearm fractures is indicated in rare cases of severe soft-tissue injury or contamination

Question 85

85. 25 y.o. patient with open BBF fracture sustained in a swamp environment, what is your treatment?
86. Primary closure with Ancef
87. Primary closure with Cloxacillin
88. Delayed closure with Cipro
89. Delayed closure with Doxycycline

Answer 85

ANSWER: C

2012

Rockwood and Green:

The following factors will classify any open injury as grade III, regardless of initial soft tissue injury:

Exposure to soil, fresh water, fecal material, oral flora, gross contamination on inspection

Delay in treatment > 12 hours

Question 86

86. Distal radius; all of the following are risk factors for failure of non-op treatment except
87. Age > 80
88. Dorsal angulation
89. Metaphyseal Comminution
90. Radial shortening

Answer 86

ANSWER: B

2011, 2012 (slight variation)

OKU 9 (p 348)

• Advanced age, shortening and metaphyseal comminution consistently predict radiographic instability
• Dorsal angulation does not
• Mackenney, McQueen (JBJS 2006) Prediction of instability in distal radius fractures
• Patient age, metaphyseal comminution of the fracture and ulnar variance were most consistent predictors of radiographic outcome
• Dorsal angulation not found to be a significant predictor
• Leone J, Bhandari M (AOTS 2004) Predictors of early and late instability following conservative treatment of extra-articular distal radius fractures
• Early instability (1 week) - radial shortening, volar tilt
• Late instability - radial inclination, age, radial shortening, volar tilt
• 33% undisplaced fractures failed (most common in age > 65)

Historically:

• Lafontaine M (Injury 1989) Stability assessment of distal radial fractures
• Dorsal angulation > 20o
• Dorsal comminution
• Ulnar fracture
• Intra-articular fracture
• Age > 80

Question 87

87. Distal radius fracture; what is a risk factor for negative prognosis of the radiocarpal joint AND the DRUJ
88. 2 mm articular displacement
89. “greater than” 5 mm shortening of distal radius
90. incongruity of the sigmoid notch
91. radial inclination of 10

Answer 87

ANSWER: B

• Articular displacement does correlate with radiocarpal radiographic arthritic change but has no effect on DRUJ
• Similarly incongruity of sigmoid notch impacts DRUJ but not radiocarpal joint
• Radial inclination impacts lunate contact forces

Question 88

88. List 4 radiographic features you study when assessing for LisFranc injury? (2010, 2011, 2013, 2016)

Answer 88

JAAOS 2010 - Treatment of LisFranc Joint Injury

• Disruption of the medial column line
• Disruption of line from medial border of 2nd MT to medial border of middle cuneiform
• Diastasis between medial cuneiform and 2nd MT of 2mm greater than contralateral side, or absolute value of 2.7mm
• Fleck sign - avulsion of 2nd MT base or medial cuneiform
• Medial base of 4th MT doesn’t line up with medial cuboid on oblique view
• Lateral step off of 2nd TMT joint due to dorsal dislocation
• Flattening of longitudinal arch on lateral

Question 89

89. List 4 important bony or ligamentous stabilizers of the lisfranc joint.

Where (plantar or dorsal) are the ligaments strongest? (2014)

Answer 89

JAAOS 2010 Treatment of Lisfranc Joint Injury

• Osseous Intrinsic Stability:
• Trapezoidal shape of middle three MT bases and cuneiforms produces a stable arch
• Recessed 2nd MT keystone
• Ligaments:
• Transverse - 2nd through 5th MT bases
• Oblique:
• Dorsal, interosseous and plantar ligaments between medial cuneiforms and 2nd MT
• Interosseous > Plantar > Dorsal

Question 90

90. Describe the position of the foot and x-ray beam to obtain a Canale view (2016)

Answer 90

Canale and Kelly (JBJS 1978)

• Cassette directly under the foot
• Ankle in maximum equinus position
• Foot is pronated 15o
• Tube directed at 75o angle from horizontal

Question 91

91. What is the most important part of your surgical plan in a depressed calcaneal fracture?
    a. Build off the sustentaculum
    b. Elevate joint with graft or substitute
    c. Must use locking plate
    d. Must use two approaches

Answer 91

ANSWER: A

2012, 2015

• Hard to find evidence for - C/D are definitely not correct
• B:
• No evidence for improved outcomes with either joint reduction or graft types

Question 92

92. 35 yo Hodgy playing hockey, checked by B’Oneil and goes plantar flexed in skate into board (he was wearing figure skates). Suffers Hawkins 3, and Cinzia fixes it using only a dorsolateral approach. Goes onto malunion. What is true?
93. Varus most common deformity
94. Best seen on AP foot xray
95. A talar neck osteotomy is contra-indicated
96. This will not affect subtalar motion

Answer 92

ANSWER A

2012

JAAOS 2001 - Talus Fractures

• Varus malunion most common
• Poorly visualized on radiographs, so probably under-diagnosed
• Talar neck osteotomy contra-indicated if severe arthrosis
• Effects subtalar motion

Question 93

93. All of the following are true regarding a Hawkin’s sign following a talar neck fracture, except:
94. It is a radiolucent line underneath the subchondral surface on xray
95. It is useful as evaluation for vascularity of the talus
96. It usually shows up at 3 weeks post injury
97. It is caused by osteopenia from bone resorption.

Answer 93

ANSWER: C

Repeat 2013, 2016

JAAOS – 2001 Talus Fractures

• “The Hawkins sign (evidence of preserved vascularity of the talus) is seen 6-8 weeks after the injury. It consists of patchy subchondral osteopenia on the AP and mortise vies of the ankle and is useful as an objective prognostic sign. The presence of the Hawkins sign is a reliable indicator that osteonecrosis is unlikely. The absence of the Hawkins sign, however, is not as reliable in predicting the development of osteonecrosis.”

Question 94

94. What is the most common fracture associated with a talar neck fracture?
95. Medial malleolus
96. Fibula
97. Calcaneus
98. Lisfranc

Answer 94

ANSWER - A

2014

JAAOS 2001 - Talus Fractures:

• In a study by Hawkins,8 15 of 57 patients (26%) had associated fractures of the medial malleolus. Canale and Kelly found that 11 of 71 patients (15%) with fractures of the talar neck had associated fractures of the medial and lateral malleoli (10 and 1, respectively). This level of incidence of malleolar fractures supports the concept that in addition to dorsiflex- ion, rotational forces contribute to displacement of a talar neck fracture.

