2014 Trauma

Question 1

1: In patients with displaced radial neck fractures treated with open reduction and internal fixation with a plate and screws, the plate must be limited to what surface of the radius to avoid impingement on the proximal ulna?

1. 2 cm distal to the articular surface of the radial head
2. 1 cm distal to the articular surface of the radial head
3. Within a 90° arc or safe zone
4. Within a 120° arc or safe zone
5. Within a 180° arc or safe zone

Answer 1

PREFERRED RESPONSE: 3

DISCUSSION: The radial head is covered by cartilage on 360° of its circumference. However, with the normal range of forearm rotation of 160° to 180°, there is a consistent area that is nonarticulating. This area is found by palpation of the radial styloid and Lister tubercle. The hardware should be kept within a 90° arc on the radial head subtended by these two structures.

Question 2

2: When harvesting an iliac crest bone graft from the posterior approach, what anatomic structure is at greatest risk for injury if a Cobb elevator is directed too caudal?

1. Sciatic nerve
2. Cluneal nerves
3. Inferior gluteal artery
4. Superior gluteal artery
5. Sacroiliac joint

Answer 2

PREFERRED RESPONSE: 4

DISCUSSION: If a Cobb elevator is directed caudally while stripping the periosteum over the iliac wing, it will encounter the sciatic notch. Although this puts the sciatic nerve at risk, the first structure encountered is the superior gluteal artery. Because it is tethered at the superior edge of the notch, it is very vulnerable to injury and can then retract inside the pelvis, making it difficult to obtain hemostasis. The inferior gluteal artery exits the sciatic notch below the piriformis and is more protected. The cluneal nerves are at risk only if the incision extends too anteriorly, and the sacroiliac joint can be entered while harvesting the graft.

Question 3

3: A 36-year-old woman sustained a tarsometatarsal joint fracture-dislocation in a motor vehicle accident. The patient is treated with open reduction and internal fixation. What is the most common complication?
1. Posttraumatic arthritis
2. Infection
3. Fixation failure
4. Malunion
5. Nonunion

Answer 3

PREFERRED RESPONSE: 1

DISCUSSION: The most common complication associated with tarsometatarsal joint injury is posttraumatic arthritis. In one series, symptomatic arthritis developed in 25% of the patients and half of those went on to fusion. In another series, 26% had painful arthritis. Initial treatment should consist of shoe modification, inserts, and anti-inflammatory drugs. Fusion is reserved for failure of nonsurgical management. Hardware failure may occur, but it is clinically unimportant.

Question 4

4: What is the most appropriate indication for replantation in an otherwise healthy 35-year-old man?

1. Isolated transverse amputation of the thumb through the middle of the nail bed
2. Isolated transverse amputation of the index finger through the proximal phalanx
3. Isolated transverse amputation of the ring finger through the proximal phalanx
4. Isolated transverse amputation of the hand at the level of the wrist
5. Forearm amputation with a 10-hour warm ischemia time

Answer 4

PREFERRED RESPONSE: 4

DISCUSSION: Vascular anastomoses are exceedingly difficult with amputations distal to the nail fold because the digital vessels bifurcate or trifurcate at this level, and little functional benefit is gained compared to other means of soft-tissue coverage. Single-digit amputations, other than the thumb, are a relative contraindication for replantation. Replantations at the level of the proximal phalanx lead to poor motion of the proximal interphalangeal joint. In a healthy, active adult, an amputation through the wrist is an appropriate situation to proceed with a replantation. A transverse forearm amputation is a good indication with a warm ischemia time of less than 6 hours.

Question 5

5: A 46-year-old man fell 20 feet and sustained the injury shown in Figure 1. The injury is closed; however, the soft tissues are swollen and ecchymotic with blisters. The most appropriate initial management should consist of

Figure 1

1. a long leg cast.
2. a short leg cast.
3. immediate open reduction and internal fixation.
4. a temporizing spanning external fixator.
5. primary ankle fusion.

Answer 5

PREFERRED RESPONSE: 4

DISCUSSION: Although this is a fracture of the medial and lateral malleoli, the degree of displacement and comminution of the medial dome indicate that this injury is similar to a pilon fracture. Initial management should consistent of stabilization to allow for soft-tissue healing. The use of temporizing spanning external fixation should be the initial step, followed by limited or more extensive open reduction and internal fixation when the soft-tissue status will allow. Initial placement in either a short or long leg cast does not provide the needed stability and does not allow for care and monitoring of soft tissues. In addition, maintaining reduction of the talus may be very difficult. Immediate open reduction and internal fixation through an injured soft-tissue envelope adds the risk of difficulties with incision healing and a higher risk of deep infection. In the acute setting, a primary ankle fusion through this soft-tissue envelope is not indicated.

Question 6

6: A collegiate golfer sustained a hook of the hamate fracture. After 12 weeks of splinting and therapy, the hand is still symptomatic. What is the most appropriate management to allow return to competitive activity?

1. Continued observation
2. Open reduction and internal fixation of the fracture
3. Excision of the hook of the hamate
4. Carpal tunnel release
5. Guyon canal release

Answer 6

PREFERRED RESPONSE: 3

DISCUSSION: Excision of the fracture fragment typically leads to rapid return to function. Fixation techniques are difficult to perform because of the size of the bone; hardware prominence is common. Nerve deficits are not typically noted in this injury. The motor branch of the ulnar nerve in Guyon canal must be protected during the surgical approach.

Question 7

7: A 20-year-old man sustained a closed tibial fracture and is treated with a reamed intramedullary nail. What is the most common complication associated with this treatment?

1. Nonunion
2. Malunion
3. Infection
4. Knee pain
5. Compartment syndrome

Answer 7

PREFERRED RESPONSE: 4

DISCUSSION: The most common complication is anterior knee pain (57%). The knee pain is activity related (92%) and exacerbated by kneeling (83%). Although knee pain is the most common complication, most patients rate it as mild to moderate and only 10% are unable to return to previous employment. Some authors report less knee pain with a peritendinous approach when compared to a tendon-splitting approach. In one study, nail removal resolved pain in 27%, improved it in 70%, and made it worse in 3%. The incidence of the other complications was: infection 0% to 3%, nonunion 0% to 6%, and malunion 2% to 13%. Compartment syndrome is rare after nailing.

