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Trauma 2013 Flashcards

1
Q
  1. An 85-year-old woman with a history of poorly controlled hypertension, orally controlled diabetes, and atrial fibrillatin with controlled rate is seen on a Thursday and with an unstable intertrochanteric fracture. Evaluation reveals she is slightly hypernatremic (sodium level 155 mEq/L) (reference range, 136-142 mEq/L). What is the most appropriate treatment option?
  2. Traction and hydration because surgical intervention puts this patient at high risk
  3. One litre of normal saline and immediate (Thursday) open reduction and internal fixation with a plate
  4. Rehydration, medical evaluation, and open reduction and internal fixation with a nail within 48 hours.
  5. Rehydration, cardiac stress testing, endocrine evaluation, and open reduction and internal
  6. Immediate open reduction and internal fixation with a nail followed by admission to medicine for treatment after surgery.
A
  1. Rehydration, medical evaluation, and open reduction and internal fixation with a nail within 48 hours.

RECOMMENDED READINGS

Switzer JA, Layman MD, Bogoch ER. Perioperative and postoperative considerations in the geriatric patient. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:535-544.

Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995 Oct;77(10):1551-6. PubMed PMID: 7593064.

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2
Q
  1. What is the most important determinant of the energy imparted to the soft tissues as a result of a gunshot wound?
  2. Yaw
  3. Mass
  4. Range
  5. Caliber
  6. Velocity
A
  1. Velocity

RECOMMENDED READINGS

Bartlett CS, Helfet DL, Hausman MR, Strauss E. Ballistics and gunshot wounds: effects on musculoskeletal tissues. J Am Acad Orthop Surg. 2000 Jan-Feb;8(1):21-36. Review. PubMed PMID: 10666650.

Dougherty PJ, Najibi S, Silverton C, Vaidya R. Gunshot wounds: epidemiology, wound ballistics, and soft-tissue treatment. Instr Course Lect. 2009;58:131-9. PubMed PMID: 19385526.

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3
Q
  1. Figure 10 is the radiograph of an 18-year-old man who sustained an isolated gunshot wound to his right thigh. After appropriate evaluation and resuscitation, the fracture is repaired with a reamed intramedullary nail. What is the most commonly encountered complication in this scenario?
  2. Infection
  3. Malunion
  4. Nonunion
  5. Fat embolism
  6. Pulmonary embolism
A
  1. Malunion

RECOMMENDED READINGS

Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. 2009 May;17(5):296-305. Review. PubMed PMID: 19411641.

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4
Q
  1. A 25-year-old thin man sustained a bimalleolar left ankle fracture, a comminuted spiral midshaft left humeral fracture, and a grade IV splenic laceration during a motor vehicle collision. His left radial nerve function is intact. He underwent splenectomy immediately and his fractures were splinted. In counseling the patient regarding surgical vs nonsurgical treatment of the humerus fracture, you would advise that
  2. the risk for radial nerve palsy is higher in spiral humeral shaft fractures that are treated nonsurgically.
  3. the patient may bear weight through the plated humeral fracture for the purpose of using ambulatory aids.
  4. a functional fracture brace will not adequately maintain humeral shaft fracture alignment during the healing process.
  5. surgical fixation of the humeral fracture will alow for earlier fracture union than nonsurgical treatment with a functional fracture brace􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀁖􀁘􀁕􀁊􀁌􀁆􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁋􀁘􀁐􀁈􀁕􀁄􀁏􀀃􀁉􀁕􀁄􀁆􀁗􀁘􀁕􀁈􀀃􀁚􀁌􀁏􀁏􀀃􀁄􀁏􀁏􀁒􀁚􀀃􀁉􀁒􀁕􀀃􀁈􀁄􀁕􀁏􀁌􀁈􀁕􀀃􀁉􀁕􀁄􀁆􀁗􀁘􀁕􀁈􀀃􀁘􀁑􀁌􀁒􀁑􀀃􀁗􀁋􀁄􀁑􀀃􀁑􀁒􀁑􀁖􀁘􀁕􀁊􀁌􀁆􀁄
  6. long-term outcomes for plated humeral shaft fractures are better than for fractures treated

nonsurgically.

A
  1. the patient may bear weight through the plated humeral fracture for the purpose of using ambulatory aids.

RECOMMENDED READINGS

Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma. 2000 Aug;49(2):278-80. PubMed PMID: 10963539.

Ekholm R, Tidermark J, Törnkvist H, Adami J, Ponzer S. Outcome after closed functional treatment of humeral shaft fractures. J Orthop Trauma. 2006 Oct;20(9):591-6. PubMed PMID: 17088659.

Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005 Dec;87(12):1647-52. Review. PubMed PMID: 16326879.

Hak DJ. Radial nerve palsy associated with humeral shaft fractures. Orthopedics. 2009 Feb;32(2):111. Review. PubMed PMID: 19301795.

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5
Q
  1. Figures 32a through 32c are the radiographs of a 31-year-old man who was involved in a motor vehicle collision. He has severe foot pain, marked swelling, and is unable to ambulate. What is the most appropriate definitive treatment step?

􀁄􀁓􀁓􀁕􀁒􀁓􀁕􀁌􀁄􀁗􀁈􀀃􀁇􀁈􀂿􀁑􀁌􀁗􀁌􀁙􀁈􀀃􀁗􀁕􀁈􀁄􀁗􀁐􀁈􀁑􀁗􀀃􀁖􀁗􀁈􀁓􀀢1. External fixation

  1. Closed reduction and casting
  2. Closed reduction and percutaneous pinning
  3. Open reduction and internal fixation with rigid fixation of the first to fifth tarsometatarsal joints
  4. Open reduction and internal fixation with rigid fixation of the first to third tarsometatarsal joints and Kirschner wire fixation of the fourth and fifth tarsometatarsal joints.

􀀃 􀀃􀀃􀀃􀀃􀀃􀀃􀀃􀁍􀁒􀁌􀁑􀁗􀁖􀀃􀁄􀁑􀁇􀀃􀀮􀁌􀁕􀁖􀁆􀁋􀁑􀁈􀁕􀀃􀁚􀁌􀁕􀁈􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁉􀁒􀁘􀁕􀁗􀁋􀀃􀁄􀁑􀁇􀀃􀂿􀁉􀁗􀁋􀀃􀁗􀁄􀁕􀁖􀁒􀁐􀁈􀁗􀁄􀁗􀁄􀁕􀁖􀁄􀁏􀀃􀁍􀁒􀁌􀁑􀁗􀁖

A
  1. Open reduction and internal fixation with rigid fixation of the first to third tarsometatarsal joints and Kirschner wire fixation of the fourth and fifth tarsometatarsal joints.

RECOMMENDED READINGS

Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop Surg. 2010 Dec;18(12):718-28. Review. PubMed PMID: 21119138.

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6
Q
  1. Advantages of a locking plate implant over a 95-degree angled blade palte for fixation of a supracondylar femur fracture include:
  2. a higher union rate.
  3. a lower implant cost.
  4. a lower overall complication rate.
  5. a lower rate of prominent hardware requiring removal.
  6. improved ability to use with associated coronal fractures.
A
  1. improved ability to use with associated coronal fractures.

RECOMMENDED READINGS

Vallier HA, Immler W. Comparison of the 95-degree angled blade plate and the locking condylar plate for the treatment of distal femoral fractures. J Orthop Trauma. 2012 Jun;26(6):327-32. PubMed PMID: 22183200.

Gwathmey FW Jr, Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q. Distal femoral fractures: current concepts. J Am Acad Orthop Surg. 2010 Oct;18(10):597-607. Review. PubMed PMID: 20889949.

