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Introduction
  • Proximal third-tibia fractures 
  • Epidemiology
    • most common long bone fx
    • account for 4% of all fx seen in the Medicare population
  • Mechanism
    • low energy fx pattern
      • result of torsional injury
      • indirect trauma results in spiral fx
      • fibula fx at different level
      • Tscherne grade 0 / I soft tissue injury
    • high energy fx pattern
      • direct forces often result in wedge or short oblique fx and sometimes significant comminution
      • fibula fx at same level
      • severe soft tissue injury
        • Tscherne II / III
        • open fx
  • Associated conditions
    • soft tissue injury (open wounds)
      • critical to outcome
    • compartment syndrome
    • bone loss
    • ipsilateral skeletal injury
      • extension to the tibial plateau or plafond
      • posterior malleolar fracture
        • most commonly associated with spiral distal third tibia fracture
Classification
 
Oestern and Tscherne Classification of Closed Fractuer Soft Tissue Injury
Grade 0 Injuries from indirect forces with negligible soft-tissue damage
Grade I Superficial contusion/abrasion, simple fractures
Grade II
Deep abrasions, muscle/skin contusion, direct trauma, impending compartment syndrome
Grade III
Excessive skin contusion, crushed skin or destruction of muscle, subcutaneous degloving, acute compartment syndrome, and rupture of major blood vessel or nerve
 

Gustilo-Anderson Classification of Open Tibia Fractures
Type I Limited periosteal stripping, clean wound < 1 cm
Type II Mild to moderate periosteal stripping, wound >1 cm in length

Type IIIA Significant soft tissue injury (often evidenced by a segmental fracture or comminution), significant periosteal stripping, wound usually >5cm in length, no flap required 

Type IIIB Significant periosteal stripping and soft tissue injury, flap required due to inadequate soft tissue coverage (STSG doesn't count). Treat proximal 1/3 fxs with gastrocnemius rotation flap, middle 1/3 fxs with soleus rotation flap, distal 1/3 fxs with free flap.
Type IIIC Significant soft tissue injury (often evidenced by a segmental fracture or comminution), vascular injury requiring repair to maintain limb viability
 For prognostic reasons, severely comminuted, contaminated barnyard injuries, close range shotgun/high velocity gunshot injuries, and open fractures presenting over 24 hours from injury have all been later included in the grade III group.
 
