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A 25-year-old male is a driver in a motor vehicle accident and sustains the isolated closed injury seen in Figures A and B. He is treated with an intramedullary nail, and postoperative radiographs are shown in Figures C and D. Which of the statements concerning reaming and nails is true?
Unreamed tibias have the highest amount of mineral apposition rates
Unreamed tibias result in the highest amount of new bone formation
Unreamed nails result in the lowest porosity of bone
Reamed and unreamed tibias have similar mineral apposition rates
Tight nails results in higher cortical reperfusion than loose nails
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Which of the following factors has been shown in a clinical trial to be equivalent to autologous bone graft for treatment of tibial nonunions that were treated with intramedullary nailing?
Demineralized bone matrix
Cancellous bone allograft chips
Which of the following types of nonunions is most likely to achieve union following a reamed exchange intramedullary nailing only?
Distal femoral nonunion with less than 10% bone loss
Infected nonunion of the femoral shaft
Mid-diaphyseal humeral nonunion with less than 10% bone width loss
Proximal humeral shaft nonunion with less than 10% bone width loss
Diaphyseal tibial shaft nonunion with less than 30% cortical width bone loss
A 35-year-old male suffers the injury seen in Figures A and B following a motor vehicle collision. He is initially taken to a local hospital. The treating surgeon, concerned that his hospital does not have a plastic surgeon available for soft-tissue coverage, arranges for transfer of the patient to a nearby level I trauma center for definitive care. Upon arrival at the definitive treatment center, the patient is taken for formal debridement and external fixator application. Which of the following options has the greatest effect on this patient's risk of infection?
External fixator application
Operative debridement within 6 hours
TIme to transfer to definitive trauma center
Soft-tissue coverage within 48 hours
Which of the following is true regarding the center of rotation of angulation (CORA) as it refers to tibial diaphyseal angular deformity?
It is the point at which the proximal mechanical axis and distal mechanical axis meet
It is the point at which the proximal anatomical axis and proximal mechanical axis meet
It is always the point on the cortex at the most concave portion of the deformity
It is the point at which the distal anatomical axis and distal mechanical axis meet
It is always the point on the cortex at the most convex portion of the deformity
A 45-year-old female pedestrian is hit by an automobile. A clinical photo and radiograph are shown in Figure A and B. What is the most important factor in a surgeon's decision of determining between limb salvage and amputation?
Level of education
Lack of plantar sensation
Contralateral lower extremity open fracture(s)
Severity of soft tissue injury
Amount of tibial bone loss
A 67-year-old male is involved in a motor vehicle accident and presents with the closed orthopedic injuries shown in Figures A and B. He is also noted to have a grade 1 splenic laceration and lung contusion. He is cleared by the trauma team, and undergoes early total care with reamed femoral and tibial nailing. A tourniquet is used for the tibial nailing portion of the case, and the tibial isthmus is over reamed to accept a larger nail. The use of a tourniquet in this case has been most clearly shown to be associated with which of the following?
Tibia shaft necrosis post-operatively
Increased pulmonary morbidity post-operatively
Increased cortical bone temperature during reaming
Increased nonunion rates
Decreased pain post-operatively
A 35-year-old male patient sustains a twisting injury to his leg while playing soccer. Radiographs are seen in Figures A and B. You decide to treat this fracture with intramedullary nailing. In order to prevent a missed injury that should be addressed during the same surgery, you order the following test
MRI of the ipsilateral knee
MRI of the ipsilateral hip
CT scan of the ipsilateral knee
Radiographs of the ipsilateral ankle
Axial radiograph of the ipsilateral calcaneus
A 25-year-old male pedestrian sustained a Type II open tibia fracture after being struck by a car at 10:00PM. He was transported to a Level I trauma hospital where he was given intravenous antibiotics and tetanus at 10:45PM. He underwent irrigation and debridement of the wound with 9L of saline solution and was treated with reamed intramedullary nail fixation at 11:45PM. A vacuum assisted dressing was placed over a 5x3cm skin deficit. What part of his overall treatment has shown to reduce the risk of infection THE MOST at the site of injury?
Early tetanus administration
Early intravenous antibiotic administration
Reamed intramedullary nail fixation
Irrigation and debridement of the open fracture with 9L of solution
Vacuum assisted dressings over skin deficit
Which of the following fracture patterns is classically associated with varus malunion if treated with closed reduction and casting?
A 27-year-old female sustains a twisting injury to her leg while rollerblading. Radiographs of the tibia and fibula are provide in Figures A and B. A closed reduction is performed and the patient is placed in a long leg cast. Radiographs following cast placement are provided in Figures C and D. The decision is made to proceed with closed treatment instead of operative. Which of the following is most likely to occur with nonoperative management?