Question 8

8: What is the most likely complication following treatment of the humeral shaft fracture shown in Figure 2?

Figure 2

1. Nonunion
2. Shoulder pain
3. Infection
4. Elbow injury
5. Radial nerve injury

Answer 8

PREFERRED RESPONSE: 2

DISCUSSION: The humerus was treated with an intramedullary nail. Findings from two prospective randomized studies of intramedullary nailing or compression plating of acute humeral fractures have shown approximately a 30% incidence of shoulder pain with antegrade humeral nailing. This is the most common complication in both of these series. Nonunions are present in approximately 5% to 10% of humeral fractures treated with an intramedullary nail. Infection has an incidence of approximately 1%. Elbow injury is unlikely unless the nail is excessively long. Rarely, injury to the radial nerve is possible if it is trapped in the intramedullary canal.

Question 9

9: A 16-year-old girl sustained the injury shown in Figure 3A. CT scans are shown in Figures 3B through 3D. The results of treatment of this injury have been shown to correlate most with which of the following factors?

Figure 3

1. Surgical approach
2. Location of the transverse fracture
3. Timing of surgery
4. Accuracy of reduction
5. Use of skeletal traction

Answer 9

PREFERRED RESPONSE: 4

DISCUSSION: The patient has a very low T-type acetabular fracture; however, the head is not congruent under the dome so surgical reduction is necessary. The anterior and posterior columns are displaced and will move independently of each other. The extended iliofemoral is the only approach allowing for visualization and reduction of each column. A combined anterior and posterior approach may also be used. The timing of surgery should be within the first 3 weeks of injury to optimize chances of obtaining an accurate reduction because this is an important factor in determining outcome.

Question 10

10: An active 49-year-old woman who sustained a diaphyseal fracture of the clavicle 8 months ago now reports persistent shoulder pain with daily activities. An AP radiograph is shown in Figure 4. Management should consist of

Figure 4

1. external electrical stimulation.
2. external ultrasound stimulation.
3. implanted electrical stimulation.
4. closed reduction and percutaneous fixation.
5. open reduction and internal fixation with bone graft.

Answer 10

PREFERRED RESPONSE: 5

DISCUSSION: The radiograph reveals an atrophic nonunion of the diaphysis of the clavicle. Electrical or ultrasound stimulation may be an option in diaphyseal nonunions that have shown some healing response with callus formation, but these techniques are not successful in an atrophic nonunion. The preferred technique for achieving union is open reduction and internal fixation with bone graft. Percutaneous fixation has no role in treatment of nonunions of the clavicle.

Question 11

11: Examination of a 25-year-old man who was injured in a motor vehicle accident reveals a fracture-dislocation of C5-6 with a Frankel B spinal cord injury. He also has a closed right femoral shaft fracture and a grade II open ipsilateral midshaft tibial fracture. Assessment of his vital signs reveals a pulse rate of 45/min, blood pressure of 80/45 mm Hg, and respirations of 25/min. A general surgeon has assessed the abdomen, and peritoneal lavage results are negative. His clinical presentation is most consistent with what type of shock?

1. Neurogenic
2. Hemorrhagic
3. Spinal
4. Septic
5. Hypovolemic

Answer 11

PREFERRED RESPONSE: 1

DISCUSSION: Assessment of the acutely injured patient follows the Advanced Trauma Life Support protocol. Cervical cord injury is often associated with a disruption in sympathetic outflow. Absent sympathetic input to the lower extremities leads to vasodilatation, decreased venous return to the heart, and subsequent hypotension. With hypotension, the physiologic response of tachycardia is not possible because of the unopposed vagal tone. This results in bradycardia. Patient positioning, fluid support, pressor agents, and atropine are used to treat neurogenic shock.

Question 12

12: A 32-year-old woman sustained an injury to her left upper extremity in a motor vehicle accident. Examination reveals a 2-cm wound in the midportion of the dorsal surface of the upper arm and deformities at the elbow and forearm; there are no other injuries. Her vital signs are stable, and she has a base deficit of -1 and a lactate level of less than 2. Radiographs are shown in Figures 5A and 5B. In addition to urgent débridement of the humeral shaft fracture, management should include

Figure 5

1. closed management of the medial condyle and humeral shaft fractures and open reduction and internal fixation of the both-bones forearm fracture.
2. closed management of the humeral shaft fracture and open reduction and internal fixation of the medial condyle and the both-bones forearm fractures.
3. open reduction and internal fixation of the humeral shaft, medial condyle, and the both-bones forearm fractures.
4. open reduction and internal fixation of the medial condyle and both-bones forearm fractures, and external fixation of the humeral shaft fracture.
5. delayed stabilization of all fractures after the open wound has healed.

Answer 12

PREFERRED RESPONSE: 3

DISCUSSION: With a severe injury to the upper extremity, the best opportunity for achieving a good functional result for a floating elbow is immediate débridement of the open fracture, followed by internal fixation of the fractures. The ability to do this depends on the patient’s physiologic status. In this patient, the procedure is acceptable because she has normal vital signs and no chest or abdominal injuries, and normal physiologic parameters (base excess and lactate) show adequate peripheral perfusion. The surgical approaches will be determined by the associated injury patterns and open wounds. In this patient, the humerus was débrided and stabilized through a posterior approach as was the medial condyle fracture. The ulna was fixed through an extension of the posterior incision and the radius through a separate dorsal approach.

Question 13

13: A patient sustained the injuries shown in the radiographs and clinical photograph seen in Figures 6A through 6C. The neurovascular examination is normal. The first step in emergent management of the extremity injuries should consist of

Figure 6

1. application of a femoral traction pin.
2. intramedullary nailing of the femur and tibia.
3. surgical irrigation and débridement.
4. external fixation of the femoral fracture.
5. reduction of the femoral head.

Answer 13

PREFERRED RESPONSE: 5

DISCUSSION: The figures show an open tibial fracture, a femoral shaft fracture, and femoral head dislocation. The most urgent treatment is reduction of the femoral head, as timing to reduction has been correlated with preventing osteonecrosis. After reduction of the femoral head, the next priority is wound management, followed by stabilization of the femoral and tibial fractures with either splinting, traction, or external fixation.