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7
Q
  1. A 55-year-old man has a draining wound at the end of his transfemoral amputation residual limb. He reports that he sustained a “compound fracture” of his thigh bone approximately 30 years ago, requiring amputation and rodding of a fracture near his hip. His wound drains intermittently and has done so since his amputation. Intermittent administration of oral antibiotics temporarily ceases wound drainage, but the drainage returns after antibiotics are stopped. Wound culture reveals Pseudomonas aeruginosa, which is sesnitive to fluoroquinolones, carbapenems, aminoglycosides and cephalosporins. Radiographs of the residual limb are seen in Figures 63a and 63b. What is the recommended treatment?
  2. Administration of oral ciprofloxacin for 3 months􀀃 􀀔􀀑􀀃􀀃􀀃􀀃􀀤􀁇􀁐􀁌􀁑􀁌􀁖􀁗􀁕􀁄􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁒􀁕􀁄􀁏􀀃􀁆􀁌􀁓􀁕􀁒􀃀􀁒􀁛􀁄􀁆􀁌􀁑􀀃􀁉􀁒􀁕􀀃􀀖􀀃􀁐􀁒􀁑􀁗􀁋􀁖
  3. Administration of oral ciprofloxacin for the rest of his life􀀃 􀀕􀀑􀀃􀀃􀀃􀀃􀀤􀁇􀁐􀁌􀁑􀁌􀁖􀁗􀁕􀁄􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁒􀁕􀁄􀁏􀀃􀁆􀁌􀁓􀁕􀁒􀃀􀁒􀁛􀁄􀁆􀁌􀁑􀀃􀁉􀁒􀁕􀀃􀁗􀁋􀁈􀀃􀁕􀁈􀁖􀁗􀀃􀁒􀁉􀀃􀁋􀁌􀁖􀀃􀁏􀁌􀁉􀁈
  4. Surgical debridement and irrigation with implant removal and postsurgical ciprofloxacin for 3 months
  5. Surgical debridement and irrigation with implant removal, placement of a gentamicin-impregnated polymethylmethacrylate medullary rod, and postsurgical ciprofloxacin for 3 months
  6. Surgical debridement and irrigation with implant removal, sinus tract biopsy, placement of a gentamicin-impregnated polymethylmethacrylate medullary rod, and postsurgical ciprofloxacin for 3 months

􀀃 􀀃􀀃􀀃􀀃􀀃􀀃􀀃􀁌􀁓􀁕􀁒􀃀􀁒􀁛􀁄􀁆􀁌􀁑􀀃􀁉􀁒􀁕􀀃􀀖􀀃􀁐􀁒􀁑􀁗􀁋􀁖

A
  1. Surgical debridement and irrigation with implant removal, sinus tract biopsy, placement of a gentamicin-impregnated polymethylmethacrylate medullary rod, and postsurgical ciprofloxacin for 3 months

RECOMMENDED READINGS

McGrory JE, Pritchard DJ, Unni KK, Ilstrup D, Rowland CM. Malignant lesions arising in chronic osteomyelitis. Clin Orthop Relat Res. 1999 May;(362):181-9. PubMed PMID: 10335297.

Paley D, Herzenberg JE. Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases. J Orthop Trauma. 2002 Nov-Dec;16(10):723-9. PubMed PMID: 12439196.

Riel RU, Gladden PB. A simple method for fashioning an antibiotic cement-coated interlocking intramedullary nail. Am J Orthop (Belle Mead NJ). 2010 Jan;39(1):18-21. PubMed PMID: 20305835.

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8
Q
  1. Figures 73a through 73c are the current radiographs of a 35-year-old woman who fractured her ankle 3 years ago. Her course after surgery was complicated by a wound dehisance over her fibula plate. She had hardware removed and saucerization of her fibula at 9 months. She is now experiencing pain reproduced with dorsiflexion/plantarflexion that limits all of her daily living activities. She is unable to obtain a plantigrade foot with knee extension, has no pain with inversion/eversion, and has well-healed wounds. Laboratory studies show that her erythrocyte sedimentation rate and C-reactive protein levels are within defined limits. What is the best treatment option?
  2. Total ankle replacement
  3. Tibiotalar arthrodesis
  4. Tibiotalar and subtalar arthrodesis
  5. Tibiotalar arthrodesis with gastrocnemius recession
  6. Tibiotalar and subtalar arthrodesis with gastrocnemius recession
A
  1. Tibiotalar arthrodesis with gastrocnemius recession

RECOMMENDED READINGS

Hendrickx RP, Stufkens SA, de Bruijn EE, Sierevelt IN, van Dijk CN, Kerkhoffs GM. Medium- to longterm outcome of ankle arthrodesis. Foot Ankle Int. 2011 Oct;32(10):940-7. PubMed PMID: 22224322.

Bai LB, Lee KB, Song EK, Yoon TR, Seon JK. Total ankle arthroplasty outcome comparison for post-traumatic and primary osteoarthritis. Foot Ankle Int. 2010 Dec;31(12):1048-56. PubMed PMID: 21189204.

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9
Q

􀀷􀁋􀁈􀀃􀁉􀁕􀁄􀁆􀁗􀁘􀁕􀁈􀀃􀁖􀁋􀁒􀁚􀁑􀀃􀁌􀁑􀀃􀀩􀁌􀁊􀁘􀁕􀁈􀀃􀀛􀀕􀀃􀁌􀁖􀀃􀁖􀁆􀁋􀁈􀁇􀁘􀁏􀁈􀁇􀀃􀁗􀁒􀀃􀁅􀁈􀀃􀂿􀁛􀁈􀁇􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀀃􀁕􀁈􀁗􀁕􀁒􀁊􀁕􀁄􀁇􀁈􀀃􀁑􀁄􀁌􀁏􀀑􀀃􀀃􀀤􀁑􀀃􀁄􀁕􀁗􀁋􀁕􀁒􀁗􀁒􀁐􀁜􀀃􀁖􀁋􀁒􀁘􀁏􀁇􀀃􀁅􀁈􀀃82. The fracture shown in Figure 82 is schedulled to be fixed with a retrograde nail. An arthrotomy should be performed during the procedure because it

  1. ensures proper nail depth.
  2. provides control of the distal fragment.
  3. allows assessment for occult infection.
  4. allows protection of the polyethylene liner.
  5. allows assessment of the loosening component requiring revision.
A
  1. allows protection of the polyethylene liner.

RECOMMENDED READINGS

Ellis TJ, White RR, Lhowe DW. Periprosthetic fractures. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:569- 577.

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10
Q
  1. A 52-year-old woman sustained a closed bimalleolar ankle fracture. She was treated with open reduction and internal fixation. A syndesmotic screw was added; however, there is persistent assymetry of the ankle mortise as shown in Figures 87a and 87b. What is the most likely reason for this finding?
  2. The syndesmosis is malreduced.
  3. The lateral malleolus is malreduced.
  4. The posterior tibial tendon is entrapped in the medial joint.
  5. The deltoid ligament is interposed in the medial joint space.
  6. An osteochondral fragment is entrapped in the joint.
A
  1. The lateral malleolus is malreduced.

RECOMMENDED READINGS

WeberBG, Simpson LA: Corrective lengthening osteotomy of the fibula. Clin Orthop Relat Res 1985; 188L61-67 PubMed PMID: 4042497.

