Updated: 1/19/2023

Femoral Shaft Fractures

0%
Topic
Review Topic
0
0
0%
0%
Flashcards
65
N/A
N/A
Questions
71
0
0
0%
0%
Evidence
226
0
0
0%
0%
Videos / Pods
15
0%
0%
Cases
70
0%
Techniques
2
Topic
Images
https://upload.orthobullets.com/topic/1040/images/key image.jpg
https://upload.orthobullets.com/topic/1040/images/anterior bow.jpg
https://upload.orthobullets.com/topic/1040/images/type 0 femoral shaft radiograph.jpg
https://upload.orthobullets.com/topic/1040/images/type 1 radiograph.jpg
https://upload.orthobullets.com/topic/1040/images/type 4 femur fracture radiograph.jpg
  • 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
          • 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
        • CT Capsular Sign
          • a difference of >1mm capsular distension between injured and uninjured sides on the axial soft tissue window
      • 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
        • 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

Please rate this review topic.

You have never rated this topic.

Thank you. You can rate this topic again in 12 months.

Technique Guides (2)
Flashcards (65)
Cards
1 of 65
Questions (71)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(OBQ20.64) A 32-year-old patient presents with the injury depicted in figures A and B after a motorcycle accident. Fracture comminution has been associated with which complication when treating with intramedullary nailing?

QID: 215475
FIGURES:

Increased operative time

3%

(34/1255)

Femoral malrotation

92%

(1149/1255)

Hardware failure

0%

(5/1255)

Varus malalignment

4%

(52/1255)

Anterior cortical perforation

1%

(11/1255)

N/A E

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(SBQ18TR.50) A 32-year-old male sustained a left femoral shaft fracture after a boating accident. He is treated with a retrograde femoral nail with an uncomplicated postoperative course. He presents 11-months postop with persistent thigh pain that is worse with weight-bearing. His current radiographs are demonstrated in figure A. His current ESR and C-reactive protein are 12 mm/hr (reference <20 mm/hr) and 0.9 mg/dL (reference <2.5 mg/dL). What is the best treatment option for this patient?

QID: 211650
FIGURES:

Continued observations

2%

(21/1256)

Placement of an antibiotic nail

0%

(5/1256)

Nail removal with external fixator

1%

(13/1256)

Reamed exchange nailing

96%

(1210/1256)

Nail removal and casting

0%

(2/1256)

L 1 E

Select Answer to see Preferred Response

(OBQ18.241) A 28-year-old male that sustained a closed left femoral shaft fracture 12 months ago and underwent intramedullary nailing presents with persistent pain in the right thigh. The patient walks with an antalgic gait. He denies any fevers or chills. His surgical sites are well healed and there are no signs of drainage. Serum ESR and CRP are 12 mm/hr (reference <20 mm/hr) and 0.9 mg/L (reference <2.5 mg/L), respectively. Figures A and B are the AP and lateral radiographs of the left femur. Which treatment option offers the highest chance of union and enables immediate weight-bearing?

QID: 213137
FIGURES:

Nail removal with compression plating and open bone grafting

8%

(199/2371)

Closed reamed exchange nailing

58%

(1380/2371)

Nail dynamization

9%

(224/2371)

Nail retention with plate augmentation and bone grafting

23%

(549/2371)

Electrical bone stimulator

0%

(6/2371)

L 5 A

Select Answer to see Preferred Response

(OBQ18.70) Which of the following will most likely result with the use of a fracture table when treating the injury shown in Figures A and B?

QID: 212966
FIGURES:

Internal malrotation deformity

64%

(1489/2328)

External malrotation deformity

17%

(407/2328)

Recurvatum deformity

11%

(267/2328)

Varus deformity

5%

(113/2328)

Valgus deformity

2%

(38/2328)

L 4 A

Select Answer to see Preferred Response

(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

External rotation of the distal femoral segment relative to the proximal femoral segment during nailing

8%

(232/3082)

Internal rotation of the proximal femoral segment relative to the distal femoral segment during nailing

5%

(168/3082)

Iatrogenic decrease in femoral anteversion on the operative leg during nailing

3%

(91/3082)

Increased contralateral femoral retroversion during surgery

1%

(16/3082)

Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing

83%

(2554/3082)

L 2 A

Select Answer to see Preferred Response

(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:

Femoral anteversion of 36 degrees, no further procedures required

4%

(118/2981)

Femoral anteversion of 36 degrees, to undergo femoral de-rotation

27%

(802/2981)

Neutral version, no further procedures required

50%

(1501/2981)

Neutral version, to undergo femoral de-rotation

9%

(269/2981)

Femoral retroversion of 36 degrees, to undergo femoral de-rotation

8%

(250/2981)

L 4 A

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
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:

Internal rotational malalignment of 13°

42%

(1239/2963)

External rotational malalignment of 13°

47%

(1379/2963)

Internal rotational malalignment of 3°

5%

(149/2963)

External rotational malalignment of 3°

4%

(119/2963)

No malalignment

1%

(43/2963)

L 4 A

Select Answer to see Preferred Response

(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

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.

45%

(1014/2258)

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.

33%

(756/2258)

Malrotation does not depend on fracture location, but whether the nail is placed antegrade or retrograde.

6%

(125/2258)

Both femora are at increased risk of internal malrotation.