Presentation
  • Symptoms
    • pain, inability to bear weight, deformity
  • Physical exam
    • inspection and palpation
      • deformity / angulation / malrotation
      • contusions
      • blisters
      • open wounds
      • compartments
        • palpation
        • pain
        • passive motion of toes
        • intracompartmental pressure measurement if indicated (i.e., sedated or intubated)
    • neurologic
      • deep peroneal n.
      • superficial peroneal n.
      • sural n.
      • tibial n.
      • saphenous n.
    • pulse
      • dorsalis pedis
      • posterior tibial
        • be sure to check contralateral side
Imaging
  • Radiographs
    • recommended views
      • full length AP and lateral views of affected tibia
      • AP, lateral and oblique views of ipsilateral knee and ankle
  • CT
    • indications
      • intra-articular fracture extension or suspicion of joint involvement
      • CT ankle for spiral distal third tibia fracture  
        • to exclude posterior malleolar fracture
Treatment of Closed Tibia Fractures
  • Nonoperative
    • closed reduction / cast immobilization 
      • indications
        • closed low energy fxs with acceptable alignment
          • < 5 degrees varus-valgus angulation
          • < 10 degrees anterior/posterior angulation
          • > 50% cortical apposition
          • < 1 cm shortening
          • < 10 degrees rotational malalignment
          • if displaced perform closed reduction under general anesthesia
        • certain patients who may be non-ambulatory (ie. paralyzed), or those unfit for surgery 
      • technique
        • place in long leg cast and convert to functional (patellar tendon bearing) brace at 4 weeks
      • outcomes
        • high success rate if acceptable alignment maintained
        • risk of shortening with oblique fracture patterns 
          • mean shortening is 4 mm
        • risk of varus malunion with midshaft tibia fractures and an intact fibula 
        • non-union occurs in 1.1% of patients treated with closed reduction
  • Operative
    • external fixation
      • indications
        • can be useful for proximal or distal metaphyseal fxs
      • complications 
        • pin tract infections common
      • outcomes
        • higher incidence of malalignment compared to IM nailing
    • IM Nailing
      • indications
        • unacceptable alignment with closed reduction and casting
        • soft tissue injury that will not tolerate casting
        • segmental fx
        • comminuted fx
        • ipsilateral limb injury (i.e., floating knee)
        • polytrauma
        • bilateral tibia fx
        • morbid obesity
      • contraindications
        • pre-existing tibial shaft deformity that may preclude passage of IM nail
        • previous TKA or tibial plateau ORIF (not strict contraindication)
      • outcomes
        • IM nailing leads to (versus external fixation) 
          • decreased malalignment
        • IM nailing leads to (versus closed treatment) 
          • decrease time to union
          • decreased time to weight bearing
        • reamed vs. unreamed nails 
          • reamed possibly superior to unreamed nails for treatment of closed tibia fxs for decrease in future bone grafting or implant exchange (SPRINT trial)
          • recent studies show no adverse effects of reaming (infection, nonunion)
          • reaming with use of a tourniquet is NOT associated with thermal necrosis of the tibial shaft 
    • percutaneous locking plate 
      • indications
        • proximal tibia fractures with inadequate proximal fixation from IM nailing
        • distal tibia fractures with inadequate distal fixation from IM nail
      • complications
        • non-union and delayed union 
        • wound infection and dehiscence
        • long plates may place superficial peroneal nerve at risk q q
      • Percutaneous plate shown to have (versus infrapatellar IMN) q
        • Equivalent time to union
        • Greater radiation exposure
        • Longer surgical duration
        • Lower postoperative pain scores
        • More difficulty in hardware removal
Treatment of Open Tibia Fractures
  • Operative
    • antibiotics, I&D
      • indications
        • all open fractures require an emergent I&D
      • timing of I&D
        • surgical debridement 6-8 hours after time of injury is preferred 
        • grossly contaminated wounds are irrigated in emergency department
      • antibiotics
        • standard abx for open fractures (institution dependent)
          • cephalosporin given for 24-48 hours in Grade I,II, and IIIA open fractures
          • aminoglycoside added in Grade IIIB injuries 
            • minimal data to support this
          • penicillin administered in farm injuries
            • minimal data to support this
        • tetanus prophylaxis
      • outcomes
        • early antibiotic administration is the most important factor in reducing infection 
        • emergent and thorough surgical debridement is also an important factor 
        • must remove all devitalized tissue including cortical bone
    • external fixation
      • indications
        • provisional external fixation an option for open fractures with staged IM nailing or plating
        • falling out of favor in last decade
        • indicated in children with open physis
    • IM Nailing 
      • indications
        • most open fx can be treated with IM nail within 24 hours
        • contraindicated in children with open physis (use flexible nail, plate, or external fixation instead)
      • outcomes for open fxs
        • IM nailing vs. external fixation
          • no difference with respect to
            • infection rate
            • union rate
            • time to union
          • IM nailing superior with respect to
            • decreased malalignment
            • decreased secondary surgeries
            • shorter time to weight bearing
        • reamed nails vs. unreamed nails
          • reaming does not negatively affect union, infection, or need for additional surgeries in open tibia fractures     
          • gapping at the fracture site is greatest risk for non-union 
            • transverse fx pattern and open fractures also at increased risk for non-union
        • rhBMP-2 
          • prior studies have shown use in open tibial shaft fractures    
            • accelerate early fracture healing
            • decrease rate of hardware failure
            • decrease need for subsequent autologous bone-grafting
            • decrease need for secondary invasive procedures
            • decrease infection rate
          • recent studies have not fully supported the above findings and rhBMP-2 remains highly controversial
    • amputation
      • indications
        • no current scoring system to determine if an amputation should be performed
        • relative indications for amputation include
          • significant soft tissue trauma
          • warm ischemia > 6 hrs
          • severe ipsilateral foot trauma
      • outcomes
