Introduction High energy injuries frequently associated with life-threatening conditions Epidemiology incidence 37.1 per 100,000 person-years Mechanism traumatic high-energy most common in younger population often a result of high-speed motor vehicle accidents low-energy more common in elderly often a result of a fall from standing gunshot Associated conditions orthopaedic ipsilateral femoral neck fracture 2-6% incidence often basicervical, vertical, and nondisplaced missed 19-31% of time bilateral femur fractures significant risk of pulmonary complications increased rate of mortality as compared to unilateral fractures Anatomy Osteology largest and strongest bone in the body femur has an anterior bow linea aspera rough crest of bone running down middle third of posterior femur attachment site for various muscles and fascia acts as a compressive strut to accommodate anterior bow to femur Muscles 3 compartments of the thigh anterior sartorius quadriceps posterior biceps femoris semitendinosus semimembranosus adductor gracilis adductor longus adductor brevis adductor magnus Biomechanics musculature acts as a deforming force after fracture proximal fragment abducted gluteus medius and minimus abduct as they insert on greater trochanter flexed iliopsoas flexes fragment as it inserts on lesser trochanter distal segment varus adductors inserting on medial aspect of distal femur extension gastrocnemius attaches on distal aspect of posterior femur Classification Winquist and Hansen Classification Type 0 • No comminution Type I • Insignificant amount of comminution Type II • Greater than 50% cortical contact Type III • Less than 50% cortical contact Type IV • Segmental fracture with no contact between proximal and distal fragment OTA Classification 32A - Simple • A1 - Spiral • A2 - Oblique, angle > 30 degrees • A3 - Transverse, angle < 30 degrees 32B - Wedge • B1 - Spiral wedge • B2 - Bending wedge • B3 - Fragmented wedge 32C - Complex • C1 - Spiral • C2 - Segmental • C3 - Irregular Presentation Initial evaluation Advanced Trauma Life Support (ATLS) should be initiated Symptoms pain in thigh Physical exam inspection tense, swollen thigh blood loss in closed femoral shaft fractures is 1000-1500ml for closed tibial shaft fractures, 500-1000ml blood loss in open fractures may be double that of closed fractures affected leg often shortened tenderness about thigh motion examination for ipsilateral femoral neck fracture often difficult secondary to pain from fracture neurovascular must record and document distal neurovascular status Imaging Radiographs recommended views AP and lateral views of entire femur AP and lateral views of ipsilateral hip important to rule-out coexisting femoral neck fracture AP and lateral views of ipsilateral knee CT indications may be considered in midshaft femur fractures to rule-out associated femoral neck fracture Treatment Nonoperative long leg cast indications nondisplaced femoral shaft fractures in patients with multiple medical comorbidities Operative antegrade intramedullary nail with reamed technique indications gold standard for treatment of diaphyseal femur fractures outcomes stabilization within 24 hours is associated with decreased pulmonary complications (ARDS) decreased thromboembolic events improved rehabilitation decreased length of stay and cost of hospitalization exception is a patient with a closed head injury critical to avoid hypotension and hypoxemia consider provisional fixation (damage control) retrograde intramedullary nail with reamed technique indications ipsilateral femoral neck fracture floating knee (ipsilateral tibial shaft fracture) use same incision for tibial nail ipsilateral acetabular fracture does not compromise surgical approach to acetabulum multiple system trauma bilateral femur fractures avoids repositioning morbid obesity outcomes results are comparable to antegrade femoral nails immediate retrograde or antegrade nailing is safe for early treatment of gunshot femur fractures external fixation with conversion to intramedullary nail within 2-3 weeks indications unstable polytrauma victim vascular injury severe open fracture ORIF with plate indications ipsilateral neck fracture requiring screw fixation fracture at distal metaphyseal-diaphyseal junction inability to access medullary canal outcomes inferior when compared to IM nailing due to increased rates of: infection nonunion hardware failure Surgical Techniques Antegrade intramedullary nailing approach 3 