Summary Femoral shaft fractures are high energy injuries to the femur that are associated with life-threatening injuries (pulmonary, cerebral) and ipsilateral femoral neck fractures. Diagnosis is made radiographically with radiographs of the femur as well as the hip to rule out ipsilateral femoral neck fractures. Treatment generally involves intramedullary nailing which is associated with >95% union rates. Epidemiology Incidence common 37.1 per 100,000 person annually Etiology 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 Fracture patterns transverse pure bending moment spiral rotational moment oblique uneven bending moment segmental 4-point bending moment comminuted high-speed crush or torsion mechanism Associated conditions orthopaedic ipsilateral femoral neck fracture 2-6% incidence often basicervical, vertical, and nondisplaced lack of displacement due to majority of energy dissipated through femoral shaft missed 19-31% of time bilateral femur fractures significant risk of pulmonary complications increased rate of mortality as compared to unilateral fractures ipsilateral tibial shaft fractures ipsilateral acetabular fracture thoracic pulmonary injury early surgical treatment of femur fracture can lead to ARDS approximately 2% of cases treatment can proceed when patient is appropriately resuscitated cerebral hemorrhage, subdural hemorrhage early surgical treatment can exacerbate neurologic injury intraoperative hypotension can decrease brain perfusion 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 AO/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 - Irregula Presentation Initial evaluation Advanced Trauma Life Support (ATLS) should be initiated adequate resuscitation normal vital signs HR < 100 bpm SBP >100 mm Hg DBP >70 mm Hg normothermia (> 35° C) adequate urine output 0.5 - 1.0 mL/kg/hr (30 mL/hr) labs lactate <2.5 mmol/L base deficit within -2 and +2 IL-6 levels <500 pg/dL gastric mucosal pH >7.3 compensated shock commonly missed normotensive tachycardia without fever cool extremities narrowing pulse pressure weak peripheral pulses delayed capillary refill 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 Ipsilateral femoral neck rule-out protocol dedicated 10° internal rotation AP hip radiographs placed femoral neck in profile fine-cut CT of the hip 2 mm cuts intraoperative fluoroscopic exam of the ipsilateral hip dedicated post-operative radiographs of the affected while patient is still in operating room Labs Septic nonunion ESR CRP most sensitive to the presence of a occult infection CBC WBC Adequate resuscitation IL-6 less than 500 pg/dL serum lactate less than 2.5 mmol/L base deficit within -2 or +2 Treatment Nonoperative long leg cast or hip spica cast indications nondisplaced femoral shaft fractures in patients with multiple medical comorbidities pediatric patients Operative antegrade intramedullary nail 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 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 avoids difficult of antegrade start point with obesity pregnancy (especially 1st trimester) low radiation exposure to uterus contraindications skeletal immaturity history of knee sepsis soft tissue injury surrounding knee 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 outcomes no difference in union rates and infections rates with acute nailing infection rate does increase if ex-fix left in place >28 days reduced risk of ARDS and fat embolism sydnrome open reduction internal fixation 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 Techniques Long leg cast or hip spica cast hip spica casting typically used in pediatric patients <5 years of age with length stable fractures long leg casting can be used in adult patients who are not surgical candidates need frequent follow-up for skin checks Antegrade intramedullary nail approach 3 cm incision proximal to the greater trochanter in line with the femoral canal technique positioning supine on fracture table perineum well seated against post nonopearative leg in lithotomy bolster important to ensure adequate postioning to allow C-arm maneuvering during case "sloppy" lateral position radiolucent jackson table large bumps placed underneath operative hip places patient in partial decubitus position 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 too lateral starting point can result in varus malalignment ideal starting point is dependent on the relative position of the greater trochanter to the long axis of the femur just lateral to the long axis of the femur entry reamer with soft tissue protector or awl pass ball-tip guidwire to desired depth/length of nail reaming beging with 8.5 to 9 mm reamer increase by 0.5 mm increments 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 femoral rod insertion