OR2.14-16 | Fracture Complications and Special Situations — Graded Quiz

Correct. Infected non-union requires identification of the organism via culture before fixation/bone grafting; proceeding without this risks implant failure and persistent sepsis.

This presentation is infected non-union (hypertrophic pattern with systemic inflammation). Before deciding on reconstruction, tissue culture and sensitivity is essential to identify the causative organism and guide targeted antibiotic therapy, which must accompany any surgical intervention.

Tissue culture is essential before definitive surgical reconstruction in infected non-union; organism-directed antibiotics must cover the entire perioperative period.

Correct. Grade IIIC is defined by a vascular injury requiring repair. Absent pulses confirmed by Doppler makes this IIIC regardless of wound size.

Grade IIIC = ANY open fracture associated with an arterial injury that requires vascular repair, regardless of wound size or degree of soft-tissue damage. The vascular injury is the defining criterion for IIIC and is the most limb-threatening grade.

Arterial injury requiring repair = Grade IIIC. This is a critical known-trap: IIIC is defined by vascular injury, not by wound size alone.

Correct. Absent pulse + pale hand = vascular emergency. Reduce and fix first; explore brachial artery if pulse does not return post-fixation.

Vascular compromise (absent pulse + pale hand) in a supracondylar fracture is an emergency. The immediate priority is urgent surgical reduction and fixation. If the pulse does not return after reduction and K-wire fixation, vascular exploration for brachial artery injury is mandatory. The brachial artery is the vessel most commonly injured.

Absent pulse with pallor demands urgent reduction and K-wire fixation. The brachial artery is the vessel at risk, and exploration follows if the pulse does not return.

Correct. Type IV fractures that are not anatomically reduced form physeal bars (bony bridges) across the growth plate, causing premature closure and leg length discrepancy or angular deformity.

Salter-Harris Type IV fractures cross the metaphysis, physis (growth plate), and epiphysis. If not anatomically reduced, premature physeal closure (growth arrest) and angular deformity are the major long-term risks because bone bridges form across the physis, tethering growth.

Salter-Harris Type IV's defining long-term risk is growth arrest and angular deformity due to physeal bar formation — hence the need for anatomic reduction.

Correct. Atrophic non-union = absent callus, sclerotic ends, avascular. Treatment = stable fixation (exchange nail or plate) + autologous bone graft to provide osteogenic/osteoconductive stimulus.

Atrophic non-union with no infection (normal ESR, negative cultures) requires biological stimulation: bone grafting (autologous iliac crest) combined with stable internal fixation (exchange nailing or plating). The atrophic end must be freshened, medullary canal reopened, and bone graft applied.

Absent callus + sclerotic ends + normal inflammatory markers = atrophic non-union. It requires both mechanical stability AND biological stimulus (bone graft).

Correct. Definitive soft-tissue coverage within 72 hours is the current standard for Grade IIIB open fractures to minimise infection and facilitate healing.

BOAST/NICE guidelines recommend definitive soft-tissue coverage for Grade IIIB open fractures within 72 hours (ideally in a combined ortho-plastic operating list). Early coverage reduces infection risk and promotes fracture healing; primary closure under tension should be avoided.

Grade IIIB requires definitive soft-tissue coverage within 72 hours. Primary closure under tension at the time of debridement is incorrect.

Correct. Recurrence prevention = caregiver education to avoid traction on the forearm. No surgical or prolonged immobilisation is needed.

Pulled elbow (nursemaid's elbow) is caused by sudden axial traction on the extended, pronated forearm. Recurrence is prevented by advising caregivers never to pull a child by the hand/wrist and never to swing the child by the arms. The annular ligament matures by age 5–6, making recurrence uncommon after this age.

Pulled elbow recurs due to repeated traction. Caregiver education — specifically to avoid pulling the hand or swinging the child by the arms — is the correct prevention strategy.

Correct. Significant angulation in a greenstick fracture requires completion of the fracture to release the intact periosteum and allow proper reduction, then cast immobilisation.

Greenstick fractures in children with significant angulation require completion of the fracture (to allow proper reduction) followed by above-elbow cast immobilisation. Simply casting without completing the fracture leaves a spring-loaded periosteum that re-angulates. Completion converts it to a stable, reducible fracture.

Significant angulation in a greenstick fracture needs completion of the fracture under anaesthesia before casting — uncompleted fractures re-angulate due to intact periosteal spring.

Correct. Three-phase Tc-99m bone scan quantifies vascularity and bone turnover at the non-union site — low uptake confirms avascular atrophic non-union.

Tc-99m three-phase bone scan (or SPECT-CT) assesses local blood flow and bone turnover at the non-union site. Atrophic non-unions show decreased uptake reflecting poor vascularity, helping surgeons distinguish atrophic from hypertrophic subtypes and plan the extent of débridement and bone grafting needed.

Tc-99m three-phase bone scan is the investigation that directly quantifies bone blood flow and turnover, distinguishing avascular atrophic from vascular hypertrophic non-union.

Correct. Present pulse does NOT exclude compartment syndrome (a critical known-trap). Pain on passive stretch + tense compartment mandates urgent pressure measurement and fasciotomy if delta P <30 mmHg.

Compartment syndrome is a clinical diagnosis based on the 5 Ps; CRITICALLY, a present pulse does NOT exclude compartment syndrome — pulses are preserved until very late stages. The 'pain on passive stretch' is the earliest and most reliable sign. If intracompartmental pressure delta (diastolic BP − compartment pressure) is <30 mmHg, emergency fasciotomy is indicated. Do NOT be falsely reassured by a present pulse.

Critical known-trap: a present radial pulse does NOT exclude compartment syndrome. Pain on passive stretch + tense compartment requires urgent pressure measurement, and fasciotomy if delta P <30 mmHg.