Updated: 5/19/2021

Tibial Shaft Fractures

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  • Summary
    • Diaphyseal tibial fractures are the most common long bone fracture.
    • Diagnosis is confirmed by plain radiographs of the tibia and adjacent joints.
    • Treatment is generally operative with intramedullary nailing. In rare cases, external fixation or ORIF is more appropriate depending on the location and orientation of the fracture.
  • Epidemiology 
    • Incidence
      • most common long bone fx
        • make up about 17% of all lower extremity fractures
        • account for 4% of all fractures seen in the Medicare population
    • Demographics
      • M > F
      • age bracket
        • bimodal distribution
          • young patients - high energy mechanisms
          • older patients - falls, lower energy mechanisms
    • Anatomic location
      • proximal 1/3 tibia fractures account for 5-10% of tibial shaft fractures
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • low energy (fall from standing, twisting, etc)
          • result of indirect, torsional injury
            • leads to spiral fracture pattern with fibula fracture at a different level
            • high association of posterior malleolus fractures with spiral distal tibia fractures
          • more likely to be associated with a lower degree of soft tissue injury
        • high energy fx (MVA, fall from height, athletics, etc)
          • result of direct force
            • leads to wedge or short oblique fracture that may have significant comminution with fibula fracture at same level
          • more likely to be associated with severe soft tissue injury
            • Oestern and Tscherne II / III
            • open fractures
      • pathoanatomy
        • proximal third tibia fractures
          • must rule out extension into tibial plateau on plain films or CT scan
          • high risk for valgus/procurvatum deformity with IM nailing
        • distal third tibia fracture
          • higher rates of ankle injury seen with distal 1/3 tibia fracture and spiral fracture pattern
            • posterior malleolus most common associated ankle injury which, in some cases, may affect syndesmotic stability
          • extension into or adjacent to tibial plafond may require separate/additional fixation and are managed differently than tibial shaft fractures
      • associated conditions
        • soft tissue injury
          • severity of muscle injury has highest impact on eventual need for amputation
        • compartment syndrome
          • more common in diaphyseal tibial shaft fractures than proximal or distal tibia fractures
            • 8.1% risk in diaphyseal fractures, compared to proximal (1.6%) and distal (1.4%) fractures
          • can occur even in the setting of an open fracture
          • all four compartments must be examined. If patient is unable to participate in examination and concern is high clinically, intracompartmental compartment measurements should be performed
        • bone loss
        • ipsilateral skeletal injury
          • tibial plateau fractures
          • tibial plafond fractures
          • femoral shaft fractures
            • floating knee is an indication for antegrade tibial nailing and retrograde femoral nailing
          • posterior malleolar fracture
            • distal 1/3 and spiral tibial shaft fractures
  • Anatomy
    • Osteology
      • tibial shaft is triangular in cross-section
      • proximal medullary canal is centered laterally
        • important for start point with IM nailing
      • anteromedial tibial crest is composed of dense, cortical bone and rests in a subcutaneous position, making it useful as a landmark
      • tibial tubercle sits anterolaterally, approximately 3 cm distal to joint line
        • attachment of patellar tendon
      • gerdy's tubercle lies laterally on proximal tibia
        • attachment of iliotibial band
      • pes anserinus lies medially on proximal tibia
        • attachment of sartorius, semitendinosus, and gracilis
    • Muscles
      • anterior compartment
        • tibialis anterior
        • extensor digitorum longus (EDL)
        • extensor hallicus longus (EHL)
      • lateral compartment
        • peroneus longus
        • peroneus brevis
      • superficial posterior compartment
        • gastrocnemius (medial/lateral heads)
        • soleus
        • popliteus
        • plantaris
      • deep posterior compartment
        • tibialis posterior
        • flexor digitorum longus (FDL)
        • flexor hallicus longus (FHL)
    • Ligaments
      • superficial medial collateral ligament (MCL) attaches approximately 5-7 cm distal to joint line deep to the pes anserinus
      • adjacent fibula supports attachments for the lateral collateral ligament complex and long head of biceps femoris
    • Blood Supply
      • anterior tibial a.
      • peroneal a.
      • posterior tibial a.
      • medial sural a.
      • lateral sural a.
    • Nervous System
      • superficial peroneal n.
      • deep peroneal n.
      • tibial n.
      • sural n.
    • Biomechanics
      • proximal tibiofibular joint
        • gliding synovial joint
        • tibia is responsible for about 80-85% of lower extremity weight-bearing
      • interosseous membrane
        • fibrous structure interconnecting tibia/fibula which provides axial stability
      • tibiofibular syndesmosis
        • fibula rests in distal tibial incisura and is stabilized by syndesmotic ligaments
