CCOC dag 1

Question 1

1. Most of the body of the talus is vascularized by the:
2. Anterior tibial artery
3. Deltoid artery
4. Deltoid and peroneal artery
5. Posterior tibial artery
6. Deltoid and anterior tibial artery

Answer 1

4. Posterior tibial artery

Question 2

2. A 30 year old male missed a step and fell. He complains about pain in his foot. On initial exam the foot is swollen and tender, mainly at the midfoot. Neurological and vascular exam is normal.
   An x-ray of the foot shows no abnormalities.
   What will you suggest?
3. Admittance to the hospital, check regularly for a compartment syndrome
4. A MRI scan
5. Non Weightbearing cast, check again in 10-14 days
6. A CT scan
7. Nothing, clearly this is just a sprain

Answer 2

3. Non Weightbearing cast, check again in 10-14 days

Question 3

3. A snowboarder’s fracture:
4. Is a fracture of the talar neck
5. Must be treated with ORIF
6. Can lead to permanent instability of the ankle joint
7. Can lead to subtalair osteoarthritis
8. Can only be diagnosed by a CT scan

Answer 3

4. Can lead to subtalair osteoarthritis

Question 4

4. A medial column shortening (adduction) may be
   caused by a:
5. A tuberosity fracture of the navicular
6. A posterior tibial tendon disfunction
7. A comminuted navicular fracture
8. A processus anterior calcanii fracture
9. A stress fracture of the navicular

Answer 4

3. A comminuted navicular fracture

Question 5

5. The Lauge-Hansen classification is best described by
   the following combinations:
6. supination-abduction, supination-external rotation, pronation-external rotation, pronation-adduction
7. supination-external rotation, supinationexternal rotation, pronation-external rotation, pronation-abduction
8. supination-inversion, supination-external rotation, pronation-external rotation, pronation-internal rotation
9. supination-adduction, supination-external rotation, pronation-external rotation, pronation-abduction

Answer 5

4. supination-adduction, supination-external rotation, pronation-external rotation, pronation-abduction

Question 6

6. For a high-energy pilon fracture is the most common
   sequence of treatment:
7. ex-fix, CT, 1-3 weeks wait, final osteosynthesis
8. CT, ex-fix, 3-4 day wait, final osteosynthesis
9. CT, cast, 3-4 day wait, final osteosynthesis
10. CT, cast, 1 week, hybrid (Ilizarov) fixation
11. CT, immediate osteosynthesis before swelling occurs

Answer 6

1. ex-fix, CT, 1-3 weeks wait, final osteosynthesis

Question 7

7. The Chaput tubercle lies:
8. anterolateral of the distal fibula
9. anterolateral of the distal tibia
10. posterolateral of the distal tibia
11. posteromedial of the distal tibia
12. posterolateral of the fibula

Answer 7

2. anterolateral of the distal tibia

Question 8

8. The debate whether you should or should not fix a
   tertius fragment is usually about the size of the tertius
   fragment. The percentage of articular surface of the
   fragment is usually:
9. 10%
10. 20%
11. 25%
12. 30%
13. 40%

Answer 8

3. 25%

Question 9

9. The tibia plateau is:
10. medial bigger than lateral
11. convex medial and lateral concave
12. on the edge coated by a hyaline meniscus
13. running medial higher than laterally
14. about 5 cm above the top edge of the tibial tuberosity

Answer 9

1. medial bigger than lateral

Question 10

10. A Schatzker 5 fracture is characterized by:
11. bicondylar fracture with medial impression
12. bicondylar fracture with lateral impression
13. 3 column fracture with posterior dislocation
14. a dissociation between shaft and plateau
15. a bicondylar fracture where there is somewhere continuity between shaft and cartilage plateau

Answer 10

5. a bicondylar fracture where there is somewhere continuity between shaft and cartilage plateau

Question 11

11. The anterior compartment of the lower leg
    comprises of the following structures:
12. mm. peroneus longus and brevis, m. tibialis anterior, m. extensor hallucis longus
13. mm. peroneus longus and brevis, m. tibialis anterior, n. peroneus profundus
14. a. tibialis anterior, m. flexor hallucis longus, n. superficial peroneal
15. m. tibialis anterior, m. extensor digitorum longus, n. superficial peroneal
16. a. tibialis anterior, m. extensor hallucis longus, m. tibialis anterior

Answer 11

5. a. tibialis anterior, m. extensor hallucis longus, m. tibialis anterior

Question 12

12. The effect of VAC therapy in open tibia fracture is:
13. less infections
14. less nonunions
15. less pain
16. less Indication for free flap surgery
17. less likely to develop a compartment syndrome