        • LEAP study
          • most important predictor of eventual amputation is the severity of ipsilateral extremity soft tissue injury 
          • most important predictor of infection other than early antibiotic administration is transfer to definitive trauma center 
          • study shows no significant difference in functional outcomes between amputation and salvage
          • loss of plantar sensation is not an absolute indication for amputation 
Technique
  • IM nailing of shaft fractures
    • preparation
      • anesthesia
        • general anesthesia recommended
      • positioning
        • patient positioned supine on radiolucent table
        • bring fluoro in from opposite, non-injured, side
        • bump placed under ipsilateral hip
        • leave full access to foot and ankle to help judge intraoperative length, rotation, and alignment of extremity
      • tourniquet
        • tourniquet placed on proximal thigh
        • not typically inflated
        • use in patients with vascular injury or significant bleeding associated with extensive soft tissue injuries
        • deflate during reaming or nail insertion (weak data to support this)
    • approach
      • options include
        • medial parapatellar
          • most common starting point
          • can lead to valgus malalignment when used to treat proximal fractures
        • lateral parapatellar
          • helps maintain reduction when nailing proximal 1/3 fractures
          • requires mobile patella
        • patellar tendon splitting
          • gives direct access to start point
          • can damage patellar tendon or lead to patella baja (minimal data to support this)
        • semiextended medial or lateral parapatellar
          • used for proximal and distal tibial fractures
        • suprapatellar (transquadriceps tendon)
          • requires special instruments
          • can damage patellofemoral joint 
      • starting point
        • medial parapatellar tendon approach with knee flexed
          • incision from inferior pole of patella to just above tibial tubercle
          • identify medial edge of patellar tendon, incise
          • peel fat pad off back of patellar tendon
          • starting guidewire is placed in line with medial aspect of lateral tibial spine on AP radiograph, just below articular margin on lateral view   
          • insert starting guide wire, ream
        • semiextended lateral or medial parapatellar approach
          • skin incision made along medial or lateral border of patella from superior pole of patella to upper 1/3 of patellar tendon
          • knee should be in 5-30 degrees of flexion
          • choice to go medial or lateral is based of mobility of patella in either direction
          • open retinaculum and joint capsule to level of synovium
          • free retropatellar fat pad from posterior surface of patellar tendon
          • identify starting point as mentioned previously
    • fracture reduction techniques
      • spanning external fixation (ie. traveling traction)
      • clamps
      • femoral distractor
      • small fragment plates/screws
      • intra-cortical screws
    • reaming
      • reamed nails superior to unreamed nails in closed fractures 
      • be sure tourniquet is released
      • advance reamers slowly at high speed
      • overream by 1.0-1.5mm to facilitate nail insertion
      • confirm guide wire is appropriately placed prior to reaming
    • nail insertion
      • insert nail in slight external rotation to move distal interlocking screws anteriorly decreasing risk of NVS injury
      • if nail does not pass, remove and ream 0.5-1.0mm more
    • locking screws
      • statically lock proximal and distally for rotational stability
        • no indication for dynamic locking acutely
      • number of interlocking screws is controversial
        • two proximal and two distal screws in presence of <50% cortical contact
        • consider 3 interlock screws in short segment of distal or proximal shaft fracture
Complications
  • Knee pain
    • >50% anterior knee pain with IM nailing 
      • occurs with patellar tendon splitting and paratendon approach 
      • pain relief unpredictable with nail removal
    • lateral radiograph is best radiographic views to make sure nail is not too proud proximally 
  • Malunion 
    • high incidence of valgus and procurvatum (apex anterior) malalignment in proximal third fractures  
    • varus malunion leads to ipsilateral ankle pain and stiffness 
    • chronic angular deformity is defined by the proximal and distal anatomical/mechanical axis of each segment
      • center of rotation of angulation is intersection of proximal and distal axes
  • Nonunion
    • definition
      • delayed union if union at 6-9 mos.
      • nonunion if no healing after 9 mos.
    • treatment
      • nail dynamization if axially stable
      • exchange nailing if not axially stable 
        • reamed exchange nailing most appropriate for aseptic, diaphyseal tibial nonunions with less than 30% cortical bone loss.    
        • consider revision with plating in metaphyseal nonunions
      • posterolateral bone grafting if significant bone loss
      • non-invasive techniques (electrical stimulation, US)
      • BMP-7 (OP-1) has been shown equivalent to autograft 
        • often used in cases of recalcitrant non-unions
      • compression plating has been shown to have 92-96% union rate after open tibial fractures initially treated with external fixation
      • fibular osteotomy of tibio-fibular length discrepancy associated with healed or intact fibula 
  • Malrotation 
    • most commonly occurs after IM nailing of distal 1/3 fractures 
    • can assess tibial rotation by obtaining perfect lateral fluoroscopic image of knee, then rotating c-arm 105-110 degrees to obtain mortise view of ipsilateral ankle
    • reduced risk with adjunctive fibular plating   
  • Compartment syndrome
    • incidence 1-9%
      • can occur in both closed and open tibia shaft fxs
    • diagnosis
      • high index of clinical suspicion
      • pain out of proportion
      • pain with passive stretch
      • compartment pressure within 30mm Hg of diastolic BP is most sensitive diagnostic test
    • treatment
      • emergent four compartment fasciotomy
    • outcome
      • failure to recognize and treat compartment syndrome is most common reason for successful malpractice litigation against orthopaedic surgeons
    • prevention
      • increased compartment pressure found with
        • traction (calcaneal
        • leg positioning
  • Nerve injury
    • LISS plate application without opening for distal screw fixation near plate holes 11-13 put superficial peroneal nerve at risk of injury due to close proximity 
    • saphenous nerve can be injured during placement of locking screws
    • transient peroneal nerve palsy can be seen after closed nailing 
      • EHL weakness and 1st dorsal webspace decreased sensation
      • treated nonoperatively; variable recovery is expected
 