          • anterior inferior tibiofibular ligament (AITFL)
          • posterior inferior tibiofibular ligament (PITFL)
          • inferior transverse tibiofibular ligament (ITL)
          • interosseous ligament (IOL) - continuation of interosseus membrane
        • syndesmotic stability can be affected by distal, spiral tibial shaft fractures
  • Classification
    • Fracture classification is primarily descriptive based on pattern and location
    • OTA Classification
      42A
      Simple fracture patterns
      42B
      Wedge patterns
      42C
      Complex/comminuted patterns
    • Oestern and Tscherne Classification of Closed Fracture 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
      Minimal periosteal stripping, wound >1 cm in length without extensive soft-tissue injury damage
      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 included in the grade III group.
  • Presentation
    • Symptoms
      • severe leg pain
      • inability to bear weight
      • deformity
    • Physical exam
      • inspection
        • deformity / angulation / malrotation
        • contusions
        • blisters
        • open wounds
      • palpation
        • check firmness of each compartment to evaluate for compartment syndrome
      • motion
        • fracture crepitus noted
      • neurovascular
        • peripheral nerve exam
          • deep peroneal n.
          • superficial peroneal n.
          • sural n.
          • tibial n.
          • saphenous n.
        • dorsalis pedis and posterior tibial pulses - compare to contralateral side
          • doppler if necessary
          • CT angiography indicated if pulses not dopplerable
  • Imaging
    • Radiographs
      • recommended views
        • full-length AP and lateral views of the affected tibia
        • AP, lateral and oblique views of ipsilateral knee and ankle
        • repeat radiographs recommended after splinting or fracture manipulation
    • CT
      • indications
        • intra-articular fracture extension or suspicion of plateau/plafond involvement
        • distal 1/3 or spiral tibia fracture
          • used to exclude posterior malleolar fracture
        • also used to identify nonunion
      • findings
        • high variation in reported incidence of posterior malleolus fracture with distal 1/3 spiral tibia fractures (25-60%)
  • Treatment
    • Nonoperative
      • closed reduction / cast immobilization
        • indications
          • closed, low energy fractures with acceptable alignment
            • < 5 degrees varus-valgus angulation
            • < 10 degrees anterior/posterior angulation
            • > 50% cortical apposition
            • < 1 cm shortening
            • < 10 degrees rotational malalignment
          • certain patients who may be non-ambulatory (ie. paralyzed), or those unfit for surgery
        • outcomes
          • angulation and rotational alignment are well maintained with casting, however, shortening is hard to control
            • risk of shortening higher with oblique and comminuted fracture patterns
            • mean shortening is 4 mm
          • risk of varus malunion with midshaft tibia fractures and an intact fibula
          • high success rate if acceptable alignment maintained
          • non-union occurs in approximately 1% of patients treated with closed reduction
    • Operative
      • I&D + antibiotics
        • indications
          • all open tibia fractures require an emergent I&D
            • surgical debridement within 12-24 hours of injury
            • wounds should be irrigated and dressed with saline-soaked gauze in the emergency department before splinting
          • all open tibia fractures require immediate antibiotics
            • should be administered within 3 hours of injury
            • standard abx for open fractures (institution dependent)
              • cephalosporin given continuously for 24 hours after definitive surgery 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
                • theoretically covers Clostridium
            • tetanus vaccination status should be confirmed and appropriate prophylaxis should be administered if necessary
        • 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
          • damage control for polytrauma patients
          • open fractures with soft tissue defects/contamination
          • proximal or distal metaphyseal fractures
        • techniques
          • uniplanar, circular, hybrid external fixators all available
          • should be converted to intramedullary nail within 7-21 days, ideally less than 7 days
        • outcomes
          • longer time to union and worse functional outcomes with definitive external fixation compared to IM nailing in type III open tibia fractures
          • higher incidence of malalignment compared to IM nailing
          • high rate of pin tract infections; avoid intra-articular placement given risk for septic arthritis
      • 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
        • techniques
          • reamed vs. unreamed nailing
            • reamed nailing allows for larger diameter nail
          • suprapatellar vs. infrapatellar nailing
          • provisional reduction techniques (blocking screws, plating, etc)
            • particularly useful for proximal 1/3 tibial shaft fractures
        • outcomes
          • union rates >80% for closed tibia fractures treated with nailing
            • risks for nonunion: gapping at fracture site, open fracture and transverse fracture pattern
