Trauma (2008-2019)

Question 1

1. 8 Parameters to consider in a trauma patient for DCO vs Early total care (2010, 2011, 2013)

Answer 1

• Shock Factors
  
  • Systolic BP < 90mm Hg and MAP less than 60
  • Dependency on vasopressors to maintain BP
  • Urine output less than 0.5cc/hr/kg
  • Massive transfusion requirements (6 or more units in 2 hours)
  • Lactate greater than 2.5mmol/L: this is the most sensitive indicator as to whether tissues are under perfused
  • Base deficit greater than 6 mmol/L. normal range for deficit is -2 to +2
  • Ph less than 7.2
• Coagulation parameters (i.e. things that indicate the patient is coagulopathic)
  
  • Platelet count less than 90 000
  • Elevated d-dimer
  • Fibrinogen less than 1
  • Elevated PTT (i.e. decreased factor II and V)
• Temperature
  
  • Core temp less than 35 (some say 33) degrees C
• Soft tissue injury to extremity, lungs or abdomen
  
  • Lung function: PaO2/FiO2 ratio of less than 250-300
  • Pulmonary contusions bilaterally on initial chest xray
  • Severe chest trauma as indicated by AIS score of 2 or more
  • Mangled extremity or severe crush injury to extremity
  • Bilateral femoral shaft fractures or multiple long bone fractures
  • Severe abdominal trauma (Moore III or greater) in polytrauma patient
  • Severe Pelvic fracture (AO class B or C pelvic fracture) in poly trauma patient
• Other factors
  
  • Head injured patient with AIS of 3 or more
  • ISS score greater than 20 with chest trauma
  • ISS score greater than 40 w/o chest trauma
  • Presumed OR time greater than 6 hours in a borderline patient
  • IL-6 values above 500pg/dL at the time of surgery and development of multiple organ failure (Second hit).

Question 2

2. What are 8 radiographic features of acute traumatic aortic rupture? (2011, 2013, 2015)

Answer 2

• ATLS Manual:
• Loss of Aortic Arch:
  
  • Widened mediastinum (>8mm)
  • Obliteration of the aortic knob
  • Loss of Aorto-pulmonary window
  • Widened paraspinal interfaces
• Trachea and Esophageal Findings:
  
  • Tracheal deviation to the right
  • Deviation of esophagus/NG to right
  • Widened paratracheal stripe
• Intra-pulmonary and chest wall findings
  
  • Left apical cap (apical pleural hematoma)
  • Left hemothorax
  • Depression of left mainstem bronchus
  • Elevation of right mainstem bronchus
  • Fractures of first or second rib, scapula

Question 3

3. List the 4 major and 4 minor criteria of fat embolism syndrome (2014)

Answer 3

Gurd and Wilson Criteria: (1 major with 4 minor)

• Major Criteria:
  
  • Hypoxemia
  • CNS depression/change in mental status
  • Petechial Rash
  • Pulmonary Edema
• Minor Criteria:
  
  • Tachycardia
  • Pyrexia
  • Retinal emboli
  • Fat in urine/sputum
  • Thrombocytopenia
  • Decreased hematocrit

Question 4

4. List signs of class 4 hypovolemic shock. (2011, 2014)

Answer 4

ATLS Manual:

• Heart Rate > 140bpm
• Decreased blood pressure
• Decreased pulse pressure
• Respiratory rate > 35
• Negligible urine output
• Lethargic/comatose

Question 5

5. Young female with polytrauma. Shown an xray with bilateral inf and sup ramus # but perfect SI joints. Been to OR for slenectomy and found a large retroperitoneal hematoma. Still hypotense 95/50 and 90bpm. What to do next?
6. Angio with embolization
7. “External fixator or C – clamp” (For sure this answer was as written)
8. Return to OR for re-exloration and packing
9. Pelvic binder

Answer 5

ANSWER: A

2013

Eastern Association for the Surgery of Trauma Practice Management Guidelines for Hemorrhage in Pelvic Fracture—Update and Systematic Review (J Trauma. 2011;71: 1850–1868) 

• Angiography
  
  • There is level 1 evidence that patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out should have pelvic angiography/embolization. 
• External Pelvic Fixation
  
  • Sadri et al.[11] found that blood loss was not statistically different before/after placement of the pelvic C-clamp or Ex fix.
  • In addition, there is evidence that pelvic binders are more effective at decreasing transfusion requirements because they are faster to apply, and are as effective as external fixators in decreasing pelvic volume. 
  • Temporary Pelvic Binders:
  • TPBs may limit pelvic hemorrhage, but reports on this are mixed in the literature. They do not seem to affect mortality.
  • TPBs work as well or better than emergent EPF in controlling hemorrhage.  
• Retroperitoneal Packing:
  
