Introduction Characteristics of orthopaedic implants depends on material properties structural properties Screws Definitions pitch distance between threads lead distance advanced with one revolution screw working distance (length) defined as the length of bone traversed by the screw outer diameter root (inner) diameter bending strength is proportionate to inner (minor) diameter^3 pullout strength is proportionate to outer (major) diameter^2 maximized by large outer diameter difference fine pitch pedicle screw pullout most affected by quality of bone (degree of osteoporosis) Types of screws cortical screws cancellous screws locking screws Plate Properties Overview & definitions a load-bearing device that is most effective when placed on the tension side plate working distance the length between the 2 screws closest to the fracture on each end of the fracture. decreasing the working distance increases the stiffness of the fixation construct Structural properties bending rigidity proportional to thickness to the 3rd power titanium has Young's modulus of elasticity that most closely approximates cortical bone Biomechanics absolute stability constructs heal with primary (Haversian) healing must eliminate micromotion with lag screw fixation must be low strain at fracture site with high fixation stiffness relative stability constructs heal with enchondral healing strain rates must be <10%, or fibrous union will predominate Plate Variations Concave plates placing a concave bend on a plate is useful in transverse fractures to ensure compressive forces occur on both the far and near cortices of the fracture Compression plates compression plates work by placing a cortical screw eccentrically into an oval hole in the plate Locking plates advantages of locking plates locked plate/screw constructs compared to non-locked plate/screw constructs result in less angulation in comminuted metaphyseal fractures indications for locking plate technology indirect fracture reduction diaphyseal/metaphyseal fractures in osteoporotic bone bridging severely comminuted fractures plating of fractures where anatomical constraints prevent plating on the tension side of the bone (e.g. short segment fixation). locking plate screw biomechanics bicortical locking screws have significantly more resistance to all applied forces, with resistance to torsion increased the most (versus unicortical) unicortical locking screws have less torsion fixation strength than non-locking bicortical constructs percutaneous locking plates application has less soft-tissue stripping but higher chance malunion hybrid locked plates utilize locking and nonlocking screws in order to assist with fracture reduction (nonlocking screws) as well as provide a fixed angle construct (locking screws). locking plate construct stability increases with: bicortical locking screws increased number of screws screw divergence from screw hole < 5 degrees longer plate Bridging plates provides relative stability, relative length and alignment preserves the blood supply to the fracture fragments as the fracture site is undisturbed during the operative procedure this theoretically improves secondary bone healing allows some motion at fracture site; relative stability leads to callus formation Intramedullary nails Overview a load-sharing device Structural Properties stiffness torsional rigidity defined as amount of torque needed to produce torsional (rotational) deformation proportional to the radius to the 4th power depends on shear modulus polar moment of inertia increased by reaming decreased by slotting of nail bending rigidity proportional to the radius to the 4th power for a solid nail area moment of inertia of a solid cylinder proportional to the radius to the 3rd power (approximately) for a hollow nail area moment of inertia of a hollow cylinder where r1 is inner radius and r2 is outer radius for thin cylinders, {\displaystyle r\equiv r_{1}\approx r_{2}}and {\displaystyle r_{2}\equiv r_{1}+t}. and depends on material properties Young modulus of elasticity of material structural properties area moment of inertia length Radius of curvature intramedullary nail radius of curvature is greater (straighter) than the radius of curvature of the femur Interlocking options dynamic locking-->axially and rotationally stable fractures static locking-->axially and rotationally unstable fractures secondary dynamization for nonunion remove proximal interlocking screw or move proximal interlocking screw from the static to dynamic slot External