Question 95

95. A patient with a lateral subtalar dislocation, what is a block to reduction?
96. Tib ant
97. FHL
98. EHL
99. TN capsule

Answer 95

ANSWER - B

Repeat: 2012, 2014, 2016

• We discussed this with Dr. Le - the most common block to reduction for a lateral subtalar dislocation is Tib post but since that isn’t an option FHL is the next best answer. Capsule is more of an issue with a medial dislocation.
• Lateral Subtalar Dislocation: A Review of the Literature and Case Presentation. Tucker, Burian and Boylan. Journal of Foot and Ankle Surgery. 1998.
• Failure to obtain anatomic reduction of a lateral subtalar dislocation by closed manipulation may be due to one or more interposing structures. Osteochondral fractures of the talonavicular joint, buttonholing of the talar head through the extensor retinaculum, entrapment of the PT or FDL tendons, or interposition of the extensor digitorum brevis (EDB) muscle have all been reported to interfere with closed reduction
•  
• Subtalar dislocation: two cases requiring surgery and a literature review of the last 25 years. Hoexum and Heetveld. Arch Orthop Trauma Surg. 2014.  

Question 96

96. What is a block to reduction in a medial subtalar dislocation:
97. FHL
98. TN capsule
99. FDL
100. Talar body impaction fracture

Answer 96

ANSWER: B

2013, 2015

• Anatomical considerations of irreducible medial subtalar dislocation. Heck BE et al., Foot Ankle Int. 1996 Feb;17(2):103-6. 
• “Irreducible medial subtalar dislocation has been associated with the talar head “buttonholing” through the extensor digitorum brevis (EDB) muscle, entrapment of the talar head in the extensor retinaculum, talonavicular impaction, interpositioning of the EDB muscle between the talus and navicular, and buttonholing of the talar head through the talonavicular ligament and joint capsule”

Question 97

97. List 4 complications associated with the hemi-lithotomy position and the fracture table when nailing a midshaft femur fracture. (2012, 2014)

Answer 97

JAAOS 2010 - Traction Table-related Complications in Orthopedic Surgery

• Compartment syndrome on well leg
• Pudendal nerve palsy
• Fracture malalignment
• Sciatic/peroneal Nerve Injury of well leg

Question 98

98. What are 4 features of “post tourniquet syndrome”? (2013)

Answer 98

JAAOS 2001 - Pneumatic tourniquet in extremity surgery

• Post tourniquet syndrome is secondary to prolonged muscle ischemia –> acidosis
• Stiffness
• Edema
• Pallos
• Weakness without paralysis
• Subjective numbness to the extremity without objective anesthesia
• Resolves over weeks to months
• Times: Thigh 300-350min, arm 250-300

Question 99

99. What are 3 things you can do to minimize complications if you anticipate a tourniquet time of over 3 hours? (2016)

Answer 99

JAAOS 2001 - Pneumatic tourniquet in extremity swelling

• Allow intermittent re-perfusion
• Hypothermia of the limb
• Wider cuff and lower inflation pressure
• Alternate inflation of two tourniquets

Question 100

100. List 6 modifiable risk factors for fracture non-union. (2015)

Answer 100

JAAOS 2008 - Femoral non-union: risk factors and treatment options

JAAOS 2012 - Assessment of compromised fracture healing

• Smoking
• NSAID use
• Alcohol Abuse
• Low Vitamin D Levels (Ca/Vit D supplementation)
• Poor nutrition
• Poorly controlled diabetes
• Hypothyroidism
• Anemia
• Identification/treatment of infection

Question 101

101. What is true about compartment syndrome:
102. Most common in males <35yo
103. Open fractures are less likely to have a compartment syndrome
104. Compartment pressure measurements are necessary for diagnosis
105. Forearm fractures are not a common cause of compartment syndrome

Answer 101

ANSWER: A

2015, 2016

Question 102

102. What is true regarding bone loss of 6cm:
103. More common in diaphyseal fractures
104. More common in the femur
105. Should amputate if >10cm
106. Must plate it to maintain alignment and rotation

Answer 102

ANSWER: A

2015

Most common in tibia (B)

Need to maintain alignment and rotation, but don’t need a plate (ex fix/nail)

Question 103

103. Regarding driving guidelines in orthopedic surgery, all of the following are TRUE except?
     a. You shouldn’t drive with a cast or air boot on the right leg
     b. Orthopedic surgeons have a good knowledge of the law in regard to driving
     c. Braking ability returns to normal at 3-4 weeks post arthroscopy
     d. You can drive 4-6 weeks after THA

Answer 103

ANSWER: B

2015

• JAAOS 2013 - Driving after orthopedic surgery
• Braking function returns to normal 4 weeks after knee arthroscopy, 9 weeks after surgical management of ankle fracture, and 6 weeks after the initiation of weight bearing following major lower extremity fracture
• Patients may safely drive 4-6 weeks after right total hip arthroplasty

Question 104

104. What is the most important factor in preventing infection in an open fracture in a pediatric patient?
105. Administration of antibiotics in the ER
106. I&D within 7 hours of injury
107. I&D between 7-24 hours from injury
108. Reduction, sterile dressing, and splinting in ER

Answer 104

ANSWER: A

2014

Skaggs DL (JBJS 2005) Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children

• Analysis of 554 open fractures
• No difference between I&D before 6 hours and after 6 hours
• Patzakis and Wilkins
• 1025 open fractures
• Infection rate 4.7% with abx before 3 hours and 7.4% antibiotics after 4 hours

Question 105

105. XR showing a reverse obliquity hip fracture in an elderly woman. Which of the following is true for this particular injury:
106. Cost effective to do a SHS
107. IM nail has lower failure rate than SHS
108. SHS has a high likelihood of union with shortening
109. Timing of fixation has no bearing on outcome

Answer 105

ANSWER: B

2019

• IM nail has lower failure rate than SHS
• Reverse obliquity hip #
• NOT well treated with SHS
• JAAOS 2004 – Unstable intertrochanteric hip fractures in the elderly
• A review of severe unstable fractures (AO/OTA types A3.1 and A3.3) revealed a 56% failure rate (cutout and nonunion [9/16]) for compression hip screw fixation.5 Intramedullary hip screw fixation was used in three patients without complications. Sadowski et al28 had no hardware failures and one nonunion in 18 patients with reverse oblique fractures treated with the intramedullary sliding hip screw.

Question 106

106. What is true about pubic symphysis injuries
107. A 2 hole plate fixation is equivalent to a plate with 4 or more hole fixation
108. Removal of cartilage leads to decreased joint space and less hardware failure
109. Preserving the cartilage improves pain and decreases failure rate
110. Bilateral SI screw fixation is recommended to augment anterior plate fixation

Answer 106

ANSWER: B

2019

• Removal of cartilage leads to decreased joint space and less hardware failure
• 2 hole plate not equivalent to 4 hole (eliminates a)
• Higher failure rate & malunion with 2 hole plating
• https://www.ncbi.nlm.nih.gov/pubmed/18594300
• Can use anterior-only fixation to close down SI joints (unless vertically unstable or needs more augmentation) – (eliminates d)
• Symphyseal cartilage*
• https://www.ncbi.nlm.nih.gov/pubmed/26165255
• Symphyseal cartilage excision led to closer apposition of the symphyseal bodies, which correlated with substantially lower rates of implant failure, and revision surgery.

