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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?
External rotation of the distal femoral segment relative to the proximal femoral segment during nailing
Internal rotation of the proximal femoral segment relative to the distal femoral segment during nailing
Iatrogenic decrease in femoral anteversion on the operative leg during nailing
Increased contralateral femoral retroversion during surgery
Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing
Select Answer to see Preferred Response
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?
Femoral anteversion of 36 degrees, no further procedures required
Femoral anteversion of 36 degrees, to undergo femoral de-rotation
Neutral version, no further procedures required
Neutral version, to undergo femoral de-rotation
Femoral retroversion of 36 degrees, to undergo femoral de-rotation
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?
Internal rotational malalignment of 13°
External rotational malalignment of 13°
Internal rotational malalignment of 3°
External rotational malalignment of 3°
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?
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.
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.
Malrotation does not depend on fracture location, but whether the nail is placed antegrade or retrograde.
Both femora are at increased risk of internal malrotation.
Malrotation does not depend on fracture location, but whether the nail uses a piriformis entry point or a trochanteric entry point.
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?
Internally by 20°
Externally by 20°
Internally by 14°
Externally by 14°
Internally by 40°
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?
Antegrade cephalomedullary nail
Retrograde intramedullary nail and 3 cannulated screws
Retrograde intramedullary nail and sliding hip screw
Antegrade intramedullary nail and 3 cannulated screws
Plate fixation of the diaphyseal fracture and 3 cancellous screws
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?
L4 burst fracture
Bifrontal cerebral contusion
Open ipsilateral tibia fracture
LC1 pelvic ring injury
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?
After consolidation is seen
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?
Closed reduction and percutaneous screw fixation of the femoral neck, followed by reamed antegrade nailing of the femur fracture
Reamed antegrade nailing of the femoral shaft fracture, followed by open reduction and percutaneous screw fixation of the femoral neck fracture
Reamed retrograde nailing of the femoral shaft fracture, followed by closed reduction and percutaneous screw fixation of the femoral neck
Open reduction and screw fixation of the femoral neck, followed by reamed retrograde nailing of the femoral shaft fracture
Open reduction and screw fixation of the femoral neck, followed by plating of the femoral shaft fracture
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?
Raising the leg
Lowering the leg
Internal (or external) rotation of the leg
Abduction (or adduction) of the leg
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?
Anterior to posterior placement above the lesser trochanter
Anterior to posterior placement below the lesser trochanter
Lateral to medial placement above the lesser trochanter
Lateral to medial placement below the lesser trochanter
Open placement with blunt dissection down to bone
Which of the following is an advantage of computer-assisted navigation used to place medullary nail interlocking screws compared to a freehand techinque?
Reduced fluoroscopy time
More reliable placement of interlocking screws through the nail
Reduced procedure time
Increased quality of fluoroscopic images
Improved accuracy of screw length
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?
Ipsilateral acetabular fracture
lumbar spine burst fracture
Ipsilateral femoral shaft fracture
Anterior-posterior compression pelvic injury
Ipsilateral calcaneus fracture
Which of the following factors is most associated with malrotation during antegrade or retrograde femoral nailing?
Level of primary fracture line
Use of a piriformis starting portal
Closed reduction technique
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?
Early stabilization of the patient's femur fracture places him at risk for increased pulmonary complications
Surgical intervention should be delayed due to the patient's head injury
Damage control orthopaedics (DCO) using external fixation is indicated for this patient
Early stabilization of the patient's femur fracture does not place the patient at increased risk for worsening neurologic outcomes
A concomitant chest injury would always be a contraindication to early fixation of the patient's femur fracture
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?
Skeletal traction and observation until the patient is better resuscitated
External fixation of both femurs
Plate and screw fixation of both femurs
Unreamed antegrade nailing of both femurs
Reamed retrograde nailing of both femurs
Antegrade femoral nailing has an increased rate of which of the following when compared to retrograde femoral nailing?
Subsequent operative procedures
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?
Ipsilateral femoral neck fracture
Ipsilateral posterolateral corner injury
Pudendal nerve injury
Ipsilateral superficial femoral artery injury
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?
Weakness with hip abduction and knee flexion
Weakness with hip abduction and knee extension
Weakness with knee flexion and knee extension
Weakness with hip external rotation and hip abduction
Weakness with hip external rotation and hip flexion
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?
Posterior perforation of the distal femur
Comminution of the fracture site
Iatrogenic femoral neck fracture
Anterior perforation of the distal femur
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?
Need for transfusion
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?
It is associated with an increased rate of femoral shaft nonunion
It has no effect on the healing time of the posterior wall fracture
It is associated with a faster time to union
Indomethacin is superior to radiation treatment in the prevention of heterotopic ossification
There is a decreased rate of revision surgery needed when indomethacin is administered post-operatively
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?
Increased rate of union
Decreased rate of infection
Shorter operative time
Lower rates of hip pain
Lower rates of knee pain
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?
Use of a piriformis entry nail through a greater trochanteric entry portal
Use of a greater trochanteric entry nail through a piriformis entry portal
Use of a lateral entry nail through a piriformis entry portal
Use of a femoral distractor device to obtain reduction
Use of a fracture table to obtain reduction
The greatest amount of iatrogenic injury to the piriformis tendon is associated with which of the following?
Antegrade piriformis entry femoral nailing
Antegrade greater trochanteric entry femoral nailing
Retrograde femoral nailing
External fixation of a femoral shaft fracture
Open reduction and internal fixation of an intertrochanteric fracture
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?
Increased risk of post-operative bleeding
Increased risk of pneumonia
Decreased IV fluid administration
Lower Glasgow Coma Scale scores at the time of discharge from hospital
Improved central nervous system outcomes at the time of discharge from hospital
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?
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?
Symptomatic distal interlocking screws
Final knee range of motion
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?
Increased operative time
Decreased internal malrotation deformities
Increased external malrotation deformities
Increased pudendal nerve injury
Increased need for revision
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?
Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and casting
External fixation of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF
Antegrade nailing of the femur, external fixation of the tibia and ankle after debridement
Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF
External fixation of the tibia and femur, and ankle debridement and external fixation
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?
Bilateral retrograde femoral nailing and pelvic binder application
Bilateral retrograde femoral nailing and anterior pelvic external fixation
Bilateral antegrade femoral nailing and pelvic binder application
Bilateral femoral external fixation and anterior pelvic external fixation
Bilateral femoral plating and anterior pelvic external fixation
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?
Improved placement of screws through the nail into the femoral head
Decreased risk of varus alignment
Decreased risk of joint penetration
Decreased risk of avascular necrosis of femoral head
Decreased risk of iatrogenic proximal femur fracture
Which of the following has been shown to have similar biochemical and clinical characteristics as iliac crest autograft?
BMP-7 with collagen matrix carrier
Platelet rich plasma with allograft cancellous bone carrier
Femoral intramedullary reaming contents
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?
Hypotension upon initial evaluation
Open skull fractures
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?
Loss of locking screw trajectory into the lesser trochanter
Creation of a recurvatum deformity
Iatrogenic fracture of the proximal fragment
Decrease in hoop stresses