Question 14

14: A 25-year-old patient sustains the injury shown in Figures 7A through 7C after falling off a curb. Initial management should consist of

Figure 7

1. weight bearing as tolerated in a hard-soled shoe.
2. weight bearing as tolerated in an ankle lacer.
3. weight bearing as tolerated in a short leg cast.
4. no weight bearing in a hard-soled shoe.
5. no weight bearing in a short leg cast.

Answer 14

PREFERRED RESPONSE: 5

DISCUSSION: The radiographs reveal a fracture entering the 4-5 intermetatarsal articulation, consistent with a zone 2 injury. This classically is also referred to as a Jones fracture. The history and radiographic findings indicate this is an acute fracture, which guides management. A zone 1 fracture enters the fifth tarsometatarsal joint, and a zone 3 fracture is a proximal diaphyseal fracture distal to the 4-5 articulation. Initial management is usually nonsurgical and consists of no weight bearing in a short leg cast. This method has been shown to result in a better healing rate compared to weight bearing as tolerated.

Question 15

15: What structure is most often injured in a volar proximal interphalangeal joint dislocation?

1. Sagittal bands
2. Central slip
3. Lumbrical
4. Juncturae tendinum
5. Terminal extensor tendon

Answer 15

PREFERRED RESPONSE: 2

DISCUSSION: Closed ruptures of the central slip of the extensor tendon may occur with volar proximal interphalangeal joint dislocation, forced flexion of the proximal interphalangeal joint, or blunt trauma to the dorsum of the proximal interphalangeal joint. The other structures are not typically injured in proximal interphalangeal joint dislocations. Treatment typically requires static splinting of the proximal interphalangeal joint. In the more common dorsal proximal interphalangeal joint dislocation, the volar plate is injured, and early range of motion may be started after reduction.

Question 16

16: What patient factor is predictive of better outcomes for surgical management of a displaced calcaneal fracture compared to nonsurgical management?

1. Young man injured at the work site
2. Young woman injured during recreational activities
3. Heavy smoker
4. Patient older than 50 years
5. Patient with bilateral fractures

Answer 16

PREFERRED RESPONSE: 2

DISCUSSION: A recent randomized trial of surgical versus nonsurgical management of calcaneal fractures showed that patients who were on workers’ compensation did poorly with surgical care. These patients had less favorable outcomes regardless of their initial management. Factors such as age, smoking, and vasculopathies compromise skin healing, leading to greater surgical risks. The best results were obtained in patients who are younger than age 40 years, have unilateral injuries, and are injured during noncompensable activities. Women tend to do better with surgery than men.

Question 17

17: Figures 8A and 8B show the initial radiographs of an 18-year-old man who fell while snowboarding. Figures 8C and 8D show the radiographs obtained following closed reduction. Examination reveals that the elbow is stable with range of motion. Management should now consist of

Figure 8

1. immediate return to unrestricted activity.
2. a posterior long arm splint for 7 to 10 days, followed by elbow range-of-motion exercises.
3. a long arm cast for 4 weeks.
4. immediate surgical repair of the collateral ligaments.
5. immediate surgical repair of the collateral ligaments and placement of a hinged external fixator.

Answer 17

PREFERRED RESPONSE: 2

DISCUSSION: The initial radiographs reveal a simple elbow dislocation without associated fractures. After successful closed reduction, the range of stability should be assessed. If the elbow is stable, nonsurgical management should consist of a short period of immobilization followed by range-of-motion exercises. Immobilization for more than 3 weeks results in significant elbow stiffness. Surgical repair is indicated for dislocations that are irreducible, have associated fractures, or where stability cannot be maintained with closed treatment.

Question 18

18: Which of the following is an advantage of unreamed nailing of the tibia compared to reamed nailing?

1. Less surgical time
2. Lower risk of nonunion
3. Lower rate of malunion
4. Faster time to union
5. Less secondary procedures to achieve union

Answer 18

PREFERRED RESPONSE: 1

DISCUSSION: The debate between reamed versus unreamed intramedullary nailing of the tibia continues. Although unreamed nailing was proposed for open fractures to minimize infection, its simplicity made it appealing for closed fractures. However, most studies to date show that the only advantage of unreamed nailing is less surgical time. All studies show higher nonunion rates with increased hardware failure and increased time to union for unreamed nailing. Even in open fractures graded up to Gustilo grade IIIA, the reamed tibial nail performs better.

Question 19

19: An otherwise healthy 35-year-old woman reports dorsal wrist pain and has trouble extending her thumb after sustaining a minimally displaced fracture of the distal radius 3 months ago. What is the most appropriate next step in management?

1. Neurophysiologic test to evaluate the posterior interosseous nerve
2. Transfer of the extensor indicis proprius to the extensor pollicis longus tendon
3. Interphalangeal joint arthrodesis of the thumb
4. Extension splinting of the thumb
5. Fine-cut CT of the distal radius to evaluate Lister tubercle

Answer 19

PREFERRED RESPONSE: 2

DISCUSSION: Extensor pollicis longus tendon rupture can occur after a fracture of the distal radius, even a minimally displaced one. Poor vascularity of the tendon within the third dorsal compartment is the suspected etiology, not the displaced fracture fragments. Tendon transfer will suitably restore active extension of the thumb interphalangeal joint.

Question 20

20: Figure 9A is a radiograph from a 34-year-old woman who sustained a basicervical fracture of the femoral neck. The fracture was treated with a compression screw and side plate. Seven months postoperatively, she continues to have significant hip pain and cannot bear full weight on her hip. A recent radiograph is shown in Figure 9B. Management should now consist of

Figure 9

1. continued non-weight-bearing and a bone stimulator.
2. removal of the hardware, bone grafting of the femoral neck, and refixation.
3. removal of the hardware and hemiarthroplasty.
4. removal of the hardware and total hip arthroplasty.
5. removal of the hardware and a valgus osteotomy.

Answer 20

PREFERRED RESPONSE: 5

DISCUSSION: The patient sustained a high-angle femoral neck fracture. The follow-up clinical findings and radiograph show that she now has a nonunion with failed internal fixation. The joint appears preserved. In a healthy, young patient, arthroplasty of the femoral head, although possible, is not ideal. Excellent healing and function can be obtained in 70% to 80% of patients with femoral neck nonunion with a valgus intertrochanteric osteotomy.