insert femoral nail with 90° of internal rotation leverages the anterior bow of the nail to direct the tip of the nail into the canal avoids medial comminution with nail contact along medial cortex careful mallet nail to appropriate depth after crossing fracture site interlocking screws technique computer-assisted navigation for screw placement decreases radiation exposure perfect circles technique obtain perfect trajectory of interlock holes with C-arm transducer use the angle of the transducer to guide trajectory of drill 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 reamed nailing has been associated with higher union rates compared to unreamed nailing reaming disrupts endosteal blood supply, but stimulates soft tissue and periosteal blood supply to fracture periosteal and soft tissue blood supply is predominate source after fracture reaming extrudes medullary contents into fracture site autologous bone grafting increased micro emboli to lungs with reaming intraoperative echocardiogram studies have not demonstrated this to be significant mild increases in marrow pressure with reaming greatest increase occurs with nail insertion can be decreased with fluted nails allows canal contents to extrude around the nail reaming allows are a larger diameter nail to be placed larger nail is stiffer and is related to the diameter to the 4th power increases the area of isthmic contact with nail no increase in infection rates after reaming open fractures 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 nail 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 positioned supine on radiolucent table bump under operative hip radiolucent triangle useful for eliminating extension moment of gastrocnemius in distal fragment entry point intercondylar starting 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 trajectory in line with the canal on AP and lateral views medial condylar starting point preserves articular surface requires a curves nail to prevent valgus malalignment entry reamer with soft tissue protecting sleeve pass ball-tip guidewire should end proximal to lesser trochanter ream femoral canal fracture must be reduced to avoid eccentrically reaming the cortex F-tool bumps joysticking with Schanz pins manual traction start with 8.5 mm reamer increase in size by increments of 0.5 mm ream canal 1 to 1.5 mm greater than size of intended implant insert femoral nail should seat ~1 cm deep to articular surface to prevent patellofemoral symptoms place interlocking screws aiming arm used for distal lockings can place first and then mallet the nail to gain compression at fracture with transverse patterns perfect circles technique for proximal interlocks femoral neurovascular bundle safe if screws placed proximal to lesser trochanter postoperative care weight-bearing as tolerated range of motion of knee and hip is encouraged pros technically easier faster operative times quicker OR set-up allows for addressing other injuries surgically without changing patient position less blood loss than antegrade nailing allows for direct comparison of rotation and leg length to nonoperative extemity 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 Open reduction and internal fixation with plate technique submuscular plating less soft tissue stripping than with direct lateral approach preserves periosteal blood supply to fracture direct lateral approach lateral incision in line with femoral shaft incision iliotibial band fascia elevate vastus lateralis from ITB fascia and posterior septum place chandler over anterior cortex to expose lateral femur reduce fracture with traction and reduction forceps fracture fixation can place interfragmentary screw for simple fracture patterns comminuted fractures will require bridge plate 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 usually two-construct fixation 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 single constuct fixation is associated with femoral neck fracture displacement and loss of reduction less preferred methods antegrade nail with screws anterior to nail technically challenging usually done if neck fracture is identified after the femoral shaft fracture has been addressed 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 femoral artery is medial to femur if proximal locking screw is placed proximal to lesser trochanter in retrograde nails 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 femoral rotation = β - α anterversion and external rotation are positive values for equation retroversion and internal rotation are negative values for equation R(β - α) - L(β - α) = relative alignment 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 incomplete healing within 9 months of injury or no evidence of healing on successive radiographs over 