          • shorter immobilization time, earlier time to weight-bearing, and decreased time to union compared to casting
          • decreased malalignment compared to external fixation
          • suprapatellar vs. infrapatellar nailing
            • improved fracture alignment with suprapatellar nailing
          • reamed vs. unreamed nails
            • reamed may have higher union rates and lower time to union than unreamed nails in closed fractures (controversial)
            • reamed nails are safe for use with open fractures, with no evidence of decreased nonunion rates in open fractures
            • recent studies show no adverse effects of reaming (infection, embolism, nonunion)
            • reaming with the use of a tourniquet is not associated with thermal necrosis of the tibial shaft, despite prior studies suggesting otherwise
            • higher rate of locking screw breakage with unreamed nailing
      • open reduction and internal fixation
        • indications
          • proximal tibia fractures with inadequate proximal fixation from IM nailing
          • distal tibia fractures with inadequate distal fixation from IM nail
          • tibia fractures in the setting of adjacent implant/hardware (i.e. prior total knee arthroplasty)
        • outcomes
          • compared to IM nailing of tibia fractures:
            • larger incision
            • increased risk of wound complications and hardware irritation
            • similar rates of union in closed fractures
            • more difficult hardware removal
            • greater radiation exposure intraoperatively
            • possibly less angular deformity
          • risk of damage to the superficial peroneal nerve during percutaneous screw insertion
            • holes 11,12, and 13 (proximally) of a 13 hole plate place nerve at risk
      • augmentation with rhBMP-2
        • indications
          • prior studies have demonstrated some use in open tibial shaft fractures
        • outcomes (controversial, as recent studies have not fully supported these findings)
          • 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
      • 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
    • Closed reduction/cast immobilization
      • technique
        • long leg casting initially
        • may convert to functional (patellar tendon bearing) brace at around 4 weeks
        • close follow-up with repeat radiographs to ensure no displacement
          • can wedge cast to correct slight deformity
          • monitor for skin irritation
    • Incision and drainage
      • timing
        • within 24 hours of initial injury to decrease risk of infection
      • technique
        • sharp debridement of nonviable soft tissue & bone
        • thorough irrigation of contaminated wound
        • may require multiple debridements
        • immediate closure of open wounds is acceptable if minimal contamination is present and is performed without excessive skin tension
          • if skin cannot be closed, vac-assisted closure should be considered in short-term.
    • External fixation
      • technique
        • bypass fracture, likely adjacent joint (i.e. open 1/3 tibial shaft fracture with placement of proximal 1/3 tibia and calcaneus/metatarsal pins to span fracture)
        • construct stiffness increased with larger pin diameter, number of pins on each side of fracture, rods closer to bone, and a multiplanar construct
      • complications
        • pin site infections common
    • Intramedullary nailing
      • approach
        • infrapatellar nailing
          • medial parapatellar
            • most common starting point
            • incision from inferior pole of patella to just above tibial tubercle
            • identify medial edge of patellar tendon, incise
            • insert guidewire as detailed below and ream
            • can lead to valgus malalignment in proximal 1/3 tibial 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
            • 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
            • identify starting point and ream as detailed below
        • suprapatellar nailing (transquadriceps tendon)
          • requires special instruments
          • can damage patellofemoral joint
          • easier positioning if additional instrumentation needed
          • more advantageous for proximal or distal 1/3 tibia fractures
      • technique
        • starting point
          • starting guidewire is placed in line with medial aspect of lateral tibial spine on AP radiograph, just below articular margin on lateral view
            • in proximal 1/3 tibia fractures starting point should cheat laterally to avoid classic valgus/procurvatum deformity
          • ensure guidewire is aligned with tibia in coronal and sagittal planes as you insert
          • opening reamer is placed over guidewire and ball-tipped guidewire can then be passed
        • fracture reduction
          • spanning external fixation (ie. traveling traction)
          • clamps
          • femoral distractor
          • small fragment unicortical plates/screws
          • blocking (poller) screws
            • placed in metaphyseal segment at the concavity of the deformity
              • in proximal 1/3 tibia fractures, posteriorly placed blocking screw in proximal fragment and laterally placed blocking screw in the metaphyseal fragment help direct the nail more centrally, avoiding valgus/procurvatum deformities
            • increase biomechanical stability of bone/implant construct by 25%
        • reaming