Question 21

21: An 18-year-old man was in a motor vehicle accident and sustained a closed head injury, right displaced scapular body and glenoid fractures, a right proximal humeral fracture, fractures of ribs one through three, facial fractures, and bilateral pubic rami fractures with minimal displacement. He has a systolic blood pressure of 80/40 mm Hg despite fluid resuscitation. A radiograph is shown in Figure 10. Spiral CT does not identify any thoracic or abdominal injuries. What is the most appropriate next step in management?

Figure 10

1. Pelvic angiography
2. Intracranial pressure monitoring
3. Pelvic external fixation
4. Evaluation of peripheral pulses
5. Urgent open stabilization of the clavicular and humeral fractures

Answer 21

PREFERRED RESPONSE: 4

DISCUSSION: The patient has sustained high-energy upper extremity and chest injuries. He continues to remain hemodynamically unstable with no obvious thoracic or abdominal injury responsible for bleeding. The pelvic fracture is unlikely to be causing significant bleeding. A scapulothoracic dissociation and possible disruption of one of the great vessels of the upper extremity should be considered. Evaluation of peripheral pulses or blood pressure indices bilaterally in the upper extremities is a simple way to evaluate the need for further work-up. If there is any discrepancy or further concern, angiography of the involved extremity is necessary.

Question 22

22: What is the major difference in outcome following open reduction and internal fixation (ORIF) of the tibial plafond at 2 to 5 days versus 10 to 20 days?

1. Improved ankle range of motion
2. Increased risk of wound complications
3. Decreased ankle pain
4. Decreased risk of nerve injuries
5. Decreased risk of development of traumatic arthritis

Answer 22

PREFERRED RESPONSE: 2

DISCUSSION: Long-term outcomes following tibial plafond fractures treated with ORIF are satisfactory in most patients despite a high incidence of posttraumatic osteoarthritis. If ORIF is delayed until 10 to 20 days following injury, the major difference in outcomes is fewer complications associated with wound healing. Ankle strength, pain, range of motion, and the development of arthritis are equal regardless of the time until fixation.

Question 23

23: Figure 11 shows the radiograph of a 45-year-old woman who has a painful nonunion. Treatment should consist of

Figure 11

1. revision internal fixation with a longer side plate and bone grafting.
2. open reduction and internal fixation with a 95° fixed angle device and bone grafting.
3. hardware removal and retrograde intramedullary nailing.
4. placement of an implantable bone stimulator.
5. proximal femoral resection and total hip arthroplasty.

Answer 23

PREFERRED RESPONSE: 2

DISCUSSION: The radiograph reveals a reverse obliquely subtrochanteric/intertrochanteric fracture. Open reduction and internal fixation should be accomplished with a 95° fixed-angle device. An intramedullary nail with screw fixation into the head is another possible technique. Either method should correct the varus deformity. Exchange of a high-angled screw and plate device to a longer side plate and bone grafting does not afford any improvement in mechanical stability. Hardware removal and retrograde intramedullary nailing is not indicated for this level of proximal femoral injury. Placement of an implantable bone stimulator may change local biologic factors but would not enhance mechanical stability. The patient’s femoral head is intact without signs of collapse; therefore, hardware removal, proximal femoral resection, and total hip arthroplasty are not warranted.

Question 24

24: What is the treatment of choice for the injury shown in Figures 12A through 12C?

Figure 12

1. Closed reduction and a short arm cast
2. Splinting in a functional position and early motion
3. Closed or open reduction and internal fixation with Kirschner wires
4. Open reduction and internal fixation with minifragment screws
5. Primary arthrodeses of the carpometacarpal joints

Answer 24

PREFERRED RESPONSE: 3

DISCUSSION: The radiographs show multiple carpometacarpal dislocations. Reduction is often obtainable but difficult to maintain. Internal fixation is required to maintain the reduction, preferably with Kirschner wires. Closed reduction and percutaneous pinning is preferred by some surgeons. Others recommend open reduction to remove irreconstructable osteochondral fragments from the individual joints and to ensure correct reduction of the carpometacarpal joints. Kirschner wires are removed at 6 to 8 weeks.

Question 25

25: A 55-year-old woman fell and sustained an elbow dislocation with a coronoid fracture and a radial head fracture. The elbow is reduced and splinted. What is the most common early complication?

1. Brachial artery intimal tear
2. Recurrent dislocation
3. Forearm compartment syndrome
4. Posterior interosseous nerve injury
5. Ulnar nerve palsy

Answer 25

PREFERRED RESPONSE: 2

DISCUSSION: The patient has a dislocation of the elbow with displaced coronoid process and radial head fractures. The elbow is extremely unstable after this injury, and recurrent dislocation in a splint is the most common early complication. Skeletal stabilization of the fractures is required to restore stability of the joint. Characteristics of the fractures will determine the techniques required to restore stability.

Question 26

26: A 25-year-old man sustained the closed injury shown in Figures 13A and 13B. Examination reveals that this is an isolated injury, and the patient is hemodynamically stable. Treatment should consist of

Figure 13

1. multiple flexible intramedullary nails.
2. unreamed intramedullary nailing with static interlocking.
3. unreamed intramedullary nailing with dynamic interlocking.
4. reamed intramedullary nailing with static interlocking.
5. reamed intramedullary nailing with dynamic interlocking.

Answer 26

PREFERRED RESPONSE: 4

DISCUSSION: The treatment of choice for closed diaphyseal femoral fractures in adults is reamed intramedullary nailing with static interlocking. Reaming allows placement of a larger, stronger implant and offers better healing rates than unreamed nailing. Static interlocking ensures that there is no loss of reduction because of underappreciated fracture lines or comminution.

Question 27

27: Figure 14 shows the radiograph of an elderly man who fell on his right arm. What is the most important determinate of a good outcome following this injury?

Figure 14

1. Early open reduction and internal fixation
2. Initiation of physical therapy and passive motion within 2 weeks of the injury
3. Fracture involvement of the greater tuberosity
4. Immobilization with a sling and swathe for 4 weeks
5. Age younger than 70 years

Answer 27

PREFERRED RESPONSE: 2

DISCUSSION: Minimally displaced fractures of the proximal humerus have a good outcome if physical therapy is initiated within 2 weeks of the injury. Results are not affected by age, open reduction and internal fixation, or involvement of the greater tuberosity. Immobilization for longer than 3 weeks will often result in stiffness.