fixators Factors that increase stability of conventional external fixators contact of ends of fracture larger diameter pins (most important) additional pins decreased bone to rod distance pins in different planes increasing size or stacking rods rods in different planes increased spacing between pins Factors that increase stability of circular (Ilizarov) external fixators larger diameter wires decreased ring diameter olive wires extra wires wires cross perpendicular to each other increased wire tension placement of two central rings close to fracture increased number of rings Total Hip Implants Structural Properties rigidity depends on length and radius of femoral stem Biomechanics place femoral component in neutral or slight valgus to reduce moment arm and stress on cement increasing femoral offset does the following advantages moves abductor moment away from center of rotation increase abductor moment arm reduces abductor force required for normal gait disadvantages increased strain on implant increases strain on medial cement mantle
QUESTIONS 1 of 39 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE13BS.53) What method of spinal fixation requires the largest force to disrupt the bone-implant interface? Tested Concept QID: 8290 Type & Select Correct Answer 1 Sublaminar cables 4% (11/306) 2 Laminar hooks 3% (8/306) 3 Pedicle hooks 3% (9/306) 4 Pedicle screws 90% (274/306) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ13.117) A 35-year-old patient is involved in a motor vehicle accident and sustains multiple fractures including a closed comminuted proximal meta-diaphyseal tibia fracture. The surgeon is considering bridge plating the fracture using a minimally invasive approach. Which of the following is true regarding bridge plating? Tested Concept QID: 4752 Type & Select Correct Answer 1 A locked plate construct (locked screws) or hybrid construct (locked and non-locked screws) is necessary. 24% (802/3287) 2 Periosteal stripping is performed through two incisions proximal and distal to the fracture. 3% (102/3287) 3 Bridge plating is performed following direct reduction of the fracture. 3% (91/3287) 4 AO Type A diaphyseal fractures are best treated with this technique. 3% (85/3287) 5 Bridge plating with a long working length creates a flexible, axially stable construct. 67% (2189/3287) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12TR.28) After application of a unilateral tibial external fixator, it is observed that the frame does not provide sufficient rigidity across the fracture site. Altering the external fixator in which of the following ways will have the greatest impact on frame stiffness? Tested Concept QID: 3943 Type & Select Correct Answer 1 Increasing the distance between pins in each fragment 7% (279/3814) 2 Increasing the pin diameter 53% (2014/3814) 3 Reducing the distance between bone and connecting bar 28% (1067/3814) 4 Increasing the connecting bar diameter 2% (63/3814) 5 Adding one stacked connecting bar 10% (372/3814) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.7) Which of the following techniques increases strength and stability to an external fixation construct? Tested Concept QID: 3430 Type & Select Correct Answer 1 Unicortical pin fixation 0% (4/3100) 2 Decreasing total pin separation distance 3% (102/3100) 3 Increased working distance from the pin to fracture site 2% (71/3100) 4 Decreasing the distance between the bone and the construct 93% (2897/3100) 5 Using smaller diameter pins 0% (6/3100) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ11.59) A 27-year-old male undergoes intramedullary nailing of a midshaft tibia fracture with static locking proximally and distally. There is minimal healing noted 3 months postoperatively and the decision is made to dynamize the nail. For intramedullary nail dynamization, an interlocking screw should be placed in which of the holes shown in Figure A? Tested Concept QID: 3482 FIGURES: A Type & Select Correct Answer 1 A only 73% (1284/1769) 2 C only 1% (11/1769) 3 B only 23% (402/1769) 4 A and C 2% (28/1769) 5 C and B 2% (32/1769) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ10.226) A locked plate used in a bridge plate fashion is biomechanically most similar to which of the following fixation methods? Tested Concept QID: 3325 Type & Select Correct Answer 1 Lag screw 0% (6/1715) 2 Lag screw plus non-locked neutralization plate 2% (32/1715) 3 External fixator without compression 92% (1570/1715) 4 Lag screw plus locked neutralization plate 1% (22/1715) 5 External