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11
Q
  1. The World Health Organization Fracture Risk Assessment Tool (FRAX) calculates which fracture risk?
  2. 5-year risk for hip fracture
  3. 5-year risk for distal radius fracture
  4. 5-year risk for any fragility fracture
  5. 10-year risk for hip fracture
  6. 10-year risk for distal radius fracture
A
  1. 10-year risk for hip fracture

RECOMMENDED READINGS

Unnanuntana A, Gladnick BP, Donnelly E, Lane JM. The assessment of fracture risk. J Bone Joint Surg Am. 2010 Mar;92(3):743-53. Review. PubMed PMID: 20194335.

Ekman EF. The role of the orthopaedic surgeon in minimizing mortality and morbidity associated with fragility fractures. J Am Acad Orthop Surg. 2010 May;18(5):278-85. Review. PubMed PMID: 20435878.

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12
Q
  1. Figure 102 is an intraoperative figure taken during fixation of ar right lateral tibial plateau fracture luxation. Which structure is indicated by the arrow?
  2. Iliotibial band
  3. Popliteus tendon
  4. Medial meniscus
  5. Lateral meniscus
  6. Lateral collateral ligament
A
  1. Lateral meniscus

RECOMMENDED READINGS

Higgins TF, Severson EP. Tibial plateau fractures. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:475- 486.

Gardner MJ, Yacoubian S, Geller D, Pode M, Mintz D, Helfet DL, Lorich DG. Prediction of soft-tissue injuries in Schatzker II tibial plateau fractures based on measurements of plain radiographs. J Trauma. 2006 Feb;60(2):319-23; discussion 324. PubMed PMID: 16508489.

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13
Q
  1. If a physician elects to shorten a femur by 4 cm for traumatic bone loss treatment and places an intramedullary nail for fixation, which deformity will be created in the lower extremity?
  2. Patella alta
  3. Medial mechanical axis deviation
  4. Lateral mechanical axis deviation
  5. Increased anatomic tibiofemoral angle
  6. Translation of the anatomical axis of the femur
A
  1. Medial mechanical axis deviation

RECOMMENDED READINGS

Paley DP. Principles of Deformity Correction. New York, NY: Springe

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14
Q
  1. The radiograph seen in Figure 117 reveals a submuscular plate palcement with locking screws for fixation. The biomechanics of the construct can be best described as
  2. Stiff and axially stable.
  3. Stiff and axially unstable.
  4. Flexible and axially stable.􀀃 􀀖􀀑􀀃􀀃􀀃􀀃􀃀􀁈􀁛􀁌􀁅􀁏􀁈􀀃􀁄􀁑􀁇􀀃􀁄􀁛􀁌􀁄􀁏􀁏􀁜􀀃􀁖􀁗􀁄􀁅􀁏􀁈􀀑
  5. Flexible and axially unstable. 􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀃀􀁈􀁛􀁌􀁅􀁏􀁈􀀃􀁄􀁑􀁇􀀃􀁄􀁛􀁌􀁄􀁏􀁏􀁜􀀃􀁘􀁑􀁖􀁗􀁄􀁅􀁏􀁈􀀑
  6. Flexible and rotationally unstable. 􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀃀􀁈􀁛􀁌􀁅􀁏􀁈􀀃􀁄􀁑􀁇􀀃􀁕􀁒􀁗􀁄􀁗􀁌􀁒􀁑􀁄􀁏􀁏􀁜􀀃􀁘􀁑􀁖􀁗􀁄􀁅􀁏􀁈􀀑
A
  1. Flexible and axially stable.􀀃 􀀖􀀑􀀃􀀃􀀃􀀃􀃀􀁈􀁛􀁌􀁅􀁏􀁈􀀃􀁄􀁑􀁇􀀃􀁄􀁛􀁌􀁄􀁏􀁏􀁜􀀃􀁖􀁗􀁄􀁅􀁏􀁈􀀑

RECOMMENDED READINGS

Graves M, Nork SE. Fractures of the humerus. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:201-224.

Livani B, Belangero WD. Bridging plate osteosynthesis of humeral shaft fractures. Injury. 2004 Jun;35(6):587-95. PubMed PMID: 15135278.

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15
Q
  1. A 22-year-old man was an unrestrained driver who was ejected from his car during a rollover motor vehicle crash. He sustained a closed head injury, multiple closed right rib fractures with an ipsilateral pneumothorax, and an open midshaft right tibia fracture. The tibia wound measures approximately 3 mm in length and is free of gross contamination. What is the most important factor shown to minimize risk for infection at the site of an open tibia fracture?
  2. Transfer to a Level I trauma center within 3 hours
  3. Intravenous antibiotic administration within 3 hours
  4. Irrigation and debridement of the open fracture wound within 6 hours
  5. Open reduction with plate-and-screw fixation at the index tip within 6 horus􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀀲􀁓􀁈􀁑􀀃􀁕􀁈􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁚􀁌􀁗􀁋􀀃􀁓􀁏􀁄􀁗􀁈􀀐􀁄􀁑􀁇􀀐􀁖􀁆􀁕􀁈􀁚􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀃􀁄􀁗􀀃􀁗􀁋􀁈􀀃􀁌􀁑􀁇􀁈􀁛􀀃􀁗􀁌􀁓􀀃􀁚􀁌􀁗􀁋􀁌􀁑􀀃􀀙􀀃􀁋􀁒􀁘􀁕􀁖
  6. Tibia wound irrigation within 3 hours with a solution containing bacitracin
A
  1. Intravenous antibiotic administration within 3 hours

RECOMMENDED READINGS

Pollak AN, Jones AL, Castillo RC, Bosse MJ, MacKenzie EJ; LEAP Study Group. The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma. J Bone Joint Surg Am. 2010 Jan;92(1):7-15. PubMed PMID: 20048090.

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16
Q
  1. A 68-year-old woman fell and sustained a displaced femoral neck fracture. She is a community ambulator and enjoys playing tennis weekly. Which treatment will provide her with the best hip function?
  2. Hip resurfacing
  3. Hemiarthroplasty
  4. Total hip arthroplasty
  5. Internal fixation with cannulated screws􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀀬􀁑􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀃􀁚􀁌􀁗􀁋􀀃􀁆􀁄􀁑􀁑􀁘􀁏􀁄􀁗􀁈􀁇􀀃􀁖􀁆􀁕􀁈􀁚􀁖
  6. Internal fixation with a sliding hip screw and antirotation screws􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀀬􀁑􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀀃􀁖􀁏􀁌􀁇􀁌􀁑􀁊􀀃􀁋􀁌􀁓􀀃􀁖􀁆􀁕􀁈􀁚􀀃􀁄􀁑􀁇􀀃􀁄􀁑􀀃􀁄􀁑􀁗􀁌􀁕􀁒􀁗􀁄􀁗􀁌􀁒􀁑􀀃􀁖􀁆􀁕􀁈􀁚
A
  1. Total hip arthroplasty

RECOMMENDED READINGS

Avery PP, Baker RP, Walton MJ, Rooker JC, Squires B, Gargan MF, Bannister GC. Total hip replacement and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck: a seven- to ten-year follow-up report of a prospective randomised controlled trial. J Bone Joint Surg Br. 2011 Aug;93(8):1045-8. PubMed PMID: 21768626.

Hedbeck CJ, Enocson A, Lapidus G, Blomfeldt R, Törnkvist H, Ponzer S, Tidermark J. Comparison of bipolar hemiarthroplasty with total hip arthroplasty for displaced femoral neck fractures: a concise fouryear follow-up of a randomized trial. J Bone Joint Surg Am. 2011 Mar 2;93(5):445-50. PubMed PMID: 21368076.