Question 28

28: A 40-year-old man was involved in a motor vehicle accident and sustained the pelvic injury seen in Figures 15A and 15B. Definitive management of the injury should consist of reduction by

Figure 15

1. skeletal traction, and bed rest.
2. anterior external fixation.
3. internal fixation of the symphysis pubis.
4. internal fixation of the symphysis pubis with supplemental external fixation.
5. internal fixation of the symphysis pubis and sacral fracture.

Answer 28

PREFERRED RESPONSE: 5

DISCUSSION: The radiograph reveals disruption of the symphysis pubis and a displaced left sacral fracture. A posterior injury with displacement of greater than 1 cm is unstable, and a sacral fracture is particularly unstable. Surgical stabilization is required for these unstable anterior and posterior injuries. External fixation provides little stability to an unstable posterior pelvic injury. Reduction and internal fixation of the symphysis pubis and sacral fracture will provide the most stable pelvis with the least resultant deformity and allow patient mobilization.

Question 29

29: A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most reliable method of predicting a tear of the interosseous membrane?

1. Level of the fibular fracture
2. Lauge-Hansen fracture class
3. Intraoperative stress testing
4. Widening of the medial clear space
5. Talar dislocation

Answer 29

PREFERRED RESPONSE: 3

DISCUSSION: The Weber and Lauge-Hansen fracture classifications suggest that the interosseous membrane (IOM) is torn with certain fracture patterns. In a recent study that evaluated ankle fractures with MRI, Nielson and associates identified 30 patients with IOM tears. Ten of the tears did not correspond with the level of the fibular fracture. The authors concluded that stability of the syndesmosis should not be based on the level of the fibular fracture alone but should also include an intraoperative stress test. Transsyndesmotic fixation should be considered for those fractures where the intraoperative stress test demonstrates instability. A widened medial clear space may occur with a deltoid injury and distal fibular fracture in the absence of a significant tear of the interosseous membrane.

Question 30

30: A distal radius fracture in an elderly man is strongly predictive for what subsequent injury?

1. Another distal radius fracture
2. Insufficiency fracture of the spine
3. Insufficiency fracture of the pelvis
4. Hip fracture
5. Proximal humerus fracture

Answer 30

PREFERRED RESPONSE: 4

DISCUSSION: Fractures of the distal radius increase the relative risk of a subsequent hip fracture significantly more in men than in women. A previous spinal fracture has an equally important effect on the risk of a subsequent hip fracture in both sexes.

Question 31

31: What measure of physiologic status best evaluates whether an injured patient is fully resuscitated and best predicts that perioperative complications will be minimized following definitive stabilization of long bone fractures?

1. Urine output greater than 100 mL/h
2. Cardiac output greater than 2
3. Serum lactate level less than 2.5 mmol/L
4. Systolic blood pressure greater than 100 mm Hg
5. Hemoglobin level greater than 10 g/dL

Answer 31

PREFERRED RESPONSE: 3

DISCUSSION: Serum lactate levels can be used to evaluate the effectiveness of the resuscitation of patients who have multiple injuries. Even after resuscitation, patients may have occult hypoperfusion as defined by a serum lactate level greater than 2.5 mmol/L. The studies referenced indicate that these patients are at increased risk of perioperative complications such as organ failure or adult respiratory distress syndrome if definitive surgical fixation of the orthopaedic injuries is pursued prior to correction of the occult hypoperfusion. The other markers may be an indication of current physiology but have not been correlated with perioperative risks.

Question 32

32: In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by

1. a posterior-lateral approach.
2. a lateral approach.
3. a medial approach.
4. an anterior-medial approach.
5. rigid cast immobilization.

Answer 32

PREFERRED RESPONSE: 2

DISCUSSION: In the treatment of ankle fractures, the superficial peroneal nerve is most commonly injured by the use of a direct lateral approach to the ankle. The superficial peroneal nerve and its branches exit the fascial hiatus approximately 9 cm to 10 cm proximal to the tip of the distal fibula with a range of 4 cm to 13 cm, and their course is typically anterior to the midlateral plane of the fibula. However, small branches may course across the surgical plane directly laterally. A posterior-lateral approach diminishes the risk of injury to the superficial peroneal nerve and its branches; however, by moving farther posterior, the sural nerve and its branches may be at increased risk. Cast immobilization may injure the cutaneous nerves about the ankle; however, the risks are greater with surgical intervention. A medial or anterior-medial approach to the ankle will not injure the superficial peroneal nerve at the ankle level.

Question 33

33: A 54-year-old man sustained a small superficial abrasion over the left acromioclavicular joint after falling from his bicycle. Examination reveals no other physical findings. Radiographs show a displaced fracture of the lateral end of the clavicle distal to a line drawn vertically to the coracoid process. Management should consist of

1. open reduction and plate fixation.
2. a figure-of-8 bandage for 4 to 6 weeks.
3. a sling for comfort, followed by physical therapy when pain free.
4. excision of the outer end of the clavicle.
5. a tension band and Kirschner wires.

Answer 33

PREFERRED RESPONSE: 3

DISCUSSION: Displaced clavicular fractures lateral to the coracoid process (Neer type II and III) are best managed nonsurgically with sling immobilization and physical therapy, starting with pendulum exercises and progressing to active-assisted exercises when comfortable. Supervised therapy should be performed for 3 months or until full painless motion is achieved. In a study by Robinson and Cairns, this form of treatment provided patients with an 86% chance of avoiding a secondary reconstructive procedure.

Question 34

34: A 47-year-old man sustained a degloving injury over the pretibial surface and anterior ankle region in a motor vehicle accident. After débridement and irrigation, there is inadequate tissue for closure of the exposed anterior tibial tendon and tibia. Prior to definitive soft-tissue coverage, management should consist of

1. immediate split-thickness skin grafting.
2. immediate xenograft application.
3. a vacuum-assisted closure device.
4. dressing changes with sulfasalazine cream.
5. a cross-leg flap.