  • This is effective at controlling hemorrhage from an intrapelvic bleeding source if done in conjunction with either an ex fix or pelvic binder to close the pelvic volume.
  • Colorado trial**2017 - RPP faster and saves lives (charles) do packing and ex fix first, then consider embolizing
  • But was with true pelvic fractures (unstable), vs this is no unstable pelvis or disruption of posterior SI lig

Question 6

6.23 yo woman in a MVC. Presents with C7 complete cord lesion and a closed femur fracture. She has received 2 L of crystalloid. Heart rate is 110 and BP is 86/55. The cause of her hypotension is

1. Hypovolemia due to unrecognized abdominal bleeding
2. Hypovolemia due to her femur fracture
3. Spinal shock
4. Neurogenic shock

Answer 6

ANSWER: A

2013

• Obviously on-going hypotension due to bleeding. Disagreement on source –> some say femur fracture should respond to crystalloid and therefore given the mechanism the abdomen is likely bleeding
• Student Course Manual ATLS 10th edition (Charles)

Question 7

7.Regarding compartment syndrome which will NOT help treat acute compartment syndrome:

1. Transfusing to keep HGB greater than 100
2. fixing hypotension
3. Giving O2 by mask
4. Cutting all circumferential dressings and casts

Answer 7

ANSWER: A

2013

• Correction of hypotension and removal of dressings are common sense answers
• JAAOS - Acute Compartment Syndrome of the Lower Extremity
  
  • Casts or occlusive dressings should be split completely. Cast padding or circumferential dressings should be released around their entire circumference. The affected limb should not be elevated higher than the patient’s heart in order to maximize perfusion while minimizing swelling
  • Talk about perfusion gradient that might be inadequate with systemic hypotension and that hypotension should be avoided (anesthesia methods of hypotension to decrease blood loss can create/exacerbate ACS)
  • No mention of transfusion or transfusion above 100
• Hyperbaric oxygen therapy useful Fitzpatrick et al. 1998. Adjunctive treatment of compartment syndrome with hyperbaric oxygen.

Question 8

8.A 24yo male is found 24 hours after a single vehicle collision/rollover. He has a closed head injury (GCS12), a pneumothorax, and an open tibia fracture with a 10cm wound over the anteromedial tibia. Both of his legs have been lying in ditch water for 24 hours. You are shown x-rays which demonstrate a comminuted midshaft tibia fracture. Optimal treatment includes irrigation & debridement and what else?

1. Reamed IM nail
2. Unreamed IM nail
3. Ex-fix
4. Cast with conversion to an IM nail when soft tissues improve

Answer 8

ANSWER: C

2014

Argument:

• Delayed presentation + head injury (weak) + lung injury = indication for DCO
• Best stabilization without definitive hardware is external fixation

Question 9

9. Motorcycle crash 2 hours ago with hypotension, unstable. Tibia fracture with large soft tissue defect, 12cm bone on road (in paper bag with EMS), vascular injury with no pulses, insensate foot. Ipsilateral femur and acetabular fractures. How will you treat the leg?
10. I+D, Vascular repair, replace extruded tibia and unreamed nail
11. I+D, Vascular repair, discard extruded tibia and unreamed nail
12. I+D, Vascular repair, discard extruded tibia and ring fixator
13. Below knee amputation

Answer 9

ANSWER: D **

2013, 2016

Difficult question to find evidence for

• Very sick, unstable patient
• Reconstruction would take many hours
• Would consider vascular repair + ex-fix of femur and tibia but this is not an option
• LEAP trial - patient cannot survive recon, vasc, large ST injury, insensate foot not indication (usually comes back) but overall disvascular limb with large ST injury = amp

Question 10

10. Which of the following is a reason NOT to put O2 on an old person in trauma
11. Chronic lung disease with increased PaCO2
12. Chronic lung disease with decrease PaCO2
13. Heart disease
14. No reason to not put O2 on

Answer 10

ANSWER: D

2013

Callaway DW, Wolfe R Geriatric trauma. Emerg Med Clin North Am. 2007 Aug;25(3):837-60

“Supplemental oxygen should be placed on all elderly trauma patients. This practice provides the needed oxygen reserves if rapid sequence intubation is needed and contributes to cellular oxygenation”