Please rate topic.

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Technique Guides (1)
Questions (55)

(OBQ05.79) 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? Review Topic

QID: 965
FIGURES:
1

Unreamed tibias have the highest amount of mineral apposition rates

4%

(20/571)

2

Unreamed tibias result in the highest amount of new bone formation

30%

(171/571)

3

Unreamed nails result in the lowest porosity of bone

5%

(27/571)

4

Reamed and unreamed tibias have similar mineral apposition rates

58%

(330/571)

5

Tight nails results in higher cortical reperfusion than loose nails

4%

(20/571)

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PREFERRED RESPONSE 4
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(OBQ07.126) 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? Review Topic

QID: 787
1

BMP-4

19%

(86/462)

2

BMP-7

58%

(269/462)

3

BMP-10

4%

(17/462)

4

Demineralized bone matrix

7%

(32/462)

5

Cancellous bone allograft chips

12%

(57/462)

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PREFERRED RESPONSE 2

(OBQ08.163) Which of the following types of nonunions is most likely to achieve union following a reamed exchange intramedullary nailing only? Review Topic

QID: 549
1

Distal femoral nonunion with less than 10% bone loss

13%

(66/489)

2

Infected nonunion of the femoral shaft

2%

(12/489)

3

Mid-diaphyseal humeral nonunion with less than 10% bone width loss

21%

(103/489)

4

Proximal humeral shaft nonunion with less than 10% bone width loss

4%

(20/489)

5

Diaphyseal tibial shaft nonunion with less than 30% cortical width bone loss

59%

(287/489)

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PREFERRED RESPONSE 5
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(OBQ11.54) 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? Review Topic

QID: 3477
FIGURES:
1

External fixator application

1%

(21/2501)