Answer 34

PREFERRED RESPONSE: 3

DISCUSSION: With soft-tissue loss, local or free flap coverage may be necessary to treat exposed tendon and bone. However, a vacuum-assisted closure device is a good temporizing dressing. It prevents external contamination, reduces edema around the wound, increases oxygen tension in the wound, and promotes the formation of granulation tissue. The use of this negative pressure device has been described in both acute traumatic and in chronic wound scenarios. If sufficient granulation tissue forms, closure may be by split graft, avoiding a more complex coverage procedure. Immediate skin grafting over the exposed anterior tibial tendon and tibia would have a low likelihood of success. Dressing changes with sulfasalazine may be beneficial in a burn wound to assist with removal of skin slough; however, in a granulating wound, the material may be toxic to early epithelialization. Xenograft is a foreign body and should not be applied to an acute contaminated open wound. Historically, a cross-leg flap was a treatment alternative for lower extremity soft-tissue loss; however, its current applications are extremely limited.

Question 35

35: The humeral nonunion shown in Figure 16 is most likely to unite when using what method of treatment?

Figure 16

1. Intramedullary nail
2. Pulsed electromagnetic fields
3. Compression plate
4. Intramedullary nail and bone graft
5. Compression plate and bone graft

Answer 35

PREFERRED RESPONSE: 5

DISCUSSION: The radiograph shows an atrophic nonunion of the humeral shaft. The management of humeral nonunions has been studied with compression plates and bone graft, as well as intramedullary nailing and bone graft. Compression plating with bone graft results in the highest rate of union. Compression plating by itself is not adequate, given the bone loss and lack of callus in this nonunion. Pulsed electromagnetic fields is a viable option for hypertrophic nonunions where there is inherent stability. Intramedullary nailing does not provide as much compression and stability as that achieved with compression plating.

Question 36

36: An adult with a distal humeral fracture underwent open reduction and internal fixation. What is the most common postoperative complication?

1. Loss of elbow range of motion
2. Nonunion
3. Malunion
4. Infection
5. Ulnar nerve dysfunction

Answer 36

PREFERRED RESPONSE: 1

DISCUSSION: Most patients lose elbow range of motion after open reduction and internal fixation of a distal humeral fracture. Ulnar nerve dysfunction, nonunion, and infection all occur less commonly.

Question 37

37: The radiographs and CT scan seen in Figures 17A through 17D reveal what type of acetabular fracture pattern?

Figure 17

1. Transverse
2. Transverse with posterior wall
3. Both column
4. Posterior wall anterior hemitransverse
5. T-type

Answer 37

PREFERRED RESPONSE: 2

DISCUSSION: The AP, obturator oblique, and iliac oblique views of the pelvis reveal a fracture that disrupts the iliopectineal and ilioischial lines, indicating a fracture that involves both anterior and posterior columns. However, it does not have the other features of anterior or posterior column fracture patterns. A displaced posterior wall fracture is also present, best seen on the obturator oblique view. The anterior to posterior directed fracture line on the CT scan indicates a transverse fracture; therefore, the patient has a transverse with posterior wall fracture pattern. A T-type fracture would be similar but would have a break into the obturator ring.

Question 38

38: A 26-year-old man sustained an isolated injury to his left hip joint in a motor vehicle accident. Closed reduction was performed, and the postreduction radiograph is shown in Figure 18. Management should now consist of

Figure 18

1. emergent open reduction and fixation of the fracture.
2. skeletal traction and expedient open reduction and fixation of the fracture.
3. skeletal traction for 6 weeks, followed by physical therapy.
4. crutches and no weight bearing for 6 weeks.
5. bed rest for 1 week and follow-up radiographs to determine if the fragment has moved.

Answer 38

PREFERRED RESPONSE: 2

DISCUSSION: The patient has a posterior fracture-dislocation of the hip and following reduction, an incarcerated fragment of bone resulted in an incongruent reduction. Whereas expedient removal of the fragment is required to limit articular cartilage damage, this situation is not an emergency and the procedure may be performed when the appropriate surgical team is available and the patient’s condition stabilized. Skeletal traction through either the femur or tibia may relieve some pressure on the joint and prevent articular damage. Nonsurgical care for incarcerated fragments is contraindicated.

Question 39

39: A 35-year-old man is brought to the emergency department following a motorcycle accident. He is breathing spontaneously and has a systolic blood pressure of 80 mm Hg, a pulse rate of 120/min, and a temperature of 98.6° F (37° C). Examination suggests an unstable pelvic fracture; AP radiographs confirm an open book injury with vertical displacement on the left side. Ultrasound evaluation of the abdomen is negative. Despite administration of 4 L of normal saline solution, he still has a systolic pressure of 90 mm Hg and a pulse rate of 110. Urine output has been about 20 mL since arrival 35 minutes ago. What is the best next course of action?

1. Continued resuscitation with fluids and blood
2. Ongoing resuscitation and pelvic angiography
3. Application of an external fixator in the emergency department
4. A pelvic binder and continued resuscitation
5. A pelvic binder, skeletal traction, and continued resuscitation

Answer 39

PREFERRED RESPONSE: 5

DISCUSSION: The patient is at risk for pelvic vascular injury and major hemorrhage. This type of complication of pelvic trauma is highest in motorcyclists. Once it is recognized that the pelvic ring has opened, it is important to close that ring to tamponade any venous bleeding with a pelvic binder and to add a skeletal traction pin to the limb on the involved side. This will correct any translational displacement. The noninvasive pelvic binders or sheets are easy to apply and are very effective. They do not compromise future care and allow the surgeons access to the abdomen. External fixation or pelvic resuscitation clamps require a certain amount of skill to apply and are not always available. If the pelvic stabilization does not improve the hemodynamic parameters in 10 to 15 minutes, angiography is necessary.

Question 40

40: A healthy 25-year-old man sustains a grade IIIB open tibial fracture. Following appropriate débridement, irrigation, and stabilization with an external fixator, the soft-tissue injury is shown in Figure 19. What is the most appropriate definitive soft-tissue coverage procedure?

