Femoral Shaft Fractures - Trauma

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(OBQ10.12) A 34-year-old male is involved in a motor vehicle collision and sustains several orthopaedic injuries. Figure A shows a red line representating a fracture of the proximal femur. This fracture orientation is most often present when found concomitantly with which of the following orthopaedic injuries? Review Topic

QID: 3100

FIGURES:

A

1

Ipsilateral acetabular fracture

6%

(75/1167)

2

lumbar spine burst fracture

3%

(33/1167)

3

Ipsilateral femoral shaft fracture

82%

(953/1167)

4

Anterior-posterior compression pelvic injury

2%

(20/1167)

5

Ipsilateral calcaneus fracture

7%

(80/1167)

ML 2

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(OBQ09.195) Antegrade femoral nailing has an increased rate of which of the following when compared to retrograde femoral nailing? Review Topic

QID: 3008

1

Varus malalignment

5%

(35/644)

2

Union rate

2%

(11/644)

3

Operative time

4%

(23/644)

4

Subsequent operative procedures

1%

(6/644)

5

Hip pain

88%

(566/644)

ML 1

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PREFERRED RESPONSE 5

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(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? Review Topic

QID: 4645

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.

43%

(605/1409)

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%

(492/1409)

3

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

6%

(87/1409)

4

Both femora are at increased risk of internal malrotation.

13%

(183/1409)

5

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

2%

(26/1409)

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(OBQ13.144) A 23-year-old man undergoes intramedullary nailing for a comminuted right femur fracture. Three weeks after surgery, CT scans are performed to assess for rotational malalignment. In Figure A, the angular rotation of the right femoral neck is internal rotation of 13° while the angular rotation of the left femoral neck is external rotation of 13°. In Figure B, the angular rotation of the right and left femoral condyles is external rotation of 17° and 3°, respectively. At revision surgery, in order to correct the rotational malalignment, the right distal femur must be rotated which of the following? Review Topic

QID: 4779

FIGURES:

A
B

1

Internally by 20°

14%

(407/2871)

2

Externally by 20°

7%

(195/2871)

3

Internally by 14°

33%

(937/2871)

4

Externally by 14°

11%

(317/2871)

5

Internally by 40°

35%

(995/2871)

ML 5

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PREFERRED RESPONSE 5

(OBQ04.188) Placing the starting point for an antegrade femoral nail too anterior to the axis of the medullary canal can most commonly lead to what intraoperative complication? Review Topic

QID: 1293

1

Nail incarceration

4%

(25/602)

2

Loss of locking screw trajectory into the lesser trochanter

3%

(19/602)

3

Creation of a recurvatum deformity

22%

(135/602)

4

Iatrogenic fracture of the proximal fragment

69%

(416/602)

5

Decrease in hoop stresses

0%

(2/602)

ML 2

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PREFERRED RESPONSE 4

(SBQ12TR.10) A 24-year-old male sustains the isolated injuries shown in Figures A and B during a high-speed motor vehicle accident. On physical examination, the overlying skin is intact and there is no evidence of a Morel-Lavallée lesion. Which of the following surgical techniques is considered to have the highest rate of fracture malreduction with this combined injury? Review Topic

QID: 3925

FIGURES:

A
B

1

Antegrade cephalomedullary nail

74%

(2070/2811)

2

Retrograde intramedullary nail and 3 cannulated screws

6%

(181/2811)

3

Retrograde intramedullary nail and sliding hip screw

5%

(135/2811)

4

Antegrade intramedullary nail and 3 cannulated screws

10%

(271/2811)

5

Plate fixation of the diaphyseal fracture and 3 cancellous screws

5%

(135/2811)

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PREFERRED RESPONSE 1

(SBQ12TR.2) A 25-year-old male presents following a motor vehicle collision with a Glasgow Coma Scale of 7. Subsequent imaging in the trauma bay demonstrates a bifrontal cerebral contusion, an L4 burst fracture, multiple rib fractures, an LC-1 type pelvic ring injury, a femoral shaft fracture, and an open ipsilateral tibial shaft fracture. He is intubated and an intracranial pressure monitor is placed which consistently measures 30mm Hg. He is normotensive with a lactate of 1.5 after 2 liters of crystalloid and 1 unit of packed red blood cells. Which of his injuries would most dictate a temporizing approach with external fixation of his femoral shaft fracture instead of reamed intramedullary nailing? Review Topic

QID: 3917

1

L4 burst fracture

4%

(102/2787)

2

Bifrontal cerebral contusion

71%

(1990/2787)

3

Open ipsilateral tibia fracture

6%

(155/2787)

4

LC1 pelvic ring injury

3%

(97/2787)

5

Rib fractures

15%

(413/2787)