Question 107

107. Which is true about the cast index:
108. A higher index is associated with less displacement
109. Correlates with better functional outcomes
110. Cast index is measured by dividing the sagittal inside cast width by the coronal inside cast width
111. The cast index is measured by dividing the cumulative space between skin and cast, divided by the total space inside the cast

Answer 107

ANSWER: C

2019

Cast index is measured by dividing the sagittal inside cast width by the coronal inside cast width

Lower index = less displacement

Likely does not correlate with outcomes

D incorrect

Question 108

108. Which of the following is not one of the major criteria for atypical femur fractures according to ASBMR 2013 criteria:
109. Localized endosteal and cortical thickening of the lateral femoral cortex at the level of the fracture (ie beaking)
110. Generalized diaphyseal femoral cortical thickening
111. Not comminuted or minimally comminuted
112. A complete fracture that goes across both cortices, and may have a medial spike

Answer 108

ANSWER: B

2019

Generalized diaphyseal femoral cortical thickening (minor criteria)

Question 109

109. What is the most important risk factor for compartment syndrome:
110. Young age
111. Increasing gustilo grade
112. Segmental tibia fracture

Answer 109

ANSWER: A

2019

• Young age
• Compartment syndrome RISK FACTORS
• JBJS 2000 – Acute Compartment Syndrome: Who is at risk? – Edinburgh study
• Young age, male gender
• No association with Gustilo class or level of energy

Question 110

110. Following ORIF of an unstable ankle fracture, early WB leads to:
111. Increased risk of hardware failed
112. Increased risk of wound complications
113. Increased ROM
114. Earlier return to work

Answer 110

ANSWER: C

2019

• Increased ROM
• 2016 - Early Weightbearing and Range of Motion Versus Non-Weightbearing and Immobilization After Open Reduction and Internal Fixation of Unstable Ankle Fractures: A Randomized Controlled Trial.
• Dehghan N1, McKee MD, Jenkinson RJ, Schemitsch EH, Stas V, Nauth A, Hall JA, Stephen DJ, Kreder HJ.
• There was no difference in RTW.
• At 6 weeks postoperatively, patients in the Early WB group had significantly improved ankle ROM (41 vs. 29, P < 0.0001); Olerud/Molander ankle function scores (45 vs. 32, P = 0.0007), and SF-36 scores on both the physical (51 vs. 42, P = 0.008) and mental (66 vs. 54, P = 0.0008) components.
• There were no differences with regard to wound complications or infections and no cases of fixation failure or loss of reduction. Patients in the Late WB group had higher rates of planned/performed hardware removal due to plate irritation (19% vs. 2%, P = 0.005).

Question 111

111. All of the following are CRPS risk factors except:
112. Female
113. Isotope scan will show increased uptake in the acute phase
114. Age >55
115. Allodynia is the most common sign

Answer 111

ANSWER: C

2019

• Age >55
• CRPS risk factors
• Female gender
• Acute phase –> positive 3-phase bone scan (technetium 99)
• In a neurological study of 145 patients with CRPS, Birklein et al. [2] identified hyperalgesia to pinprick in the affected limb of 37% of patients and brush-evoked allodynia in 30% of patients
• Allodynia amongst major criteria for diagnosis
• Age -  It peaks between age 45 and 55.
• CRPS occurs more frequently in the upper extremity, in females, and in individuals 50 to 70 years of age.
• INCONSISTENT results on age being a risk factor****
• AAOS - Diagnosis and Management of Complex Regional Pain Syndrome I and II
• Most common symptom is “pain” or “Hyperalgesia”

Question 112

112. Risk factors for poor outcome following acetabular ORIF, all except:
113. Hip dislocation
114. Displacement >2cm
115. Marginal impaction
116. Transverse fracture

Answer 112

ANSWER: D

2019

• Transverse fracture
• 2016 - Part 2: outcome of acetabular fractures and associated prognostic factors—a ten-year retrospective study of one hundred and fifty six operated cases with open reduction and internal fixation
• Prognostic factors
• Transverse fracture (+ posterior wall #)
• Roof impaction
• Surgeons in training
• Hip dislocation
• Acetabular fractures with an associated dislocation have worse long-term functional outcomes with higher rates of complications and conversion to late THA compared to acetabular fractures without a dislocation.
• Factors that correlated with arthritis included: 1) radiographic evidence of arthritis, 2) associated fracture pattern of posterior wall with posterior column, 3) marginal impaction, and 4) residual displacement of > 2 mm.
• JBJS 2012 - Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures. - Tannast M, Najibi S, Matta JM
• Non-controllable independent predictors of negative outcome include:
• 1) Age > 40
• 2) anterior dislocation
• 3) femoral head cartilage lesion
• 4) involvement of the posterior wall
• 5) marginal impaction
• 6) initial displacement > 20 mm.
• In this study, 20-year survivorship was poorest for anterior wall fractures (34%) and highest for transverse (89%) and both-column (87%) acetabular fractures
• 2019 Outcomes after surgical treatment of acetabular fractures: a review
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6420740/

Question 113

113. 50F, diaphyseal femoral shaft # with ipsilateral displaced femoral neck #. What is the most appropriate treatment:
114. Femoral plate and DHS combo
115. CM nail
116. Retrograde nail and DHS combo
117. THA

Answer 113

ANSWER: C

2019

• Retrograde nail and DHS
• 2 fractures = 2 constructs***
• Algorithm
• Displaced FNF – retrograde femur, then reduce / ORIF FNF
• Undisplaced FNF – provisional/definitive neck fixation, retrograde femur
• In both cases, over-ream canal by at least 1.5mm (consider 2mm in undisplaced neck) to avoid worsening displacement

Question 114

114. What is not associated with DVT in ankle fracture surgery:
115. BMI >30
116. Age >40
117. Tourniquet use
118. Tranexamic acid

Answer 114

ANSWER: D

2019

• https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/issues/articles/ajo04407e220.pdf
• https://pdfs.semanticscholar.org/3ccd/42bb22fc11b89203bf28e2bc2ba6d781a1d7.pdf
• Obesity (BMI, ≥30 kg/m2 ) had the strongest association with VTEs in this study. Obesity, which is a growing public health concern, can make postoperative care and mobilization more difficult.19
• History of heart disease was also associated with VTEs in this study
• Dependent functional status was the final risk factor found to be associated with VTE after ankle fracture ORIF. This association likely derives from an inability to mobilize independently, leading to increased venous stasis. Immobilization has been previously associated with increased risk for VTE after ankle surgery.7
• Prophylaxis may also be considered in this patient population. Several risk factors that were significant on bivariate analysis (increased age; increased ASA class; history of diabetes, pulmonary disease, hypertension) were not significant in the final multivariate model.
• Simon et al29 found that the use of a thigh tourniquet was not associated with an increased risk of VTE following forefoot surgery BUT
• Factors associated with an increased risk of venographically or ultrasound-proven VTE in foot and ankle surgery include prolonged tourniquet and operating theatre times, a longer delay to surgery following ankle trauma, hindfoot surgery, post-operative cast immobilisation and nonweight-bearing.
• Tranexamic NOT mentioned