2

Tetanus prophylaxis

1%

(29/2501)

3

Operative debridement within 6 hours

17%

(433/2501)

4

TIme to transfer to definitive trauma center

67%

(1680/2501)

5

Soft-tissue coverage within 48 hours

13%

(330/2501)

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PREFERRED RESPONSE 4
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(OBQ12.73) Which of the following is true regarding the center of rotation of angulation (CORA) as it refers to tibial diaphyseal angular deformity? Review Topic

QID: 4433
1

It is the point at which the proximal mechanical axis and distal mechanical axis meet

64%

(2717/4278)

2

It is the point at which the proximal anatomical axis and proximal mechanical axis meet

12%

(494/4278)

3

It is always the point on the cortex at the most concave portion of the deformity

9%

(396/4278)

4

It is the point at which the distal anatomical axis and distal mechanical axis meet

8%

(345/4278)

5

It is always the point on the cortex at the most convex portion of the deformity

6%

(243/4278)

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(OBQ09.187) 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? Review Topic

QID: 3000
FIGURES:
1

Level of education

1%

(10/867)

2

Lack of plantar sensation

24%

(211/867)

3

Contralateral lower extremity open fracture(s)

2%

(18/867)

4

Severity of soft tissue injury

70%

(610/867)

5

Amount of tibial bone loss

1%

(13/867)

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PREFERRED RESPONSE 4

(SBQ12TR.9) 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? Review Topic

QID: 3924
FIGURES:
1

Tibia shaft necrosis post-operatively

7%

(273/4084)

2

Increased pulmonary morbidity post-operatively

49%

(1990/4084)

3

Increased cortical bone temperature during reaming

41%

(1670/4084)

4

Increased nonunion rates

2%

(102/4084)

5

Decreased pain post-operatively

1%

(34/4084)

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PREFERRED RESPONSE 2

(OBQ13.211) 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 Review Topic

QID: 4846
FIGURES:
1

MRI of the ipsilateral knee

17%

(527/3014)

2

MRI of the ipsilateral hip

1%

(21/3014)

3

CT scan of the ipsilateral knee

3%

(104/3014)

4

Radiographs of the ipsilateral ankle

78%

(2336/3014)

5

Axial radiograph of the ipsilateral calcaneus

0%

(14/3014)

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PREFERRED RESPONSE 4

(OBQ13.120) 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? Review Topic

QID: 4755
1

Early tetanus administration

0%

(10/2786)

2

Early intravenous antibiotic administration

85%

(2364/2786)

3

Reamed intramedullary nail fixation

1%

(17/2786)

4

Irrigation and debridement of the open fracture with 9L of solution

13%

(363/2786)

5

Vacuum assisted dressings over skin deficit

1%

(22/2786)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(SBQ12TR.29) Which of the following fracture patterns is classically associated with varus malunion if treated with closed reduction and casting? Review Topic

QID: 3944
FIGURES:
1

Figure A

5%

(167/3088)

2

Figure B

72%

(2228/3088)

3

Figure C

4%

(120/3088)

4

Figure D

13%

(415/3088)

5

Figure E

5%

(140/3088)

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PREFERRED RESPONSE 2

(OBQ10.217) 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? Review Topic

QID: 3310
FIGURES:
1

Malunion due to unacceptable coronal alignment

17%

(84/498)

2

Malunion due to unacceptable sagittal alignment

4%

(19/498)

3

Fracture displacement due to the mechanism of injury

5%

(27/498)

4

Fracture displacement due to the age of the patient

1%

(5/498)

5

Shortening due to the oblique nature of the tibia fracture

72%

(361/498)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ09.209) Which of the following nonunions is appropriately treated with exchange reamed nailing without bone graft augmentation? Review Topic

QID: 3022
1

Infected tibial shaft nonunion 6 months status post intramedullary nail fixation

7%

(34/457)

2

Oligotrophic humeral shaft nonunion 7 months status post non-operative management