Question 11

11. A patient presents to ER with C5/6 jumped facets and complete quadriplegia following an MVC (or some other similar trauma). It is an isolated injury. The patient is bradycardic (HR 60?) and hypotensive (80/45 mmHg). So far the patient has been given 6L of crystalloid. What should you do now?
12. Slow IV to maintenance rate
13. Start transfusing blood
14. Give albumin
15. Rapid bolus with IV crystalloid

Answer 11

ANSWER: A

2014

JAAOS 1999 - Acute Management of Spinal Cord Injury

Patients in neurogenic shock typically have a heart rate between 50 and 70 beats per minute and a systolic pressure 30-50mm Hg below normal

Treatment of neurogenic shock includes an initial fluid challenge, Trendelenberg positioning, vasopressors after central line insertion and atropine for treatment of bradyarrhythmias

Question 12

12. What is the best predictor of resuscitation in polytrauma?
    a. base deficit
    b. urine output
    c. blood pressure
    d. heart rate

Answer 12

 ANSWER: A

2015

Crowl AC (J Trauma 2000)

Patients with ISS > 18 and IMN within 24 hours

Compensated shock (normal BP, HR, U/O)

Pt with lactate > 2.5 had higher pulmonary and infectious complications

Question 13

13. Patient presents with a femur fracture and a pulmonary contusion. Hemodynamically stable. What is the most appropriate treatment?
14. Subcutaneous plate
15. External fixation
16. Unreamed IM nail
17. Reamed IM nail

Answer 13

ANSWER: D

2016

• Pape (Ann Surg 2007) RCT of IMN vs DCO
• Exclusion AIS thorax > 2, body weight > 250lb
• Stable patients –> IMN associated with decreased ventilator time
• Borderline patients –> acute IMN associated with increased acute lung injury
• JAAOS - Damage Control Orthopedics
• Borderline Patients:
• ISS > 20 + thoracic injury
• ISS > 40
• Bilateral pulmonary contusion
• Polytrauma with abdominal/pelvic trauma and hemodynamic shock
• Elevated pulmonary arterial pressure > 24 mmHg
• Pulmonary arterial pressure increase of 6mmHg during procedure
• Hypothermia
• ? Severe abdominal injury (AIS > 3)
• Morshed (JBJS 2009)
• 50% relative risk reduction in mortality in patients treated after 12 hours
• Significant abdominal injury benefitted most from delay
• ? Bilateral femur fractures
• ? Head Injury
• O’Toole RV (J Trauma 2009)
• Retrospective review of protocol for treatment of femur fractures
• ISS > 17, 229 patients
• 88% had reamed IM nailing, 12% DCO
• “normalizing lactate” parameter for adequate resuscitation
• Mean time to nail 14 hours
• 1.5% ARDS, 2.0% ARDS with pulmonary injury, 3.3% with pulm injury and ISS > 28
• COTS (J Trauma 2006)
• 322 femur fractures
• IMN within 24 hours
• No significant differences
• Reamed 3/63
• Unreamed 2/46
• 40000 patients needed for appropriate power
• Bosse MJ (JBJS 1997)
• No difference in patients treated with nails vs plates

Question 14

14. List 5 factors that increase the 30 day morbidity of a patient with a hip fracture (2012, 2014)

Answer 14

Nottingham Hip Fracture Score:

• Age
• Male
• Hemoglobin < 100
• MMSE < 6
• Institutionalized
• > 2 Comorbidities
• Malignancy

Question 15

15. Describe the Leadbetter maneuver. (2010, 2015)

Answer 15

• Flex hip to 45-90, slight adduction
• Inline traction
• Internal rotation to 45o
• Maintain traction and IR, then abduction and extension

Question 16

16. What are three radiographic factors indicate adequate reduction of a displaced femoral neck? (2010, 2013, 2015)

Answer 16

Question 17

17. List 3 strategies while antegrade nailing a subtrochanteric femur fracture to assist with reduction and avoid varus malunion. (2013)

Answer 17

• Lateral positioning for nail
• Limb positioning with flexion, abduction, traction
• Crutch/Cobb/Mallet/F-tool
• Open Reduction with clamp/uni-cortical plate/cerclage wire
• Blocking screws
• Medial start point on nail

Question 18

18. Give 2 advantages of doing a piriformis starting point vs. a trochanteric starting point for an antegrade femoral nail. (2011)

Answer 18

• JAAOS - Intramedullary Nailing of femoral shaft fractures
• Piriformis Advantage:
  