          • reamed nails superior to unreamed nails in closed fractures
          • ensure fracture is reduced before reaming
          • overream by 1.0-1.5mm to facilitate nail insertion
          • confirm guide wire is appropriately placed prior to reaming
            • should be "center-center" in the coronal and sagittal planes distally at the physeal scar
        • nail insertion
          • anterior aspect of nail should be lined up with axis of tibia when inserting nail - typically should line up with 2nd metatarsal in absence of tibial deformity
        • 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
              • prefer multiplanar screw fixation in these short segments
    • Open reduction and internal fixation
      • approach
        • lateral vs. medial
          • lateral may have more soft tissue interference but may be preferred in setting of soft tissue/wound issues
      • technique
        • generally, minimally invasive plating is used to preserve soft tissues
          • plate attached to external jig to allow for percutaneous insertion of screws
          • must ensure appropriate contour of plate to avoid malreduction
      • complications
        • higher risk for wound issues, particularly in open fractures
        • neurovascular risk
          • superficial peroneal nerve (SPN) commonly at risk laterally
    • Amputation
      • approach
        • below knee amputation (BKA) vs. above knee amputation (AKA) based on degree of soft tissue damage
      • technique
        • standard BKA vs. ertl/bone block technique
      • complications
        • infection
        • hematoma
        • phantom pain
  • Complications
    • Anterior knee pain
      • incidence
      • risk factors
        • infrapatellar nailing with patellar tendon splitting and paratendon approach
          • suprapatellar nailing may have lower rate of anterior knee pain
        • more common if nail left proud proximally
          • lateral radiograph is best radiographic views to evaluate proximal nail position
      • treatment
        • removal of nail
          • pain relief unpredictable with nail removal
    • Malunion
      • incidence
        • all tibial shaft fractures - between 8-10%
        • higher in proximal 1/3 tibia fractures - up to 50%
          • valgus/procurvatum deformity
            • patellar tendon pulls proximal fragment into extension, while hamstring tendons and gastrocnemius pull the distal fragment into flexion (procurvatum)
        • distal 1/3 fractures have a higher rate of valgus malunion with IM nailing compared to plating
      • risk factors
        • definitive management with casting or external fixation
          • most common deformity is varus with nonsurgical management
            • varus malunion may place patient at risk for ipsilateral ankle pain and stiffness
        • starting point too medial with IM nailing
        • poor reduction intraoperatively
      • treatment
        • prevention is most important
          • adequate reduction, proper start point when nailing
        • if malalignment is noted immediately after surgery, return to operating room is appropriate with removal of nail, reduction and nail reinsertion
        • if malunion is appreciated at later followup, eventual nail removal and tibial osteotomy can be considered
    • Nonunion (no healing at 9 months)
      • incidence
        • estimated between 2-10%
      • risk factors
        • open fracture
        • cortical contact <50%
        • transverse fracture pattern
      • treatment
        • rule out infection
        • nail dynamization if axially stable
        • exchange nailing if not axially stable
          • reamed exchange nailing most appropriate for aseptic, diaphyseal tibial nonunions
          • oblique tibial shaft fractures have the highest rate of union when treated with exchange nailing
          • consider revision with plating in metaphyseal nonunions
        • posterolateral bone grafting if significant bone loss
        • 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 a 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
      • incidence
        • highest after IM nailing of distal 1/3 tibia fractures
          • increases risk of adjacent ankle arthrosis
      • treatment
        • should always assess rotation in operating room
          • obtain perfect lateral fluoroscopic image of knee, then rotate c-arm 105-110 degrees to obtain mortise view of ipsilateral ankle
        • may have reduced risk with adjunctive fibular plating
    • Compartment syndrome
      • incidence
        • estimated between 1-9%
          • can occur in both closed and open tibia shaft fractures
      • risk factors
        • high energy injuries
        • significant soft tissue injuries
      • treatment
        • emergent four-compartment fasciotomy
    • Nerve injury
      • incidence
        • true incidence unknown
        • believed to be a rare complication
      • risk factors
        • 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
      • treatment
        • usually nonoperatively with variable recovery expected
        • may need AFO if foot drop present
    • Infection
      • incidence
        • approximately 5%
      • risk factors
        • open fracture
        • severe soft tissue injury with contamination
        • longer time to definitive soft tissue coverage
      • treatment
        • may require I&D or eventual removal of hardware
        • use of wound vacuum-assisted closure does not decrease risk of infection