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17
Q
  1. A 23-year-old-man was tackled while playing football. He felt a “pop” in his knee and noted significant deformity. Examination reveals a closed posterior knee dislocation that is irreducible despite adequate sedation. He is unable to dorsiflex his toes or ankle. His ankle-brachial index is 0.6. What is the next most appropriate treatment step?
  2. Surgical intervention
  3. Splint and monitor peripheral pulse oximetry
  4. Magnetic resonance angiography
  5. Computed tomography angiography
  6. Standard angiography
A
  1. Surgical intervention

RECOMMENDED READINGS

Rihn JA, Groff YJ, Harner CD, Cha PS. The acutely dislocated knee: evaluation and management. J Am Acad Orthop Surg. 2004 Sep-Oct;12(5):334-46. Review. PubMed PMID: 15469228.

Patterson BM, Agel J, Swiontkowski MF, Mackenzie EJ, Bosse MJ; LEAP Study Group. Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma. 2007 Oct;63(4):855-8. PubMed PMID: 18090017.

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18
Q
  1. A 24-year-old man sustained a medial tibial plateau fracture (Schatzker type IV) after being involved in a motor vehicle-pedestrian collision. What is the best next step?
  2. An MRI scan
  3. Ankle brachial index
  4. Immediate open reduction and internal fixation􀀃 􀀖􀀑􀀃􀀃􀀃􀀃􀀬􀁐􀁐􀁈􀁇􀁌􀁄􀁗􀁈􀀃􀁒􀁓􀁈􀁑􀀃􀁕􀁈􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁌􀁑􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑
  5. Closed reduction and percutaneous screw fixation􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀀦􀁏􀁒􀁖􀁈􀁇􀀃􀁕􀁈􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁓􀁈􀁕􀁆􀁘􀁗􀁄􀁑􀁈􀁒􀁘􀁖􀀃􀁖􀁆􀁕􀁈􀁚􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑
  6. Definitive treatment with a hybrid external fixator􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀀧􀁈􀂿􀁑􀁌􀁗􀁌􀁙􀁈􀀃􀁗􀁕􀁈􀁄􀁗􀁐􀁈􀁑􀁗􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀀃􀁋􀁜􀁅􀁕􀁌􀁇􀀃􀁈􀁛􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁒􀁕
A
  1. Ankle brachial index

RECOMMENDED READINGS

Berkson EM, Virkus WW. High-energy tibial plateau fractures. J Am Acad Orthop Surg. 2006 Jan;14(1):20-31. Review. PubMed PMID: 16394164.

Gardner MJ, Yacoubian S, Geller D, Suk M, Mintz D, Potter H, Helfet DL, Lorich DG. The incidence of soft tissue injury in operative tibial plateau fractures: a magnetic resonance imaging analysis of 103 patients. J Orthop Trauma. 2005 Feb;19(2):79-84. PubMed PMID: 15677922.

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19
Q
  1. A 45-year-old woman sustained a fall from height and has the injury shown in Figures 135a and 135b. A 3-dimensional reconstruction CT scan is shown in Figure 135c. Joint-spanning external fixation is applied on the day of injury. Ten days later, her skin is acceptable for definitive fixation. What is the most approapriate type of fixation for her fracture?
  2. Percutaneous screws and cast
  3. Conversion to a circular fixator􀀃 􀀕􀀑􀀃􀀃􀀃􀀃􀀦􀁒􀁑􀁙􀁈􀁕􀁖􀁌􀁒􀁑􀀃􀁗􀁒􀀃􀁄􀀃􀁆􀁌􀁕􀁆􀁘􀁏􀁄􀁕􀀃􀂿􀁛􀁄􀁗􀁒􀁕
  4. Medial and anterolateral locked plates
  5. Medial and anterolateral nonlocked plates
  6. Lateral locked plate and medial malleolus screws
A
  1. Medial and anterolateral nonlocked plates

RECOMMENDED READINGS

Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 2004 Sep;18(8 Suppl):S32-8. PubMed PMID: 15472563.

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20
Q
  1. The fracture seen in Figure 137 was most likely caused by what type of mechanism?
  2. Direct impact to the fibula􀀃 􀀔􀀑􀀃􀀃􀀃􀀃􀀧􀁌􀁕􀁈􀁆􀁗􀀃􀁌􀁐􀁓􀁄􀁆􀁗􀀃􀁗􀁒􀀃􀁗􀁋􀁈􀀃􀂿􀁅􀁘􀁏􀁄
  3. Abduction of the foot relative to the tibia
  4. Adduction of the foot relative to the tibia
  5. Internal rotation of the foot relative to the tibia
  6. External rotation of the foot relative to the tibia
A
  1. Abduction of the foot relative to the tibia

RECOMMENDED READINGS

Barei DP Crist BD. Fractures of the ankle and distal tibial pilon. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:499-518.

Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimentalroentgenologic investigations. Arch Surg. 1950 May;60(5):957-85. PubMed PMID: 15411319.

21
Q
  1. The best way to avoid sentinel event errors is through better
  2. training.
  3. staffing ratios􀀃 􀀕􀀑􀀃􀀃􀀃􀀃􀁖􀁗􀁄􀁉􀂿􀁑􀁊􀀃􀁕􀁄􀁗􀁌􀁒􀁖􀀑
  4. communication.
  5. patient assessment.
  6. availability of information.
A
  1. communication.
22
Q
  1. A 22-year-old man wants a second opinion 3 weeks after intramedullary nailing of a comminuted diaphyseal femoral shaft fracture. Examination reveals his injured leg has 26 degrees’ more external rotation than the contralateral limb and is 3 cm shorter based on a block measurement. He should be advised to
  2. let the fracture unite as it is because there is sufficienct hip rotation to accomodate the external rotation deformity, and a small soe lift can accomodate for the limb length discrepancy
  3. let the fracure unite, and if he later finds it bothersome, consider a corrective osteotomy of the injured femur for correction of deformity
  4. let the fracture unite because there is sufficient hip rotation to accomodate the external rotation deformity; if he later finds the leg length discrepancy bothersome, hr should consider contralateral clsed femoral shortening
  5. consider revision surgery to correct the rotational deformity but not alter length because this

may impair fracture union if performed at this time.

  1. consider revision surgery to correct both the rotational deformity and leg length discrepancy.
A
  1. consider revision surgery to correct both the rotational deformity and leg length discrepancy.

RECOMMENDED READINGS

Jaarsma RL, Pakvis DF, Verdonschot N, Biert J, van Kampen A. Rotational malalignment after intramedullary nailing of femoral fractures. J Orthop Trauma. 2004 Aug;18(7):403-9. PubMed PMID: 15289684.

23
Q
  1. On an anteroposteriorly directed fluroscopic radiograph, the appropriate entry point for an intramedullary tibia nail being used for fixation of a proximal third diaphyseal tibial fracture is ideally positioned
  2. centered between the medial and lateral tibial eminences.
  3. in line with the lateral border of the lateral tibial eminence.
  4. in line with the medial border of the lateral tibial eminence.
  5. in line with the lateral border of the medial tibial eminence.
  6. in line with the medial border of the medial tibial eminence.
A
  1. in line with the medial border of the lateral tibial eminence.

RECOMMENDED READINGS

McConnell T, Tornetta P III, Tilzey J, Casey D. Tibial portal placement: the radiographic correlate of the anatomic safe zone. J Orthop Trauma. 2001Mar-Apr;15(3):207-9. PubMed PMID: 11265012.