13%

(301/2258)

Malrotation does not depend on fracture location, but whether the nail uses a piriformis entry point or a trochanteric entry point.

2%

(39/2258)

L 4 B

Select Answer to see Preferred Response

Question locked
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:

Internally by 20°

15%

(549/3684)

Externally by 20°

8%

(277/3684)

Internally by 14°

32%

(1187/3684)

Externally by 14°

12%

(425/3684)

Internally by 40°

33%

(1218/3684)

L 1 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
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:

Antegrade cephalomedullary nail

73%

(2573/3506)

Retrograde intramedullary nail and 3 cannulated screws

7%

(234/3506)

Retrograde intramedullary nail and sliding hip screw

5%

(172/3506)

Antegrade intramedullary nail and 3 cannulated screws

9%

(325/3506)

Plate fixation of the diaphyseal fracture and 3 cancellous screws

5%

(177/3506)

L 2 B

Select Answer to see Preferred Response

(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

L4 burst fracture

4%

(126/3500)

Bifrontal cerebral contusion

71%

(2490/3500)

Open ipsilateral tibia fracture

6%

(225/3500)

LC1 pelvic ring injury

4%

(126/3500)

Rib fractures

14%

(500/3500)

L 2 B

Select Answer to see Preferred Response

(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:

Immediately

68%

(3409/4999)

4-6 weeks

10%

(497/4999)

8 weeks

4%

(187/4999)

12 weeks

4%

(179/4999)

After consolidation is seen

14%

(697/4999)

L 4 B

Select Answer to see Preferred Response

(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:

Closed reduction and percutaneous screw fixation of the femoral neck, followed by reamed antegrade nailing of the femur fracture

5%

(367/6786)

Reamed antegrade nailing of the femoral shaft fracture, followed by open reduction and percutaneous screw fixation of the femoral neck fracture

4%

(277/6786)

Reamed retrograde nailing of the femoral shaft fracture, followed by closed reduction and percutaneous screw fixation of the femoral neck

8%

(570/6786)

Open reduction and screw fixation of the femoral neck, followed by reamed retrograde nailing of the femoral shaft fracture

78%

(5291/6786)

Open reduction and screw fixation of the femoral neck, followed by plating of the femoral shaft fracture

4%

(246/6786)

L 2 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
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:

Raising the leg

1%

(32/2489)

Lowering the leg

1%

(35/2489)

Internal (or external) rotation of the leg

7%

(167/2489)

Abduction (or adduction) of the leg

89%

(2224/2489)

Fluoroscopic magnification

0%

(5/2489)

L 1 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
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:

Anterior to posterior placement above the lesser trochanter

27%

(876/3197)

Anterior to posterior placement below the lesser trochanter

48%

(1547/3197)

Lateral to medial placement above the lesser trochanter

8%

(267/3197)

Lateral to medial placement below the lesser trochanter

15%

(477/3197)

Open placement with blunt dissection down to bone

0%

(12/3197)

L 1 B

Select Answer to see Preferred Response

(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

Reduced fluoroscopy time

83%

(2394/2892)

More reliable placement of interlocking screws through the nail

9%

(273/2892)

Reduced procedure time

3%

(98/2892)

Increased quality of fluoroscopic images

1%

(18/2892)

Improved accuracy of screw length

4%

(103/2892)

L 2 C

Select Answer to see Preferred Response

Question locked
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:

Ipsilateral acetabular fracture

6%

(115/1944)

lumbar spine burst fracture

3%

(55/1944)

Ipsilateral femoral shaft fracture

82%

(1599/1944)

Anterior-posterior compression pelvic injury

2%

(35/1944)

Ipsilateral calcaneus fracture

7%

(133/1944)

L 2 B

Select Answer to see Preferred Response

(OBQ10.256) Which of the following factors is most associated with malrotation during antegrade or retrograde femoral nailing?

QID: 3352

Surgeon experience

13%

(155/1170)

Level of primary fracture line

5%

(53/1170)

Use of a piriformis starting portal

2%

(22/1170)

Fracture comminution

72%

(843/1170)

Closed reduction technique

8%

(89/1170)

L 1 B

Select Answer to see Preferred Response

(SBQ09TR.15.1) A 23-year-old male presents following a motorcycle collision with the injury shown in figure 1. In addition to orthogonal radiographs, which of the following studies is best to evaluate for an ipsilateral femoral neck fracture?

QID: 214673
FIGURES:

AP radiograph of the hip in external rotation

3%

(27/921)

AP femur in traction

4%

(38/921)

CT scan with 2-mm cuts

90%

(827/921)

Bone Scan

1%

(7/921)

No additional studies are needed

2%

(21/921)

L 2 C

Select Answer to see Preferred Response

(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:

Early stabilization of the patient's femur fracture places him at risk for increased pulmonary complications

3%

(65/2157)

Surgical intervention should be delayed due to the patient's head injury

3%

(71/2157)

Damage control orthopaedics (DCO) using external fixation is indicated for this patient

13%

(270/2157)

Early stabilization of the patient's femur fracture does not place the patient at increased risk for worsening neurologic outcomes

78%

(1680/2157)

A concomitant chest injury would always be a contraindication to early fixation of the patient's femur fracture

3%

(59/2157)

L 2 C

Select Answer to see Preferred Response

(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