Question 115

115. You have a proximal tibia fracture that is in valgus. What is the best technique to prevent malalignment:
116. Laterally directed nail
117. Medial start point
118. Medial blocking screw in proximal fragment
119. Lateral blocking screw in proximal fragment

Answer 115

ANSWER: D

• 2019
• orthobullets - https://www.orthobullets.com/trauma/12076/tibial-intramedullary-nail
• Blocking Screws
• if coronal or sagittal malalignment is noted, blocking screws are placed on the concavity of the deformity
• most commonly placed posterior or lateral to the guide wire in the proximal segment in proximal 1/3 fractures
• these screws serve as a pseudo-cortex to guide the nail
• these screws also serve to increase construct stiffness

Question 116

116. What is true regarding treatment of glenoid neck fractures?
117. Deltopectoral approach is the approach of choice
118. Good outcomes with nonsurgical treatment
119. Indication for ORIF is >1cm medicalization
120. Stable injury if there are no other ligament or bony injuries

Answer 116

ANSWER: D

2019

• A- no, posterior for neck
• B - ambiguous but says yes if displaced less then 2 mm
• C - yes, but define it as 1-2 and author says 2 cm
• CORR - Analysis of Operative versus Nonoperative Treatment
• of Displaced Scapular Fractures
• • JAAOS 2012 Management of scapular fractures
• The most explicit recent surgical indications include medial displacement of the lateral border >25 mm, shortening >25 mm, angular deformity >45°, concomitant intra- articular step-off >3 mm, or displaced double disruption of the SSSC.

Question 117

117. How do you avoid AVN in a proximal humerus fracture?
118. Preserve anterior humeral circumflex artery
119. Preserve posterior humeral circumflex artery
120. Minimally invasive plating
121. IM nail

Answer 117

ANSWER: B

2019

Historical? Old info?

• Sagar’s says preserve anterior HCA
• Recent article says MIS plating
• A cadaver study found that the posterior humeral circumflex artery supplied blood to 64% of the humeral head, which may explain the low rate of osteo- necrosis after proximal humeral fractures.
• • JAAOS 2017 – Management of Acute Prox humeral fractures
• Sagar’s SP-SS notes
• Historically, the ascending branch of the anterior humeral circumflex artery has been described as the primary source of the vascular supply to the humeral head.6 The high rate of injury to this vessel and lower rates of osteonecrosis associated with proximal humeral fractures emphasize the importance of the vascular anastomoses about the humeral head. A cadaver study found that the posterior humeral circumflex artery supplied blood to 64% of the humeral head, which may explain the low rate of osteo- necrosis after proximal humeral fractures.
• Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient - Geriatric Orthopaedic Surgery & Rehabilitation 2017
• Plate fixation is thought to have a higher risk of avascular necrosis secondary to periosteal stripping. This may be obviated by newer minimally invasive designs, w
• Nailing may thus be recommended for 3-part fractures, because osteonecrosis is less frequent, more focused, and better tolerated in this sub-group. In contrast, antegrade nailing was not more beneficial than other internal fixation techniques for preventing osteonecrosis or head malunion in patients with 4-part fractures.

Question 118

119. What is true about lower extremity trauma according to LEAP trial
120. Provides information that is sensitive but not specific for outcomes of limb salvage
121. Outcome scores have low clinical utility in predicting outcomes
122. MESS score is the best for predicting limb salvage

Answer 118

ANSWER: B

2019

• http://www.orthoguidelines.org/guidelines
• Absolute contraindications include severely crushed or mangled parts, amputations at multiple levels, prolonged warm ischemia more than 12 hours, and amputations in patients with other serious injuries
• Score >25) [17] o en simply cannot withstand the persistent toxic load that a mangled extremity presents to them without exacting a toll on the overall system. Early amputation therefore is part of the life-saving process that must be considered even though the limb may be potentially salvageable.
• ot require amputation [30].
• To add to the turmoil, a large multicentre study has documented poor sensitivity and specicity of these scores in type IIIB injuries where vascularity was intact
• based on an extensive literature search, no single trauma scoring system is superior to the other and none is the gold standard.
• scoring assessments cannot replace clinical judgement.
• Important findings from the LEAP study include the following.
• (1) the study could not recommend an existing index for determining when to perform amputation versus limb salvage.
• (2) Severe muscle injury had a strong influence on salvage. In essence, what the remaining long-term function will be with the existing motor units.
• (3) Bone loss was not particularly relevant.
• (4) Core morbidities, particularly alcohol use, created problems in long-term limb salvage.
  *

Question 119

119. Regarding bone grafting for tibial plateau fractures, which is the strongest graft choice?
120. Calcium sulfate
121. Calcium phosphate
122. Cancellous allograft
123. Cancellous autograft

Answer 119

ANSWER: B

2019

• https://www.ncbi.nlm.nih.gov/pubmed/18829901
• JBJS 2008 - Comparison of Autogenous Bone Graft and Endothermic Calcium Phosphate Cement for Defect Augmentation in Tibial Plateau Fractures
• he bioresorbable calcium phosphate cement used in this study appears to be a better choice, at least in terms of the prevention of subsidence, than autogenous iliac bone graft for the treatment of subarticular defects associated with unstable tibial plateau fractures.

Question 120

120. Regarding the posterior malleolus fractures, what is true?
121. Fixation of posterior malleolus results in stiffer syndesmosis vs syndesmotic screws
122. 5% of spiral tibia fractures extend intra-articularly
123. 10% involvement involves posterior subluxation
124. Often starts posteriolaterally and extends into the medial malleolus

Answer 120

ANSWER: A

• 2019
• Fixation of posterior malleolus results in stiffer syndesmosis vs syndesmotic screws –
• 5% of spiral tibia fractures extend intra-articularly – 9 %
• 10% involvement involves posterior subluxation – couldn’t find a number
• Often starts posteriolaterally and extends into the medial malleolus – no different type
• JAAOS 2013 – Posterior Malleolus fracture
• In the same study, a cadaver model demonstrated that posterior malleolus fixation restored 70% of syndesmotic stiffness compared with 40% with syndesmotic screw fixation.
• Posterolateral oblique (type I) fractures have a wedgeshaped fragment involving the posterolateral tibial plafond. Transverse medial-extension (type II) fractures contain a fracture line extending from the fibular notch to the medial malleolus. Small-shell (type III) fracture.
• • JOT 2016 - Posterior Malleolar Fractures Associated With Tibial Shaft Fractures and Sequence of Fixation
• 9% of spiral had post mal