3 months 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 broken distal interlock screws can be seen on radiographs race between healing and implant failure is lost distal interlock screws are exposed to the greatest stresses undergo 4-point bending stress results in fracture of the interlock screw in the region inside the nail treatment reamed exchange nailing works by increasing construct stiffness, enhanced isthmic fit, and extrusion of reaming contents to nonunion site plate augmentation with nail retention some studies have demonstrated higher union rates than exchange nailing enables full weight bearing compression plating allows compression of the fracture site bone grafting removal of interposed fibrous material 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 increased cortical hoop stresses with anterior starting points using an anterior start point for a piriformis nail can result in a proximal femur fracture failure to overream canal by at least .5 mm 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 due to mismatch of the radius of curvature of the nail to the radius of curvature of the femur average radius of curvature of human femur is 120 +/- 36 cm starting points that are too posterior (especially piriformis start points) with relatively straight nails
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Femoral Shaft Fracture Antegrade Intramedullary Nailing Andrew Hsu Benjamin C. Taylor Trauma - Subtrochanteric Fractures Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Femoral Shaft Fracture Retrograde Intramedullary Nailing Team Orthobullets (D) Trauma - Femoral Shaft Fractures
QUESTIONS 1 of 66 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 64 65 66 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 (OBQ16.235) A 55-year-old male is involved in a motorcycle crash and sustains a closed, right-sided, midshaft femur fracture. This is an isolated injury. He is treated with retrograde femoral nailing, and post-operatively is noted to have 30 degrees of internal rotation of the operative extremity, when compared with his nonsurgical side. Which of the following is the most likely cause of this malrotation deformity? QID: 8997 Type & Select Correct Answer 1 External rotation of the distal femoral segment relative to the proximal femoral segment during nailing 8% (203/2643) 2 Internal rotation of the proximal femoral segment relative to the distal femoral segment during nailing 6% (152/2643) 3 Iatrogenic decrease in femoral anteversion on the operative leg during nailing 3% (71/2643) 4 Increased contralateral femoral retroversion during surgery 0% (12/2643) 5 Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing 83% (2186/2643) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept (OBQ16.212) A 37-year-old male sustained the injury shown in figure A. He was treated with an intramedurally nail and a post-operative radiograph is shown in figure B. He underwent a post-operative CT Scanogram to assess for rotation. Figures C and D are of the operative side and Figures E and F are of the uninjured side. What is the version of the injured side and should any further procedures be undertaken for correction? QID: 8974 FIGURES: A B C D E F Type & Select Correct Answer 1 Femoral anteversion of 36 degrees, no further procedures required 4% (107/2484) 2 Femoral anteversion of 36 degrees, to undergo femoral de-rotation 28% (690/2484) 3 Neutral version, no further procedures required 48% (1201/2484) 4 Neutral version, to undergo femoral de-rotation 10% (236/2484) 5 Femoral retroversion of 36 degrees, to undergo femoral de-rotation 9% (214/2484) L 4 Question Complexity A 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 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 (OBQ13.201) A radiologist uses CT scans to perform research on rotational malalignment of femoral shaft fractures treated with intramedullary nailing. He determines the angle between a line drawn tangential to the femoral condyles and a line drawn through the axis of the femoral neck. He does this for both the injured and uninjured sides. In Figure A, what malalignment is present for the injured left side compared with the uninjured right side? QID: 4836 FIGURES: A Type & Select Correct Answer 1 Internal rotational malalignment of 13° 42% (1157/2729) 2 External rotational malalignment of 13° 46% (1259/2729) 3 Internal rotational malalignment of 3° 5% (129/2729) 4 External rotational malalignment of 3° 4% (112/2729) 5 No malalignment 1% (39/2729) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept (OBQ13.10) A 35-year-old man is thrown from his vehicle and sustains a left proximal femoral shaft fracture and right distal femoral shaft fracture. The surgeon elects to treat both fractures with reamed intramedullary nailing. Which of the following is true regarding the risk of malrotation? QID: 4645 Type & Select Correct Answer 1 The left femur (proximal fracture) is at increased risk of internal malrotation and the right femur (distal fracture) is at increased risk of external malrotation. 