cm incision proximal to the greater trochanter in line with the femoral canal technique starting points piriformis entry pros colinear trajectory with long axis of femoral shaft cons starting point more difficult to access, especially in obese patients causes the most significant damage to abductor muscles and tendons may result in abductor limp blood supply to the femoral head may result in AVN in pediatric patients trochanteric entry pros minimizes soft tissue injury to abductors easier starting point than piriformis entry nail cons not colinear with the long axis of femoral shaft must use nail specifically designed for trochanteric entry use of a straight nail may lead to varus malalignment reaming reamed nailing superior to unreamed nailing, with: increased union rates decreased time to union no increase in pulmonary complications indications for unreamed nail consider for patient with bilateral pulmonary injuries interlocking screws technique computer-assisted navigation for screw placement decreases radiation exposure widening/overlap of the interlocking hole in the proximal-distal direction correct with adjustment in the abduction/adduction plane widening/overlap of the interlocking hole in the anterior-posterior plane correct with adjustment in the internal/external rotation plane postoperative care weight-bearing as tolerated range of motion of knee and hip is encouraged pros 98-99% union rate low complication rate infection risk 2% cons not indicated for use with ipsilateral femoral neck fracture increased rate of HO in hip abductors with antegrade nailing increased rate of hip pain compared with retrograde nailing mismatch of the radius of curvature of the femoral shaft and intramedullary nails can lead to anterior perforation of the distal femur Retrograde intramedullary nailing approach 2 cm incision starting at distal pole of patella medial parapatellar versus transtendinous approaches nail inserted with knee flexed to 30-50 degrees technique entry point center of intercondylar notch on AP view extension of Blumensaat's line on lateral posterior to Blumensaat's line risks damage to cruciate ligaments postoperative care weight-bearing as tolerated range of motion of knee and hip is encouraged pros technically easier union rates comparable to those of antegrade nailing no increased rate of septic knee with retrograde nailing of open femur fractures cons knee pain increased rate of interlocking screw irritation cartilage injury cruciate ligament injury with improper starting point External fixation with conversion to intramedullary nail within 2-3 weeks technique safest pin location sites are anterolateral and direct lateral regions of the femur 2 pins should be used on each side of the fracture line pros prevents further pulmonary insult without exposing patient to risk of major surgery may be converted to IM fixation within 2-3 weeks as a single stage procedure cons pin tract infection knee stiffness due to binding/scarring of quadriceps mechanism Special considerations ipsilateral femoral neck fracture priority goes to fixing femoral neck because anatomic reduction is necessary to avoid complications of AVN and nonunion technique preferred methods screws for neck with retrograde nail for shaft screws for neck and plate for shaft compression hip screw for neck with retrograde nail for shaft less preferred methods antegrade nail with screws anterior to nail technically challenging Complications Heterotopic ossification incidence 25% treatment rarely clinically significant Pudendal nerve injury incidence 10% when using fracture table with traction Femoral artery or nerve injury incidence rare cause can occur when inserting proximal interlocking screws during a retrograde nail Malunion and rotational malalignment most accurately determined by the Jeanmart method angle between a line drawn tangential to the femoral condyles and a line drawn through the axis of the femoral neck malrotation up to 15 degrees is usually well tolerated incidence proximal fractures 30% distal fractures 10% risk factors use of a fracture table increases risk of internal rotation deformities when compared to manual traction fracture comminution night-time surgery treatment if noticed intraoperatively, remove distal interlocking screws and manually correct rotation if noticed after union, osteotomy is required Delayed union treatment dynamization of nail with or without bone grafting Nonunion incidence <10% risk factors postoperative