Song SJ, Jeong BO. Three-dimensional analysis of the intramedullary canal axis of tibia: clinical relevance to tibia intramedullary nailing. Arch Orthop Trauma Surg. 2010 Jul;130(7):903-7. Epub 2009 Nov 3. PubMed PMID: 19885665.

24
Q
  1. Figures 156a and 156b are the radiographs of a 38-year-old man with diabetes mellitus who fell 8 feet from a ladder and sustained an isolated closed injury of his leg. Examination revealed swollen but soft compartments. His neurovascular examination was unremarkable. A damage-control fixator was initially applied, and his soft-tissue envelope is now amenable to further intervention. What is the most appropriate treatment?
  2. Conversion to a peri-articular hybrid frame
  3. Open reduction and internatal fixatin with a lateral locking plate
  4. Open reduction and internal fixation with a lateral nonlocking plate
  5. Open reduction and internal fixation with medial and lateral plates
  6. Open reduction and internal fixation with posteriomedial and lateral plates
A
  1. Open reduction and internal fixation with posteriomedial and lateral plates

RECOMMENDED READINGS

Barei DP, O’Mara TJ, Taitsman LA, Dunbar RP, Nork SE. Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop Trauma. 2008 Mar;22(3):176-82. PubMed PMID: 18317051.

Barei DP, Nork SE, Mills WJ, Coles CP, Henley MB, Benirschke SK. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am. 2006 Aug;88(8):1713-21. PubMed PMID: 16882892.

25
Q

160.

Figure 160 is the intrasurgical photo of a 35-year-old woman with an open tibial fracture. Examination reveals no Doppler signal of hte peroneal arthery or anterior tibial artery. However, flow in her posterior tibial artery is detected by Doppler. According to the Gustillo-Anderson classification system, the fracture should be classified as

  1. type I.
  2. type II.
  3. type IIIA.
  4. type IIIB.
  5. type IIIC.
A
  1. type IIIB.
26
Q
  1. To minimize complications and to maximize the likelihood of successful outcomes after percutaneousfixation of displaced extension-type supracondylar humeral fractures in children, the physician should
  2. use a divergent wire technique with wires placed medially.
  3. use a divergent wire technique with wires placed laterally.
  4. use a crossed-wire technique with wires placed laterally and medially.
  5. apply a postsurgical circumferential cast with the elbow fully extended to prevent postsurgical displacement.
  6. apply a postsurgical circumfrential cast with the elbow flexed past 90 degrees to prevent postsurgical displacement
A
  1. use a divergent wire technique with wires placed laterally.

RECOMMENDED READINGS

Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop. 2010 Jul-Aug;30(5):430-6. Review. PubMed PMID: 20574258.

Woratanarat P, Angsanuntsukh C, Rattanasiri S, Attia J, Woratanarat T, Thakkinstian A. Meta-analysis of pinning in supracondylar fracture of the humerus in children. J Orthop Trauma. 2012 Jan;26(1):48-53. PubMed PMID: 21909033.

Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am. 2008 May;90(5):1121-32. Review. PubMed PMID: 18451407.

McKeon KE, O’Donnell JC, Bashyal R, Hou CC, Luhmann SJ, Dobbs MB, Gordon JE. Immobilization after pinning of supracondylar distal humerus fractures in children: use of the A-frame cast. J Pediatr Orthop. 2012 Jan-Feb;32(1):e1-5. PubMed PMID: 22173398.

27
Q
  1. A 24-year-old football player sustained an injury to his left foot when another player fell directly on his heel. He is unabl to bear weight, but radiograph findings were negative. He is exquistely tender at the midfoot. What is the best next diagnostic study?
  2. A CT scan
  3. A bone scan
  4. Weight-bearing views
  5. Contralateral foot radiographs
  6. Repeat radiograph in 2 weeks
A
  1. Weight-bearing views

RECOMMENDED READINGS

􀀱􀁘􀁑􀁏􀁈􀁜􀀃􀀭􀀤􀀏􀀃􀀹􀁈􀁕􀁗􀁘􀁏􀁏􀁒􀀃􀀦􀀭􀀑􀀃􀀦􀁏􀁄􀁖􀁖􀁌􀂿􀁆􀁄􀁗􀁌􀁒􀁑􀀏􀀃􀁌􀁑􀁙􀁈􀁖􀁗􀁌􀁊􀁄􀁗􀁌􀁒􀁑􀀏􀀃􀁄􀁑􀁇􀀃􀁐􀁄􀁑􀁄􀁊􀁈􀁐􀁈􀁑􀁗􀀃􀁒􀁉􀀃􀁐􀁌􀁇􀁉􀁒􀁒􀁗􀀃􀁖􀁓􀁕􀁄􀁌􀁑􀁖􀀝􀀃􀀯􀁌􀁖􀁉􀁕􀁄􀁑􀁆􀀃Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop Surg. 2010 Dec;18(12):718-28. Review. PubMed PMID: 21119138.

28
Q
  1. What is the most common nerve injury seen in Figures 172a and 172b?
  2. Ulnar
  3. Radial
  4. Median
  5. Anterior interosseous
  6. Lateral antebrachial cutaneous
A
  1. Anterior interosseous

RECOMMENDED READINGS

Abzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg. 2012 Feb;20(2):69-77. Review. PubMed PMID: 22302444.

Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010 Apr-May;30(3):253-63. PubMed PMID: 20357592.

29
Q
  1. The risk for developing complex regional pain syndrome after surgery to the foot and ankle or the wrist can be decreased through the use of
  2. capsaicin.
  3. vitamin C.
  4. vitamin D and calcium.
  5. dexamethasone block.
  6. multimodal pain therapy.
A
  1. vitamin C.

RECOMMENDED READINGS

Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am. 2007 Jul;89(7):1424-31. PubMed PMID: 17606778.

Besse JL, Gadeyne S, Galand-Desmé S, Lerat JL, Moyen B. Effect of vitamin C on prevention of complex regional pain syndrome type I in foot and ankle surgery. Foot Ankle Surg. 2009;15(4):179-82. Epub 2009 Apr 5. PubMed PMID: 19840748.

30
Q
  1. What is the most common complication seen after patellar fracture open reduction and internal fixation?
  2. Loss of reduction
  3. Knee extensor lag
  4. Symptomatic implants
  5. Flexion contracture exceeding 5 degrees
  6. Extension contracture exceeding 15 degrees
A
  1. Symptomatic implants

RECOMMENDED READINGS

Lebrun CT, Langford JR, Sagi HC. Functional outcomes after operatively treated patella fractures. J Orthop Trauma. 2012 Jul;26(7):422-6. PubMed PMID: 22183197. Melvin JS, Mehta S. Patellar fractures in adults. J Am Acad Orthop Surg. 2011 Apr;19(4):198-207. Review. PubMed PMID: 21464213.

31
Q
  1. An athletic 30-year-old sustained multiple injuries in a high-speed motor vehicle collision that resulted in a loss of approximately 30% of blood volume. On arrival to the emergency department, the heart rate is 100 and blood pressure is 104/62. The best means with which to evaluate true hemodynamic status is
  2. hematocrit.
  3. serial heart rate.
  4. serial blood pressure with a manual cuff.
  5. serial blood pressure with an arterial line.
  6. lactate and base deficit levels􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀁏􀁄􀁆􀁗􀁄􀁗􀁈􀀃􀁄􀁑􀁇􀀃􀁅􀁄􀁖􀁈􀀃􀁇􀁈􀂿􀁆􀁌􀁗􀀃􀁏􀁈􀁙􀁈􀁏􀁖􀀑
A
  1. lactate and base deficit levels􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀁏􀁄􀁆􀁗􀁄􀁗􀁈􀀃􀁄􀁑􀁇􀀃􀁅􀁄􀁖􀁈􀀃􀁇􀁈􀂿􀁆􀁌􀁗􀀃􀁏􀁈􀁙􀁈􀁏􀁖􀀑

RECOMMENDED READINGS

Hak DJ, Stahel PF, Giannoudis P. Pathophysiology of the polytrauma patient. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:117–131.