Malunion due to unacceptable coronal alignment
Malunion due to unacceptable sagittal alignment
Fracture displacement due to the mechanism of injury
Fracture displacement due to the age of the patient
Shortening due to the oblique nature of the tibia fracture
Which of the following nonunions is appropriately treated with exchange reamed nailing without bone graft augmentation?
Infected tibial shaft nonunion 6 months status post intramedullary nail fixation
Oligotrophic humeral shaft nonunion 7 months status post non-operative management
Hypertrophic tibial shaft nonunion 7 months status post intramedullary nail fixation
Comminuted open tibial shaft nonunion with segmental bone loss 8 months status post intramedullary nail fixation
Supracondylar femoral shaft nonunion 6 months status post intramedullary nail fixation with 4 distal locking screws
Percutaneous placement of a lateral proximal tibial locking plate that extends down to the distal third of the leg is associated with postoperative decreased sensation of which of the following distributions?
First dorsal webspace
A 45-year-old male presents with the fracture seen in Figures A and B after a motor vehicle collision. After debridement and external fixation, he is taken to the operating room for definitive soft tissue flap coverage and intramedullary nailing. Administration of recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) at the time of fracture fixation will lead to which of the following?
Decreased risk of subsequent bone grafting procedures
Shorter hospital stay
Increased blood loss
Decreased risk of angular deformity at final union
Increased risk of deep vein thrombosis
A 21-year-old male undergoes intramedullary nailing of the closed tibial shaft fracture shown in Figure A. At his 6-week follow-up, he is noted to have peroneal nerve deficits that were not present preoperatively. Which of the following findings is most consistent with a diagnosis of transient peroneal nerve neurapraxia as the result of his intramedullary nailing?
Decreased lateral hindfoot sensation
Decreased Achilles reflex
Decreased peroneus longus strength
Decreased extensor hallucis longus strength
Decreased plantar forefoot sensation
When discussing treatment options with a 35-year-old healthy male with an isolated, closed tibial shaft fracture, the surgeon should inform him that in comparison to closed treatment, the advantages of intramedullary nail fixation include all of the following EXCEPT?
Quicker time to union
Decreased risk of malunion
Decreased risk of compartment syndrome
Decreased risk of shortening
Quicker return to work
A 36-year-old male is brought to the trauma center following a motor vehicle accident. Physical exam shows a deformed left lower extremity with a 1-cm open wound over the anterolateral aspect of his leg. Radiographs are provided in Figures A and B. Which of the following interventions has been shown in the literature to decrease the occurrence of infection at the fracture site?
Operative debridement within 6 hours of injury
Immediate prophylactic antibiotic administration
Immediate stabilization with internal fixation after debridement
Irrigating with a saline solution that is mixed with an antibiotic
Irrigating with high pressure pulsatile lavage following surgical debridement
A 30-year-old man presents with a distal third tibia fracture that has healed in 25 degrees of varus alignment. The patient is at greatest risk of developing which of the following conditions as a result of this malunion?
Degenerative lumbar spine changes
Ipsilateral ankle pain and stiffness
Ipsilateral hip joint degenerative changes
Contralateral hip joint degenerative changes
Ipsilateral medial knee degenerative changes
A 21-year-old male sustains the open injury shown in Figure A, which is associated with a 12 centimeter laceration over the fracture site. This laceration is able to be closed during initial surgery. What adjunct treatment has been shown to improve outcomes when using an intramedullary nail?
Adjunctive fracture plating
Antibiotic impregnated cement beads
A 56-year-old male sustains a Type IIIB open, comminuted tibial shaft fracture distal to a well-fixed total knee arthroplasty that is definitively treated with a free flap and external fixation. Nine months after fixator removal, he presents with a painful oligotrophic nonunion. Laboratory workup for infection is negative. Passive knee range of motion is limited to 15 degrees. What is the most appropriate treatment for his nonunion?
Knee manipulation under anesthesia
Cast immobilization and use of a bone stimulator
Unilateral external fixation
A 42-year-old male sustains a left leg injury as the result of a high-speed motor vehicle collision. Physical exam reveals a grossly deformed left leg with a 1 centimeter open wound over the anterolateral aspect of his tibia; no gross neurovascular deficits are noted. Injury radiographs are shown in Figures A and B. He undergoes immediate tibial nailing with debridement and primary closure of his traumatic wound. Which of the following is the Gustilo-Anderson classification for his fracture?
A 54-year-old female sustains a communited tibial shaft fracture from an accident at work. She undergoes simultaneous external fixation and ORIF using minimally invasive plate osteosynthesis. Following surgery, she complains of numbness along the dorsum of her medial and lateral foot. In which location (labeled A - E) on Figure A did percutaneous placement without careful dissection of a pin/screw likely cause her nerve injury?