Answer 12

4. less Indication for free flap surgery

Question 13

13. From how many damaged ligaments you should
    consider the diagnosis of knee dislocation?
14. 0
15. 1
16. 2
17. 3
18. 4

Answer 13

3. 2

Question 14

14. What is the typical direction of dislocation in the
    case of injury to the peroneal nerve?
15. posteromedial
16. posterolateral
17. anteromedial
18. anterolateral
19. pure anterior

Answer 14

2. posterolateral

Question 15

15. Within how many hours should revascularization be
    performed in case of vascular damage after knee
    dislocation?
16. Within 1 hour
17. Within 2 hours
18. Within 4 hours
19. Within 6 hours
20. Within 12 hours

Answer 15

4. Within 6 hours

Question 16

16. Which indication is most correct to perform ORIF of
    a patella?
17. Closed fractures
18. An articular gap of 1 mm
19. A step-off of 2 mm or more
20. An intact extension device
21. An accompanying femoral artery injury

Answer 16

3. A step-off of 2 mm or more

Question 17

17. A 25-year-old male involved in a motorcycle accident
    sustains a grade 3A open fracture. After initial adequate
    debridement of nonviable tissue, which of the following
    irrigation methods and devices should be used?
18. Antibiotic solution applied by low pressure gravity flow device
19. Antibiotic solution applied by high pressure pulsatile flow device
20. Saline solution applied by low pressure gravity flow device
21. Saline solution applied by high pressure pulsatile flow device
22. Povidon jodium solution by high pressure pulsatile flow device

Answer 17

3. Saline solution applied by low pressure gravity flow device

Question 18

18. Which of the following is true?
19. The entrance wound is larger than the exit wound in GSWs.
20. Bullets are so hot, that they are sterile and therefore do not need antibiotics.
21. A GSW through the bowel needs surgical exploration.
22. You do not have to debride the entrance or exit wounds.
23. A bullet in a joint does not have to be removed

Answer 18

3. A GSW through the bowel needs surgical exploration.

Question 19

19. If the plastic surgeon considers doing flap coverage
    in an grade 3b open fracture.
    Which of the following sentences is false?
20. The wound should be clean
21. The fracture should always be well aligned
22. The fracture should be stable
23. The flap has lower infection rates , if you do the flap within 3 days of the injury than later
24. People with immune compromising morbidities have a smaller chance of success in flap coverage

Answer 19

2. The fracture should always be well aligned

Question 20

20. A 20-year-old female presents following a motor vehicle collision she was initially hypotensive and tachycardic however she now has stable vital signs following a 2 liter bolus of saline and 2 units of packed red blood cells. Which of the following would indicate that this patient has occult end-organ hypoperfusion and should be further resuscitated prior to definitive fixation?
21. Base deficit of -1.8 mEq/L
22. Heart rate of 80 beats per minute
23. Serum lactate of 5 mmol/Liter
24. Systolic blood pressure of 120 mmHg
25. Urine output of 40ml/hour

Answer 20

3. Serum lactate of 5 mmol/Liter

Question 21

21. Femoral shaft and distal femoral fractures can dislocate in different directions due to forces generated by muscles acting on the different parts of the fracture. Which of the following descriptions is correct?
22. The Iliopsoas extends the proximal fragment, the
    adductor longus, brevis and magnus contribute to a
    varus force on the distal fragment
23. The Iliopsoas flexes the proximal fragment,, the
    adductor longus, brevis and magnus contribute to a
    valgus force on the distal fragment
24. Gluteus medius and minimus abduct the proximal
    fragment, the adductor longus, brevis and magnus
    contribute to a varus force on the distal fragment
25. Gluteus medius and minimus adduct the proximal
    fragment, the adductor longus, brevis and magnus
    contribute to a varus force on the distal fragment
26. Gluteus medius and minimus adduct the proximal
    fragment, the adductor longus, brevis and magnus
    contribute to a valgus force on the distal fragment

Answer 21

3. Gluteus medius and minimus abduct the proximal
   fragment, the adductor longus, brevis and magnus
   contribute to a varus force on the distal fragment

Question 22

22. A femoral fracture can be treated by antegrade or retrograde intramedullary nailing. Which indication is the most correct to perform retrograde intra-medullary nailing?
23. Fracture of the ipsilateral tibia
24. Isolated distal femoral fracture
25. Pulmonary compromised patient
26. Slim patient
27. All the above

Answer 22

1. Fracture of the ipsilateral tibia

Question 23

23. A femoral shaft fracture can be treated by reamed or nonreamed intra-medullary nailing. What is the main advantage of nonreaming above reaming?
24. Lower chance of ARDS
25. Lower chance of avascular necrosis of
    the femoral head
26. Less likely to have an infection
27. Less likely to have a malunion
28. None of the above

Answer 23

5. None of the above

Question 24

24. Patient G, 42 yr, Involved in a Motor Vehicle Accident (MVA ) is seen on the Emergency Department. After extraction by the firemen(dashboard trauma) he ’s presented for ATLS screening. No ABC abnormalities were seen. A Pelvic X-ray showed the following. The X ray shows a left hip disclocation. You made the decision to obtain adjuvant imaging. Which statement is correct?
25. Judet views (iliac and obturator) have no advantage
    prior to reduction
26. MRI scanning can be useful prior to reduction to
    evaluate the Sciatic nerve
27. CT scanning prior to reduction is not indicated as it
    is time consuming and not very helpful
28. CT scanning after reduction is seldom needed
29. Based on the AP Pelvic imaging above the chance
    of succesfull reduction is 60%

Answer 24

3. CT scanning prior to reduction is not indicated as it

is time consuming and not very helpful

Question 25

25. Patient G, 42 yr, Involved in a Motor Vehicle Accident (MVA ) is seen on the Emergency Department. After extraction by the firemen(dashboard trauma) he ’s presented for ATLS screening. No ABC abnormalities were seen. A Pelvic X-ray showed the following. The X ray shows a left hip disclocation. You made the decision to obtain adjuvant imaging. Which statement is correct?

Reduction is planned ASAP as a posterior dislocation is expected.
Which statement is true?

1. Sciatic nerve palsy is present in 70 % in this
   injury
2. Reduction should usually be followed by traction
3. Open reduction is always approached from the
   dorsal side (Kocher Langenbeck)
4. Prior to open reduction in case of unsuccesfull
   reduction a CT scan is mandatory
5. Adequate fluoroscopy imaging is sufficient for evaluation of the joint surface

Answer 25

4. Prior to open reduction in case of unsuccesfull

reduction a CT scan is mandatory

Question 26

26. Patient was taken to theatre and within an hour his hip was reduced. After succesful reduction this patient didn’t need further surgery. He was discharged after 2 days. What can you tell the patient at discharge?
27. 6 weeks of non weight bearing is usually necessary
28. The chance of redislocation is high and he will need a brace
29. The chance of osteonecrosis is between 2 and 10%
30. His chance of developing osteoarthritis is very low, about 1%
31. Hyperflexion should be trained extensively with his physiotherapist

Answer 26

3. The chance of osteonecrosis is between 2 and 10%

Question 27

27. Patient F, 50 yo male, sustained a MVA and has severe hip pain as he was brought in the Emergency department. ATLS screening showed no abnormalities except hip pain and impaired function Imaging and CT scanning of the left hip showed a femoral head fracture.
    As you evaluate the CT and fracture, which statement is true?
28. The fracture is usually approached from the dorsal
    side (Kocher Langenbeck)
29. Osteonecrosis is no risk at all using the Smith
    Peterson approach
30. Pipkin classification type IV is displayed in the images
31. Hip dislocation and femoral head fractures are not seen simultaneously
32. Decreased internal rotation of the hip is frequently
    seen after succesfull treatment but seldom leads to
    disability

Answer 27

5. Decreased internal rotation of the hip is frequently
   seen after succesfull treatment but seldom leads to
   disability

Question 28

28. What can be assessed best with the pelvic inlet view?
29. integrity of the iliac wing and anteroposterior
    displacement of pelvic ring
30. integrity of the iliac wing and craniocaudal
    displacement of pelvic ring
31. rotation of hemipelvis and anteroposterior
    displacement of pelvic ring
32. rotation of hemipelvis and cranio-caudal
    displacement of pelvic ring
33. none of the above

Answer 28

3. rotation of hemipelvis and anteroposterior

displacement of pelvic ring

Question 29

29. A 25-year old male pedestrian, who is otherwise healthy, was struck by a car (60km/hr). Upon arrival in the ER he is hemodynamically unstable. Soon after initial resuscitation according to the ATLS-principles he appears to be a transient responder. The pelvic AP-view is shown here. Note: there are no signs of chest injury, neurologic injury or injury to the extremities. What is the best next step for this patient?
30. angiography with coiling
31. application of a C-clamp
32. application of a pelvic binder
33. contrast enhanced CT
34. emergency laparotomy and pelvic packing

Answer 29

3. application of a pelvic binder

Question 30

30. Percutaneous SI screw fixation of sacral fractures is indicated in situations or injuries. What are these situations and/or injuries?
31. all of the below
32. open book fractures
33. suicidal jumper’s fractures
34. type C injuries without neurological deficit
35. acute resuscitation of type C injuries in combination with anterior external fixator

Answer 30

4. type C injuries without neurological deficit

Question 31

31. Posterior wall fractures can have certain characteristics or have associated injuries for which ORIF is indicated. What are these characteristics and/or associated injuries?
32. all of the below
33. associated Pipkin fracture
34. subluxation of femoral head
35. marginal impaction of articular surface
36. associated displaced posterior column
    fracture

Answer 31

1. all of the below

Question 32

32. A 50-year-old male fractured his humerus shaft.
    Which is not an absolute indication for surgical treatment?
33. Open fracture
34. Multiply injured patient
35. Floating elbow
36. Pathologic fracture
37. Concomitant vascular injury

Answer 32

2. Multiply injured patient

Question 33

33. Which statement of a distal humerus fracture with
    intra-articular involvement is true?
34. All fractures needs surgical treatment
35. An olecranon osteotomy is always necessary
36. after surgery the treatment preferably consist of an above-elbow cast
37. Both distal humerus plates preferably end proximally on the same height
38. Generally the articular surface is reconstructed first

Answer 33

5. Generally the articular surface is reconstructed first

Question 34

34. A closed humerus shaft fracture can be treated with
    an intramedullary nail. Which statement is true about
    intramedullary nails?
35. The surgeon should check the contralateral
    shoulder function preoperatively
36. Should not be used in pathological fractures
37. Are most frequently placed in a retrograde fashion
38. Reaming is always necessary
39. Neurovascular structures are not at risk during locking distally

Answer 34

1. The surgeon should check the contralateral

shoulder function preoperatively

Question 35

35. An external fixator can be used to stabilise a humerus shaft fracture. Which statement is true about the application of the external fixator?
36. all pins are placed percutaneously with stab
    incisions
37. the radius is preferred location for pin placement
38. is the treatment of choice for all open fractures
39. can be used for vascular injury with acute repair
40. one pin on each site of the fracture is sufficient

Answer 35

4. can be used for vascular injury with acute repair

Question 36

36. What was the most common type of complication in
    older patients who were admitted to a hospital with a
    hipfracture in a Dutch multicenter study?
37. delirium
38. inflammation/infection (urinary tractinfection,
    pneumonia or other infections)
39. cardiac complications (cardiac ischemia,
    heart failure)
40. bleeding/leakage (wound or other regions)
41. falling

Answer 36

2. inflammation/infection (urinary tractinfection,

pneumonia or other infections)

Question 37

37. Older patients with a hipfracture are vulnerable. Which
    statement is correct? One year after a hipfracture…….
38. the mortality is 10% and 10% of the patients who
    lived independent before the hipfracture now live in
    a nursing home
39. the mortality is 20% and 10% of the patients who
    lived independent before the hipfracture now live in
    a nursing home
40. the mortality is 25% and 25% of the patients who
    lived independent before the hipfracture now live in
    a nursing home
41. the mortality is 35% and 35% of the patients who
    lived indepedently before the hipfracture now live in
    a nursing home
42. the mortality is more then 40% and of the patients
    who lived independently before the hipfracture more
    then 40% now live in a nursing home.

Answer 37

3. the mortality is 25% and 25% of the patients who
   lived independent before the hipfracture now live in
   a nursing home

Question 38

38. Orthogeriatric care models lead to better outcomes in
    older hipfracture patients in comparison with usual care.
    On which of the following items a better outcome has not
    (sufficiently) been proved?
39. in-hospital mortality
40. quality of life
41. longterm mortality
42. length of stay in the hospital
43. all of the outcomes mentioned above are improving

Answer 38

2. quality of life

Question 39

39. Which kind of pre- and perioperative analgesia is
    relatively contraindicated in older patients with a
    hipfracture?
40. paracetamol
41. opiods
42. nerve-blocks (femoral/fascia iliaca)
43. non-steroidal anti-inflammatory drugs (NSAID’s)
44. none of these

Answer 39

4. non-steroidal anti-inflammatory drugs (NSAID’s)