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PREFERRED RESPONSE 2

(OBQ05.221) A 20-year-old male is involved in a motorcycle accident and presents with the injuries shown in Figures A-F. The left ankle injury is open medially, with a clean 3cm laceration, and the right femur and tibia are closed. He has no visceral or head injury, and is hemodynamically stable. He is cleared to go to the operating room. Without taking into account order of fixation, how should his injuries be treated? Review Topic

QID: 1107

FIGURES:

A
B
C
D
E
F

1

Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and casting

2%

(11/546)

2

External fixation of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF

1%

(3/546)

3

Antegrade nailing of the femur, external fixation of the tibia and ankle after debridement

8%

(46/546)

4

Retrograde nailing of the femur, intramedullary nailing of the tibia, ankle debridement and ORIF

84%

(457/546)

5

External fixation of the tibia and femur, and ankle debridement and external fixation

5%

(25/546)

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(OBQ05.57) A 32-year-old male sustains a closed head injury, a closed pelvic ring injury, as well as the bilateral open femoral fractures shown in Figures A-C. He remains borderline hypotensive with a base deficit of 4.9 after an exploratory laparatomy and splenectomy. After irrigation and debridement of his open fractures, what is the most appropriate treatment for this patient at this time? Review Topic

QID: 943

FIGURES:

A
B
C

1

Bilateral retrograde femoral nailing and pelvic binder application

2%

(28/1552)

2

Bilateral retrograde femoral nailing and anterior pelvic external fixation

4%

(65/1552)

3

Bilateral antegrade femoral nailing and pelvic binder application

1%

(16/1552)

4

Bilateral femoral external fixation and anterior pelvic external fixation

92%

(1430/1552)

5

Bilateral femoral plating and anterior pelvic external fixation

0%

(6/1552)

ML 1

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PREFERRED RESPONSE 4

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

QID: 3352

1

Surgeon experience

16%

(108/664)

2

Level of primary fracture line

5%

(33/664)

3

Use of a piriformis starting portal

2%

(11/664)

4

Fracture comminution

68%

(454/664)

5

Closed reduction technique

8%

(54/664)

ML 3

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PREFERRED RESPONSE 4

(OBQ06.33) The greatest amount of iatrogenic injury to the piriformis tendon is associated with which of the following? Review Topic

QID: 144

1

Antegrade piriformis entry femoral nailing

83%

(501/601)

2

Antegrade greater trochanteric entry femoral nailing

8%

(47/601)

3

Retrograde femoral nailing

0%

(3/601)

4

External fixation of a femoral shaft fracture

0%

(1/601)

5

Open reduction and internal fixation of an intertrochanteric fracture

8%

(48/601)

ML 1

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PREFERRED RESPONSE 1

(OBQ04.204) Which of the following variables has not been shown to be increased in patients who sustain bilateral femoral shaft fractures as compared to patients with unilateral femoral shaft fractures? Review Topic

QID: 1309

1

Hypotension upon initial evaluation

7%

(40/604)

2

Mortality

8%

(47/604)

3

Rib fractures

40%

(242/604)

4

Open skull fractures

36%

(218/604)

5

Pelvic fractures

9%

(53/604)

ML 5

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PREFERRED RESPONSE 3

(OBQ07.19) Your 25-year-old patient complains of anterior knee pain after retrograde femoral nailing for a diaphyseal fracture and asks you why you didn’t perform antegrade nailing as he has seen on the internet. You tell him that retrograde nailing is your preferred technique over antergrade nailing for diaphyseal femoral fractures because it has been shown to have which of the following? Review Topic

QID: 680

1

Increased rate of union

7%

(47/696)

2

Decreased rate of infection

2%

(11/696)

3

Shorter operative time

15%

(101/696)

4

Lower rates of hip pain

74%

(516/696)

5

Lower rates of knee pain

2%

(17/696)

ML 2

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PREFERRED RESPONSE 4

(OBQ07.194) Postoperative varus alignment of a subtrochanteric femur fracture treated with an intramedullary nail has been shown to be related to which of the following factors? Review Topic

QID: 855

1

Use of a piriformis entry nail through a greater trochanteric entry portal

64%

(352/546)

2

Use of a greater trochanteric entry nail through a piriformis entry portal

15%

(82/546)

3

Use of a lateral entry nail through a piriformis entry portal

15%

(81/546)

4

Use of a femoral distractor device to obtain reduction

1%

(7/546)

5

Use of a fracture table to obtain reduction

4%

(22/546)

ML 3

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PREFERRED RESPONSE 1

(OBQ12.232) A 22-year-old male sustains the injury seen in Figures A and B as the result of a motor vehicle collision. He subsequently undergoes the procedure shown in Figures C and D with a 12 millimeter nail. When would full weight-bearing be allowed after surgery? Review Topic