use of nonsteroidal anti-inflammatory drugs smoking is known to decrease bone healing in reamed antegrade exchange nailing for atrophic non-unions treatment reamed exchange nailing Infection incidence < 1% treatment removal of nail and reaming of canal external fixation used if fracture not healed Weakness quadriceps and hip abductors are expected to be weaker than contralateral side Iatrogenic fracture etiologies risk factors antegrade starting point 6mm or more anterior to the intramedullary axis however, anterior starting point improves position of screws into femoral head failure to overream canal by at least .5mm Mechanical axis deviation (MAD) lengthening along the anatomical axis of the femur leads to lateral MAD shortening along the anatomical axis of the femur leads to medial MAD Anterior cortical penetration
Technique Guide 10/9/2017 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Femoral Shaft Fracture Antegrade Intramedullary Nailing Andrew Hsu Benjamin C. Taylor Trauma - Subtrochanteric Fractures Technique Guide 10/9/2017 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Femoral Shaft Fracture Retrograde Intramedullary Nailing Team Orthobullets (D) Trauma - Femoral Shaft Fractures
QUESTIONS 1 of 63 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 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 Previous Next 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 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 (OBQ07.74) A 26-year-old male presents after a motor vehicle accident. Work-up reveals a closed left femoral shaft fracture, and an ipsilateral posterior wall fracture. He undergoes intramedullary nailing of the femur, and open reduction internal fixation of the posterior wall. He is treated with 25 mg of indomethacin three times daily for 6 weeks following an initial dose on the evening of surgery for heterotopic ossification prophylaxis. Which of the following is true regarding this post-operative treatment protocol? Review Topic QID: 735 1 It is associated with an increased rate of femoral shaft nonunion 48% (459/960) 2 It has no effect on the healing time of the posterior wall fracture 30% (285/960) 3 It is associated with a faster time to union 1% (8/960) 4 Indomethacin is superior to radiation treatment in the prevention of heterotopic ossification 4% (42/960) 5 There is a decreased rate of revision surgery needed when indomethacin is administered post-operatively 17% (165/960) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ04.204) Which of the following variables has not been shown to be increased in patients who sustain bilateral femoral shaft fractures as compared to patients with unilateral femoral shaft fractures? Review Topic QID: 1309 1 Hypotension upon initial evaluation 7% (38/563) 2 Mortality 8% (45/563) 3 Rib fractures 41% (230/563) 4 Open skull fractures 36% (200/563) 5 Pelvic fractures 8% (47/563) ML 5 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ06.33) The greatest amount of iatrogenic injury to the piriformis tendon is associated with which of the following? Review Topic QID: 144 1 Antegrade piriformis entry femoral nailing 83% (443/534) 2 Antegrade greater trochanteric entry femoral nailing 8% (42/534) 3 Retrograde femoral nailing 1% (3/534) 4 External fixation of a femoral shaft fracture 0% (1/534) 5 Open reduction and internal fixation of an intertrochanteric fracture 8% (44/534) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.91) A 25-year-old male sustained a closed midshaft femur fracture following a motor vehicle collision. He is taken to the operating room for supine intramedullary nail fixation of the fracture. Figure A is a lateral fluoroscopic view of the distal femur taken just prior to distal interlocking screw placement. What change in position (with the C-arm stationary) would be expected to produce a perfect lateral view of the interlocking hole? Review Topic QID: 3514 FIGURES: A 1 Raising the leg 1% (22/1762) 2 Lowering the leg 1% (20/1762) 3 Internal (or external) rotation of the leg 5% (90/1762) 4 Abduction (or adduction) of the leg 91% (1612/1762) 5 Fluoroscopic magnification 0% (4/1762) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ10.12) A 34-year-old male is involved in a motor vehicle collision and sustains several orthopaedic injuries. Figure A shows a red line representating a fracture of the proximal femur. This fracture orientation is most often present when found concomitantly with which of