44% (801/1832) 2 The left femur (proximal fracture) is at increased risk of external malrotation and the right femur (distal fracture) is at increased risk of internal malrotation. 35% (633/1832) 3 Malrotation does not depend on fracture location, but whether the nail is placed antegrade or retrograde. 6% (104/1832) 4 Both femora are at increased risk of internal malrotation. 13% (242/1832) 5 Malrotation does not depend on fracture location, but whether the nail uses a piriformis entry point or a trochanteric entry point. 2% (32/1832) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept 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? QID: 4779 FIGURES: A B Type & Select Correct Answer 1 Internally by 20° 15% (495/3341) 2 Externally by 20° 7% (239/3341) 3 Internally by 14° 32% (1076/3341) 4 Externally by 14° 11% (383/3341) 5 Internally by 40° 34% (1124/3341) L 5 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 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3925 FIGURES: A B Type & Select Correct Answer 1 Antegrade cephalomedullary nail 73% (2347/3199) 2 Retrograde intramedullary nail and 3 cannulated screws 7% (219/3199) 3 Retrograde intramedullary nail and sliding hip screw 5% (155/3199) 4 Antegrade intramedullary nail and 3 cannulated screws 9% (303/3199) 5 Plate fixation of the diaphyseal fracture and 3 cancellous screws 5% (154/3199) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept (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? QID: 3917 Type & Select Correct Answer 1 L4 burst fracture 4% (116/3172) 2 Bifrontal cerebral contusion 71% (2253/3172) 3 Open ipsilateral tibia fracture 6% (186/3172) 4 LC1 pelvic ring injury 4% (113/3172) 5 Rib fractures 15% (475/3172) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept (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? QID: 4592 FIGURES: A B C D Type & Select Correct Answer 1 Immediately 67% (3145/4678) 2 4-6 weeks 10% (473/4678) 3 8 weeks 4% (180/4678) 4 12 weeks 4% (175/4678) 5 After consolidation is seen 14% (676/4678) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept (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? QID: 4411 FIGURES: A B Type & Select Correct Answer 1 Closed reduction and percutaneous screw fixation of the femoral neck, followed by reamed antegrade nailing of the femur fracture 5% (348/6460) 2 Reamed antegrade nailing of the femoral shaft fracture, followed by open reduction and percutaneous screw fixation of the femoral neck fracture 4% (263/6460) 3 Reamed retrograde nailing of the femoral shaft fracture, followed by closed reduction and percutaneous screw fixation of the femoral neck 8% (539/6460) 4 Open reduction and screw fixation of the femoral neck, followed by reamed retrograde nailing of the femoral shaft fracture 78% (5044/6460) 5 Open reduction and screw fixation of the femoral neck, followed by plating of the femoral shaft fracture 4% (233/6460) L 2 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 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? QID: 3514 FIGURES: A Type & Select Correct Answer 1 Raising the leg 1% (22/2175) 2 Lowering the leg 1% (28/2175) 3 Internal (or external) rotation of the leg 6% (134/2175) 4 Abduction (or adduction) of the leg 90% (1966/2175) 5 Fluoroscopic magnification 0% (4/2175) 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 (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? QID: 3668 FIGURES: A B Type & Select Correct Answer 1 Anterior to posterior placement above the lesser trochanter 28% (804/2918) 2 Anterior to posterior placement below the lesser trochanter 49% (1420/2918) 3 Lateral to medial placement above the lesser trochanter 8% (226/2918) 4 Lateral to medial placement below the lesser trochanter 15% (439/2918) 5 Open placement with blunt dissection down to bone 0% (11/2918) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept (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? QID: 3533 Type & Select Correct Answer 1 Reduced fluoroscopy time 83% (2148/2588) 2 More reliable placement of interlocking screws through the nail 9% (242/2588) 3 Reduced procedure time 3% (88/2588) 4 Increased quality of fluoroscopic images 1% (14/2588) 5 Improved accuracy of screw length 4% (91/2588) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3100 FIGURES: A Type & Select Correct Answer 1 Ipsilateral acetabular fracture 6% (98/1569) 2 lumbar spine burst fracture 3% (42/1569) 3 Ipsilateral femoral shaft fracture 82% (1286/1569) 4 