Question 121

121. When using a kocher-langenbeck approach for acetabular fractures, which if the following is INCORRECT regarding positioning
122. Lateral useful for transverse fractures
123. Lateral useful for ipsilateral pubic symphasis fractures
124. Prone useful for decreasing tension on sciatic nerve
125. Prone useful to palpate the quadrilateral plate

Answer 121

ANSWER: A

2019

• JAAOS 2015 - Surgical Approaches to the Acetabulum and Modifications in Technique
• In a retrospective study of patients with transverse fractures treated using the Kocher-Langenbeck approach with the patient positioned prone or lateral, Collinge et al18 found no significant difference in bleeding, surgical time, or perioper- ative complications. The authors did find a trend toward increased malre- ductions in the lateral versus prone groups
• Lateral positioning is preferred in the setting of concomitant pubic rami fractures or bladder injuries. Prone positioning allows for easier palpa- tion of the quadrilateral surface and facilitates clamp placement through the greater sciatic notch
• Prone positioning eliminates gravity as a potential deforming force and allows for easier hip extension and knee flexion, relieving tension on the sciatic nerve.

Question 122

122. Which is true regarding a traumatic hip dislocation with an associated sciatic nerve palsy?
123. It is not an indication for open reduction
124. No recovery after 6 months is an indication for surgery
125. EMG at 3 months can influence your management plan
126. Sciatic nerve injury is more likely in a simple dislocation versus a fracture dislocation?

Answer 122

ANSWER: A

2019

• It is not an indication for open reduction
• No recovery after 6 months is an indication for surgery – can be up to 8-10mths
• EMG at 3 months can influence your management plan
• Sciatic nerve injury is more likely in a simple dislocation versus a fracture dislocation? - more likely in # dislocation
• Nerve injury in traumatic dislocation of the hip. Cornwall R1, Radomisli TE. 2000 Clinical orthopaedic related reseaerch.

Question 123

123. When fixing a femur fracture using a fracture table in the supine position versus manual traction, which of the following is true?
124. Decreased anteversion
125. External malrotation
126. Internal malrotation
127. No difference

Answer 123

ANSWER: C

2019

• Sagar notes: Malunion diaphyseal fracture
• IR deformity – higher with use of fracture table, fracture comminution, night time surgery
• May require an osteotomy if healed

Question 124

124. With respect to elastic nail fixation in pediatric humerus fractures, all true EXCEPT?
125. Low risk to radial nerve palsy
126. Low risk of delayed union
127. Should not be used in osteogenesis imperfecta
128. Humeral length changes are well tolerated

Answer 124

ANSWER: C

2019

Question 125

125. Luxatio erecta (inferior humeral dislocation), all is true except:
126. Failure of closed reduction is due to the humeral head stuck behind the biceps tendon
127. Reduction maneuver involves longitudinal traction in line with the humeral shaft
128. The humeral shaft is upwards (i.e. superiorly oriented) and stuck in that position
129. Palpable axillary thrill is a common finding

Answer 125

ANSWER: A

2019

• Discussed with Ottawa – agreed A) is the best answer amongst all choices
• https://www.tandfonline.com/doi/pdf/10.3109/17453678909149262
• Case reports of axillary artery thrill post anterior dislocation. LE has highest rate of NV injury thus could assume D is more true than A.
• Inferior Shoulder Dislocations (Luxatio Erecta). Kammel et al 2019
• In some cases a “buttonhole” deformity exists (humeral head is trapped in a tear of the inferior capsule), in which case open reduction is required.
• To reduce an inferior shoulder dislocation, extend the arm at the elbow and then apply overhead traction in the longitudinal direction of the humerus, an assistant may also apply cephalad pressure over the humeral head to help guide it into the joint.
• An inspection usually will reveal the classic appearance of the arm being fully abducted above the head with the elbow flexed at a 90-degree angle.
• Has greatest incidence of neurovascular injury of all types of shoulder dislocations
• brachial plexopathy
• axillary artery injuries

Question 126

126. What is not an indication for surgery in an isolated posterior wall fracture
127. 40% posterior wall
128. Roof arc < 20
129. Positive stress test
130. Incarcerated posterior wall fragment in the joint

Answer 126

ANSWER: B

2019

• Repeat 2013, 2015
• JAAOS 2001 Displaced Acetabular Fractures
• JOT 1996 The Effect of Variable Size Posterior Wall Acetabular Fractures on the Contact Characteristics of the Hip Joint
• “Articular incongruity is one indication for open reduction and internal fixation of these fractures. For fractures of the posterior wall, the indications for operative treatment also include instability of the hip, incarcerated or impacted osteochondral fragments, and irreducible fracture-dislocation of the hip.”
• From the OTA powerpoint slides:
• Cannot use roof arc measurements for wall fractures since these can only be treated non-operatively if hip joint remains completely stable and congruent

Question 127

127. What is associated with indomethacin for 6 weeks post posterior wall acetabular surgery:
128. Decreased risk of HO
129. Increase risk of non union of the posterior wall

Answer 127

ANSWER: B (2017,2019)

• Conclusions: Treatment with 6 weeks of indomethacin does not appear to have a therapeutic effect for decreasing HO formation after acetabular fracture surgery and appears to increase the incidence of nonunion. Treatment with 1 week of indomethacin may be beneficial for decreasing the volume of HO formation without increasing the incidence of nonunion.

Question 128

128. Repeat question with xray showing double ring/bubble sign, what is true
129. Involves capitellum but not trochlea
130. Involves trochlea but not capitellum
131. An anterior approach is not appropriate to address this fracture

Answer 128

ANSWER: C

2019

Question 129

129. What is true with respect to the use of blocking screws in proximal third tibia fracture?
130. Placed in the posterior aspect of the proximal fragment prevents recurvatum (yes it said recurvatum)
131. Blocking screws should not touch the nail
132. The screws should be put in after the nail is inserted
133. They increase stability

Answer 129

ANSWER: D

2019

• blocking (Poller) screws
• coronal blocking screw
• prevents apex anterior (procurvatum) deformity
• place in posterior half of proximal fragment
• sagittal blocking screw
• prevents valgus deformity
• place on lateral concave side of proximal fragment
• enhance construct stability if not removed

Question 130

130. What is true with respect to management of tibial shaft non-union fractures? 
131. Requires open bone grafting 
132. Exchange nailing is better than dynamization 
133. There is no difference between exchange nailing and dynamization with respect to healing 
134. You should change the type of the construct when you revise it (example as given, of changing a nail to a plate) 

Answer 130

ANSWER: C

2019

• JAAOS 2011 - Management_of_Aseptic_Tibial_Nonunion.7.
• The reported success of exchange reamed nailing for aseptic tibial nonunion ranges from 76% to 100%.21,22 Although it is not necessary to perform a fibular osteotomy to achieve successful union, it may occasionally be required for deformity correction
• No mention of dynamization
• https://journals.lww.com/jorthotrauma/Abstract/2015/12000/Dynamizations_and_Exchanges__Success_Rates_and.9.aspx
• • Overall, this study demonstrates high rates of union for both interventions, making them both viable options.