Figure 19

1. Split-thickness skin graft
2. Full-thickness skin graft
3. Soleus rotation flap
4. Medial gastrocnemius rotation flap
5. Free latissimus dorsi flap with microvascular anastomosis

Answer 40

PREFERRED RESPONSE: 5

DISCUSSION: This is a very large, near-circumferential defect with posterior as well as anterior skin and muscle injury. Bone is exposed. The posterior muscles cannot be rotated because they are part of the zone of injury. The bone and other poorly vascularized areas of this wound would not accept a skin graft. The best chance for limb salvage will be to obtain soft-tissue coverage with a free tissue transfer using the latissimus dorsi.

Question 41

41: A 25-year-old woman undergoes surgical treatment of a displaced proximal humeral fracture via a deltopectoral approach. At the first postoperative visit, she reports a tingling numbness along the anterolateral aspect of the forearm. What structure is most likely injured?

1. Medial cord of the brachial plexus
2. Radial nerve
3. Median nerve
4. Axillary nerve
5. Musculocutaneous nerve

Answer 41

PREFERRED RESPONSE: 5

DISCUSSION: Sensation along the anterolateral aspect of the forearm is supplied by the lateral antebrachial cutaneous nerve, the terminal branch of the musculocutaneous nerve. The musculocutaneous nerve can be injured by proximal humeral fractures or dislocations, and is also at risk during surgical exposure if excessive retraction is placed on the conjoint tendon. The musculocutaneous nerve enters the conjoint tendon 1 cm to 5 cm distal to the coracoid process.

Question 42

42: A 32-year-old man sustained a fracture of his upper arm in a motor vehicle accident. Radiographs are shown in Figure 20. Because of other associated injuries, surgical stabilization is chosen. What technique will result in the fewest complications and the best outcome?

Figure 20

1. Retrograde locked intramedullary nail
2. Antegrade reamed locked intramedullary nail
3. Flexible nails
4. Open reduction and plate fixation
5. External fixation

Answer 42

PREFERRED RESPONSE: 4

DISCUSSION: Most humeral fractures will heal with nonsurgical functional brace management. When the initial pain has subsided in a coaptation splint, the patient is converted to a functional brace and allowed to use the arm for activities. The fracture should heal within 6 to 12 weeks with acceptable results. Surgery is indicated if there is vascular injury, open injury, floating elbow, chest injury, bilateral humeral fractures, or if a reduction cannot be obtained or maintained. The surgical treatment of choice is either antegrade reamed locked intramedullary nailing or plate osteosynthesis. Plate osteosynthesis appears to offer better results with respect to union, function, and risk of complications.

Question 43

43: During a posterior approach to the glenoid with retraction as shown in Figure 21, care should be taken during superior retraction to avoid injury to which of the following structures?

Figure 21

1. Axillary artery
2. Axillary nerve
3. Branch of the circumflex scapular artery
4. Profunda brachii artery
5. Suprascapular nerve and artery

Answer 43

PREFERRED RESPONSE: 5

DISCUSSION: During a posterior approach to the shoulder for either a scapular fracture, glenoid fracture, or posterior shoulder pathology, the interval between the teres minor and infraspinatus is split. Excessive superior retraction on the infraspinatus, or excessive dissection superomedially under the infraspinatus muscle and tendon can cause injury to the suprascapular nerve and/or artery. During dissection in this interval, the axillary artery and axillary nerve are well protected. A branch of the circumflex scapular artery ascends between the teres minor and infraspinatus muscle, but it is at risk during dissection on the scapula in the midportion of the interval and not during superior retraction. The profunda brachii artery is not present in this interval.

Question 44

44: A 42-year-old woman sustained a closed, displaced talar neck fracture in a motor vehicle accident. Which of the following is an avoidable complication of surgical treatment?

1. Posttraumatic arthritis of the subtalar joint
2. Posttraumatic arthritis of the ankle joint
3. Malunion of the talus
4. Osteonecrosis of the talus
5. Complex regional pain syndrome

Answer 44

PREFERRED RESPONSE: 3

DISCUSSION: Malunion of the talus is a devastating complication that leads to malpositioning of the foot and subsequent arthrosis of the subtalar joint complex. This is considered an avoidable complication in that accurate surgical reduction will minimize its development. Posttraumatic arthritis of the subtalar joint, osteonecrosis of the talus, posttraumatic arthritis of the ankle joint, and complex regional pain syndrome all may develop as a result of the initial traumatic event and may not be avoidable despite anatomic reduction.

Question 45

45: Figures 22A and 22B show the radiographs of a 48-year-old woman who smokes cigarettes and sustained a segmental femoral shaft fracture in a motor vehicle accident 9 months ago. Initial management consisted of stabilization with a reamed statically locked intramedullary nail. She now reports lower leg pain that increases with activity. In addition to advising the patient to quit smoking, management should include

Figure 22

1. ultrasonic stimulation for 3 months.
2. removal of the nail and plate fixation.
3. continued observation.
4. removal of the distal locking screws to dynamize the nail.
5. exchange reamed nailing with bone graft.

Answer 45

PREFERRED RESPONSE: 5

DISCUSSION: The patient has an oligotrophic nonunion of the distal femoral fracture. Although the proximal fracture appears incompletely united, it was stable at exchange nailing. The treatment of choice is exchange reamed nailing to at least 2 mm above the nail in place. Bone grafting is debatable. Recent studies have shown a 70% to 75% success rate with exchange nailing only, so in nonhypertrophic nonunions, bone grafting can be considered. Nonsurgical management consisting of observation or external stimulation runs the risk of implant failure. Plate fixation is acceptable but is considered a second choice because of the need to consider stabilization of the proximal fracture until union is achieved. Also, plate fixation definitely requires bone grafting.

Question 46

46: A 34-year-old man sustained a tibial fracture in a motorcycle accident. What perioperative variable is associated with the greatest relative risk for reoperation to achieve bone union?

1. Sex
2. Delay in initial surgical treatment
3. Use of NSAIDs
4. Smoking
5. Cortical contact of ≤; 50%

Answer 46

PREFERRED RESPONSE: 5

DISCUSSION: In a recent analysis of 200 patients with tibial fractures, Bhandari and associates attempted to identify variables that were predictive of reoperation. The variables in the study were type of injury (fracture pattern), degree of open injury, mechanism of injury, cortical bone contact, postoperative complications, polytrauma, anti-inflammatory drug use, nail insertion technique (reamed versus nonreamed), smoking history, alcohol use, diabetes mellitus, peripheral vascular disease, age, disability status preinjury, sex, surgeon, time to surgery, steroid use, phenytoin use, antibiotic use, anticoagulant use, and type of fixation used. Three variables were statistically significant predictors of reoperation to achieve bone union in the first postinjury year: transverse fracture pattern, open fracture, and cortical contact of 50% or less. Using these three variables, four reoperation risk groups were identified based on the number of these three variables present: 0, 1, 2, or 3. The risk for reoperation was 0%, 18%, 47%, and 94%, respectively. The authors concluded that these statistics can provide prognostic information to patients and help identify those high-risk patients where early intervention to achieve union is indicated. In addition, the data highlight the significance of achieving cortical contact at the time of initial fixation.