  • Straight trajectory with shaft
  • Decreased risk of varus malreduction
  • Decreased risk of iatrogenic fracture comminution
  • Decreased risk of GT fracture
• Disadvantages:
  
  • More difficult start point
  • Sensitive to anterior/posterior misplacement
  • Increased theoretical risk of blood supply disruption
  • Risk of femoral neck fracture
• Trochanteric Start Point:
• Advantage:
  
  • Easier start point
  • Less hoop stresses in GT, more forgiving to AP mistakes with start point
  • Less soft tissue damage

Question 19

19. Given an x-ray of a varus malunited femoral neck fracture. List 4 clinical findings found on physical exam other than decreased ROM. (2011)

Answer 19

• Trendelenberg Sign/Abductor Weakness
• Leg length discrepancy
• Prominent GT
• Impingement with ROM
• Obligate external rotation with flexion

Question 20

20. In an adult femur supracondylar fracture, intraarticular and metaphyseal comminution what are 3 advantages over a distal femoral locking plate over a 95 degree sliding dynamic condylar screw. (2013)

Answer 20

• Better fixation in osteoporotic/comminuted bone (multiple points of fixation)
• Ability to control multiple fracture fragments
• Anatomic contour helps with reduction of joint
• Biomechanically superior in cyclic load and ultimate strength
• Preserves more distal bone stock
• Less soft tissue stripping

JAAOS 1997 Supracondylar Fractures of the Femur. Albert.

Gwathmey FWF, Jones-Quaidoo SMS, Kahler DD, Hurwitz SS, Cui QQ. Distal femoral fractures: current concepts. J Am Acad Orthop Surg. 2010;18(10):597–607

Question 21

21. List 3 radiographic strategies to properly determine the rotation of the distal femur when nailing a femoral shaft fracture. (2014, 2015, 2016)

Answer 21

• Tornetta Technique (1995): anteversion determined off c-arm angles for perfect lateral of proximal and knee of non-injured limb, recreate with rotation of distal femur to match.
  
  • Results in rotational discrepancy under 8 degrees
• Lateral-only imaging (2000): true lateral knee, measure anteversion on screen, recreate this
  
  • Results in rotational discrepancy under 10 degrees
• Lesser-trochanter profile: true lateral of knee, then 90 degrees to this take AP of lesser trochanter, use as template
  
  • Results in <10 degrees of malrotation

Question 22

22. List 5 intra-operative techniques to aid in reduction of a proximal tibial shaft fracture (2012,2015)

Answer 22

• Unicortical plate
• Poller Screws
• Semi-extended positioning/supra-patellar start point
• Lateralize start point
• More proximal Herzog Angle
• Femoral Distractor

Question 23

23. 4 principles of managing a Pilon excluding soft tissue (2012)

Answer 23

JAAOS 2011 - Pilon Fractures

• Reduce and fix fibula fracture to re-establish length
• Correct varus/valgus deformity
• Anatomic Reduction of articular surface
• Back fill metaphyseal defect
• Fix articular block to tibial shaft

Question 24

24. 3 radiographic findings suggesting syndesmotic injury (2012)

Answer 24

JAAOS 2007 Ankle Syndesmotic Injury

• Increased medial clear space on mortise >4mm
• Decreased tibio-fibular overlap (<6mm AP, <1mm on mortise)
• Increased TibFib clear space (>6mm on AP and mortise)
• Avulsion fracture off posterior mal
• Proximal spiral fibular fracture with no tibia fracture

Question 25

25. List 3 complications of doing an ankle ORIF in a patient with DM (2010, 2011)

Answer 25

JAAOS 2008 - Complications of Ankle Fractures in Patients with Diabetes * Increased risk of infection * Delayed wound healing * Delayed time to union * Non-union * Mal-union/loss of reduction * Increased hardware failure * Charcot neuroarthropathy * CRPS * Amputation

Question 26

26. For an isolated posterior wall acetabular fracture, all of the following are indications for ORIF EXCEPT: 1. Intra-articular fragment 2. Roof arc less than 20 3. Positive stress test 4. 40% wall involvement

Answer 26

ANSWER: B Repeat 2013, 2015 JAAOS 2001 Displaced Acetabular Fractures * JOT 1996 The Effect of Variable Size Posterior Wall Acetabular Fractures on the Contact Characteristics of the Hip Joint * "Articular incongruity is one indication for open reduction and internal fixation of these fractures. For fractures of the posterior wall, the indications for operative treatment also include instability of the hip, incarcerated or impacted osteochondral fragments, and irreducible fracture-dislocation of the hip." * From the OTA powerpoint slides: * Cannot use roof arc measurements for wall fractures since these can only be treated non-operatively if hip joint remains completely stable and congruent