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(OBQ13.196) A 35-year-old male presents with the post-traumatic deformity shown in Figures A and B. He has pain and difficulty walking, and deformity correction with a ring fixator is planned. When considering the principles of deformtiy surgery, it should be noted that angular corrections performed as opening or closing wedges NOT at the level of the apex of the deformity will create which of the following secondary deformities?

QID: 4831
FIGURES:
1

Translational

61%

(2070/3380)

2

Angular

21%

(705/3380)

3

Excessive shortening

6%

(190/3380)

4

Rotational

9%

(300/3380)

5

Excessive lengthening

3%

(88/3380)

L 3 B

Select Answer to see Preferred Response

(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

QID: 4846
FIGURES:
1

MRI of the ipsilateral knee

16%

(620/3860)

2

MRI of the ipsilateral hip

1%

(26/3860)

3

CT scan of the ipsilateral knee

3%

(130/3860)

4

Radiographs of the ipsilateral ankle

79%

(3046/3860)

5

Axial radiograph of the ipsilateral calcaneus

1%

(21/3860)

L 2 B

Select Answer to see Preferred Response

(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?

QID: 4755
1

Early tetanus administration

0%

(11/3598)

2

Early intravenous antibiotic administration

86%

(3099/3598)

3

Reamed intramedullary nail fixation

1%

(22/3598)

4

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

12%

(426/3598)

5

Vacuum assisted dressings over skin deficit

1%

(25/3598)

L 1 B

Select Answer to see Preferred Response

(SBQ12TR.110) A 27-year-old male presented to the trauma bay following a motor vehicle crash and was diagnosed with a comminuted open tibia fracture. He was subsequently treated with an irrigation and debridement, and un-reamed intramedullary nail. At 4 months follow-up, despite some signs of healing, the fracture is not fully united. Which of the following is true?

QID: 4025
1

Patient should be scheduled for exchange nailing.

8%

(151/1895)

2

Use of an un-reamed nail increased this patients risk of infection.

1%

(16/1895)

3

Use of an un-reamed nail increased this patient's risk of non-union.

26%

(489/1895)

4

Patient should continue to be observed without intervention.

63%

(1193/1895)

5

Use of an un-reamed nail decreased this patient's risk of infection.

2%

(34/1895)

L 3 A

Select Answer to see Preferred Response

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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?

QID: 4433
1

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

63%

(3082/4880)

2

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

12%

(571/4880)

3

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

9%

(457/4880)

4

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

8%

(385/4880)

5

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

6%

(287/4880)

L 3 C

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(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?

QID: 3924
FIGURES:
1

Tibia shaft necrosis post-operatively

7%

(335/4863)

2

Increased pulmonary morbidity post-operatively

48%

(2317/4863)

3

Increased cortical bone temperature during reaming

42%

(2019/4863)

4

Increased nonunion rates

3%

(125/4863)

5

Decreased pain post-operatively

1%

(48/4863)

L 4 C

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

QID: 3944
FIGURES:
1

Figure A

6%

(223/4003)

2

Figure B

73%

(2920/4003)

3

Figure C

4%

(161/4003)

4

Figure D

13%

(507/4003)

5

Figure E

4%

(172/4003)

L 3 B

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(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?