8%

(38/457)

3

Hypertrophic tibial shaft nonunion 7 months status post intramedullary nail fixation

77%

(350/457)

4

Comminuted open tibial shaft nonunion with segmental bone loss 8 months status post intramedullary nail fixation

2%

(10/457)

5

Supracondylar femoral shaft nonunion 6 months status post intramedullary nail fixation with 4 distal locking screws

5%

(22/457)

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PREFERRED RESPONSE 3

(OBQ09.246) 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? Review Topic

QID: 3059
1

Medial hindfoot

1%

(5/645)

2

Lateral hindfoot

8%

(51/645)

3

First dorsal webspace

25%

(159/645)

4

Dorsal midfoot

65%

(421/645)

5

Plantar foot

1%

(8/645)

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PREFERRED RESPONSE 4

(OBQ07.182) 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? Review Topic

QID: 843
FIGURES:
1

Decreased risk of subsequent bone grafting procedures

85%

(366/429)

2

Shorter hospital stay

1%

(5/429)

3

Increased blood loss

4%

(19/429)

4

Decreased risk of angular deformity at final union

4%

(18/429)

5

Increased risk of deep vein thrombosis

4%

(18/429)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ12.185) 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? Review Topic

QID: 4545
FIGURES:
1

Decreased lateral hindfoot sensation

6%

(250/4328)

2

Decreased Achilles reflex

0%

(20/4328)

3

Decreased peroneus longus strength

28%

(1192/4328)

4

Decreased extensor hallucis longus strength

63%

(2739/4328)

5

Decreased plantar forefoot sensation

3%

(109/4328)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ05.192) 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? Review Topic

QID: 1078
1

Quicker time to union

8%

(41/487)

2

Decreased risk of malunion

3%

(16/487)

3

Decreased risk of compartment syndrome

82%

(398/487)

4

Decreased risk of shortening

2%

(8/487)

5

Quicker return to work

5%

(22/487)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ05.171) 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? Review Topic

QID: 1057
FIGURES:
1

Operative debridement within 6 hours of injury

8%

(93/1237)

2

Immediate prophylactic antibiotic administration

88%

(1086/1237)

3

Immediate stabilization with internal fixation after debridement

2%

(29/1237)

4

Irrigating with a saline solution that is mixed with an antibiotic

1%

(9/1237)

5

Irrigating with high pressure pulsatile lavage following surgical debridement

1%

(15/1237)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ06.64) 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? Review Topic

QID: 175
1

Degenerative lumbar spine changes

0%

(2/572)

2

Ipsilateral ankle pain and stiffness

68%

(390/572)

3

Ipsilateral hip joint degenerative changes

5%

(27/572)

4

Contralateral hip joint degenerative changes

1%

(6/572)

5

Ipsilateral medial knee degenerative changes

26%

(147/572)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ09.228) 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? Review Topic

QID: 3041
FIGURES:
1

rhBMP-7

19%

(88/456)

2

Adjunctive fracture plating

6%

(26/456)

3

Calcium phosphate

3%

(15/456)

4

Antibiotic impregnated cement beads

8%

(36/456)

5

rhBMP-2

64%

(291/456)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ04.114) 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? Review Topic

QID: 1219
1

Knee manipulation under anesthesia

3%

(11/434)

2

Cast immobilization and use of a bone stimulator

6%

(24/434)

3

Unilateral external fixation

1%

(5/434)

4

Intramedullary nailing

14%

(61/434)

5

Compression plating

76%

(330/434)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ04.256) 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? Review Topic

QID: 1361
FIGURES:
1

I

11%

(60/554)

2

II

15%

(81/554)

3

IIIA

71%

(393/554)

4

IIIB

3%

(15/554)

5

IIIC

1%

(5/554)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ11.224) 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? Review Topic

QID: 3647
FIGURES:
1

A

2%

(48/2554)

2

B

7%

(178/2554)

3

C

7%

(167/2554)

4

D

8%

(214/2554)