Question 47

47: A 17-year-old boy sustained a 5-mm laceration on the lateral aspect of the hindfoot while working on a farm. Examination in the emergency department revealed no fractures. Twenty-four hours later, he returns to the emergency department with increasing foot pain. A thin, brown drainage is seen emanating from the wound. He has a temperature of 102.0° F (38.9° C), a pulse rate of 120, and a blood pressure of 80/40 mm Hg. Examination of the foot reveals diffuse swelling, ecchymosis, tenderness, and crepitus with palpation. Current radiographs are shown in Figures 23A and 23B. Management should now consist of

Figure 23

1. intravenous antibiotics.
2. hyperbaric oxygen therapy and intravenous antibiotics.
3. surgical débridement, primary wound closure, and intravenous antibiotics.
4. surgical débridement, closure of the wound over drains, and intravenous antibiotics.
5. surgical débridement, leaving the wound open, and intravenous antibiotics.

Answer 47

PREFERRED RESPONSE: 5

DISCUSSION: The mechanism and environment in which the injury occurred, the clinical picture, and the radiographic findings of gas in the tissues suggest an anaerobic gram-positive bacterial infection. This can be a life- and limb-threatening infection. Treatment should consist of wide débridement of all devitalized tissue, and intravenous antibiotics should be started. Wounds should be left open to allow bacterial effluent and increase oxygen tension in the wound. Hyperbaric oxygen may be used as an adjuvant but is no substitute for débridement.

Question 48

48: A healthy, active, independent 74-year-old woman fell and sustained the elbow injury shown in Figures 24A and 24B. Management should consist of

Figure 24

1. a sling and early elbow range-of-motion exercises.
2. a long arm cast for 6 weeks.
3. open reduction and internal fixation.
4. total elbow arthroplasty.
5. elbow arthrodesis.

Answer 48

PREFERRED RESPONSE: 4

DISCUSSION: Open reduction and internal fixation of distal humeral fractures in elderly patients often fails. These fractures characteristically have a very small distal segment and poor bone quality, resulting in failure of fixation and nonunion. Nonunion is often painful and functionally debilitating. Total elbow arthroplasty provides good results when used for distal humeral fractures in elderly patients with osteopenic bone and fracture patterns thought to be irreconstructable. Long arm casting may result in union, but the resulting stiffness is unacceptable for an active patient. Elbow arthrodesis has few indications. A sling and range-of-motion exercises will often result in a painful and debilitating nonunion at the fracture site.

Question 49

49: A 25-year-old man is brought to the emergency department following a motor vehicle accident. Extrication time was 2 hours, and in the field he had a systolic blood pressure by palpation of 90 mm Hg. Intravenous therapy was started, and on arrival to the emergency department his systolic blood pressure is 90 mm Hg with a pulse rate of 130. Examination reveals a flail chest and a femoral diaphyseal fracture. Ultrasound of the abdomen is positive. The trauma surgeons take him to the operating room for an exploratory laparotomy. At the conclusion of the procedure, systolic pressure of 100 mm Hg with a pulse rate of 110. Oxygen saturation is 90% on 100% oxygen, and the patient’s temperature is 95.0° F (35° C). What is the recommended treatment of the femoral fracture at this time?

1. Reamed intramedullary nail
2. Unreamed intramedullary nail
3. Percutaneous plate fixation
4. Skeletal traction
5. External fixation

Answer 49

PREFERRED RESPONSE: 5

DISCUSSION: This is a borderline trauma patient for whom serious consideration for damage control orthopaedic surgery is required. His prolonged hypotension, abdominal injury, and chest injury put him at higher risk for serious postinjury complications. Further surgery, such as definitive fracture fixation, adds metabolic load and injury to his system. It is prudent to consider femoral fracture stabilization with an external fixator until he is physiologically recovered as evidenced by a normal base excess and/or lactate acid levels, as well as all other parameters of resuscitation. A borderline patient has been described as polytrauma with an Injury Severity Score (ISS) >; 20 and thoracic trauma (Abbreviated Injury Scale [AIS] >; 2); polytrauma and abdominal/pelvic trauma (Moore >; 3) and hemodynamic shock (initial blood pressure ; 40; bilateral lung contusions on radiographs; initial mean pulmonary arterial pressure >; 24 mm Hg; pulmonary artery pressure increase during intramedullary nailing >; 6 mm Hg. Factors that worsen the situation following surgery include multiple long bones and truncal injury (AIS >; 2), estimated surgery time of more than 6 hours, arterial injury and hemodynamic instability, and exaggerated inflammatory response (eg, interleukin-6 >; 800 pg/mL). It is incumbent on the orthopaedic surgeon who is a member of the trauma team to make sure that he or she is aware of these factors and guides the team to the best patient care.

Question 50

50: A 26-year-old man was thrown from a car and sustained the injury seen in Figures 25A and 25B. Nonsurgical management of this injury is recommended. Which of the following factors increases the risk of nonunion?

Figure 25

1. Male sex
2. Diaphyseal location
3. Comminuted displaced fracture
4. Young age
5. Associated injuries

Answer 50

PREFERRED RESPONSE: 3

DISCUSSION: The patient has a displaced comminuted clavicle middle one- third fracture from a high-energy mechanism. Recent literature on high-energy clavicular fractures suggests a higher rate of nonunion than previously reported. A nonunion rate of 30% has been reported by Hill and associates when the fracture fragments are displaced more than 1.5 cm. In addition, several patients had neurologic symptoms related to the injury. Robinson and associates reported an increased risk of nonunion in women, elderly patients, comminuted fractures, and injuries with a lack of cortical contact.