QID: 4592

FIGURES:

A
B
C
D

1

Immediately

67%

(2863/4273)

2

4-6 weeks

10%

(430/4273)

3

8 weeks

4%

(167/4273)

4

12 weeks

4%

(157/4273)

5

After consolidation is seen

15%

(630/4273)

ML 4

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PREFERRED RESPONSE 1

(OBQ06.57) A trauma patient presents with a major head injury and femoral shaft fracture. He undergoes early fixation of the femur fracture with a prolonged period of intraoperative hypotension. What is the most likely outcome to be expected post-operatively in this patient? Review Topic

QID: 168

1

Increased risk of post-operative bleeding

6%

(41/703)

2

Increased risk of pneumonia

7%

(49/703)

3

Decreased IV fluid administration

27%

(191/703)

4

Lower Glasgow Coma Scale scores at the time of discharge from hospital

58%

(405/703)

5

Improved central nervous system outcomes at the time of discharge from hospital

2%

(17/703)

ML 4

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PREFERRED RESPONSE 4

(OBQ12.51) A 34-year-old male presents after falling off a roof at his job. He has an obvious deformity of his left lower extremity, and injury radiographs are shown in Figures A and B. He has no other injuries. Which of the following definitive treatment algorithms will most likely lead to the best outcomes in this patient? Review Topic

QID: 4411

FIGURES:

A
B

1

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

5%

(332/6064)

2

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

4%

(236/6064)

3

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

8%

(491/6064)

4

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

78%

(4754/6064)

5

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

4%

(220/6064)

ML 2

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PREFERRED RESPONSE 4

(OBQ09.28) A 29-year-old male sustained a mid-shaft femur fracture in a motorcycle accident. Which of the following is associated with approximately 5% of patients sustaining this injury? Review Topic

QID: 2841

1

Heterotopic ossification

1%

(21/2261)

2

Ipsilateral femoral neck fracture

96%

(2168/2261)

3

Ipsilateral posterolateral corner injury

1%

(22/2261)

4

Pudendal nerve injury

1%

(18/2261)

5

Ipsilateral superficial femoral artery injury

1%

(27/2261)

ML 1

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PREFERRED RESPONSE 2

(OBQ05.189) A patient undergoes the treatment seen in Figure A for a displaced intertrochanteric femoral fracture. With use of this construct, a starting point 3 mm anterior to the center of the piriformis fossa has which of the following benefits? Review Topic

QID: 1075

FIGURES:

A

1

Improved placement of screws through the nail into the femoral head

32%

(191/596)

2

Decreased risk of varus alignment

19%

(113/596)

3

Decreased risk of joint penetration

2%

(14/596)

4

Decreased risk of avascular necrosis of femoral head

22%

(131/596)

5

Decreased risk of iatrogenic proximal femur fracture

24%

(143/596)

ML 4

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PREFERRED RESPONSE 1

(OBQ09.102) A 26-year-old male sustains a femoral shaft fracture treated with the implant shown in Figure A. Postoperatively, what muscular deficits can be expected at medium and long-term follow-up? Review Topic

QID: 2915

FIGURES:

A

1

Weakness with hip abduction and knee flexion

5%

(32/614)

2

Weakness with hip abduction and knee extension

29%

(177/614)

3

Weakness with knee flexion and knee extension

1%

(8/614)

4

Weakness with hip external rotation and hip abduction

59%

(364/614)

5

Weakness with hip external rotation and hip flexion

5%

(32/614)

ML 4

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PREFERRED RESPONSE 2

(OBQ06.39) In patients with ipsilateral femoral neck and shaft fractures, what percent of femoral neck fractures are diagnosed on a delayed basis if fine cut CT is not utilized? Review Topic

QID: 150

1

1%

(19/1500)

2

10%

31%

(472/1500)

3

30%

57%

(855/1500)

4

60%

7%

(109/1500)

5

75%

2%

(28/1500)

ML 3

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PREFERRED RESPONSE 3

(OBQ08.105) A 38-year-old male was struck by a truck and sustained the injury seen in figure A. Treating this injury with an intramedullary nail with a larger radius of curvature can lead to what complication? Review Topic

QID: 491

FIGURES:

A

1

Posterior perforation of the distal femur

7%

(126/1926)

2

Varus malreduction

2%

(38/1926)

3

Comminution of the fracture site

1%

(23/1926)

4

Iatrogenic femoral neck fracture

3%

(49/1926)

5

Anterior perforation of the distal femur

88%

(1689/1926)

ML 1

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PREFERRED RESPONSE 5

(OBQ08.220) Reamed femoral intramedullary nailing is associated with a higher rate of which of the following, as compared to nonreamed nailing for distal femoral shaft fractures? Review Topic