Anterior-posterior compression pelvic injury 2% (25/1569) 5 Ipsilateral calcaneus fracture 7% (112/1569) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept (OBQ10.256) Which of the following factors is most associated with malrotation during antegrade or retrograde femoral nailing? QID: 3352 Type & Select Correct Answer 1 Surgeon experience 15% (135/889) 2 Level of primary fracture line 5% (47/889) 3 Use of a piriformis starting portal 2% (17/889) 4 Fracture comminution 69% (616/889) 5 Closed reduction technique 8% (67/889) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept (SBQ09TR.83.1) A 32-year-old man is brought to the emergency department after being involved in an MVC. He is found to have a closed left femoral shaft fracture (Figures A and B) and a Glasgow Coma Scale (GCS) score of 13. A CT scan of the head is performed and demonstrates no significant bleeding. He has no other injuries and is hemodynamically stable. Which of the following statements is true? QID: 9109 FIGURES: A B Type & Select Correct Answer 1 Early stabilization of the patient's femur fracture places him at risk for increased pulmonary complications 3% (49/1681) 2 Surgical intervention should be delayed due to the patient's head injury 3% (55/1681) 3 Damage control orthopaedics (DCO) using external fixation is indicated for this patient 14% (242/1681) 4 Early stabilization of the patient's femur fracture does not place the patient at increased risk for worsening neurologic outcomes 76% (1281/1681) 5 A concomitant chest injury would always be a contraindication to early fixation of the patient's femur fracture 3% (47/1681) L 2 Question Complexity C 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 (SBQ09TR.9.1) A 20-year old male was involved in a motor vehicle accident. He is complaining of bilateral leg pain. He has a mean arterial pressure of 80, heart rate of 90, a lactate level of 1.2 mmol/L, and base deficit of 0.5. On physical examination, he has no open wounds and is neurologically intact in both lower extremities. Imaging of the right femur (Figures A and B) and the left femur (Figures C and D) is shown. What is the next best step in treatment? QID: 9089 FIGURES: A B C D Type & Select Correct Answer 1 Skeletal traction and observation until the patient is better resuscitated 9% (188/2165) 2 External fixation of both femurs 10% (209/2165) 3 Plate and screw fixation of both femurs 0% (5/2165) 4 Unreamed antegrade nailing of both femurs 11% (246/2165) 5 Reamed retrograde nailing of both femurs 69% (1502/2165) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept (OBQ09.195) Antegrade femoral nailing has an increased rate of which of the following when compared to retrograde femoral nailing? QID: 3008 Type & Select Correct Answer 1 Varus malalignment 8% (72/926) 2 Union rate 2% (19/926) 3 Operative time 5% (44/926) 4 Subsequent operative procedures 1% (8/926) 5 Hip pain 84% (777/926) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept (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? QID: 2841 Type & Select Correct Answer 1 Heterotopic ossification 1% (35/2574) 2 Ipsilateral femoral neck fracture 95% (2449/2574) 3 Ipsilateral posterolateral corner injury 1% (28/2574) 4 Pudendal nerve injury 1% (20/2574) 5 Ipsilateral superficial femoral artery injury 1% (35/2574) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept (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? QID: 2915 FIGURES: A Type & Select Correct Answer 1 Weakness with hip abduction and knee flexion 5% (41/853) 2 Weakness with hip abduction and knee extension 28% (235/853) 3 Weakness with knee flexion and knee extension 2% (14/853) 4 Weakness with hip external rotation and hip abduction 60% (515/853) 5 Weakness with hip external rotation and hip flexion 5% (46/853) L 4 Question Complexity D 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 (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? QID: 491 FIGURES: A Type & Select Correct Answer 1 Posterior perforation of the distal femur 7% (155/2333) 2 Varus malreduction 2% (48/2333) 3 Comminution of the fracture site 1% (29/2333) 4 Iatrogenic femoral neck fracture 2% (55/2333) 5 Anterior perforation of the distal femur 88% (2045/2333) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept (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? QID: 606 Type & Select Correct Answer 1 Malalignment 1% (20/1478) 2 Pulmonary complications 31% (455/1478) 3 Need for transfusion 2% (36/1478) 4 Iatrogenic fracture 2% (33/1478) 5 Union 63% (930/1478) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept (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? QID: 735 Type & Select Correct Answer 1 It is associated with an increased rate of femoral shaft nonunion 45% (711/1591) 2 It