Question 131

131. What results in the greatest amount of injury with respect to ballistics?  
132. A bullet traversing the lung is worse than muscle 
133. Greater bullet YAW 
134. High velocity gun fired from is worse than a low velocity fired from close range 
135. Solid tipped is worse than hollow-tipped bullets 

Answer 131

ANSWER: B (C debated but the way question worded = yaw)

2019

• the higher the tissue specific gravity the higher the damage
• Some civilian GSW injuries may cause greater degree of soft-tissue injury, even though they may be classified as low-velocity injuries, and may require surgical débride- ment. For example, shotgun in- juries, especially close-range ones, cause extensive soft-tissue damage, and surgical débridement is neces- sary.

BUT still high velocity worst mv squared

Ottawa, Edmonton, Toronto agree with yaw

The energy transfer is also affected by the tissue involved in the projectiles tract, and is related to the den- sity and rigidity of the tissue. More rigid tissue such as bone resists deformation, and offers a greater resistance, resulting in greater energy transfer.

The direction of the projectile is described as its rotation axis, and the deviation is a yaw. If the bullet remains parallel with its line of flight, the energy loss is proportional to the difference of velocity squares and hence the energy decreases over longer distances [15]. Under these conditions its initial direction, strikes the target. If a bullet wobbles and then tumbles to 90° to its initial direction, maximal energy transfer is achieved

Hollow-point causes more damage than solid point

The higher the specific gravity, the greater the damage. The greater the elasticity, the less the damage. Thus, lung tissue of low density and high elasticity is damaged less than muscle with higher density but some elasticity. Liver, spleen, and brain have no elasticity and are easily injured, as is adipose tissue. Fluid-filled organs (bladder, heart, great vessels, bowel) can burst because of pressure waves generated. A bullet striking bone may cause fragmentation of bone and/or bullet, with numerous secondary missiles formed, each producing additional woundin

Question 132

132. Regarding below the knee fracture, DVT prophylaxis, what is true? 
133. It should be given routinely 
134. All patients who had a tourniquet should receive DVT prophylaxis 
135. The risk of symptomatic DVT is the same for ankle as it is in the pelvis 
136. You should provide DVT prophylaxis if you have >1 risk factors (written like that) 

Answer 132

ANSWER: D (2019, 2017)

• In summary, the incidence of clinically relevant VTE is low in fractures of the tibia. Chemical thromboprophylaxis is not warrented in every patient’s case. Identification of risk factors is imperative for the judicious use of these agents. We recommend against the routine use of chemical prophylaxis and alternatively recommend chemical prophylaxis use based on the presence of risk factors that are associated with these complications
• It seems that DVT is not a common complication of below knee fixation and chemoprophylaxis is not necessary when the patient has less than 3 predisposing factors. With 3 or more risk factors chemoprophylaxis and periodic follow-ups must be considered

Meta-analysis and suggested guidelines for prevention of venous thromboembolism (VTE) in foot and ankle surgery

James D. F. Calder, Richard Freeman, Erica Domeij-Arverud, C. Niek van Dijk, and Paul W. Ackermann

• Isolated foot and ankle surgery has a lower incidence of clinically apparent VTE when compared to general lower limb procedures, and this rate is not significantly reduced using low molecular weight heparin. The incidence of VTE following Achilles tendon rupture is high whether treated surgically or conservatively. With the exception of those with Achilles tendon rupture, routine use of chemical VTE prophylaxis is not justified in those undergoing isolated foot and ankle surgery, but patient-specific risk factors for VTE should be used to assess patients individually.

Question 133

133. When should you not give supplemental O2 to an elderly person in the setting of a trauma?
134. Increased PaCO2 due to COPD
135. Decreased PaCO2 due to COPD
136. Increased PaCO2 due to constrictive lung disease
137. Never

Answer 133

Answer: D (2017)

Old exams. Oxygen is awesome. Always give it even in COPD. In COPD can give lower O2 in COPD.

Question 134

134. Which of the following is a risk factor for nonunion in distal femur # treated with lateral locking plate
135. Using a short plate
136. simple # pattern
137. diaphyseal extension
138. ex-smoker - quit 4 years ago

Answer 134

Answer: A (2017)

A – yes (probable)

B - no

C – doesn’t matter

D - nope

Question 135

135. 50m fatty, MVC with right femur fracture, fixed with CMN in hemilithotony position. Post op has left leg pain swelling and pain with passive stretch. What is the most likely cause for this?
136. Positioning
137. Crush injury to left leg
138. Missed left tibia fracture
139. intimal tear

Answer 135

Answer: A – well leg syndrome compartment syndrome (2017)

Question 136

136. Which of the following is true regarding TKA after tibia plateau fracture
137. The risk of complication is the same as primary TKA
138. Younger patients have a higher risk of requiring TKA
139. The risk of requiring subsequent TKA is over 5%
140. Patients with Schatzker I and II fractures are most likely to require TKA

Answer 136

Answer: C (2017) 7.3% at 10 years

A - No higher

B – opposite

C Yes

D – Wrong.

The mean age of patients at time of fracture was 56 in the overall cohort and 65 in those requiring TKA; this was statistically significant (p=0.04)

• The Schatzker I fractures were the least likely to require TKA at 1% with the most likely requiring arthroplasty surgery being type III at 6%
• The overall incidence of TKA after tibial plateau fractures was 3%. 2018
• Complication rates were higher in the PTOA cohort and included wound complications 
• Two (6%) PTOA patients required revision total knee arthroplasty at 57 and 114 months. 
• Risk factors were increasing age, split depression fractures and female gender.