fixator used in compression mode 4% (76/1715) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (OBQ10.234) Which of the following defines the working distance of a plate in a plate/screw fracture fixation construct? Tested Concept QID: 3333 Type & Select Correct Answer 1 The length of the interfragmentary lag screw 0% (8/2588) 2 The length between the 2 screws closest to the fracture on each end of the fracture 71% (1827/2588) 3 The distance from the bone to the plate 3% (68/2588) 4 The length from the screw closest to the fracture to the screw furthest from the fracture on the same end of the plate 8% (203/2588) 5 The length between the 2 screws furthest from the fracture on each end of the plate 18% (459/2588) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ10.169) A 24-year-old female presents with a transverse midshaft humerus fracture. Which of the following implants would create the most compression on both the far and near cortices? Tested Concept QID: 3262 Type & Select Correct Answer 1 Compression plate with concave bend (ends bowed towards bone) 77% (1677/2164) 2 Large fragment locking plate with 3 bicortical locking screws proximal and distal to the fracture 3% (70/2164) 3 Intramedullary nail 2% (50/2164) 4 Compression plate with convex bend (ends bowed away from the bone) 16% (346/2164) 5 Sarmiento style fracture brace 0% (10/2164) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ10.183) Which of the following is true regarding rigid locking plate constructs in fracture fixation? Tested Concept QID: 3276 Type & Select Correct Answer 1 Locking plates always enhance fracture healing more than non-locking plating 1% (20/1632) 2 Locking plates reduce interfragmentary strain more than non-locking plating 74% (1214/1632) 3 Locking plates are best utilized in diaphyseal fractures 2% (40/1632) 4 Locking plates are contraindicated in patients with osteoporosis 0% (8/1632) 5 Fractures treated with anatomic reduction and locked plate fixation demonstrate more strain than fractures treated with intramedullary fixation 21% (341/1632) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ10.33) A surgeon chooses a periarticular locking plate with unicortical proximal locking screws for an extra-articular distal femur fracture as seen in Figure A. Compared to an identical construct with bicortical unlocked proximal screw fixation, the periarticular locking plate with unicortical locking screws has which biomechanical properties? Tested Concept QID: 3121 FIGURES: A Type & Select Correct Answer 1 Greater torsional and axial fixation strength 14% (485/3562) 2 Less torsional but greater axial fixation strength 46% (1632/3562) 3 Equal torsional and axial fixation strength 4% (134/3562) 4 Greater torsional but less axial fixation strength 19% (660/3562) 5 Less torsional and axial fixation strength 18% (634/3562) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ10.60) Which of the following scenarios of treatment of a humerus fracture best achieves low strain at the fracture site and high stiffness of the treatment construct? Tested Concept QID: 3148 Type & Select Correct Answer 1 Functional bracing of a transverse midshaft fracture 1% (6/726) 2 Comminuted midshaft fracture with locked bridge plating 19% (136/726) 3 Short oblique fracture with interfragmentary lag screw and locked neutralization plate 76% (549/726) 4 Uniplane external fixation of a spiral open fracture 1% (4/726) 5 Oblique fracture with intramedullary nail fixation 3% (24/726) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.169) The greatest biomechanical difference between unicortical and bicortical locking screws is seen when what force is applied? Tested Concept QID: 2982 Type & Select Correct Answer 1 Compression 6% (43/695) 2 Torsion 70% (489/695) 3 Distraction 4% (31/695) 4 Bending on the side of the plate 8% (55/695) 5 Bending on the surface perpendicular to the plate 11% (75/695) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ09.109) Which of the following fracture patterns (Figures A through E) has the least amount of evidence-based support for use of locking or hybrid plating techniques? Tested Concept QID: 2922 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 6% (45/806) 2 Figure B 4% (32/806) 3 Figure C 24% (193/806) 4 Figure D 7% (59/806) 5 Figure E 58% (471/806) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ09.177) Which of the following Figures shows a fixation construct achieving absolute stability? Tested Concept QID: 2990 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 