the following orthopaedic injuries? Review Topic QID: 3100 FIGURES: A 1 Ipsilateral acetabular fracture 7% (69/1027) 2 lumbar spine burst fracture 3% (31/1027) 3 Ipsilateral femoral shaft fracture 81% (832/1027) 4 Anterior-posterior compression pelvic injury 2% (18/1027) 5 Ipsilateral calcaneus fracture 7% (73/1027) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.256) Which of the following factors is most associated with malrotation during antegrade or retrograde femoral nailing? Review Topic QID: 3352 1 Surgeon experience 16% (108/657) 2 Level of primary fracture line 5% (33/657) 3 Use of a piriformis starting portal 2% (10/657) 4 Fracture comminution 68% (449/657) 5 Closed reduction technique 8% (53/657) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 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 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 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 (OBQ09.195) Antegrade femoral nailing has an increased rate of which of the following when compared to retrograde femoral nailing? Review Topic QID: 3008 1 Varus malalignment 5% (28/588) 2 Union rate 2% (11/588) 3 Operative time 4% (22/588) 4 Subsequent operative procedures 1% (6/588) 5 Hip pain 88% (519/588) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.144) A 23-year-old man undergoes intramedullary nailing for a comminuted right femur fracture. Three weeks after surgery, CT scans are performed to assess for rotational malalignment. In Figure A, the angular rotation of the right femoral neck is internal rotation of 13° while the angular rotation of the left femoral neck is external rotation of 13°. In Figure B, the angular rotation of the right and left femoral condyles is external rotation of 17° and 3°, respectively. At revision surgery, in order to correct the rotational malalignment, the right distal femur must be rotated which of the following? Review Topic QID: 4779 FIGURES: A B 1 Internally by 20° 14% (397/2805) 2 Externally by 20° 7% (187/2805) 3 Internally by 14° 33% (920/2805) 4 Externally by 14° 11% (313/2805) 5 Internally by 40° 35% (969/2805) ML 5 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ04.188) Placing the starting point for an antegrade femoral nail too anterior to the axis of the medullary canal can most commonly lead to what intraoperative complication? Review Topic QID: 1293 1 Nail incarceration 4% (22/574) 2 Loss of locking screw trajectory into the lesser trochanter 3% (19/574) 3 Creation of a recurvatum deformity 22% (127/574) 4 Iatrogenic fracture of the proximal fragment 70% (400/574) 5 Decrease in hoop stresses 0% (1/574) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (SBQ12TR.10) A 24-year-old male sustains the isolated injuries shown in Figures A and B during a high-speed motor vehicle accident. On physical examination, the overlying skin is intact and there is no evidence of a Morel-Lavallée lesion. Which of the following surgical techniques is considered to have the highest rate of fracture malreduction with this combined injury? Review Topic QID: 3925 FIGURES: A B 1 Antegrade cephalomedullary nail 74% (1978/2677) 2 Retrograde intramedullary nail and 3 cannulated screws 6% (171/2677) 3 Retrograde intramedullary nail and sliding hip screw 5% (129/2677) 4 Antegrade intramedullary nail and 3 cannulated screws 10% (255/2677) 5 Plate fixation of the diaphyseal fracture and 3 cancellous screws 5% (126/2677) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (SBQ12TR.2) A 25-year-old male presents following a motor vehicle collision with a Glasgow Coma Scale of 7. Subsequent imaging in the trauma bay demonstrates a bifrontal cerebral contusion, an L4 burst fracture, multiple rib fractures, an LC-1 type pelvic ring injury, a femoral shaft fracture, and an open ipsilateral tibial shaft fracture. He is intubated and an intracranial pressure monitor is placed which consistently measures 30mm Hg. He is normotensive with a lactate of 1.5 after 2 liters of crystalloid and 1 unit of packed red blood cells. Which of his injuries would most dictate a temporizing approach with external fixation of his femoral shaft fracture instead of reamed intramedullary nailing? Review Topic QID: 3917 1 L4 burst fracture 4% (102/2690) 2 Bifrontal cerebral contusion 71% (1910/2690) 3 Open ipsilateral tibia fracture 6% (151/2690) 4 LC1 pelvic ring injury 4% (96/2690) 5 Rib fractures 15% (403/2690) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ05.221) A 20-year-old