Question 137

137. Which of the following patient who has been on long-term bisphosphonate therapy is at highest risk of atypical femoral fracture
138. Female, >70yrs, Independent
139. Female, <70yrs, Independent
140. Female, >70yrs, dependant
141. Male >70yrs, Independent

Answer 137

Answer: B (2017) – female and active

A – False – Too old

B - True

C – False - male less likely

D – False – dependent is wrong

• AFFs accounted for 5% of hip and shaft fractures. Women accounted for 80% of all femoral shaft fractures and 95% of AFF. The proportion of AFF was higher in women than men (63/110 vs. 3/21, relative risk=3.95, 95% CI=1.37- 11.39, p=0.0006).
• By multivariate analysis hypocalcemia, obesity, and younger age (<70 yr) were confirmed to be independent predictors of AFF

Question 138

138. A patient suffers a comminuted, Hawkins III talar neck fracture, and is treated with open reduction and internal fixation using a dorsolateral approach. He is subsequently diagnosed with a malunion. Which of the following statements is TRUE?
139. The malunion does not affect motion of the subtalar complex
140. The malunion is best seen on an AP radiograph
141. A talar neck osteotomy is contraindicated
142. Varus malunion is most common

Answer 138

Answer: D (2017)

Question 139

139. All of the following can be used as an adjunct to surgical treatment of compartment syndrome EXCEPT
140. Remove all circumferential dressings or splints
141. Provide supplemental oxygen
142. Correct systemic hypotension
143. Transfuse to a target hemoglobin >100

Answer 139

Answer: D (2017)

Hyprebaric oxygen is good.

• good to correct acute anemia but no numbers are given and this is done for “impending” compartment syndrome…not already established.
• Aside: according to JAAOS review 1996, Hypothermia can be used if surgical treatment cant be performed in timely manner; elevating the limb is contraindicated because it decreases arterial blood flow, releasing one side of the plaster cast can reduce compartment pressure by 30% and bivalving can reduce by additional 35%, correct hypoperfusion with either saline or blood products, relative hypertension and correction of acute anemia may help prevent the development of impending compartment syndrome, nitric oxide role being investigated, hyperbaric oxygen beneficial.

Question 140

140. What is true regarding bone loss of 6 cm:
141. More common in diaphyseal fractures
142. More common in the femur
143. Should amputate if >10cm
144. Must plate it to maintain alignment and rotation

Answer 140

Answer: A (2017)

A- true
B – no , tibia

C – no. 20 cm yes

D – no can use IM nail

Question 141

141. What is the best augment to use in a depressed tibial plateau fracture?
142. Calcium sulphate
143. Allograft
144. Autograft
145. Calcium phosphate

Answer 141

Answer: D (2017)

• The α-BSM™ bone substitute displayed significantly greater stiffness than cancellous bone constructs in Schatzker II split depression fractures of the lateral tibial plateau (P < 0.0001). Plateau defects displaced significantly less at 1000N when using α-BSM™ in comparison to cancellous bone (P < 0.0001).
•  Secondary collapse of the knee joint surface ≥ 2 mm was reported in 8.6% in the biological substitutes (allograft, DBM, and xenograft), 5.4% in the hydroxyapatite, 3.7% in the calcium phosphate cement, and 11.1% in the calcium sulphate cases. 
• calcium phosphate cement has high compressive strength for filling metaphyseal void

Question 142

142. What parameter is best to judge resuscitation of a trauma patient?
143. Urine output
144. Blood pressure
145. Base deficit
146. Heart rate

Answer 142

Answer: C (2017)

Question 143

143. Indomethacin for 6 weeks following a posterior wall acetabular ORIF is associated with:
144. Decreased HO
145. Earlier mobilization
146. Increased nonunion of PW fragment
147. Less risk of sciatic nerve injury

Answer 143

Answer: C (2017, 2019)

• Treatment with 6 weeks of indomethacin does not appear to have a therapeutic effect for decreasing HO formation after acetabular fracture surgery and appears to increase the incidence of nonunion. Treatment with 1 week of indomethacin may be beneficial for decreasing the volume of HO formation without increasing the incidence of nonunion.

Question 144

144. All the following lead to poor outcomes following acetabular ORIF, except?
145. Labral tear
146. Cartilage abrasion
147. Femoral head fracture
148. Acetabular marginal impaction

Answer 144

Answer: A

2017

A- false

B - true

C - true

D – true

• poor outcomes are associated with:
• multi-system trauma
• increasing age
• poor articular congruency
• associated femoral head articular injury
• post-traumatic arthritis

Question 145

146. What deformity is caused by a too lateral start point using a trochanteric nail for a subtrochanteric hip fracture?
147. Varus
148. Valgus
149. Anteversion
150. External rotation

Answer 145

Answer: A (2017, SIMILAR REPEAT 2015)

Question 146

146. 50-year-old female has a displaced femoral neck fracture and ipsilateral femur fracture. What is the best way to treat this?
147. CM nail
148. Plate femur and DHS
149. Plate femur and THA
150. Retrograde nail and DHS

Answer 146

ANSWER: D

2018

-2 fractures 2 constructs

Shit research on this… JAAOS 1998 that says can use both CMN and retro+DHS but authors preferred two constructs

Question 147

147. Regarding tightrope fixation of syndesmosis (they called it something else…like suspension fixation or something), which is TRUE:
148. More loss of fixation with the tightrope
149. Equivalent outcomes with tightrope and screws
150. More hardware failure with tightrope

Answer 147

ANSWER: B

2018

• higher rates of hardware removal with screws (leads to greater costs)
• some studies suggest higher rates of malreduction with tightrope, but has been disproven in recent studies

Question 148

148. Regarding ligamentous lisfranc injuries, what has the best outcomes in terms of patient pain (yes, they said pain)?
149. Midfoot arthrodesis
150. ORIF
151. Casting
152. CRPP

Answer 148

ANSWER: A

2018

Question 149

149. You decide you want to do an ORIF of both the glenoid (?neck) and scapular body (because it’s Tuesday and you’re feeling wild). What is the best surgical approach to accomplish this?
150. Anterior deltopect (Henry’s)
151. Acromion osteotomy
152. Modified Judet approach between posterior deltoid and infraspinatous (it gave this specific interval)
153. Axillary approach utilizing the interval between infraspinatous and teres minor

Answer 149

ANSWER: C or D…should be modified judet between infra and teres minor

2018

Can use direct lateral approach to scapula, vertical incision but same interval

ALL have same interval between infra and teres minor so c is wrong

Question 150

150. What is true about nailing of an open tibia fracture?
151. Unreamed nails are better biomechanically and have ?stronger fixation and maintenance of alignment (something like this)
152. Thermal necrosis from reaming has no affect on (can’t remember if they said infection or if they said union)
153. Reamed nails are associated with fewer infections
154. Reaming allows for a larger nail which has improved fixation strength and maintenance of alignment

Answer 150

ANSWER: D

2018

• reaming has no effect on infection rates, increases union rates, larger nails (both tibial and femoral) lead to better fixation and lower failure rates
• SPRINT and SPRINT 2 studies

Question 151

151. In a CM nail, using a distal locking screw does which of the following?
152. Provides rotational control
153. Has an increased risk of fracture

Answer 151

ANSWER: A

2018

Question 152

152. Which of the following is most likely to contribute to acute respiratory distress syndrome in someone with a femur fracture and multiple injuries
153. Severe thoracic injury
154. Head injury
155. Stabilization after 18hours
156. Reamed nail

Answer 152

ANSWER: A

2018

Question 153

153. All of the following are complications of the hemilithotomy position EXCEPT:
154. Well leg compartment syndrome
155. Erectile dysfunction
156. Malrotation
157. Femoral nerve palsy???