Intramedullary nailing of proximal tibial shaft fractures are technically demanding, and use of an extended medial parapatellar incision with a semiextended technique can prevent what common deformity at the fracture site?
Isolated exchange reamed interlocking nailing is most likely indicated as the next step in treatment for which of the following clinical scenarios:
Tibial shaft nonunion with a 4cm bone defect
Infected tibial shaft nonunion
Hypertrophic diaphyseal tibial nonunion
Atrophic tibial shaft nonunion
Hypertrophic metadiaphyseal distal tibia nonunion
A 32-year-old male sustains the closed injury shown in Figure A. He undergoes reamed intramedullary nailing 4 hours after his injury. Postoperative images are shown in Figures B and C. Compared to unreamed nailing, reamed nailing of this injury has been associated with which of the following?
Decreased infection rate
Increased need for additional surgeries to obtain union
Increased infection rates
Decreased time to union
Increased compartment syndrome rate
Which of the following tibial injuries is most commonly treated with staged open reduction and internal fixation with free flap soft tissue reconstruction?
Type IIIB intra-articular distal tibia fracture
Type IIIB segmental midshaft tibia fracture
Type IIIB transverse midshaft tibia fracture
Type IIIB Schatzker I proximal tibia fracture
Type IIIC Schatzker IV proximal tibia fracture
A 32-year-old male sustains the injury shown in Figure A and undergoes treatment as shown in Figure B. Following placement of this implant, what is the best technique to confirm it is not too proud proximally?
Lateral radiograph of the knee
AP radiograph of the knee
Oblique radiographs of the knee
Merchant radiograph of the knee
Internally rotated 45 degree view of the knee
A 40-year-old woman is involved in motorcycle accident 2 hours ago and sustains an isolated right leg injury shown in Figure A. She has dopplerable posterior tibial and dorsalis pedis artery signals with less than 2 second capillary refill as shown in Figure B. Sensation is intact in the distribution of the tibial nerve but decreased in the distribution of the peroneal nerve. She is cleared by the general surgery trauma team to go to the operating room for treatment of her leg. What is the most appropriate Gustilo classification and initial treatment for her injury?
Gustilo 3A with spanning external fixation and delayed definitive fixation with soft tissue coverage
Gustilo 3A with immediate medial and lateral plating followed by delayed soft tissue coverage
Gustilo 3B with spanning external fixation and delayed definitive fixation with soft tissue coverage
Gustilo 3B with immediate medial and lateral plating followed by delayed soft tissue coverage
Gustilo 3C with spanning external fixation and delayed definitive fixation with soft tissue coverage
A 25-year-old man is struck by car while crossing the street. His injuries include the closed left tibial shaft fracture shown in Figure A. He is a smoker, but is otherwise healthy. Intramedullary nailing is performed without initial complications. Which of the following puts this patient at greatest risk for tibial nonunion?
Use of anti-inflammatories post-operatively
Post-operative gapping at the fracture site
Presence of an associated fibular fracture
History of smoking
Mechanism of injury
What percentage of patients will complain of knee pain at the time of union of a tibial shaft fracture treated with a reamed intramedullary nail?
A 35-year-old male has a closed mid-shaft tibia fracture following a skiing accident. You have recommended intramedullary nailing of the tibia. What is the most common complication he must be advised about?
anterior knee pain
A 30-year-old patient sustains a comminuted tibia fracture and is treated with minimally invasive plating, shown in Figure A. The patient returns to the office 2 weeks after the surgery and reports persistent numbness over most of the dorsum of the foot, but motor exam is normal. What is the most likely explanation?
unrecognized compartment syndrome
common peroneal nerve injury
superficial peroneal nerve injury
sural nerve injury
tibial nerve injury
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HPI - The patient suffered an open tibial fracture 12 weeks ago.
He underwent application of an external fixator for 5 days following the injury for damage control, followed by ORIF with Titanium LCP + fibular plating (XRays shown).
The patient is now 12 weeks post-op. He is still experiencing significant pain in his leg. An XRay and CT scan show minimal callus at the fracture site.
How would you manage this patient at this point?
HPI - 20 male patient presents following a segmented tibial fracture, sustained in a motorcycle accident 1 year ago.
The fracture was treated with ORIF with plate and screws at another institution (XRays shown).
The patient had skin problems with exposed plate at approximately 8 months post-op
I removed the plates on the tibia and one fibula plate for dynamization and I used a monolateral external fixator.
Now, the skin and bone look like this after 2 months due to surgery.
How would you suggest managing this patient?
HPI - Pain in the upper leg for the past 10 days, severe pain which increases with activity, not relieved by rest.
History of fracture 2.5 years ago for which surgery was done (at an outside hospital) and recovery was quite uneventful.
Patient now has suddenly developed this problem.
What is the next best step in management?