QID: 4545
FIGURES:
1

Decreased lateral hindfoot sensation

6%

(293/4943)

2

Decreased Achilles reflex

0%

(22/4943)

3

Decreased peroneus longus strength

28%

(1382/4943)

4

Decreased extensor hallucis longus strength

63%

(3106/4943)

5

Decreased plantar forefoot sensation

2%

(117/4943)

L 3 B

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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?

QID: 3477
FIGURES:
1

External fixator application

1%

(28/3160)

2

Tetanus prophylaxis

2%

(54/3160)

3

Operative debridement within 6 hours

20%

(633/3160)

4

TIme to transfer to definitive trauma center

62%

(1974/3160)

5

Soft-tissue coverage within 48 hours

14%

(456/3160)

L 2 C

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(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?

QID: 3647
FIGURES:
1

A

2%

(67/3201)

2

B

7%

(239/3201)

3

C

7%

(235/3201)

4

D

9%

(280/3201)

5

E

74%

(2367/3201)

L 2 B

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(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?

QID: 3310
FIGURES:
1

Malunion due to unacceptable coronal alignment

17%

(142/833)

2

Malunion due to unacceptable sagittal alignment

5%

(43/833)

3

Fracture displacement due to the mechanism of injury

6%

(48/833)

4

Fracture displacement due to the age of the patient

2%

(13/833)

5

Shortening due to the oblique nature of the tibia fracture

70%

(582/833)

L 3 C

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

QID: 3243
1

Tibial shaft nonunion with a 4cm bone defect

2%

(28/1435)

2

Infected tibial shaft nonunion

3%

(44/1435)

3

Hypertrophic diaphyseal tibial nonunion

71%

(1020/1435)

4

Atrophic tibial shaft nonunion

17%

(246/1435)

5

Hypertrophic metadiaphyseal distal tibia nonunion

6%

(89/1435)

L 2 B

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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?

QID: 3000
FIGURES:
1

Level of education

1%

(22/1483)

2

Lack of plantar sensation

22%

(330/1483)

3

Contralateral lower extremity open fracture(s)

2%

(33/1483)

4

Severity of soft tissue injury

71%

(1054/1483)

5

Amount of tibial bone loss

2%

(32/1483)

L 2 B

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

QID: 3022
1

Infected tibial shaft nonunion 6 months status post intramedullary nail fixation

8%

(57/753)

2

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

7%

(49/753)

3

Hypertrophic tibial shaft nonunion 7 months status post intramedullary nail fixation

79%

(592/753)

4

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

3%

(19/753)

5

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

4%

(31/753)

L 2 B

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(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?

QID: 3059
1

Medial hindfoot

1%

(8/1168)

2

Lateral hindfoot

8%

(92/1168)

3

First dorsal webspace

25%

(291/1168)

4

Dorsal midfoot

65%

(754/1168)

5

Plantar foot

1%

(17/1168)

L 3 A

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(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?

QID: 3041
FIGURES:
1

rhBMP-7

18%

(122/674)

2

Adjunctive fracture plating

5%

(37/674)

3

Calcium phosphate

3%

(23/674)

4

Antibiotic impregnated cement beads

8%

(56/674)

5

rhBMP-2

65%

(436/674)

L 3 A

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

QID: 549
1

Distal femoral nonunion with less than 10% bone loss

12%

(119/980)

2

Infected nonunion of the femoral shaft

2%

(20/980)

3

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

19%

(183/980)

4

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

3%

(31/980)

5

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

63%

(622/980)

L 3 B

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(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?

QID: 843
FIGURES:
1

Decreased need of subsequent bone grafting procedures

89%

(647/724)

2

Shorter hospital stay

1%

(7/724)

3

Increased blood loss

2%

(18/724)

4

Decreased risk of angular deformity at final union

3%

(23/724)

5

Increased risk of deep vein thrombosis

3%

(22/724)

L 3 A

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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?

QID: 787
1

BMP-4

14%

(112/775)

2

BMP-7

62%

(481/775)

3

BMP-10

5%

(35/775)

4

Demineralized bone matrix

7%

(51/775)

5

Cancellous bone allograft chips

11%

(89/775)

L 4 C

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(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?