male is involved in a motorcycle accident and presents with the injuries shown in Figures A-F. The left ankle injury is open medially, with a clean 3cm laceration, and the right femur and tibia are closed. He has no visceral or head injury, and is hemodynamically stable. He is cleared to go to the operating room. Without taking into account order of fixation, how should his injuries be treated? Review Topic QID: 1107 FIGURES: A B C D E F 1 Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and casting 2% (10/483) 2 External fixation of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF 1% (3/483) 3 Antegrade nailing of the femur, external fixation of the tibia and ankle after debridement 9% (44/483) 4 Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF 83% (399/483) 5 External fixation of the tibia and femur, and ankle debridement and external fixation 5% (23/483) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ05.57) A 32-year-old male sustains a closed head injury, a closed pelvic ring injury, as well as the bilateral open femoral fractures shown in Figures A-C. He remains borderline hypotensive with a base deficit of 4.9 after an exploratory laparatomy and splenectomy. After irrigation and debridement of his open fractures, what is the most appropriate treatment for this patient at this time? Review Topic QID: 943 FIGURES: A B C 1 Bilateral retrograde femoral nailing and pelvic binder application 2% (28/1474) 2 Bilateral retrograde femoral nailing and anterior pelvic external fixation 4% (64/1474) 3 Bilateral antegrade femoral nailing and pelvic binder application 1% (16/1474) 4 Bilateral femoral external fixation and anterior pelvic external fixation 92% (1355/1474) 5 Bilateral femoral plating and anterior pelvic external fixation 0% (5/1474) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ07.19) Your 25-year-old patient complains of anterior knee pain after retrograde femoral nailing for a diaphyseal fracture and asks you why you didn’t perform antegrade nailing as he has seen on the internet. You tell him that retrograde nailing is your preferred technique over antergrade nailing for diaphyseal femoral fractures because it has been shown to have which of the following? Review Topic QID: 680 1 Increased rate of union 6% (39/636) 2 Decreased rate of infection 1% (8/636) 3 Shorter operative time 15% (95/636) 4 Lower rates of hip pain 75% (474/636) 5 Lower rates of knee pain 3% (16/636) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ07.194) Postoperative varus alignment of a subtrochanteric femur fracture treated with an intramedullary nail has been shown to be related to which of the following factors? Review Topic QID: 855 1 Use of a piriformis entry nail through a greater trochanteric entry portal 65% (311/478) 2 Use of a greater trochanteric entry nail through a piriformis entry portal 13% (64/478) 3 Use of a lateral entry nail through a piriformis entry portal 16% (75/478) 4 Use of a femoral distractor device to obtain reduction 1% (7/478) 5 Use of a fracture table to obtain reduction 4% (19/478) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ12.232) A 22-year-old male sustains the injury seen in Figures A and B as the result of a motor vehicle collision. He subsequently undergoes the procedure shown in Figures C and D with a 12 millimeter nail. When would full weight-bearing be allowed after surgery? Review Topic QID: 4592 FIGURES: A B C D 1 Immediately 67% (2799/4198) 2 4-6 weeks 10% (424/4198) 3 8 weeks 4% (165/4198) 4 12 weeks 4% (156/4198) 5 After consolidation is seen 15% (628/4198) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ06.57) A trauma patient presents with a major head injury and femoral shaft fracture. He undergoes early fixation of the femur fracture with a prolonged period of intraoperative hypotension. What is the most likely outcome to be expected post-operatively in this patient? Review Topic QID: 168 1 Increased risk of post-operative bleeding 6% (37/628) 2 Increased risk of pneumonia 6% (39/628) 3 Decreased IV fluid administration 30% (190/628) 4 Lower Glasgow Coma Scale scores at the time of discharge from hospital 56% (349/628) 5 Improved central nervous system outcomes at the time of discharge from hospital 2% (13/628) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ12.51) A 34-year-old male presents after falling off a roof at his job. He has an obvious deformity of his left lower extremity, and injury radiographs are shown in Figures A and