has no effect on the healing time of the posterior wall fracture 31% (496/1591) 3 It is associated with a faster time to union 1% (11/1591) 4 Indomethacin is superior to radiation treatment in the prevention of heterotopic ossification 5% (84/1591) 5 There is a decreased rate of revision surgery needed when indomethacin is administered post-operatively 18% (281/1591) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept (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? QID: 680 Type & Select Correct Answer 1 Increased rate of union 7% (72/1079) 2 Decreased rate of infection 1% (16/1079) 3 Shorter operative time 16% (176/1079) 4 Lower rates of hip pain 73% (789/1079) 5 Lower rates of knee pain 2% (19/1079) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept (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? QID: 855 Type & Select Correct Answer 1 Use of a piriformis entry nail through a greater trochanteric entry portal 65% (533/816) 2 Use of a greater trochanteric entry nail through a piriformis entry portal 16% (129/816) 3 Use of a lateral entry nail through a piriformis entry portal 13% (108/816) 4 Use of a femoral distractor device to obtain reduction 1% (7/816) 5 Use of a fracture table to obtain reduction 4% (34/816) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept (OBQ06.33) The greatest amount of iatrogenic injury to the piriformis tendon is associated with which of the following? QID: 144 Type & Select Correct Answer 1 Antegrade piriformis entry femoral nailing 84% (681/812) 2 Antegrade greater trochanteric entry femoral nailing 7% (59/812) 3 Retrograde femoral nailing 0% (4/812) 4 External fixation of a femoral shaft fracture 0% (4/812) 5 Open reduction and internal fixation of an intertrochanteric fracture 8% (61/812) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept (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? QID: 168 Type & Select Correct Answer 1 Increased risk of post-operative bleeding 6% (56/902) 2 Increased risk of pneumonia 8% (71/902) 3 Decreased IV fluid administration 22% (194/902) 4 Lower Glasgow Coma Scale scores at the time of discharge from hospital 62% (559/902) 5 Improved central nervous system outcomes at the time of discharge from hospital 2% (20/902) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept (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? QID: 150 Type & Select Correct Answer 1 1% 2% (31/1742) 2 10% 33% (569/1742) 3 30% 55% (960/1742) 4 60% 8% (132/1742) 5 75% 2% (35/1742) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept (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? QID: 349 FIGURES: A Type & Select Correct Answer 1 Operative time 16% (102/637) 2 Symptomatic distal interlocking screws 68% (431/637) 3 Hip pain 3% (19/637) 4 Union rate 5% (35/637) 5 Final knee range of motion 7% (44/637) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept (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? QID: 152 FIGURES: A Type & Select Correct Answer 1 Increased operative time 23% (484/2137) 2 Decreased internal malrotation deformities 46% (979/2137) 3 Increased external malrotation deformities 23% (501/2137) 4 Increased pudendal nerve injury 5% (109/2137) 5 Increased need for revision 2% (50/2137) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept (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? QID: 1107 FIGURES: A B C D E F Type & Select Correct Answer 1 Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and casting 2% (16/801) 2 External fixation of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF 1% (5/801) 3 Antegrade nailing of the femur, external fixation of the tibia and ankle after debridement 8% (66/801) 4 Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF 84% (672/801) 5 External fixation of the tibia and femur, and ankle debridement and external fixation 5% (37/801) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept (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? QID: 943 FIGURES: A B C Type & Select Correct Answer 1 Bilateral retrograde femoral nailing and pelvic binder application 2% (33/1788) 2 Bilateral retrograde femoral nailing and anterior pelvic external fixation 4% (79/1788) 3 Bilateral antegrade femoral nailing and pelvic binder application 1% (21/1788) 4 Bilateral femoral external fixation and anterior pelvic external fixation 92% (1638/1788) 5 Bilateral femoral plating and anterior pelvic external fixation 0% (6/1788) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept (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? QID: 1075 FIGURES: A Type & Select Correct Answer 1 Improved placement of screws through the nail into the femoral head 30% (233/766) 2 Decreased risk of varus alignment 20% (150/766) 3 Decreased risk of joint penetration