Rossaint R, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Gordini G, Stahel PF, Hunt BJ, Neugebauer E, Spahn DR. Key issues in advanced bleeding care in trauma. Shock. 2006 Oct;26(4):322- 31. Review. PubMed PMID: 16980877.

32
Q
  1. Which virtual hinge shown in Figure 196 will gain the most length with the least amount of translation and angulation at the end of deformity correction?
  2. A
  3. B
  4. C
  5. D
  6. E
A
  1. B

RECOMMENDED READINGS

Paley DP, ed. Principles of Deformity Correction. New York, NY: Springer-Verlag; 2002:99-154. Feldman DS, Shin SS, Madan S, Koval KJ. Correction of tibial malunion and nonunion with six-axis analysis deformity correction using the Taylor Spatial Frame. J Orthop Trauma. 2003 Sep;17(8):549-54. PubMed PMID: 14504575.

33
Q
  1. Figures 200a and 200b are the radiographs of an 82-year-old woman who fell on a flexed knee. She has no other injuries and was able to ambulate without assistance before her fall. The recommended treatment to optimize her quality of life consists of
  2. external fixation.􀀃 􀀔􀀑􀀃􀀃􀀃􀀃􀁈􀁛􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀑
  3. revision arthroplasty.
  4. open reduction and internal fixation.􀀃 􀀖􀀑􀀃􀀃􀀃􀀃􀁒􀁓􀁈􀁑􀀃􀁕􀁈􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁌􀁑􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀑
  5. closed reduction and casting.
  6. closed reduction and fracture bracing.
A
  1. open reduction and internal fixation.􀀃 􀀖􀀑􀀃􀀃􀀃􀀃􀁒􀁓􀁈􀁑􀀃􀁕􀁈􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁌􀁑􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀑

RECOMMENDED READINGS

Streubel PN, Gardner MJ, Morshed S, Collinge CA, Gallagher B, Ricci WM. Are extreme distal periprosthetic supracondylar fractures of the femur too distal to fix using a lateral locked plate? J Bone Joint Surg Br. 2010 Apr;92(4):527-34. PubMed PMID: 20357329.

34
Q
  1. Figure 201a is the radiograph of a patient with an open femur fracture who had debridement and nailing with antibiotic beads as shown in Figure 201b. The patient notices leg deformity while lying in bed. Subsequent CT scan s are shown in figures 201c and 201d. In addition to being fixed short, what other malalignment, if any, is seen?
  2. Fixed with approximately 24 degrees’ internal rotation deformity
  3. Fixed with approximately 24 degrees’ external rotation deformity
  4. Fixed with approximately 31 degrees’ internal rotation deformity
  5. Fixed with approximately 31 degrees’ external rotation deformity
  6. No malalignment; deformity is attributatble to postsurgical pain and reflex relaxation.􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀀱􀁒􀀃􀁐􀁄􀁏􀁄􀁏􀁌􀁊􀁑􀁐􀁈􀁑􀁗􀀞􀀃􀁇􀁈􀁉􀁒􀁕􀁐􀁌􀁗􀁜􀀃􀁌􀁖􀀃􀁄􀁗􀁗􀁕􀁌􀁅􀁘􀁗􀁄􀁅􀁏􀁈􀀃􀁗􀁒􀀃􀁓􀁒􀁖􀁗􀁖􀁘􀁕􀁊􀁌􀁆􀁄􀁏􀀃􀁓􀁄􀁌􀁑􀀃􀁄􀁑􀁇􀀃􀁕􀁈􀃀􀁈􀁛􀀃􀁕􀁈􀁏􀁄􀁛􀁄􀁗􀁌􀁒􀁑
A
  1. Fixed with approximately 24 degrees’ internal rotation deformity

RECOMMENDED READINGS

Ricci WM, Gruen GS, Summers H, Siska PA. Fractures of the femoral diaphysis. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:431-444.

Jaarsma RL, van Kampen A. Rotational malalignment after fractures of the femur. J Bone Joint Surg Br. 2004 Nov;86(8):1100-4. Review. PubMed PMID: 15568519

35
Q
  1. A 23-year-old man had a laparotomy and splenectomy with packing of the abdomen after a motorcycle collision. Laboratory studies show a hemoglobin level of 7.1 g/dL (reference range [rr], 14.0-17.5 g/ dL) and a lactate level of 8.0 mmol/L (rr, 0.6-1.7 mmol/L). He also has a left humeral fracture, an anteroposterior compression I pelvic fracture, bilateral distal third femur fractures, and an open Gustilotype IIIA tibial diaphysis fracture with moderate contamination. What is the most appropriate treatment to administer before leaving the operating room?
  2. Saline lavage and splinting of the tibia and knee immobilizers of both femurs
  3. Betadine dressing and splinting of the tibia with unlocked retrograde nailing of both femurs
  4. Betadine dressing and external fixation of the tibia and knee immobilizers of both femurs
  5. Irrigation and debridement and external fixation of the tibia and external fixation of both femurs
  6. Irrigation and debridement and external fixation of the tibia and unlocked retrograde nailing of both femurs
A
  1. Irrigation and debridement and external fixation of the tibia and external fixation of both femurs

RECOMMENDED READINGS

Hak DJ, Stahel PF, Giannoudis P. Pathophysiology of the polytrauma patients. In. Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:117-131.

Ricci WM, Gruen GS, Summers H, Siska PA. Fractures of the femoral diaphysis. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:431-444.

36
Q
  1. Which nerve identified by the arrow seen in Figure 207 is encountered during fixation of a tibial pilon fracture?
  2. Sural
  3. Saphenous
  4. Lateral cutaneous
  5. Deep peroneal
  6. Superficial peroneal􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀀶􀁘􀁓􀁈􀁕􀂿􀁆􀁌􀁄􀁏􀀃􀁓􀁈􀁕􀁒􀁑􀁈􀁄􀁏
A
  1. Superficial peroneal􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀀶􀁘􀁓􀁈􀁕􀂿􀁆􀁌􀁄􀁏􀀃􀁓􀁈􀁕􀁒􀁑􀁈􀁄􀁏

RECOMMENDED READINGS

Mehta S, Gardner MJ, Barei DP, Benirschke SK, Nork SE. Reduction strategies through the anterolateral expsure for fixation of type B and C pilon fractures. J Orthop Trauma. 2011Feb;25(2):116-22. PubMed PMID: 21245716.

Crist BD, Khazzam M, Murtha YM, Della Rocca GJ. Pilon fractures: advances in surgical management. J

Am Acad Orthop Surg. 2011 Oct;19(10):612-22. Review. PubMed PMID: 21980026.

37
Q
  1. What is the mechanism of action of tranexamic acid in controlling traumatic hemorrhage?
  2. Inhibition of vitamin K reductase
  3. Inhibition of topoisomerase II and IV
  4. Antithrombin-III selective inhibition of Factor Xa
  5. Competitive inhibition of plasminogen activation
  6. Stimulation of integrin-mediated platelet adhesion and activation
A
  1. Competitive inhibition of plasminogen activation

RECOMMENDED READINGS

Godier A, Roberts I, Hunt BJ. Tranexamic acid: less bleeding and less thrombosis? Crit Care. 2012 Jun 29;16(3):135. [Epub ahead of print] PubMed PMID: 22748073.

Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012 Feb;147(2):113-9. Epub 2011 Oct 17. PubMed PMID: 22006852.

38
Q
  1. Figures 211a and 211b are the radiographs of a 41-year-old construction worker who sustained a twisting injury to his right leg. Which injury in the ipsilateral extremity is most commonly associated with this type of fracture?
  2. Lisfranc injury
  3. Anterior cruciate ligament injury
  4. Proximal talofibular joint dislocation􀀃 􀀖􀀑􀀃􀀃􀀃􀀃􀀳􀁕􀁒􀁛􀁌􀁐􀁄􀁏􀀃􀁗􀁌􀁅􀁌􀁒􀂿􀁅􀁘􀁏􀁄􀁕􀀃􀁍􀁒􀁌􀁑􀁗􀀃􀁇􀁌􀁖􀁏􀁒􀁆􀁄􀁗􀁌􀁒􀁑
  5. Tibial plateau fracture
  6. Posterior malleolus fracture
A
  1. Posterior malleolus fracture

RECOMMENDED READINGS

Boraiah S, Gardner MJ, Helfet DL, Lorich DG. High association of posterior malleolus fractures with spiral distal tibial fractures. Clin Orthop Relat Res. 2008 Jul;466(7):1692-8. Epub 2008 Mar 18. PubMed PMID: 18347885.

Stuermer EK, Stuermer KM. Tibial shaft fracture and ankle joint injury. J Orthop Trauma. 2008 Feb;22(2):107-12. PubMed PMID: 18349778.

39
Q
  1. A 25-year-old man sustained a closed right knee dislocation in a motor vehicle collision. His pedal pulses are symmetrical in the emergency department, both before and after reduction of the dislocation. Angiography can be avoided if
  2. his ipsilateral ankle-brachial index is 0.78.
  3. he had an absent ipsilateral pedal pulse in the field before arriving at the hospital􀀃 􀀕􀀑􀀃􀀃􀀃􀀃􀁋􀁈􀀃􀁋􀁄􀁇􀀃􀁄􀁑􀀃􀁄􀁅􀁖􀁈􀁑􀁗􀀃􀁌􀁓􀁖􀁌􀁏􀁄􀁗􀁈􀁕􀁄􀁏􀀃􀁓􀁈􀁇􀁄􀁏􀀃􀁓􀁘􀁏􀁖􀁈􀀃􀁌􀁑􀀃􀁗􀁋􀁈􀀃􀂿􀁈􀁏􀁇􀀃􀁅􀁈􀁉􀁒􀁕􀁈􀀃􀁄􀁕􀁕􀁌􀁙􀁌􀁑􀁊􀀃􀁄􀁗􀀃􀁗􀁋􀁈􀀃􀁋􀁒􀁖􀁓􀁌􀁗􀁄􀁏􀀑
  4. he has a slightly cool right foot that becomes warm again over the course of 3 hours.
  5. he has normal color and warmth of the right foot with normal pedal pulses for 48 hours.
  6. he has a large hematoma that has increased in size during the first three hours after admission􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀁋􀁈􀀃􀁋􀁄􀁖􀀃􀁄􀀃􀁏􀁄􀁕􀁊􀁈􀀃􀁋􀁈􀁐􀁄􀁗􀁒􀁐􀁄􀀃􀁗􀁋􀁄􀁗􀀃􀁋􀁄􀁖􀀃􀁌􀁑􀁆􀁕􀁈􀁄􀁖􀁈􀁇􀀃􀁌􀁑􀀃􀁖􀁌􀁝􀁈􀀃􀁇􀁘􀁕􀁌􀁑􀁊􀀃􀁗􀁋􀁈􀀃􀂿􀁕􀁖􀁗􀀃􀀖􀀃􀁋􀁒􀁘􀁕􀁖􀀃􀁄􀁉􀁗􀁈􀁕􀀃􀁄􀁇􀁐􀁌􀁖􀁖􀁌􀁒􀁑􀀑
A
  1. he has normal color and warmth of the right foot with normal pedal pulses for 48 hours

RECOMMENDED READINGS

Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G Jr, Robinson JT, Volgas DA. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. 2004 May;86-A(5):910-5. PubMed PMID: 15118031.

Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004 Jun;56(6):1261-5. PubMed PMID: 15211135.

Nicandri GT, Chamberlain AM, Wahl CJ. Practical management of knee dislocations: a selective angiography protocol to detect limb-threatening vascular injuries. Clin J Sport Med. 2009 Mar;19(2):125- 9. Review. PubMed PMID: 19451767.

40
Q
  1. A 24-year-old man had multisystem injuries, including an open left femoral shaft fracture he sustained after a motorcycle collision. He received 3 liters of crystalloid and 2 units of packed red blood cells. Urgent debridement and irrigation of his open left femur fracture is planned. Which finding would support proceeding with definitive fixation of the fracture at the time of debridement?
  2. Lactate level of 2.2 mg/dL
  3. Platelet count of 70,000
  4. Urine output of 20 cc/hour
  5. Systolic blood pressure of 90
  6. Body temperature of 34.5°C
A
  1. Platelet count of 70,000

RECOMMENDED READINGS

􀀳􀁄􀁓􀁈􀀃􀀫􀀦􀀏􀀃􀀷􀁒􀁕􀁑􀁈􀁗􀁗􀁄􀀃􀀳􀀃􀀖􀁕􀁇􀀏􀀃􀀷􀁄􀁕􀁎􀁌􀁑􀀃􀀬􀀏􀀃􀀷􀁝􀁌􀁒􀁘􀁓􀁌􀁖􀀃􀀦􀀏􀀃􀀶􀁄􀁅􀁈􀁖􀁒􀁑􀀃􀀹􀀏􀀃􀀲􀁏􀁖􀁒􀁑􀀃􀀶􀀤􀀑􀀃􀀷􀁌􀁐􀁌􀁑􀁊􀀃􀁒􀁉􀀃􀁉􀁕􀁄􀁆􀁗􀁘􀁕􀁈􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀃􀁌􀁑􀀃Pape HC, Tornetta P 3rd, Tarin I, Tzioupis C, Sabeson V, Olson SA. Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg September 2009; 17:541-549. PubMed PMID: 19726738.

41
Q
  1. The World Health Organization Safe Surgery Guidelines Checklist requires that when prophylactic antibiotics are indicated, they should be administered
  2. within 30 minutes prior to incision.
  3. within 60 minutes prior to incision.
  4. within 30 minutes prior to or after incision.
  5. within 60 minutes prior to or after incision.

􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀁒􀁑􀁏􀁜􀀃􀁌􀁑􀀃􀁗􀁋􀁈􀀃􀁒􀁓􀁈􀁕􀁄􀁗􀁌􀁑􀁊􀀃􀁕􀁒􀁒􀁐􀀃􀁒􀁑􀁆􀁈􀀃􀁗􀁋􀁈􀀃􀁓􀁄􀁗􀁌􀁈􀁑􀁗􀂶􀁖􀀃􀁄􀁏􀁏􀁈􀁕􀁊􀁌􀁈􀁖􀀏􀀃􀁌􀁉􀀃􀁄􀁑􀁜􀀏􀀃􀁋􀁄􀁙􀁈􀀃􀁅􀁈􀁈􀁑􀀃􀁆􀁒􀁑􀂿􀁕􀁐􀁈􀁇􀀃􀁅􀁜􀀃􀁗􀁋􀁈􀀃

anesthesiologist and circulating nurse.