QID: 606

1

Malalignment

1%

(16/1236)

2

Pulmonary complications

30%

(365/1236)

3

Need for transfusion

2%

(29/1236)

4

Iatrogenic fracture

2%

(29/1236)

5

Union

64%

(793/1236)

ML 3

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(OBQ06.163) A 33-year-old female sustains the injury shown in Figure A. Compared to antegrade nailing of this injury, retrograde nailing has been shown to have an increased amount of which of the following? Review Topic

QID: 349

FIGURES:

A

1

Operative time

17%

(73/429)

2

Symptomatic distal interlocking screws

67%

(286/429)

3

Hip pain

3%

(13/429)

4

Union rate

6%

(24/429)

5

Final knee range of motion

7%

(32/429)

ML 3

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PREFERRED RESPONSE 2

(OBQ05.132) Which of the following has been shown to have similar biochemical and clinical characteristics as iliac crest autograft? Review Topic

QID: 1018

1

BMP-2

11%

(69/609)

2

BMP-7 with collagen matrix carrier

11%

(70/609)

3

Hydroxyapatite cement

5%

(29/609)

4

Platelet rich plasma with allograft cancellous bone carrier

6%

(37/609)

5

Femoral intramedullary reaming contents

66%

(401/609)

ML 3

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PREFERRED RESPONSE 5

(OBQ11.245) A 22-year-old male undergoes retrograde intramedullary nailing for the injury seen in Figure A. Which of the following would place branches of the femoral nerve and deep femoral artery at greatest risk during placement of the interlocking screw seen in Figure B? Review Topic

QID: 3668

FIGURES:

A
B

1

Anterior to posterior placement above the lesser trochanter

27%

(647/2432)

2

Anterior to posterior placement below the lesser trochanter

51%

(1229/2432)

3

Lateral to medial placement above the lesser trochanter

7%

(178/2432)

4

Lateral to medial placement below the lesser trochanter

15%

(358/2432)

5

Open placement with blunt dissection down to bone

0%

(9/2432)

ML 4

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PREFERRED RESPONSE 2

(OBQ11.91) A 25-year-old male sustained a closed midshaft femur fracture following a motor vehicle collision. He is taken to the operating room for supine intramedullary nail fixation of the fracture. Figure A is a lateral fluoroscopic view of the distal femur taken just prior to distal interlocking screw placement. What change in position (with the C-arm stationary) would be expected to produce a perfect lateral view of the interlocking hole? Review Topic

QID: 3514

FIGURES:

A

1

Raising the leg

1%

(22/1819)

2

Lowering the leg

1%

(20/1819)

3

Internal (or external) rotation of the leg

5%

(98/1819)

4

Abduction (or adduction) of the leg

91%

(1661/1819)

5

Fluoroscopic magnification

0%

(4/1819)

ML 1

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PREFERRED RESPONSE 4

(OBQ11.110) Which of the following is an advantage of computer-assisted navigation used to place medullary nail interlocking screws compared to a freehand techinque? Review Topic

QID: 3533

1

Reduced fluoroscopy time

84%

(1812/2159)

2

More reliable placement of interlocking screws through the nail

9%

(193/2159)

3

Reduced procedure time

3%

(70/2159)

4

Increased quality of fluoroscopic images

1%

(12/2159)

5

Improved accuracy of screw length

3%

(68/2159)

ML 1

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PREFERRED RESPONSE 1

(OBQ07.74) A 26-year-old male presents after a motor vehicle accident. Work-up reveals a closed left femoral shaft fracture, and an ipsilateral posterior wall fracture. He undergoes intramedullary nailing of the femur, and open reduction internal fixation of the posterior wall. He is treated with 25 mg of indomethacin three times daily for 6 weeks following an initial dose on the evening of surgery for heterotopic ossification prophylaxis. Which of the following is true regarding this post-operative treatment protocol? Review Topic

QID: 735

1

It is associated with an increased rate of femoral shaft nonunion

47%

(509/1077)

2

It has no effect on the healing time of the posterior wall fracture

30%

(327/1077)

3

It is associated with a faster time to union

1%

(8/1077)

4

Indomethacin is superior to radiation treatment in the prevention of heterotopic ossification

5%

(49/1077)

5

There is a decreased rate of revision surgery needed when indomethacin is administered post-operatively

17%

(183/1077)

ML 3

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PREFERRED RESPONSE 1

(OBQ06.41) A 22-year-old male sustains the injury shown in Figure A. When placing an antegrade intramedullary nail with manual traction in a supine position, which of the following is true when compared to placement of a nail using a fracture table? Review Topic

QID: 152

FIGURES: