Trauma

Question 1

Normal X-ray Parameters when evaluating syndesmosis?

Answer 1

Tib-fib overlap: AP >6mm, Mortise >1mm<div>-always need overlap!</div><div><br></br></div><div>Tib-fib clear space: AP and mortise<6mm</div><div><br></br></div><div>Medial Clear space <6mm or equivalent to space between plafond and talar dome</div><div><br></br></div><div>Other signs of syndesmosis injury:</div><div>-high fibular spiral fracture and no tibial # (or MM#)</div><div>-Post Mal</div>

Question 2

Proper Hemi Technique for PHF?

Answer 2

-retroversion: 30 deg<div>-Humeral height: GT is 10mm below articular surface, top of prosthesis 5.6cm above Pec, soft tissue tension</div><div>-Head size: contralateral Xray, males 48, females 44mm</div><div>-Cement prosthesis</div><div>-Reduce tuberosities - anatomic!</div>

Question 3

Indications for Scapula # ORIF

Answer 3

SSSC injury*<div>Body # >45 deg angular</div><div>GPA <20 deg</div><div>Glenoid >5mm</div><div>Medialization >2-3cm</div><div>shoulder instability from boney bankart</div><div><br></br></div><div><b>*if # has no assx ligamentous or # –> stable (MCQ)</b></div>

Question 4

Parameters/Union rate for Non-op Tx of Humeral Shaft?

Answer 4

<20 deg sagital plane<div><30 deg varus/valgus</div><div><3cm shortening</div><div><br></br></div><div><b>Union rate 90-95%</b></div>

Question 5

Indications for ORIF humerus? 2012, 17 SAQ

Answer 5

Open, high V GSW, Vasc injury<div>Polytrauma: bilateral humeri, floating elbow, LE fractures, brachial plexus</div><div>Inability to brace</div><div><br></br></div>

Question 6

Indications for Radial nerve exploration in humeral shaft fractures?

Answer 6

open<div>high V GSW or penetrating injury</div><div>Vascular injury</div><div>relative/controversial: palsy post closed reduction, distal 1/3rd #s (holstein-lewis)</div>

Question 7

Radial n injury in hum shaft #: incidence, recovery, first mm to recover?

Answer 7

-8-15% of closed #s<div>-average spont recovery at 7 weeks, full recovery at 6 months</div><div>-first to recover: BR</div><div>-last: EIP (D2 ext)</div>

Question 8

VPMRI - injury pattern and tx? (not on RC yet)

Answer 8

Varus posteromedial instability from AM facet coronoid # (sublime tubercle) and LUCL ligament injury<div><br></br></div><div>Fix coronoid and LUCL</div>

Question 9

Dorsal Approach to Forearm?

Answer 9

“Prox: ECRB (Rad) and EDC (pin)<div>Distal: ECRB (Rad) and EPL (pin)</div><div><img></img><br></br></div><div>Incision: lat epi to listers</div><div>plane b/t ECRB and EDC</div><div>find PIN (through distal supinator)</div><div>pronate to find distal PT, but <b>supinate</b>to protect PIN then incise supinator and detach PT</div><div><img></img><br></br></div><div>distally: work on either side of APL and EPB</div>”

Question 10

Indications for fixation of isolated HH GT#?

Answer 10

<b>Sup displacement 3mm (MCQ 2017)</b><div>Post displacement >1cm</div>

Question 11

<div>During an OR, you place a Hohmann retractor posterior to the femur during lateral exposure of the proximal third of the thigh. You encounter brisk bleeding. What did you damage?</div>

Answer 11

<div>depends where you are...</div>

-Profunda femoral artery (MCQ 2018) if proximal thigh<div>-MFCA if intertroch</div>

Question 12

tetanus tx? (not a RC yet)

Answer 12

<div>tetanus toxoid = vaccine; tetanus immuneglobulin Ig</div>

Td<10 years: Td if >5yrs<div>Td>10 years: Td</div><div>No Td ever: Td and TIG</div><div><br></br></div><div>Tetanus Prone Wound:</div> More than 6 hours old<div>Stellate Avulsion or abrasion configuration</div><div>Depth more than 1 cm</div><div>Mechanism: missile, crush, burn, frostbite</div><div>Signs of infected/devitalized tissue</div><div>Grossly contaminated</div>

Question 13

Open Fracture Abx

Answer 13

I and II: ancef (or <b>clinda</b>)<div>IIIA and IIIB: ancef and gent (or pip taz)</div><div>IIIC: ancef and gent and penicillin</div><div>Fresh water: fluoroquinolone, cipro</div><div>Salt water: doxy</div>

Question 14

FAITH Study results?

Answer 14

1100 patients: screws vs SHS for fem neck #s<div>equivalent fxn and re-op at 2 years (20%) - crazy high re-op rate (for hemis its like 5% at 5 years)</div><div>SHS preferred for displaced, basicervical, smokers</div><div>SHS had higher AVN (9% vs 5%) - fxn same</div><div><br></br></div><div>(not on exam yet)</div>

Question 15

CMN vs SHS for intertroch?

Answer 15

equal: <b>transfusion</b> (MCQ 2012, 18), length, screw cutout, union, etc<div>More in IMN group: intra-op #, post-op femur#, re-op</div>

Question 16

RC 2018 - RFs for distal femur non-union - list 3 patient, list 3 #/technical

Answer 16

Patient: smoker, BMI, DM<div>Injury: open fracture, metaphyseal comminution</div><div>Tx: shorter plate length</div>

Question 17

ATLS Buzzwords?

Answer 17

“<div>(1) Activation: I will initiate the ATLS protocol by activating the trauma team, and begin primary survery while team is assisting with:</div><div>-monitors: O2, BP, cardiac</div><div>-serial vitals</div><div>-interventions: 2 large bore IVs, O2</div><div>-Inv: labs (CBC, lytes, Hb, BHCG, tox, type and scree, Xmatch, ABG), ECG, CXR, pelvic Xray</div><div><br></br></div><div>(2) Airway:Ensuring C-spine precautions and using a spine board I will assess the airway for patency by assessing the patient’s ability to verbally communicate. I will inspect for foreign bodies, facial trauma or tracheal lacerations.</div><div>-intervention: intubation (RSI) vs surgical airway (cricothyroid membrane)</div><div><br></br></div><div>(3) Breathing: I will assess breathing by obtaining a set of vitals including oxygen saturation and resp rate</div><div>-intervention: needle thoracostomy for tension PTx, then CT</div><div><br></br></div><div>(4) Circulation: I will assess circulation by obtaining vitals including heart rate and blood pressure.</div><div>-intervention: blood (Xmatch, then type specific, then O-), control bleeding</div><div><br></br></div><div>(5) Disability: assess pupils and GCS</div><div><br></br></div><div>(6) Exposure: prevent hypothermia</div><div><br></br></div><div>complete AMPLE history and secondary survey</div>”

Question 18

Pregnant Trauma Pt considerations? not a RC Q

Answer 18

-Volume: Expanded plasma volume (40-50%) , Dilutional anemia, Greater tolerance for blood loss, Hemorrhage up to 30% may not be apparent 30% blood loss, decreases placental flow by 10-20%<div>-Supine positioning results in hypotension from compression of the IVC</div><div>-WBC count is normally elevated to 18</div><div>-Leukocytosis and ESR unreliable in pregnancy</div><div>-Hypercoagulable state<br></br></div><div><br></br></div><div>First trimester:</div><div>-Fetus is radiosensitive (organogenesis)</div><div>-Increased risk of teratogenesis</div><div>-Increased risk of spontaneous abortion with GA</div><div>Second Trimester:</div><div>-Hypotension from caval compression</div><div>-Increased risk of SA with GA</div><div>-Increased risk of seatbelts</div><div>Third Trimester:</div><div>-Expanded maternal plasma (40-50%)</div><div>-Pregnancy related osteoporosis</div><div>-Seatbelt Injuries<br></br></div><div><br></br></div><div>Peri-op</div><div>-involve multidisc team</div><div>-minimize Xray</div><div>-abx safe</div><div>-anticoag important - heparin doesnt cross placenta</div>

Question 19

Hohl and Moore Classification (Knee)? Not a RC Q yet

Answer 19

” <div> <div><img></img></div><div><br></br></div> </div>”

Question 20

Important steps in plateau fixation?

Answer 20

-visualization of joint with submeniscal arthrotomy (MCQ 2012)<div>-goal of managment = alignment first! (MCQ 2015)</div>

Question 21

Flap coverage for Tibia? (not a RC Q)

Answer 21

-prox third: gastrocs rotation flap<div>-middle: soleus rotation flap</div><div>-distal: free flap coverage</div>

Question 22

RUST criteria - not an EXAM Q

Answer 22

RUST: radiographic union scores of tibia<div>Evaluate 4 cortices, points out of 3</div><div>1 = no callus, # line visible</div><div>2 = bridging callus, # line visible</div><div>3 = no # line visible</div>

Question 23

Distal Tibia Fracture tx?

Answer 23

-plate fixation has <b>less malunion than nail (MCQ 2014, 2015)</b><div>-fixation of fibula has higher nonunion rate</div><div>-no diff b/t union rates of IMN and ORIF</div>

Question 24

Bone reconstruction ladder for segmental defects? not a RC q.

Answer 24

<div>(allograft, DBM, and BMP can be used as adjuncts)<br></br></div>

<div><br></br></div>

1- Acute shortening (1-3 cm)<div>2- Autograft (<5cm)</div><div>3- Masquelet/ Induced Membranes (5-24 cm)</div><div>4- Distraction osteogenesis (10 cm)</div><div>5- Vascularized fibular graft (10-20cm)</div><div>6- Amputation<br></br></div>

Question 25

Lauge Hansen Ankle # classification (no RC Q)

Answer 25

“SER: AITFL, fib, PM, MM<div>SAD: transverse fib, MM</div><div>PER: MM, AITFL, high fib, PM</div><div>PAbD: MM, AITFL, comminuted fib</div><div><br></br></div><div><img></img><br></br></div><div><img></img><br></br></div>”

Question 26

Tissue Damage Mechanism from GSW (not RC)

Answer 26

<div>CSCS</div>

<div>1- crush and laceration<br></br></div>

<div>2-secondary missiles (bone fragments, metal fragments from helmet)</div>

<div>3- cavitation</div>

<div>4- shockwave</div>

<div><br></br></div>

<div>Energy transfer is dependent on:</div>

<div>1-KE at time of impact (E=1/2mv2)</div>

<div>2-stability and entrance profile (yaw)</div>

<div>3-caliber, configuration of bullet</div>

<div>4-distance and path through body</div>

<div>5-characteristics of tissue impacted</div>

<div>6-mechanism of tissue disruption</div>

Question 27

Tx for low velocity GSW? (not RC Q)

Answer 27

Oral Abx for 72 hrs (As effective as IV)<div>wounds are comparable to Gustillo I/II</div>

Question 28

Assx fractures with subtalar dislocation (not a RC Q)

Answer 28

Medial (foot goes medial)<div>-talus: dorsomedial head, posterior tubercle</div><div>-lateral navicular</div><div><br></br></div><div>lateral (foot goes lateral)</div><div>-cuboid</div><div>-ant calc</div><div>-lateral talar process</div><div>-lat mal</div><div><br></br></div><div><b>Note: 89% go onto subtalar arthrosis (most symptomatic)</b></div>

Question 29

Hard and Soft signs of vasc injury (not a RC Q)

Answer 29

Hard signs: pulselessness, pallor, paresthesias, pain, paralysis, rapidly expanding hematoma, massive bleeding, palpable bruit<div>-TX: surgical intervention<br></br><div><br></br></div><div>Soft signs: hx of bleeding in transit, proximity related injury, hematoma over named artery, neuro findings</div><div>-Tx: ABI then CTA/Angiography</div><div><br></br></div></div>

Question 30

Brodens view? (not a RC Q)

Answer 30

“For posterior facet calc<div>IR 40 deg, and tube centered on lateral mal, sequentially moves from 40 deg cephalad to neutral</div><div><img></img><br></br></div>”

Question 31

Buckley Calc study op vs non-op 2002? Results (not a RC Q)

Answer 31

“<b>overall</b>, no difference in SF36 or VAS<div><b>pts who do well with sx:</b>female, Age <30, non-wcb, Bohler’s>0, Sanders<3,</div><div><b>pts who do poor with sx:</b>older, wcb, high E mech, smoker, DM, labourer</div>”

Question 32

RFs for HO? not on exam yet

Answer 32

ISS<div>TBI</div><div>SCI –> complete>incomplete, higher lvl, younger age</div><div>Neurologic compromise (prolonged coma, ventilator use)</div><div>DISH, Ankylosing spondylitis, hypertrophic OA</div><div>Decubitus ulcers</div><div>Antegrade femoral nail (particularly piriformis)</div><div>Distal femur traction pins</div><div>Amputation through zone of injury (particularly blast)</div><div>Surgical approach: Iliofemoral>KL>II> anterior</div><div>THA/TKA<br></br></div>

Question 33

HO Tx? (Not RC)

Answer 33

resection<div>Indomethacin 25 TID for 3-6 months</div><div>radiation: 700cGy in 72 hrs</div>

Question 34

Signs of Sacral Dysmorphism (?RC ORAL)

Answer 34

“AP: superior border of sacrum even with iliac crest (green), acutely down-sloped sacral ala (blue), non-circular neural foramen (purp), mammilary process (red), residual disc space (yellow)<div><img></img><br></br></div><div>Inlet: recessed anterior alar cortex</div><div><br></br></div><div>CT: tongue in groove</div><div><br></br></div><div>Note on ICD:</div><div>-in Normal pelvis, ICD is coplanar with anterior sacral alar bone</div><div>-in dysmorphic pelvis, they are not colinear - the alar anterior cortical limit is anterior and cranial to ICD (ie no safe S1 screw!) - need a 1cm corridor - 10mm screw path gives a margin of 1-2mm around screw- RC EXAM</div>”

Question 35

Acetabulum fractures that disrupt obturator ring (not a RC Q)

Answer 35

ABC<div>AC-post hemitransverse</div><div>T-type</div><div><br></br></div><div>JAAOS 2018</div>

Question 36

Cannot use Roof arc measurements in what fracture types? RC X 2

Answer 36

-PW<div>-associated both column</div>

Question 37

X-ray sequence to put on a pelvic exfix?

Answer 37

“<div>(1)outlet - obturator oblique</div><div>(2A)Inlet - iliac oblique</div><div>(2B)Inlet - obturator oblique</div><img></img><br></br><div><br></br></div><div><br></br></div>”

Question 38

Diagnostic Criteria for Atypical Femur #? Not a RC Q yet

Answer 38

Major:<div>-minimal trauma</div><div>-transverse #</div><div>-complete #</div><div>-minimal comminution</div><div>-lateral beaking/endosteal scalloping</div><div><br></br></div><div>Minor:</div><div>-delayed fracture healing</div><div>-prodromal pain</div><div>-generalized increase in diaphyseal cortices</div><div>-bilateral femur diaphysis #s</div>

Question 39

Tx for a AFF? not a RC Q

Answer 39

-consult endo<div>-stop bisphosphonates (fracture rate decreases from 40 to 20%), consider tx with teriparatide - recombinant PTH (osteogenic - stimulates osteoblasts)<br></br><div>-labs: ca, vitD</div><div>-optimize nutritional status</div><div>-fix fracture</div><div>-consider fixation of contralateral side</div></div>

Question 40

<div>65 year old female falls and has an isolated greater tuberosity fracture. What is the best indication to fix this fracture?</div>

<ol> <li>Superior displacement 3mm</li> <li>Posterior displacement 5mm</li> <li>45o internal rotation of the inferior border of the fragment</li> <li>45o external rotation of the inferior border of the fragment</li></ol>

Answer 40

A<div><div>Surgical treatment of isolated GT fractures is indicated in healthy patients who have >5 mm of superior GT displacement. Although 3 mm of GT displacement is sufficient to alter rotator cuff (RC) biomechanics, the study by Platzer et al. The magnitude of “acceptable” posterior GT displacement remains unclear</div></div>

Question 41

Letournel Classification of Acetabular Fractures? incidence?(Not a RC Q)

Answer 41

“Elementary patterns: PC, PW, AC, AW, transverse<div>Associated patterns: PC + PW, transverse + PW, T-Type, AC + Post Hemi-T, ABC</div><div><div> <div> <div><img></img></div><div><u>Distribution</u></div><div>PW 24%</div><div>ABC 22%</div><div>T-PW 20%</div><div><br></br></div><div><img></img><br></br></div> </div></div></div><div><br></br></div>”

Question 42

ABx tx for NF and Gas Gangrene? not a RC Q

Answer 42

NF: clindamycin + pip/tazo (broad spectrum)<div>GG: clindamycin + Pen G</div>

Question 43

Features of AFF?

Answer 43

“<img></img>”

Question 44

RFs for HO in acetabular sx? JAAOS 2017

Answer 44

<ul> <li>Surgical factors: </li> <ul> <li>Iliofemoral approach (Highest risk) > Kocher-Langenbeck > Ilioinguinal (Lowest risk)</li> <li>Complex exposure, double exposures & trochanteric osteotomy increases risk </li> <li>Soft tissue factors: Debridement of necrotic muscles (Specifically glut minimus) has diminished HO after acetab #</li> </ul> <li>Clinical & Systemic factors: Male, TBI or thoraco-abdominal trauma, Sciatic nerve injury, femoral head injury/ intra-articular debris, Delay to Sx, Ipsilateral femur #, Prolonged mechanical ventilation, early THA for acetabular #</li></ul>

Question 45

<div>Comanagement of hip # (ortho/geri) improve</div>

Answer 45

<div>Reduce LOS, readmission rate, time to surgery, complications, mortality rate, hospital acquired complications</div>

Question 46

Radial nerve distances from elbow?

Answer 46

<ul> <li>Medially it is 20cm above the medial epicondyle</li> <li>Laterally it is 14cm above the medial epicondyle</li> <li>Exits groove at 10-14.8cm from lateral epicondyle</li> <li>Lateral IM septum at 10cm above joint line (never closer than 7.5cm)</li> <li>Can find radial nerve proximal to lateral epicondyle by taking 1.4x of transepicondylar width (per Kamineni)</li> <ul> <li>Consider measuring this pre-operatively and marking on the skin the expected location of the nerve crossing the intermuscular septum on the skin</li> </ul> <li>Usually within 1-2cm of proximal extent of triceps aponeurosis</li></ul>

Question 47

Bryan Morrey Classification of Capitellar Fractures

Answer 47

“<ol> <li>Hahn-Steinthal –> fracture of capitellum with attached subchondral bone</li> <li>Kocher-Lorenz –> articular cartilage</li> <li>Broberg-Morrey –> comminuted fractures</li> <li>McKee –> capitellar fracture extending into trochlea - RC EXAM</li> <ol> <li>Double arc sign</li> </ol> </ol> <div><img></img></div>”

Question 48

Mason Classification for RH Fractures?

Answer 48

“<img></img>”

Question 49

Reduction methods for SC injury

Answer 49

“<ul> <li>Anterior dislocation</li> <ul> <li>Closed reduction is current tx of choice, but there is controversy given good longterm results with nonsurgical management</li> <li>Technique</li> <ul> <li>Sedation or local or general anestheia</li> <li>Supine with 3 inch pad between shoulders</li> <li>Direct pressure on medial clavicle in posterior direction</li> <li>Immobilize in figure of 8 or Velpeau sling for 6 weeks</li> </ul> </ul><li>Posterior Dislocation</li> <ul> <li>Unreduced posterior dislocation complications</li> <ul> <li>TOS</li> <li>Vascular compromise</li> <li>Erosion of medial clavicle into posterior structures</li> </ul> <li>Consult cardiothoracic surgeon if mediastinal involvement</li> <ul> <li>Dyspnea, choking, hoarseness</li> </ul> <li>Can often be reduced closed, and is then stable</li> <li>Closed Reduction</li> <ul> <li>Traction Technique #1</li> <ul> <li>Thoracic surgeon available</li> <li>Supine, sedation or GA</li> <li>4inch bolster between shoulders</li> <li>Abduct and slightly extend arm</li> <li>Traction and coutertraction</li> <li>Bring arm into extension</li> <li><img></img></li> </ul> <li>Traction Technique #2</li> <ul> <li>traction may be applied to the arm in adduction while posterior pressure is applied to the shoulder to lever the clavicle over the first rib </li> </ul> <li>Towel Clip around clavicle</li> <ul> <li>Apply traction and lift anteriorly</li> </ul> </ul> <li>Open Reduction</li> <ul> <li>Thoracic surgeon assist</li> <li>Exposure: preserve anterior capsule (this will provide stability once reduced)</li> </ul> </ul></ul>”

Question 50

Stepwise Transfusion in trauma?

Answer 50

<ol> <li>2U cross matched blood</li> <li>If unavailable, I will use type specific blood</li> <li>If unavailable, I will use O- blood</li></ol>

Question 51

Foley Contraindications in trauma?

Answer 51

<ol> <li>I will insert a foley, unless contra-indicated</li> </ol>

<ul> <li>Blood at the meatus</li> <li>Perineal ecchymosis</li> <li>Blood in scrotum</li> <li>High riding prostate</li> <li>Pelvic fracture</li> </ul>

<li>If contra-indicated I would obtain a retrograde urethrogram</li>

<ul> <li>Maintain a urine output of 0.5cc/kg/hr</li> </ul>

Question 52

Components of Secondary Survey?

Answer 52

<ol> <li>AMPLE</li> <ol> <li>Allergies, medications, past medical history, last po intake, events of the trauma</li> </ol> <li>Head to toe examination</li> <ol> <li>HEAD --> scalp, skull, eyes, ears, facial bones, basal skull fracture</li> <li>NECK:</li> </ol></ol>

<ul> <li>Remove C-spine collar, maintain inline traction</li> </ul>

<li>CHEST</li>

<li>ABDO</li>

<li>PELVIS</li>

<ol> <li>Consider vaginal exam if concerned about open pelvic fracture</li> </ol>

<li>EXTREMITIES</li>

<li>CNS</li>

<li>SPINE</li>

<ol> <li>Roll patient maintaining spinal precautions</li> <li>Palpate length of spine, looking for open wounds, areas of tenderness, step deformities</li> <li>Rectal exam looking for tone, voluntary contraction, presence of blood</li> </ol>

Question 53

Adequate resuscitation parameters in Trauma?

Answer 53

<ul> <li>surrogate of end organ perfusion</li> <ul> <li>Top 3: Lactate<2.5, BD -2 to 2, gastric pH>7.3</li> <li>Physiologic: </li> <ul> <li>MAP>60</li> <li>U/O 0.5cc/kg/hr</li> <li>HR<100</li> <li>Temp >35</li> <li>PaO2/FiO2>300</li> </ul> <li>Acidosis-related</li> <ul> <li>Lactate <2.5</li> <li>pH>7.25</li> <li>Gastric Mucosal pH >7.3 (OITE)</li> <li>Base deficit (normal -2 to +2) - excess is >8</li> </ul> <li>No Coagulopathy</li> <ul> <li>Plts>90</li> <li>Fibrinogen>1</li> </ul> </ul></ul>

Question 54

<div>Risks of prolonged lack of stabile immobilization and bedrest</div>

Answer 54

<ul> <li>Multi-organ system dysfunction</li> <li>Pneumonia</li> <li>Decubitus ulcers</li> <li>Vascular abnormalities</li> <li>Psychological disturbances</li> <li>Gastrointestinal stasis</li></ul>

Question 55

AIS score?

Answer 55

<ul> <li>polytrauma: AIS>18</li><li>9-6-3-2-1</li> <ul> <li>9 anatomic areas, each gets a score out of 6, Top 3 are squared (^2), for 1 AIS score</li> </ul><li>9 anatomic areas; head, face, neck, thorax, abdomen, spine, upper extremity, lower extremity, external</li> <li>Scored:</li> </ul>

<ol> <li>None</li> <li>Minor</li> <li>Moderate</li> <li>Serious</li> <li>Severe</li> <li>Critical</li> <li>Not Survivable</li> </ol>

Question 56

DCO principle?

Answer 56

<ul> <li>Approach to polytrauma to minimize the effect of the second hit</li> <ul> <li>Avoid:</li> <ul> <li>Multi-organ failure (MOF)</li> <li>ARDS</li></ul></ul></ul>

<ul> <li>Initial priority --> HSS - hemorrhage control, soft tissue management, provisional stability</li></ul>

Question 57

<div>What are the three intervals of death following trauma?</div>

Answer 57

“<div><ul> <li>Immediate</li> <ul> <li>Severe brain, high spinal cord injury, rupture of heart or large vessels</li> <li>Only prevention interventions can stop these deaths</li> </ul> <li>Minutes to Hours</li> <ul> <li>The Golden hour: shock, hypoxia, head injury</li> <ul> <li>Examples, hemo/pneumothorax, ruptured spleen, liver lacs, pelvic fractures</li> <li>Deaths in this time period can often be prevented by expedient care</li> </ul> </ul> <li>Days to weeks</li> <ul> <li>Sepsis and multiorgan failure</li> </ul></ul></div><img></img><br></br><div><br></br></div>”

Question 58

<div>What are five contraindications to foley catheter insertion?</div>

Answer 58

<ul> <li>Blood at the meatus</li> <li>Perineal ecchymosis</li> <li>Blood in the scrotum</li> <li>High riding or non palpable prostate</li> <li>Pelvic fracture</li> </ul>

<div>Not necessarily contraindications just indications to do a retrograde urethrogram before you place one</div>

Question 59

“ARDS Def’n?”

Answer 59

“<div><ul> <li>Acute respiratory failure characterized by decreased PaO2 and a diffuse, massive extravasation of fluid into the interstitial space of the lungs</li> <li>Release of inflammatory mediators results in organ dysfunction (increased vascular permeability)</li><li><div>Pulmonary arterial wedge pressure <18mmHg (no left atrial hypertension)</div></li></ul></div><img></img><br></br><div><br></br></div><div><ul> <li>Ventilator support</li> <ul> <li>Avoid toxic FiO2, barotrauma</li> </ul> <li>General organ support</li> <li>Outcomes:</li> <ul> <li>30-40% mortality rate</li> </ul></ul></div>”

Question 60

How to address thermal concerns in ex-fix?

Answer 60

<ul> <li>Thermal damage above 50deg C creates irreversible damage to osteocytes</li> <ul> <li>To decrease temperatures:</li> <ul> <li>Predrill</li> <ul> <li>Reduces temperatures by half</li> </ul> <li>Irrigate during drilling</li> <li>Use power to insert pins (hand insertion creates higher time at high temperatures)</li> </ul> </ul></ul>

Question 61

SOFA score?

Answer 61

“<ul> <li>SIRS is mostly being replaced by qSOFA- score from 0-3. 70% of sepsis deaths are in patients with scores of 2or 3.</li> <ul> <li>Systolic BP <100</li> <li>Altered metal status (GCS <15)</li> <li>Elevated RR (>22 breaths /min)</li> </ul> </ul> <div><img></img></div>”

Question 62

Soft tissue reconstruction ladder

Answer 62

“<img></img>”

Question 63

Patient optimization for fracture healing?

Answer 63

<div><br></br></div>

<ul> <li>Tobacco cessation</li> <li>Glycemic control</li> <li>Nutritional optimization</li> <li>Management of metabolic and endocrine abnormalities</li> <ul> <li>Brinker (JOT 2007) Metabolic and endocrine abnormalities in patients with tibial non-unions</li> <ul> <li>Correction leads to healing in >25% without intervention</li> </ul> </ul> <li>Poor vascularization</li></ul>

Question 64

“4C’s of debriding tissue?”

Answer 64

<ul> <li>Colour</li> <li>Consistency</li> <li>Contractility</li> <li>Capacity to bleed</li></ul>

Question 65

Indications for OR in GSW?

Answer 65

<ul> <li>Massive tissue damage (high velocity weapon)</li> <li>Vascular injury</li> <li>Progressive neurological deficit</li> <li>Obvious contamination or necrosis</li> <li>Joint involvement</li> <li>GI tract involvement/contamination</li> <li>Compartment syndrome</li> <li>Uncertainty as to type of weapon used</li> <li>Unstable fracture pattern requiring operative stabilization</li> <li>Selected spinal involvement cases</li> <li>Tendon injuries</li> <li>Superficial fragments in palm or sole</li></ul>

Question 66

Signs of Vascular Compromise?

Answer 66

” <div> <div><img></img></div><div>if ABI<0.9 –> CT Angio</div> </div>”

Question 67

Treatment for Nec Fasc?

Answer 67

“<ul> <li>5 principles</li> <ul> <li>Early dx and debridement</li> <li>Abx - broad-spectrum</li> <li>Aggressive resuscitation</li> <li>Frequent Re-evaluation</li> <li>Nutritional Support</li> </ul> </ul> <div></div> <div><img></img></div> <ul> <li>Abx choice</li> <ul> <li>Initial empiric therapy and confirmed polymicrobial treated the same- with broad spectrum abx (pip/taz) and clindamycin to reduce endotoxin</li> <li>Gram positive cocci in clusters represents staph species, so you can start vancomycin to cover gram positive/MRSA and add clindamycin again to prevent endotoxin production</li> <li>Gram positive chain or pairs represent strep species- so you cover with pip/taz and clindamycin</li> <li><b><u>Clindamycin has shown mortality benefit in staph and strep species due to prevention of endotoxin production</u></b></li> </ul></ul>”

Question 68

Nec Fasc vs Gas gangrene

Answer 68

<div> <div></div> <div>Necrotizing Fasciitis</div> <div>Gas Gangrene (clostridium myonecrosis)</div> <div>Etiology</div> <div>Type 1- typically post-operative GI/bowel surgery in immunocompormised host</div> <div>Type 2- typically trauma in healthy host</div> <div>Type 3- trauma and marine water exposure</div> <div>Can be trauma, but most commonly post-operative after GI bowel surgery or in immunocompromised host/ cancer</div> <div>Exam</div> <div>Erythematous infection that commonly tracts proximal</div> <div>Infection commonly tracts distally</div> <div>Bacteria</div> <div>Type 1- polymicrobial commonly includes enterobacteria and synergistic effect between bacteria</div> <div>Type 2- GAS and sometimes staph (gram positive cocci)</div> <div>Type 3- virbrios species</div> <div>Clostrium species commonly clostridium perfringes (gram positive bacilli) with relative absence of inflammotory markers and PMNs compared to nec fas</div> <div>Classification</div> <div>As above</div> <div>Differentiate whether clinical presentation consistent with cellulitic/fasciitis or more worrisome myonecrosis phenotype</div> <div>Scoring Methods</div> <div>LRINEC</div> <div>none</div> <div>Imaging</div> <div>MRI usually shows hyperintensity due to necrosis of fat and fascia tracking along fascial planes, rarely and in late stages may see muscle involvement (bad prognosis)</div> <div>MRI may be similar to nec fas but more commonly there is extensive muscle involvement which differentiates it</div> <div></div> <div>More likely to get abdominal CT to r/u GI pathology early</div> <div>Antibiotic treatment</div> <div>Pip/taz, vanco, clinda</div> <div>Pen G and clinda</div> <div>Surgical Treatment</div> <div>Radical debridment of skin and subq tissue</div> <div>Radical debridement of skin, subq, fasica, and muscle, more likely to require amputation and fasciotomy then nec fas</div> </div>

Question 69

Indications for and components of metabolic workup in fracture non-union?

Answer 69

<div> <div> <div> <div>Metabolic work up indicated in:</div> <ul> <li>A persistent nonunion despite adequate treatment without obvious technical error</li> <li>A history of multiple low-energy fractures with at least one progressing to a nonunion</li> <li>Nonunion of a nondisplaced pubic rami or sacral ala fracture (ie of an insufficiency fracture)</li> </ul> <div>Labs</div> <ul> <li>Vitamin D production</li> <ul> <li>25-hydroxyvitamin D</li> <li>Calcium</li> <li>Phosphorus</li> <li>Magnesium</li> </ul> <li>Parathyroid disorder</li> <ul> <li>PTH</li> <li>Calcium</li> <li>Phosphorus</li> </ul> <li>Thyroid disorder</li> <ul> <li>TSH</li> </ul> <li>Adrenal disorder</li> <ul> <li>Cortisol</li> <li>ACTH</li> </ul> <li>Hypopituitarism</li> <ul> <li>Testorsterone</li> <li>FSH</li> <li>LH</li> <li>Prolactin</li> </ul> <li>Infection</li> <ul> <li>ESR</li> <li>CRP</li> <li>CBC</li> <li>Joint aspiration</li> </ul> <li>Primary Immune disorder</li> <ul> <li>SPEP/UPEP</li> </ul> <li>Others</li> <ul> <li>ALP</li> <li>IGF-1</li> </ul> </ul> <div></div> </div> </div></div>

Question 70

HO RFs?

Answer 70

-Injuries: high ISS, TBI, SCI, decubitus ulcers<div>-Diseases: burns, DISH, Ank Spon, hypertrophic OA</div><div>-Procedures: antegrade fem nail (piriformis start), distal femur traction pin, amputation through zone of injury, THA (Cementless), TKA, surgical approaches (EIF>KL>II)</div>

Question 71

HO tx

Answer 71

<ul> <li>Prophylaxis</li> <ul> <li>diphosphenates are mainstay of prophylaxis and approved by FDA</li> <ul> <li>etidronate prevents HO formation by preventing formation of hydroxyapatite crystals</li> </ul> <li>NSAIDS</li> <ul> <li>indomethacin (75mg daily) </li> <li>rofecoxib (2mg daily X 4 weeks) have good evidence</li> </ul> <li>Radiation(8-10 Gy)</li> <li>PT (to retain ROM and prevent soft tissue contractures</li> </ul> <li>Surgery</li> <ul> <li>Complete resection when at mature stage </li> <ul> <li>6 months when secondary to trauma</li> <li>1 year after SCI</li> <li>1.5 years after TBI</li> </ul> <li>Intra-op Principles- wide exposure, identification of N/V bundles, hemostasis, dead space elimination</li> </ul> <li>Get CT scan to assess HO</li> <li>Balance decision about when to operate </li> <ul> <li>early resection can prevent contractures, osteopenia, and risk of intra-op fracture </li> <li>late resection leads to joint stiffness but lower rate of recurrence</li> </ul></ul>

Question 72

Flail Chest Treatment outcomes?

Answer 72

<div>Stabilization of a flail chest reduces ventilator time, pneumonia, mortality, and overall medical costs.</div>

Question 73

Retrograde Urethrogram Technique?

Answer 73

<div><br></br></div>

<ul> <ul> <li>Partially insert foley, inject 10-15cc of water soluble contrast</li> <ul> <li>Initial blush -> extraperitoneal -> treat with foley if non op pelvis </li> <ul> <li>If open pelvis, decreased intra-pelvic pressure and will not heal with foley</li> <li>Simultaneous repair with pelvic fixation</li> </ul> </ul> <li>Advance to bladder if no leak and inject 200cc</li> <ul> <li>If outlined bowel -> intraperitoneal -> operative intervention</li> </ul><li>if RUG is positive from urethral injury, then a suprapubic cystostomy tube needs to be inserted</li><li>Bladder injury requires prompt diagnosis so as to avoid hyperkalemia, hypernatremia, uremia, acidosis, and peritonitis<br></br></li> </ul></ul>

Question 74

Tile Classification for pelvis fractures?

Answer 74

“<div><img></img></div> <div></div> <ul> <li>Tile Classification</li> <ul> <li>A – Stable</li> <li>B – Vertically stable, rotationally unstable</li> <li>C – Vertically and rotationally unstable</li> </ul></ul>”

Question 75

Angiography in pelvic injuries

Answer 75

“<ul> <li>Angiography and embolization useful tool in controlling arterial hemorrhage from pelvic trauma</li> <li>Indication: active arterial bleeding in hemodynamic instability </li> <ul> <li>If + FAST –> ex lap + pelvic packing + ex fix</li> <ul> <li>Reduces need for angioembolization, blood transfusion and mortality</li> </ul> <li>If - FAST –> binder + angioembolization</li> </ul> <li>Tends to be needed more in APC II, III, LC III or Tile Type C but not clearly statistically significant in many studies</li> <li>CT to detect need for embolization</li> <ul> <li>Look for active extravasation of contrast or presence of pelvic hematoma in unstable patient with pelvic fracture</li> <li>Sensitivity 60-90%, specificity 92-100%</li> </ul> <li>Most common arteries for embolization:</li> <ul> <li>Internal iliac: 67.2% (Green)</li> <li>Unnamed arteries branching off internal iliac: 17.0%</li> <li>Superior gluteal artery(1): 4.4%</li> <li>Obturator (6): 4.1%</li> <li>Internal pudendal (7): 3.2%</li><li><img></img><br></br></li> </ul> <li>Earlier embolization is better</li> <li>Improves mortality in trauma patients</li> <ul> <li>Post embolization mortality rate 16-50% (related to concomitant injuries)</li> </ul> <li>Complications of embolization typically outweighed by benefits and success of resuscitation, but can include wound breakdown, gluteal muscle necrosis, visceral necrosis</li></ul>”

Question 76

Corona Mortis anastamosis and location?

Answer 76

“<div>The ““corona mortis”” is an anatomical variant, an anastomosis between the obturator and the external iliac or inferior epigastric arteries or veins.</div><div>It is located behind the superior pubic ramus at a variable distance from the symphysis pubis (range 40-96 mm)<br></br></div><img></img>”

Question 77

Spur sign: what is it and what Xray is needed?

Answer 77

“<ul> <li>portion of nonarticular ilium above the acetabulum that becomes visible on the<b> obturator oblique view </b> because of medial displacement of the acetabulum </li> <li><img></img></li></ul>”

Question 78

Methods to determine PW Size on CT?

Answer 78

“<img></img>”

Question 79

Outcome of Acetabular #s and RFs for failure?

Answer 79

<div>RFs for failure</div>

<ul> <li>Patient: Age > 40</li> <li>Injury: Initial displacement of > 2cm, Femoral head lesion, Impaction, Posterior wall involvement, Anterior hip dislocation</li> <li>Surgery: Non-anatomic reduction, Incongruence of roof, Iliofemoral approach</li></ul>

<div><div>80% survivorship at 20 years</div></div>

Question 80

ORIF indications for scapula #s?

Answer 80

“<div><img></img></div> <ul> <li>Glenopolar angle < 20o</li> <li>Medialization >2-3cm (or lateralization depending on theory)</li> <li>Body Angulation > 40-45o </li> <ul> <li>As seen on the trans-scapular Y view, or on sagittal cuts</li> <li>40 degrees flexion or extension of glenoid in sagittal plane</li> </ul> <li>Persistent shoulder instability secondary to large boney bankart</li> <li>>5mm intra-articular step </li> <li>Floating shoulder (SSSC disruption x 2)</li></ul>”

Question 81

Location at highes risk of humerus non-union?

Answer 81

<ul> <li>Proximal 1/3 most at risk for non-union</li> <ul> <li>Due to deforming forces of pec major (adduction) and deltoid (abduction)</li> <li>Higher risk of interposition of muscle tissue and long head biceps</li> <li>Difficulty to immobilize/stabilize</li> </ul></ul>

Question 82

Initial approach for terrible triad?

Answer 82

<div>Incision: posterior, then raise lateral fasciocutaneous flap only and do your lateral approach; may not need a medial approach at all if you can access coronoid fracture through your radial head defect</div>

Question 83

definition of radial bow

Answer 83

“<ul> <li>AP forearm</li><li>Line from radial tuberosity to ulnar edge of distal radius</li> <ul> <li>Perpendicular line drawn where it will be longest to reach radial shaft -> this is location of bow</li> </ul> <li>Should be 60% distal</li><li><img></img><br></br></li></ul>”

Question 84

MOI for terrible triad?

Answer 84

“The combination of valgus, axial, and posterolateral rotatory forces (forearm supination) can result in a ““terrible triad”” injury of the elbow”

Question 85

long term outcomes of distal radius fractures?

Answer 85

<ul> <li>Radiographic arthritis with residual intra-articular gap (not necessarily symptomatic)</li> </ul>

<ul> <li>Worse functional outcomes if severe radial shortening or residual gap +/- ulnar styloid non-union</li> </ul>

<ul> <li>Ulnar positive is bad (even if present on initial films!)</li></ul>

Question 86

Benefits of Surgical Hip dislocation for femoral head fracture? Technique?

Answer 86

“-benefits: often PW and fem head fracture - so through a posterior approach you can address PW and then dislocation to get to fem head.<div><br></br></div><div><img></img> <div></div> <img></img><br></br></div>”

Question 87

Femoral neck fractures… RFs for nonunion vs AVN

Answer 87

“<img></img><br></br><div>both 10-30% risk</div>”

Question 88

Femur Fracture: Methods of Ensuring appropriate length, alignment, and rotation

Answer 88

<ul> <li>Rotation</li> <ul> <li>Cortical step sign</li> <li>Lesser trochanter profile</li> <li>Neck version method/ Tornetta/ Perfect lateral</li> <ul> <li>Same principle as lesser trochanter sign, just uses different proximal landmark</li> </ul> <li>Use of CT post op (cuts at neck and knee) based on Jeanmart et al.</li> </ul> <li>Length</li> <ul> <li>Bovie cord/ measuring tape</li> <li>Metal ruler</li> <li>Cortical length (based off anatomic reduction of cortical fragments)</li> <li>Full length view of uninjured leg pre-operatively</li> </ul> <li>Alignment</li> <ul> <li>Bovie cord centered at femoral head and middle of ankle</li> <ul> <li>Should go through the centre of knee or slightly medial</li> </ul> </ul> <li>Tips and Tricks</li> <ul> <li>Pre-operatively consider determining version of uninjured limb using one of the above methods if fracture is quite comminuted</li> <li>Drape injured leg free so that you can use the other side for comparison during the operation</li> </ul></ul>

Question 89

RFs for Femoral Nonunion?

Answer 89

<ul> <li>JOT 2018 - NailFit: DoesNailDiameter to Canal Ratio Predict the Need forExchangeNailing in the Setting of Aseptic, HypertrophicFemoralNonunions?</li> <ul> <li>RFs for Nonunion (requiring exchange nailing)</li> <ul> <li>poor fracture reduction</li> <li>open fracture</li> <li>Winquist classification of 4 </li> <li>Poornailfit - especially with nail fit <70%</li> </ul> </ul></ul>

Question 90

RUST score?

Answer 90

<div>radiographic union score of tibias</div>

<ul> <li>Evaluates 4 cortices on AP/lat</li> <ul> <li>1 point = no callus, fracture line visible</li> <li>2 point = bridging callus, fracture line visible</li> <li>3 point = no fracture line visible</li> <li>Scores 3-12</li> </ul> </ul>

<ul> <li>Validated for inter/intra reliability but not well for clinical prediction yet</li></ul>

Question 91

Coverage options for tibia

Answer 91

<ul> <li>Proximal third --> gastrocnemius rotation flap</li> <li>Middle third --> soleus rotation flap</li> <li>Distal third --> free flap coverage</li></ul>

Question 92

Approaches for talus fracture fixation?

Answer 92

<ul> <li>Anteromedial --> medial to tib ant</li> <ul> <li>Tip of MM to base of 1st</li> <li>Consider cheating posteriorly to facilitate medial malleolar osteotomy</li> <li>MM osteotomy preserves talar blood supply as deltoid ligament has deltoid artery</li> <li>Allows view of neck alignment and medial comminution (use position screws)</li> </ul> <li>Anterolateral </li> <ul> <li>Anterior fibular tip (In line with inferior syndesmosis), then in line with 4th ray (higher up than you think!)</li> <li>Mobilize EDB as a sleeve and protect sinus tarsi contents</li> <li>Placement of shoulder screw on lateral plate</li> </ul></ul>

Question 93

Hawkins classification and rates of AVN and Arthritis

Answer 93

“<div><div><img></img></div> <div></div> <ol> <li>Non-displaced talar neck (<10%) - 9.8%</li> <li>Dislocation of the subtalar joint (~40-50%) 27.4% - most common</li> <li>Dislocation of tibiotalar and subtalar (90%) - 53.4%</li> <li>Dislocation of tibiotalar, subtalar and talonavicular (100%) - 48.0%</li></ol></div><img></img>”

Question 94

Indications for triangular osteosynthesis

Answer 94

<ul> <li><div>Indications (JAAOS 2015): comminuted transforaminal sacral fractures from a VS mechanism that cannot be controlled with trans-sacral fixation.</div></li><li>If the fracture line passes medial to the L5/S1 facet joint, the facet joint is intact and there is no vertical displacement</li> <li>If the fracture line passes l<b><u>ateral to the facet joint</u></b>, or the L5/S1 facet joint is disrupted and there is comminution, and vertical displacement of the sacral fracture, this injury would be at higher risk for further displacement</li></ul>

Question 95

osteoporosis RFs and tx?

Answer 95

“<img></img>”

Question 96

indications for DCO?

Answer 96

<ul> <li>Identify borderline patients --> Resuscitate, then reassess</li> <ul> <li>ISS > 20 + Thoracic Injury</li> <li>ISS > 40</li> <li>Bilateral Pulmonary Contusions</li> <li>Abdo/Pelvic Trauma + Shock</li> <li>Hypothermia</li><li>Head injury with AIS>3</li> <li>GCS<8</li> <li>IL-6 >500</li> </ul> <li> <div> <div>Criteria</div> <div>Borderline</div> <div>Unstable</div> <div>Transfusion</div> <div>2-8</div> <div>5-10</div> <div>Lactate</div> <div>< 2.5</div> <div>>2.5</div> <div>Platelets </div> <div>90-110</div> <div>70-90</div> <div>Fibrinogen</div> <div>=1</div> <div><1</div> <div>Temperature</div> <div>33-35oC</div> <div>30-32oC</div> <div>PaO2/FiO2</div> <div>300-350</div> <div>200-300</div> <div>Chest AIS</div> <div>2</div> <div>3</div> </div> </li> <li>Chest AIS:</li> <ul> <li>2 = 2 <3 rib#, clavicle/sternum/scapula #, stab wound into pleura</li> <li>3/4 = >3 adjacent rib #, unilateral flail segment, chest wall skin avulsion to ribs</li></ul></ul>

<div><br></br></div>

<div><div>Top 3 parameters of resus: Lactate<2.5, BD -2 to 2, gastric pH>7.3</div></div>

Question 97

“ARDS Def’n”

Answer 97

“<div><div>Acute non-cardiogenic respiratory failure characterized by decreased PaO2 and a diffuse, massive extravasation of fluid into the interstitial space of the lungs</div></div><div><br></br></div><div>Treatment: Ventilator support Avoid toxic FiO2, barotrauma General organ support Outcomes: 30-40% mortality rate Major cause of death in patients with lowest ISS scores<br></br></div><div><br></br></div><img></img>”

Question 98

Bridge plating principles?

Answer 98

“<img></img>”

Question 99

RFs for revision surgery for tibial non-union

Answer 99

<ul><li>(Bhandari, 2003)</li><ul><li>Open #</li><li>Transverse #</li><li>Fracture gap</li><li>No: smoking, DM, chronic steroids</li></ul></ul>

Question 100

The incidence of heterotopic ossification (HO) in the surgical management of acetabular fractures can be reduced by debridement of the:<div>A. Gluteus minimus</div><div>B. Quadratus femoris</div><div>C. Rectus femoris</div><div>D. Gluteus maximus</div>

Answer 100

A. Gluteus minimus<div>HO is a common complication after the surgical management of acetabular fractures. It has an incidence ranging from 7% to 100%. Substantial discomfort, stiffness, and poor functional outcomes can be seen in patients with HO. The etiology is multifactorial, and the surgical approach to the acetabular fracture pattern is an important factor in successful management. <b>Debridement of a contused gluteus minimus could prevent the formation of HO.</b> Posterior wall fractures and transverse-posterior wall fractures treated through the Koch-Langenbeck approach have an intermediate risk of developing HO. <b>Debriding the damaged gluteus minimus muscle and single-dose radiation have been shown to decrease the incidence of HO</b>. A low incidence of HO has been seen with the ilioinguinal and the Stoppa approaches, an intermediate incidence with the Kocher-Langenbeck approach, and a high incidence with the extended-iliofemoral approach.<br></br></div>

Question 101

<div>Even with a stable, anatomic reduction of the articular surface, the risk of posttraumatic arthritis after intra-articular ankle fracture is significant. In addition to direct injury to the cartilage, what factor most likely contributes to the increased risk?</div>

<div>A. Non-adherence with post-op restrictions</div>

<div>B. Post-fracture synovial fluid environment</div>

<div>C. Inflammatory reaction to the instrumentation</div>

<div>D. Prolonged post-operative immobilization</div>

Answer 101

B.<div>Most cases of ankle arthritis are posttraumatic. <b>Recent research has focused on the synovial fluid environment in the ankle after intra-articular fracture. After injury, an increase in proinflammatory cytokines and matrix metalloproteinases occurs that can lead to degradation of the cartilage. Intra-articular lavage has been proposed as a possible protective intervention to reduce the incidence of posttraumatic ankle arthritis. <br></br></b><br></br>Patient nonadherence with postoperative restrictions is frustrating and can increase the risk of postoperative complications, but this factor alone has not been demonstrated to be a risk factor for posttraumatic arthritis unless it leads to a loss of fixation. Inflammatory reactions to instrumentation are rare and have not been associated with posttraumatic arthritis. Prolonged postoperative immobilization can be associated with stiffness of the ankle joint but has not been shown to increase the risk of posttraumatic arthritis.<br></br></div>

Question 102

<div>Whatfactor has been associated with an increased risk of being the victim of Intimate Partner Violence (IPV)?</div>

<div><br></br></div>

<div>A. Male gender</div>

<div>B. Short-term relationship</div>

<div>C. Older age</div>

<div>D. Having no children</div>

Answer 102

B. Short-term relationship<div>Hackenberg and associates described a larger percentage of female patients (83%) than male patients (17%) who were affected by IPV. Of the percentage of males treated, a larger number had more substantial injuries or more than one injury (ranging from 2 to 10). The authors also showed that only 17% of the patients in their series were older. In a respective review of more than 1,000 charts of women treated for IPV, Wong and associates found that 833 patients were married, and 132 were practicing cohabitation. Sprague and associates showed that patients in short-term relationships were at higher risk of IPV (OR .584, 99% CO .396-.860, P=0.0001). The Prevalence of Abuse and Intimate Partner Violence Surgical Evaluation (PRAISE) investigators also showed that, of patients seen in orthopaedic clinics who had experienced IPV, 68% had children, compared with 32% who did not.<br></br></div>

Question 103

<div>What injury variable is associated with early conversion to total hip arthroplasty after the treatment of acetabular fractures?</div>

<div><br></br></div>

<div>A. Posterior wall comminution</div>

<div>B. Posterior hip dislocation</div>

<div>C. A femoral head cartilage lesion</div>

<div>D. Articular displacement less than 20 mm</div>

Answer 103

C. A femoral head cartilage lesion<div>Tannastand associatesfound a cumulative survival rate of 79% after a 20-year follow-up in patients with acetabular fractures who were surgically managed. <b>A femoral head cartilage lesion was an independent negative prognostic factor favoring an early arthroplasty option. </b>Other predictors were <b>nonanatomical fracture reduction, age over 40 years, anterior hip dislocation, postoperative incongruence of the acetabular roof, involvement of the posterior acetabular wall, acetabular impaction, an initial displacement of the articular surface of 20 mm or more, and use of the extended iliofemoral approach</b>. Routt and associates showed, in a review of surgically treated posterior wall acetabular fracture, that posterior wall comminution was not associated with an increased risk of conversion to total hip arthroplasty if reduction resulted in less than 1 mm of diastasis or step-off.<br></br></div>

Question 104

List 6 surgical indications for scapular fractures (Schroder and associates paper)

Answer 104

• Medial/lateral displacement of 20mm or more<div>- Angulation of 45^o or more</div><div>- Medial/lateral displacement of 15mm or more with angulation of 30^oor more</div><div>- Double disruptions of the SSSC (both with >10mm displacement)</div><div>- GPA 22^oor less</div><div>- Open fracture</div>

Question 105

Predictive factors for ischemia in the surgical management of humeral head fractures

Answer 105

• Posteromedial calcar length of the humeral head <8mm<div>- Loss of medial hinge</div><div>- 4-part fracture</div><div>- Fracture angulation >45^o</div><div>- Tuberosity displacement >10mm</div>

Question 106

In Elderly patients, six months after injury, compared with open reduction and internal fixation (ORIF), treatment with total elbow arthroplasty results in:<div>A. Decreased range of motion.</div><div>B. Improved function.</div><div>C. More complications.</div><div>D. Fewer reoperations.</div>

Answer 106

B. Improved function<div>A meta-analysis looking at the outcomes and complication rates in elderly patients with intra-articular distal humerus fractures treated with total elbow arthroplasty (TEA) or ORIF with locking platesdetermined that a trend occurred toward a higher rate of major complications and reoperation after ORIF, although this trend did not reach statistical significance. In the onlymulticenter prospective randomized controlled trial comparing these treatments in the older population,TEA was superior to ORIF as measured bythe Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder, and Hand scores, especially in the early postoperative period. Surgical time was also shorter in the TEA group, and trends also were observed toward a reduced reoperation rate and improved range of motion in the TEA group, although these trends did not reach statistical significance.<br></br></div>

Question 107

<div>The highest likelihood of a recurrent fragility fracture occurs after an initial fracture of the</div>

<div>A. Distal radius.</div>

<div>B. Hip.</div>

<div>C. Vertebral body.</div>

<div>D. Proximal humerus.</div>

Answer 107

C. Vertebral body<div>Fragility fractures are exceedingly common and, given the increasing life span of the population, their incidence will greatly increase in years to come. The various fragility fractures have different morbidity and mortality patterns, but <b>the highest likelihood of recurrent fragility fracture occurs after a vertebral compression fracture, followed closely by fractures of the proximal humerus, hip, distal radius, and ankle.</b><br></br></div>

Question 108

What fixation technique for the treatment of transverse patella fractures has been shown to have the greatest biomechanical stability?<br></br>A. Cannulated screws plus tension band using wire<div>B. Cerclage wiring</div><div>C. Lag screw fixation</div><div>D. Kirschner wire fixation plus tension band using wire</div>

Answer 108

<div>A. Cannulated screws plus tension band using wire<br></br></div>

All of the fixation techniques listed have been used in the treatment of patella fractures. Of those listed, cannulated screw fixation with associated wire placement has been shown to provide greater biomechanical stability. Both Burvant and associates and Carpenter and associates showed greater stability in a cadaver model. Burvant described fracture gaps less than half of those seen with traditional modified tension band techniques. Carpenter also described failure at earlier force for screw fixation alone (554 Newtons) than for cannulated screw fixation and wiring (732 Newtons). Benjamin and associates, in a comparison of fixation techniques, described cerclage wire fixation to be the weakest biomechanically, with fracture gaps up to 20 mm.

Question 109

Negative predictors of hip survival after ORIF of acetabular fractures

Answer 109

1. Age >40<div>2. Non-anatomic reduction</div><div>3. Hip dislocation</div><div>4. Acetabular roof or posterior wall involvement</div><div>5. Articular impaction</div><div>6. Femoral head involvement</div><div>7. Initial displacement >20mm</div>

Question 110

5 Indications for early surgery for a knee dislocation

Answer 110

<ul> <li>MAICE</li> <li>Meniscal root</li> <li>Avulsion #</li> <li>Irreducible!</li> <li>Chondral injury</li> <li>Extensor mechanism disruption</li></ul>

Question 111

Tscherne Classification

Answer 111

Not all high energy fractures are open. This classification emphasizes the importance of viability of the soft tissue envelope at the zone of injury.<div><br></br></div><div>Grade 0: Soft tissue damage is absent or negligible</div><div>Grade 1: Superficial abrasion or contusion caused by fragment pressure from within</div><div>Grade 2: Deep, contaminated abrasion associated with localized skin or muscle contusion from direct trauma</div><div>Grade 3: Skin extensively contused or crushed, muscle damage may be severe. Subcutaneous avulsion, possible artery injury, compartment syndrome</div>

Question 112

What structures can block radial head reduction (Monteggia)

Answer 112

Annular ligament<div>Joint capsule</div><div>PIN</div><div>Biceps tendon</div><div>Brachialis (can button hole through)</div>

Question 113

What is the axis of forearm rotation? (JAAOS 2017)

Answer 113

Line connecting the center of the radial head and ulnar head

Question 114

What is a method to assess the radial bow?

Answer 114

On an AP radiograph, a line is drawn from the radial tuberosity to the most ulnar edge of the distal radius. From this line, the longest possible perpendicular line is drawn to the radius.<div><br></br></div><div>Normal = 15.3 +/- 0.3mm</div><div><br></br></div><div>Patients with 80% rotation of the normal forearm have a radial bow of 15 +/- 1.5mm (i.e within 1.5mm of the well side)</div>

Question 115

What is the management of high velocity gunshot wounds?

Answer 115

1. Aggressive I&D in the OR<div>- Excise contaminated/devilatized tissue, explore wound tract</div><div>2. Associated fractures are ex-fixed or IMN</div><div>3. IV abx as per open fracture management</div><div>4. Tetanus PPx as indicated</div><div>5. Repeat I&D in 48 hours</div><div>6. Closure by secondary intension, possible graft</div>

Question 116

What are the indications for the removal of a bullet?

Answer 116

1. Intra-articular<div>2. Retained in the intervertebral disc</div><div>3. Compression of the spinal cord</div><div>4. Lead toxicity</div><div>5. Fragment in palm or sole</div>

Question 117

What are the risk factors associated with lead toxicity following GSW?

Answer 117

1. Length of time projectile has been retained<div>2. Fragmentation of the projectile</div><div>3. Retained in or near synovial fluid</div><div>4. Retained within the intervertebral disc</div><div>5. Fracture secondary to gunshot</div>

Question 118

What injuries are associated with posterior wall acetabulum fractures?

Answer 118

1. Knee ligaments<div>2. Patella fracture</div><div>3. Femoral shaft, neck and head</div><div>4. Morel-Lavallee lesion</div><div>5. Superior gluteal artery</div><div>6. Sciatic nerve</div>