1% (11/1288) 2 Figure B 4% (55/1288) 3 Figure C 6% (71/1288) 4 Figure D 88% (1134/1288) 5 Figure E 1% (12/1288) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.98) A 25-year-old male sustained the fracture seen in Figure A and undergoes open reduction internal fixation of the injury. What type of plating technique is used for the ulna? Tested Concept QID: 484 FIGURES: A Type & Select Correct Answer 1 Neutralization 1% (22/1797) 2 Locking 1% (19/1797) 3 Compression 2% (40/1797) 4 Bridging 95% (1711/1797) 5 Antiglide 0% (1/1797) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ08.126) Figure A is a radiograph taken after an open reduction and internal fixation of a periprosthetic distal femur fracture. With this type of hybrid locked plate fixation, what is the difference between screw A and screw B? Tested Concept QID: 512 FIGURES: A Type & Select Correct Answer 1 Screw A can assist in fracture reduction while screw B provides a fixed angle support 20% (127/630) 2 Screw A provides improved axial stiffness while screw B provides a fixed angle support 11% (69/630) 3 Screw A can be used to reduce the plate to bone while screw B can be used to lag fracture fragments together 3% (16/630) 4 Screw A provides a fixed angle support while screw B can be used to reduce the plate to the bone 62% (392/630) 5 Screw A can be used to lag fracture fragments together and screw B increases the plate bone frictional stability 3% (22/630) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ08.69) An adolescent patient is treated with a 6mm solid intramedullary nail. Compared to a 12mm solid nail of the same material, the 6mm nail has: Tested Concept QID: 455 Type & Select Correct Answer 1 1/2 the torsional rigidity 4% (25/587) 2 1/4 the torsional rigidity 13% (78/587) 3 1/16 the torsional rigidity 61% (361/587) 4 1/8 the torsional rigidity 16% (96/587) 5 the same torsional rigidity 4% (25/587) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (OBQ07.188) The resistance to pullout of a screw in osteoporotic bone is increased by all of the following EXCEPT? Tested Concept QID: 849 Type & Select Correct Answer 1 Placement parallel to the trabecular pattern 42% (244/577) 2 Purchase in cortical bone 1% (6/577) 3 Use of a fixed angle (locking screw construct) 3% (16/577) 4 Tapping prior to screw placement 46% (268/577) 5 Augmentation with polymethylmethacrylate 7% (40/577) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ07.13) Locking plate technology has relative indications for use in all of the following, EXCEPT: Tested Concept QID: 674 Type & Select Correct Answer 1 As a bridge for severely comminuted fractures 5% (32/598) 2 Osteoporotic metaphyseal fractures 2% (12/598) 3 Short fracture segments 18% (105/598) 4 Oligotrophic diaphyseal nonunions 56% (335/598) 5 Indirect fracture reduction techniques 19% (112/598) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ06.172) How does a dynamic compression plate achieve compression at the fracture of a long bone? Tested Concept QID: 358 Type & Select Correct Answer 1 Eccentric placement of a cortical screw into a hole in the plate 92% (553/600) 2 Placing a cortical screw in lag fashion by overdrilling the near cortex 2% (11/600) 3 Locking of the head of the screw into a threaded hole in the plate 2% (10/600) 4 Concentric placement of a cortical screw into the center of the hole in the plate 3% (17/600) 5 The plate allows secondary healing of bone and does not acheive compression at the fracture site 1% (5/600) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ06.264) Assuming all other variables are the same, which of the following increases fixation construct stiffness in a locking plate model? Tested Concept QID: 275 Type & Select Correct Answer 1 Unicortical locking screws compared to bicortical locking screws 2% (11/703) 2 Angular cross-threading screws into a plate 6% (42/703) 3 Overdrilling the near cortex for the screw holes 4% (30/703) 4 Far cortical locking screws 16% (112/703) 5 Increased number of screws in the plate 72% (504/703) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ06.191) A long oblique diaphyseal fracture is internally fixed with 2 lag screws. There is 2 mm of residual fracture fragment gap following screw fixation. This construct has which of the following compared to a comminuted diaphyseal fracture internally fixed with a long bridge plating technique? Tested Concept QID: 377 Type & Select Correct Answer 1 Greater interfragmental strain 58% (418/726) 2 Greater