Question 27

27. What type of acetabular fracture can you not use a roof angle in? 1. Associated two column (worded this way) 2. Transverse posterior wall 3. Posterior column 4. T type

Answer 27

ANSWER:A 2012 * From the OTA powerpoint slides: * Cannot use roof arc measurements for associated both column since there is no intact portion of the acetabulum to measure

Question 28

28. Posterior wall fractures (2nd question) all are true EXCEPT 1. 5 of Letournels lines are intact 2. \> 50% of posterior wall involvement requires fixation 3. Marginal impaction requires disimpaction and bone grafting. 4. Intra-articular split requires fixation

Answer 28

ANSWER: D 2013 * Isolated posterior wall fractures have all other lines intact - YES * Posterior wall fractures \>40% are associated with hip instability --\> should go on to fixation * Articular steps associated with poor outcomes --\> therefore should be disimpacted * All posterior wall fractures are intra-articular, those \<20% and stable are not an indication for fixation

Question 29

29. What is the best approach to fix an associated both column acetabular fracture: 1. Iliofemoral 2. Triradiate 3. Kocher-Langenbach 4. Ilioinguinal/Stoppa

Answer 29

ANSWER: D 2015 * From Chapt 36 of Core 2 - Stoppa is appropriate for associated both column fractures, and it is similar to the middle window of the ilioinguinal approach (which also has associated both column listed as an indication)

Question 30

30. When utilizing the Kocher-Langenbeck approach for acetabular fractures, everything is true about positioning EXCEPT?  1. Lateral: useful for transverse fractures 2. Lateral: useful for ipsilateral pubic symphysis fractures 3. Prone: useful to decrease sciatic nerve tension 4. Prone: useful to palpate the quadrilateral plate

Answer 30

ANSWER: A 2016

Question 31

31. Elderly acetabular fracture, which of the following is true? 1. Most need posterior approach 2. Gull sign is representative of interposed fragment 3. Most have an anatomic reduction 4. 20% or more go on to total hip with long term outcome

Answer 31

ANSWER: D 2016 Archdeacon (JOT 2013) Treatment of protrusio fractures of the acetabulum in patients 80 years and older * 26 patients at 1 years * 19% underwent THA * 26% died at average of 20 months

Question 32

32. Which approach gives best access for reduction and fixation to quadrilateral plate? 1. Medial window ilioinguinal 2. Stoppa 3. Kocher-langenbeck 4. Hardinge

Answer 32

ANSWER: B 2016 * JAAOS 2011 - Modified Stoppa Approach for Acetabular Fracture * Subperiosteal dissection performed along the pubis, superior pubic ramus, posterior surface of the ramus and pelvic brim into the internal iliac fossa * Ligate the corona mortis between obturator and external iliac over superior ramus * Additional exposure: * Detach the iliopectineal fascia, place deaver under iliopsoas to protect vessels * Next quadrilateral surface and medial aspect of posterior column exposed * JAAOS 2015 - Surgical Approaches to the Acetabulum * Lateral Window - inner table of ilium, anterior SI, pelvic brim * Middle Window - quad plate, pelvic brim (anterior Si to pectineal eminence) * Medial Window - superior pubic ramus and pubic symphysis * JOT 2014 - Quantification of bony pelvic exposure through the modified Stoppa approach * The modified Stoppa approach allows for exposure of most (79%) of the inner true bony pelvis including the entire pelvic brim and 80% of the quadrilateral surface. On average, visualization is possible 2 cm above the pelvic brim and 5 cm below the pelvic brim along the quadrilateral surface, providing adequate anterior exposure for clamp and implant placement

Question 33

33. A 50yo male falls from a horse. You are shown an x-ray which demonstrates 2-3cm pubic diastasis and slight right SI joint widening but no vertical instability. What was the mechanism? 1. Vertical shear 2. Anterior posterior compression 3. Lateral compression 4. Open book

Answer 33

ANSWER: B 2014

Question 34

34. What is true about SI screw placement? \*VERSION OF A REPEAT 1. To place an S2 screw 1 cm distance between the S1 and S2 foramens is required 2. You cannot place an S2 screw if there is sacral dysmorphism 3. Displacement in the AP plane of 1.5cm 4. Displacement in the cranial-caudal plane of 1.5cm