5

E

76%

(1938/2554)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ04.27) 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? Review Topic

QID: 88
1

Valgus

12%

(57/482)

2

Varus

5%

(23/482)

3

Recurvatum

10%

(48/482)

4

Procurvatum

71%

(342/482)

5

Rotational deformity

1%

(7/482)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ10.155) Isolated exchange reamed interlocking nailing is most likely indicated as the next step in treatment for which of the following clinical scenarios: Review Topic

QID: 3243
1

Tibial shaft nonunion with a 4cm bone defect

2%

(16/1059)

2

Infected tibial shaft nonunion

3%

(33/1059)

3

Hypertrophic diaphyseal tibial nonunion

72%

(765/1059)

4

Atrophic tibial shaft nonunion

16%

(165/1059)

5

Hypertrophic metadiaphyseal distal tibia nonunion

7%

(75/1059)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ04.194) 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? Review Topic

QID: 1299
FIGURES:
1

Decreased infection rate

2%

(7/390)

2

Increased need for additional surgeries to obtain union

6%

(23/390)

3

Increased infection rates

8%

(31/390)

4

Decreased time to union

78%

(304/390)

5

Increased compartment syndrome rate

6%

(23/390)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ04.200) Which of the following tibial injuries is most commonly treated with staged open reduction and internal fixation with free flap soft tissue reconstruction? Review Topic

QID: 1305
1

Type IIIB intra-articular distal tibia fracture

61%

(259/422)

2

Type IIIB segmental midshaft tibia fracture

23%

(96/422)

3

Type IIIB transverse midshaft tibia fracture

4%

(17/422)

4

Type IIIB Schatzker I proximal tibia fracture

3%

(11/422)

5

Type IIIC Schatzker IV proximal tibia fracture

9%

(38/422)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ07.76) 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? Review Topic

QID: 737
FIGURES:
1

Lateral radiograph of the knee

76%

(318/421)

2

AP radiograph of the knee

3%

(12/421)

3

Oblique radiographs of the knee

6%

(26/421)

4

Merchant radiograph of the knee

8%

(34/421)

5

Internally rotated 45 degree view of the knee

7%

(31/421)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ04.69) 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? Review Topic

QID: 1174
FIGURES:
1

Gustilo 3A with spanning external fixation and delayed definitive fixation with soft tissue coverage

2%

(8/423)

2

Gustilo 3A with immediate medial and lateral plating followed by delayed soft tissue coverage

0%

(1/423)

3

Gustilo 3B with spanning external fixation and delayed definitive fixation with soft tissue coverage

84%

(356/423)

4

Gustilo 3B with immediate medial and lateral plating followed by delayed soft tissue coverage

3%

(12/423)

5

Gustilo 3C with spanning external fixation and delayed definitive fixation with soft tissue coverage

10%

(42/423)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ06.193) 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? Review Topic

QID: 379
FIGURES:
1

Use of anti-inflammatories post-operatively

1%

(4/474)

2

Post-operative gapping at the fracture site

54%

(257/474)

3

Presence of an associated fibular fracture

1%

(7/474)

4

History of smoking

41%

(194/474)

5

Mechanism of injury

2%

(8/474)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ05.115) 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? Review Topic

QID: 1001
1

<10%

4%

(17/403)

2

10-33%

41%

(165/403)

3

33-50%

27%

(107/403)

4

50-75%

26%

(104/403)

5

>75%

2%

(9/403)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ04.34) 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? Review Topic

QID: 95
1

compartment syndrome

5%

(14/284)

2

infection

1%

(2/284)

3

anterior knee pain

92%

(261/284)

4

nonunion

0%

(0/284)

5

malunion

2%

(7/284)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ05.216) 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? Review Topic

QID: 1102
FIGURES:
1

unrecognized compartment syndrome

0%

(2/600)

2

common peroneal nerve injury

4%

(27/600)

3

superficial peroneal nerve injury

91%

(547/600)

4

sural nerve injury

2%

(15/600)

5

tibial nerve injury

1%

(7/600)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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