A
  1. within 60 minutes prior to incision.

RECOMMENDED READINGS

Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-9. Epub 2009 Jan 14. PubMed PMID: 19144931.

World Alliance for Patient Safety. WHO guidelines for safe surgery. Geneva, Switzerland: World Health Organization; 2008.

42
Q
  1. A 55-year-old man sustained a right acetabular fracture after a fall from a ladder. Anteroposterior and Judet radiographs of the pelvis are shown in Figures 226a through 226c, and an axial CT scan of the pelvis is shown in figure 226d. The acetabular fracture is best classified as
  2. associated T type.
  3. associated both column.
  4. associated transverse and posterior wall.
  5. associated posterior column and posterior wall.
  6. associated anterior and posterior hemitransverse.
A
  1. associated transverse and posterior wall.

RECOMMENDED READINGS

Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996 Nov;78(11):1632-45. PubMed PMID: 8934477.

Borrelli J Jr, Peelle M, McFarland E, Evanoff B, Ricci WM. Computer-reconstructed radiographs are as good as plain radiographs for assessment of acetabular fractures. Am J Orthop (Belle Mead NJ). 2008 Sep;37(9):455-9; discussion 460. PubMed PMID: 18982180.

43
Q
  1. A 78-year-old woman sustained a periprosthetic supercondylar femoral fracture. What is the advantage of

submuscular plating compared with an extensile lateral approach?

  1. Decreased rate of infection
  2. Decreased risk for nonunion
  3. Decreased risk for iatrogenic fracture
  4. Improved functional outcome
  5. Increased longevity of the component
A
  1. Decreased risk for nonunion

RECOMMENDED READINGS

Hou Z, Bowen TR, Irgit K, Strohecker K, Matzko ME, Widmaier J, Smith WR. Locked plating of periprosthetic femur fractures above total knee arthroplasty. J Orthop Trauma. 2012 Jul;26(7):427-32. PubMed PMID: 22357080.

Hoffmann MF, Jones CB, Sietsema DL, Koenig SJ, Tornetta P 3rd. Outcome of periprosthetic distal femoral fractures following knee arthroplasty. Injury. 2012 Jul;43(7):1084-9. Epub 2012 Feb 18. PubMed PMID: 22348954.

44
Q
  1. Figure 235 is the radiograph of a 75-year-old woman who is seen in the emergency department following a low-energy fall. What is the most appropriate treatment based on her radiographic findings?
  2. Perform a biopsy of the lesion
  3. Stabilize with an intramedullar nail
  4. Initiate immediate bisphosphonate therapy
  5. Treat with chemotherapy followed by wide resection
  6. Obtain a chest CT scan, urine protein electrophoresis, and serum protein electrophoresis
A
  1. Stabilize with an intramedullar nail

RECOMMENDED READINGS

Weil YA, Rivkin G, Safran O, Liebergall M, Foldes AJ. The outcome of surgically treated femur fractures associated with long-term bisphosphonate use. J Trauma. 2011 Jul;71(1):186-90. PubMed PMID: 21610533.

45
Q
  1. Figures 238a and 238b are the radiographs of a 60-year-old woman who fell and sustained a right midshaft humeral fracture 1 year ago. She was treated in a functional brace for 6 months and has used an electrical bone stimulator for the past 6 months. She has arm pain and limited use of her left shoulder and elbow. What is the best treatment option?
  2. A reamed intramedullary nail
  3. A change to an ultrasound bone stimulator
  4. Continued nonsurgical treatment with both functional bracing and electrical bone stimulator
  5. Systemic administration of 1-34 teriparatide
  6. Compression plating with or without bone graft
A
  1. Compression plating with or without bone graft

RECOMMENDED READINGS

Abboud JA, Boardman ND III. Shoulder trauma: bone. In: Flynn JM, ed. Orthopaedic Knowledge Update 10. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:271-284.

Ring D, Chin K, Taghinia AH, Jupiter JB. Nonunion after functional brace treatment of diaphyseal humerus fractures. J Trauma. 2007 May;62(5):1157-8. PubMed PMID: 17495717.

46
Q
  1. A 75-year-old woman fell at home and sustained the injury seen in Figures 249a through 249c. What is the most appropriate treatment option?
  2. Stand pivot transfer only
  3. Bed rest with bathroom privileges
  4. Partial weight bearing on the right
  5. Weight bearing only after surgical intervention
  6. Bilateral weight bearing as tolerated
A
  1. Bilateral weight bearing as tolerated

RECOMMENDED READINGS

Sagi HC, Liporace FA. Fractures of the pelvis and acetabulum. In: Flynn JM, ed. Orthopaedic Knowledge Update 10. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:379-397.

Sembler Soles GL, Lien J, Tornetta P III. Nonoperative immediate weightbearing of minimally displaced lateral compression sacral fractures does not result in displacement. J Orthop Trauma. 2012 Apr 10. PubMed PMID: 22495523.

47
Q

􀀤􀀃􀀖􀀓􀀐􀁜􀁈􀁄􀁕􀀐􀁒􀁏􀁇􀀃􀁐􀁄􀁑􀀃􀁖􀁘􀁖􀁗􀁄􀁌􀁑􀁈􀁇􀀃􀁗􀁋􀁈􀀃􀁌􀁑􀁍􀁘􀁕􀁜􀀃􀁖􀁈􀁈􀁑􀀃􀁌􀁑􀀃􀀩􀁌􀁊􀁘􀁕􀁈􀀃􀀕􀀙􀀔􀀑􀀃􀀃􀀤􀁆􀁆􀁒􀁕􀁇􀁌􀁑􀁊􀀃􀁗􀁒􀀃􀁗􀁋􀁈􀀃􀀯􀁄􀁘􀁊􀁈􀀐􀀫􀁄􀁑􀁖􀁈􀁑􀀃􀀦􀁏􀁄􀁖􀁖􀁌􀂿􀁆􀁄􀁗􀁌􀁒􀁑􀀃261. A 30-year-old man sustained the injury seen in Figure 261. According to the Lauge-Hansen Classification System, the fracture should be classified as

  1. pronation-abduction.
  2. pronation-adduction.
  3. pronation-external rotation.
  4. supination-adduction.
  5. supination-external rotation.
A
  1. supination-adduction.

RECOMMENDED READINGS

Davidovitch RI, Egol KA. Fractures of the ankle. In: Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, eds. Fractures and Dislocations. Philadelphia, PA: Lippincott; 2009:1975-2021.

Graves M. Ankle fractures. In: Flynn JM, ed. Orthopaedic Knowledge Update 10. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:493-505.

48
Q
  1. The condition shown in Figure 268 has been subject to 2 nailing attempts. The patient is seen 8 months after the second surgery. What is the most appropriate treatment method?
  2. Bone stimulator with vitamin D supplementation
  3. In situ noncompressive plating with a bone graft
  4. In situ repeat intramedullary nailing with a bone graft
  5. Corrective alignment with exchange nailing with a bone graft
  6. Corrective alignment and compression plating without a bone graft
A
  1. Corrective alignment and compression plating without a bone graft

RECOMMENDED READINGS

Bolhofner BR, Finnegan M, Lundy DW. Nonunions and malunions. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:145-157.

Bellabarba C, Ricci WM, Bolhofner BR. Results of indirect reduction and plating of femoral shaft nonunions after intramedullary nailing. J Orthop Trauma. 2001 May;15(4):254-63. PubMed PMID: 11371790.

49
Q
A

5. OITE (41 decks)

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