B. He has no other injuries. Which of the following definitive treatment algorithms will most likely lead to the best outcomes in this patient? Review Topic QID: 4411 FIGURES: A B 1 Closed reduction and percutaneous screw fixation of the femoral neck, followed by reamed antegrade nailing of the femur fracture 6% (330/5976) 2 Reamed antegrade nailing of the femoral shaft fracture, followed by open reduction and percutaneous screw fixation of the femoral neck fracture 4% (235/5976) 3 Reamed retrograde nailing of the femoral shaft fracture, followed by closed reduction and percutaneous screw fixation of the femoral neck 8% (482/5976) 4 Open reduction and screw fixation of the femoral neck, followed by reamed retrograde nailing of the femoral shaft fracture 78% (4686/5976) 5 Open reduction and screw fixation of the femoral neck, followed by plating of the femoral shaft fracture 4% (214/5976) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ09.28) A 29-year-old male sustained a mid-shaft femur fracture in a motorcycle accident. Which of the following is associated with approximately 5% of patients sustaining this injury? Review Topic QID: 2841 1 Heterotopic ossification 1% (21/2186) 2 Ipsilateral femoral neck fracture 96% (2100/2186) 3 Ipsilateral posterolateral corner injury 1% (20/2186) 4 Pudendal nerve injury 1% (18/2186) 5 Ipsilateral superficial femoral artery injury 1% (22/2186) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ05.189) A patient undergoes the treatment seen in Figure A for a displaced intertrochanteric femoral fracture. With use of this construct, a starting point 3 mm anterior to the center of the piriformis fossa has which of the following benefits? Review Topic QID: 1075 FIGURES: A 1 Improved placement of screws through the nail into the femoral head 32% (171/527) 2 Decreased risk of varus alignment 19% (102/527) 3 Decreased risk of joint penetration 2% (12/527) 4 Decreased risk of avascular necrosis of femoral head 21% (113/527) 5 Decreased risk of iatrogenic proximal femur fracture 24% (125/527) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ09.102) A 26-year-old male sustains a femoral shaft fracture treated with the implant shown in Figure A. Postoperatively, what muscular deficits can be expected at medium and long-term follow-up? Review Topic QID: 2915 FIGURES: A 1 Weakness with hip abduction and knee flexion 6% (32/581) 2 Weakness with hip abduction and knee extension 28% (164/581) 3 Weakness with knee flexion and knee extension 1% (8/581) 4 Weakness with hip external rotation and hip abduction 59% (345/581) 5 Weakness with hip external rotation and hip flexion 5% (31/581) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ06.39) In patients with ipsilateral femoral neck and shaft fractures, what percent of femoral neck fractures are diagnosed on a delayed basis if fine cut CT is not utilized? Review Topic QID: 150 1 1% 1% (18/1449) 2 10% 32% (458/1449) 3 30% 57% (823/1449) 4 60% 8% (109/1449) 5 75% 2% (27/1449) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ08.105) A 38-year-old male was struck by a truck and sustained the injury seen in figure A. Treating this injury with an intramedullary nail with a larger radius of curvature can lead to what complication? Review Topic QID: 491 FIGURES: A 1 Posterior perforation of the distal femur 6% (116/1811) 2 Varus malreduction 2% (34/1811) 3 Comminution of the fracture site 1% (22/1811) 4 Iatrogenic femoral neck fracture 2% (45/1811) 5 Anterior perforation of the distal femur 88% (1593/1811) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ08.220) Reamed femoral intramedullary nailing is associated with a higher rate of which of the following, as compared to nonreamed nailing for distal femoral shaft fractures? Review Topic QID: 606 1 Malalignment 1% (16/1210) 2 Pulmonary complications 30% (364/1210) 3 Need for transfusion 2% (29/1210) 4 Iatrogenic fracture 2% (28/1210) 5 Union 64% (769/1210) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ06.163) A 33-year-old female sustains the injury shown in Figure A. Compared to antegrade nailing of this injury, retrograde nailing has been shown to have an increased amount of which of the following? Review Topic QID: 349 FIGURES: A 1 Operative time 18% (71/392) 2 Symptomatic distal interlocking screws 67% (262/392) 3 Hip pain 3% (11/392) 4 Union rate 5% (19/392) 5 Final knee range of motion 7% (28/392) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ05.132) Which of the