QID: 737
FIGURES:
1

Lateral radiograph of the knee

76%

(720/943)

2

AP radiograph of the knee

2%

(17/943)

3

Oblique radiographs of the knee

6%

(60/943)

4

Merchant radiograph of the knee

8%

(75/943)

5

Internally rotated 45 degree view of the knee

7%

(69/943)

L 2 D

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(OBQ06.151) What is the most common type of malalignment after intramedullary nailing of distal 1/3 extra-articular tibia fractures using a infrapatellar approach when compared with plating?

QID: 337
1

Varus

31%

(655/2105)

2

Valgus

32%

(684/2105)

3

Translational

10%

(210/2105)

4

Shortening

13%

(268/2105)

5

Apex anterior

13%

(275/2105)

L 4 C

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(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?

QID: 175
1

Degenerative lumbar spine changes

0%

(3/895)

2

Ipsilateral ankle pain and stiffness

66%

(592/895)

3

Ipsilateral hip joint degenerative changes

4%

(36/895)

4

Contralateral hip joint degenerative changes

1%

(13/895)

5

Ipsilateral medial knee degenerative changes

27%

(246/895)

L 3 C

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(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?

QID: 379
FIGURES:
1

Use of anti-inflammatories post-operatively

1%

(8/891)

2

Post-operative gapping at the fracture site

53%

(472/891)

3

Presence of an associated fibular fracture

1%

(11/891)

4

History of smoking

42%

(376/891)

5

Mechanism of injury

2%

(19/891)

L 3 C

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(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?

QID: 965
FIGURES:
1

Unreamed tibias have the highest amount of mineral apposition rates

4%

(69/1621)

2

Unreamed tibias result in the highest amount of new bone formation

12%

(197/1621)

3

Unreamed nails result in the lowest porosity of bone

8%

(136/1621)

4

Reamed and unreamed tibias have similar mineral apposition rates

68%

(1104/1621)

5

Tight nails results in higher cortical reperfusion than loose nails

7%

(107/1621)

L 4 D

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(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?

QID: 1078
1

Quicker time to union

9%

(73/851)

2

Decreased risk of malunion

3%

(27/851)

3

Decreased risk of compartment syndrome

82%

(702/851)

4

Decreased risk of shortening

2%

(14/851)

5

Quicker return to work

4%

(30/851)

L 2 C

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(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?

QID: 1057
FIGURES:
1

Operative debridement within 6 hours of injury

7%

(106/1576)

2

Immediate prophylactic antibiotic administration

89%

(1403/1576)

3

Immediate stabilization with internal fixation after debridement

2%

(32/1576)

4

Irrigating with a saline solution that is mixed with an antibiotic

1%

(9/1576)

5

Irrigating with high pressure pulsatile lavage following surgical debridement

1%

(18/1576)

L 2 C

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(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?

QID: 1001
1

<10%

5%

(39/765)

2

10-33%

44%

(337/765)

3

33-50%

26%

(198/765)

4

50-75%

21%

(164/765)

5

>75%

3%

(21/765)

L 5 D

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(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?

QID: 1102
FIGURES:
1

unrecognized compartment syndrome

1%

(6/955)

2

common peroneal nerve injury

4%

(41/955)

3

superficial peroneal nerve injury

91%

(865/955)

4

sural nerve injury

3%

(28/955)

5

tibial nerve injury

1%

(12/955)

L 1 B

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(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?

QID: 1361
FIGURES:
1

I

11%

(106/973)

2

II

15%

(150/973)

3

IIIA

71%

(687/973)

4

IIIB

2%

(22/973)

5

IIIC

1%

(6/973)

L 2 C

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(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?

QID: 1219
1

Knee manipulation under anesthesia

3%

(20/759)

2

Cast immobilization and use of a bone stimulator

5%

(35/759)

3

Unilateral external fixation

1%

(8/759)

4

Intramedullary nailing

16%

(123/759)

5

Compression plating

75%

(570/759)

L 1 D

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(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?

QID: 88
1

Valgus

14%

(128/920)

2

Varus

7%

(66/920)

3

Recurvatum

10%

(91/920)

4

Procurvatum

66%

(608/920)

5

Rotational deformity

2%

(18/920)

L 2 C

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