Answer 153

ANSWER: D

2018

Shitty question:

Charles – traction in hemilithotomy position = compartment syndrome, erectile dysfunction, malrotation from traction table

If they are talking about only lithotomy position (as in urology, gyne, etc uses), then sciatic, femoral and peroneal nerve palsy’s have been described.

Question 154

154. A patient has a broken ankle and it gets fixed. You are shown the immediate post op xray (shows the fibula fixed in an extremely short position, medial mal fixed, and 1 syndesmosis screw). You are also shown an image of 3 months post op (now they have bone on bone OA and the hardware is failing ad the medial clear space is wide. The syndesmosis screw has been removed). What is the reason for the talar tilt?
155. Deltoid ligament disruption
156. Syndesmosis screw removed too early
157. Collapse of lateral tibial plafond
158. Fibula was fixed short

Answer 154

ANSWER: D

2018

https: //journals.lww.com/jaaos/Fulltext/2009/04000/distal_fibula_malunions.3.aspx
* JAAOS - Unstable ankle fractures may involve injury to the medial ligaments. In certain types of fractures, deltoid ligament stability is not restored with medial malleolar fixation. When the deltoid ligament is ruptured, not repairable, or chronically attenuated, reduction of the distal fibula serves several functions. One benefit is restoration of the medial talomalleolar space, which allows the deltoid ligament to heal at its resting length and tension. Additionally, anatomic reduction of the distal fibula provides stability by restoring the articular configuration of the tibiotalar joint. Finally, in the case of associated syndesmotic rupture, restoration of tibiofibular geometry secondarily provides reduction of the syndesmosis. The goal of surgical intervention in an unstable ankle fracture malunion is to repair the fixable elements, such as bone malreductions, to offer the best chance of obtaining talar stability.

Question 155

156. Which is the following stabilizes the fracture fragment in a bennet fracture? (repeat)
157. Anterior oblique ligament
158. Posterior oblique ligament
159. ?ulnar
160. ?dorsal

Answer 155

ANSWER: A

2018

Question 156

157. When fixing a monteggia fracture, what is the most common reason for ongoing posterior subluxation of the radial head (I have the wording slightly off for this)
158. Malreduction of an olecranon fracture
159. Increased apex dorsal angulation
160. Increased apex volar angulation

Answer 156

ANSWER: B

2018

Question 157

158. All of the following are acceptable strategies for terrible triad injury management EXCEPT
159. Radial head resection
160. Radial head replacement
161. Radial head ORIF
162. Coronoid ORIF

Answer 157

ANSWER: A

2018

Question 158

158. Regarding tension bands, all are true EXCEPT (recalled awkwardly, repeated question)
159. A tension band plate, applied to an eccentrically loaded bone, creates compression on the opposite side
160. A tension band can convert tension forces into compressive forces and this is a dynamic tension band
161. Tension bands prevent gapping on the tension side of a fracture
162. Tension banding of a medial mal is an example of a dynamic tension band

Answer 158

ANSWER: D

2018

Question 159

159. You are doing surgery and you place a homann posterior to the femur and get a lot of bleeding. What have you hit?
160. Profunda femoris artery
161. Popliteal artery
162. MFCA
163. ?superior formal artery (it sounded like a made up artery)

Answer 159

ANSWER: C

2018

Question 160

160. A patient has a posterior hip dislocation. You try to reduce it but it wont go. What is the MOST LIKELY block to reduction?
161. Psoas
162. Obturator internus
163. Posterior labrum
164. Sciatic nerve

Answer 160

ANSWER: C

2018

Question 161

161. All of the following are associated with poor outcomes following acetabular fractures EXCEPT:
162. Degree of initial displacement
163. Age >40
164. Intraoperative complication
165. Femoral head involvement

Answer 161

ANSWER: C

2018

• initial displacement of more than 10mm (p = 0.031) and initial intraarticular fragments (p = 0.041) were associated with worse outcome.
• Poor reduction, ass ociated injuries, fracture displacement of >20 mm, joint dislocation and late surgery definitely carry poor prognosis in predicting the outcome of surgically treated acetabular fractures
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6420740/
• Surgical treatment of acetabular fractures is challenging. Since initial studies by Letournel and Judet, numerous groups have published their results on clinical outcomes after treatment of these injuries. Based on the data presented in this chapter, the following factors are negative prognostic indicators for clinical outcome after surgical fixation of acetabular fractures:
• Patient age > 40
• Poor fracture reduction (> 3 mm)
• Multi-fragmentary fractures of the posterior/anterior wall
• Transverse multi-fragmentary fractures of the tectum
• Cartilage damage to the femoral head and/or acetabulum
• Delay to surgery > 5 days and > 15 days for associated and elementary fractures patterns, respectively.
• Initial fracture displacement > 20 mm

Question 162

162. Which of the following is most likely to require surgical intervention with respect to femoral head fractures?
163. Associated with dislocation
164. Suprafoveal fracture
165. Age <30

Answer 162

ANSWER: B

2018

Question 163

163. A Patient has an undisplaced distal radius fracture treated in a cast. Several weeks later she notices that she can’t extend her thumb. What is the best treatment?
164. Extensor indices to EPL transfer
165. ? some other transfer
166. ?some other transfer
167. ?some other transfer

Answer 163

ANSWER: A

2018

Question 164

164. What is true of scapulothoracic dissociation?
165. Axillary artery transection/rupture is a common occurrence/issue
166. Neurologic injury is predictive of outcome
167. It occurs from a low energy mechanism

Answer 164

ANSWER: B

2018

Question 165

165. Sliding hip screws (SHS) and minimally invasive CM nails are both options for displaced and undisplaced intertroch fractures. What is TRUE:
166. CM nail has better mortality
167. SHS has better outcomes
168. SHS and CM nail have equal transfusion rates

Answer 165

ANSWER: C

2018

• No statistically significant differences between the two types of fixation methods was observed for mortality, fracture healing complications, re-operations, hospital stay, length of surgery, blood transfusion requirements, medical complications, degree of residual pain or regain of independence.

Question 166

166. All of the following are risk factors for clavicle non-union except:
167. Female
168. Older age
169. Scapular fracture
170. Increased displacement

Answer 166

ANSWER: C

2018

Question 167

167. Patient sustains type III talus fracture-dislocation. You are in the OR. You have done a dual incision approach and still cannot reduce it. What is the next best step?

A) Medial malleolus osteotomy

B) Lateral malleolus osteotomy

C) In-line traction

D) Universal distractor

Answer 167

ANSWER: D (universal distractor)