following has been shown to have similar biochemical and clinical characteristics as iliac crest autograft? Review Topic QID: 1018 1 BMP-2 11% (55/512) 2 BMP-7 with collagen matrix carrier 12% (63/512) 3 Hydroxyapatite cement 5% (24/512) 4 Platelet rich plasma with allograft cancellous bone carrier 7% (34/512) 5 Femoral intramedullary reaming contents 65% (334/512) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ11.245) A 22-year-old male undergoes retrograde intramedullary nailing for the injury seen in Figure A. Which of the following would place branches of the femoral nerve and deep femoral artery at greatest risk during placement of the interlocking screw seen in Figure B? Review Topic QID: 3668 FIGURES: A B 1 Anterior to posterior placement above the lesser trochanter 27% (611/2302) 2 Anterior to posterior placement below the lesser trochanter 51% (1173/2302) 3 Lateral to medial placement above the lesser trochanter 7% (169/2302) 4 Lateral to medial placement below the lesser trochanter 14% (333/2302) 5 Open placement with blunt dissection down to bone 0% (7/2302) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ11.110) Which of the following is an advantage of computer-assisted navigation used to place medullary nail interlocking screws compared to a freehand techinque? Review Topic QID: 3533 1 Reduced fluoroscopy time 85% (1700/2007) 2 More reliable placement of interlocking screws through the nail 8% (168/2007) 3 Reduced procedure time 3% (58/2007) 4 Increased quality of fluoroscopic images 1% (12/2007) 5 Improved accuracy of screw length 3% (65/2007) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ06.41) A 22-year-old male sustains the injury shown in Figure A. When placing an antegrade intramedullary nail with manual traction in a supine position, which of the following is true when compared to placement of a nail using a fracture table? Review Topic QID: 152 FIGURES: A 1 Increased operative time 23% (400/1775) 2 Decreased internal malrotation deformities 46% (810/1775) 3 Increased external malrotation deformities 23% (416/1775) 4 Increased pudendal nerve injury 5% (91/1775) 5 Increased need for revision 3% (46/1775) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 2 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 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 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
NONUNION IN DIAPHYSEAL MIDDLE THIRD FEMURAL FRACTURE Trauma - Treatment Consult 18 YO MALE, BIKE ACCIDENT.TRANSVERSE DIAPHYSEAL MIDDLE THIRD FEMURAL FRACTU...
How I treated, Biphoshonate induced femur fracture in an 88 year old female. Trauma - Femoral Shaft Fractures - All How I treated, Biphoshonate induced femur fracture in an 88 year old female. 8/4/2018 163 views Nailing Femoral Shat Fractures: Starting Point Tips & Tricks - Anjan R. Shah, MD (CSOT #29, 2016) Trauma - Femoral Shaft Fractures - Treatment Consult Title: Nailing Femoral Shat Fractures: Starting Point Tips & Tricks Author: Anja... 2/28/2017 1307 views Short-Term Follow-Up of Pertrochanteric Fractures Treated Using the Proximal Femoral Locking Plate - Benjamin Johnson, MBBS (CSOT #27, 2016) Trauma - Femoral Shaft Fractures - Treatment Consult Title: Short-Term Follow-Up of Pertrochanteric Fractures Treated Using the Proxi... 2/28/2017 417 views See More See Less
Biphoshonate induced femur fracture in an 88F (C101089) Trauma - Femoral Shaft Fractures HPI - Bisphosphonate therapy (more than 10 years), ambulatory patient without any disability. The patient fell-down while she was walking on normal ground (low energy trauma) injuring her left leg. According to the patient's history and radiologic findings, which of the signs suggests atypical femur diaphysis fracture (Bisphosphonate induced fracture)? 6/29/2018 369 11 8 Diaphyseal femoral fracture nonunion in an 18M (C2884) Trauma - Femoral Shaft Fractures HPI - An 18 year old male presents for follow-up 6 months after suffering a transverse femur fracture in a motorcycle accident. He was treated with an external fixator as he was diagnosed with a pulmonary embolism soon after his admission. How would you manage this patient at this point? 11/10/2017 309 7 6 Atypical femoral fracture in a 73F (C2845) Trauma - Femoral Shaft Fractures HPI - Pain and deformity of the right hip/proximal femur. The patient underwent a cephalomedullary nailing of the fracture shown. Intra-op and post-op XRays are shown. Is this a nonunion? 8/14/2017 477 11 13 See More See Less