ductility 2% (12/726) 3 Greater primary Haversian remodeling 33% (238/726) 4 Greater union rate 4% (28/726) 5 Greater callus volume formation 3% (25/726) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ06.258) The distance of bone traversed by a screw is defined as which of the following terms? Tested Concept QID: 269 Type & Select Correct Answer 1 Pitch 14% (76/543) 2 Working length 66% (360/543) 3 Screw lead 15% (84/543) 4 Core diameter 1% (8/543) 5 Area moment of inertia 2% (13/543) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ06.244) Limited contact dynamic compression (LCDC) plates have what advantage over standard dynamic compression plates? Tested Concept QID: 255 Type & Select Correct Answer 1 Less implant-bone and fracture gap micromotion 4% (23/642) 2 More fracture site compression 1% (4/642) 3 Less implant-bone contact induced osteopenia 93% (594/642) 4 Stiffer fracture fixation construct 0% (2/642) 5 More stress shielding 2% (16/642) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (OBQ06.185) All of the following are indications for locked plating technology EXCEPT: Tested Concept QID: 371 Type & Select Correct Answer 1 Periarticular fracture with metaphyseal comminution 2% (11/677) 2 Fracture in osteoporotic bone 3% (23/677) 3 Bridge plating for severely comminuted fractures 5% (32/677) 4 Compression plating of transverse fracture 86% (579/677) 5 Plating of fractures where anatomical constraints prevent plating on the tension side of the bone 4% (30/677) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ06.237) Which statement is true regarding standard open plating techniques compared to minimally invasive submuscular plating techniques? Tested Concept QID: 248 Type & Select Correct Answer 1 standard plating results in greater compromise to both medullary and periosteal bloodflow 19% (104/548) 2 standard plating results in greater compromise to periosteal bloodflow only 69% (377/548) 3 standard plating results in greater compromise to medullary bloodflow only 2% (10/548) 4 standard plating results in less compromise to both medullary and periosteal bloodflow 3% (15/548) 5 there is no difference between the two techniques with respect to periosteal and medullary bloodflow 7% (41/548) L 5 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ05.141) A patient sustains the fracture shown in Figures A and B. Compared with open reduction and internal fixation with a conventional, non-locking condylar buttress plate, what potential complication is more likely to occur if this fracture is treated with closed reduction and minimally-invasive, locking screw-only fixation with a distal femur locking plate? Tested Concept QID: 1027 FIGURES: A B Type & Select Correct Answer 1 Non-anatomic reduction of the articular surface 81% (1433/1780) 2 Soft tissue stripping 1% (23/1780) 3 Shortening 8% (136/1780) 4 Absence of visible callus 9% (167/1780) 5 Devascularization of fracture fragments 1% (12/1780) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ05.275) You are planning an intramedullary nail to treat a geriatric patient with a peritrochanteric femur fracture. Which of the following preoperative considerations is correct regarding your implant? Tested Concept QID: 1161 Type & Select Correct Answer 1 The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur 64% (742/1158) 2 Closed section nails have less stiffness than slotted nails 4% (45/1158) 3 The medial/lateral nail starting point relative to the greater trochanter does not affect varus/valgus position in the fracture 3% (32/1158) 4 The bending stiffness of your nail is proportional to the second power of the radius 23% (272/1158) 5 Intramedullary nails allow for mostly direct intramembranous bone healing 5% (62/1158) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ05.114) Which of the following is the most accurate definition of stress shielding? Tested Concept QID: 1000 Type & Select Correct Answer 1 The decrease in physiologic stress in bone due to a stiffer structure sharing load 93% (672/725) 2 Electrochemical potential created between two metals in physical contact and immersed in a conductive medium 1% (10/725) 3 Degradation from exposure to a harsh environment 1% (4/725) 4 Physical movement of two plates against each other leading to mechanical wear and material transfer at the surface 5% (33/725) 5 Bone death secondary to compromise in blood supply 0% (2/725) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept
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