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Trauma 2015 Flashcards

1
Q
  1. A 5-year-old girl has a type III supracondylar humeral fracture after falling off of the monkey bars. Examination reveals normal motor function and sensation in all nerve distributions and a pink perfused hand but no palpable pulse. An urgent closed reduction of the fracture is performed with percutaneous pinning. Immediately after pinning, the hand is noted to be white; there is no pulse and no signal by Doppler. What is the most appropriate action?
  2. Splint the arm in 95 degrees of flexion and start a heparin drip
  3. Immediate angiogram of the arm
  4. Immediate removal of the pins; unreduce the fracture and assess perfusion of the hand
  5. Immediate antecubital fossa exploration and forearm fasciotomy
  6. Leave the pin fixation, splint the arm in 45 degrees of flexion, and monitor for overnight return

of perfusion

A
  1. Immediate removal of the pins; unreduce the fracture and assess perfusion of the hand

RECOMMENDED READINGS

Kelly DM, Meier J. Shoulder, upper arm, and elbow trauma: Pediatrics. In: Cannada LK, ed. Orthopaedic Knowledge Update 11. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2014:785-795.

Shah AS, Waters PM, Bae DS. Treatment of the “pink pulseless hand” in pediatric supracondylar humerus fractures. J Hand Surg Am. 2013 Jul;38(7):1399-403; quiz 1404. doi: 10.1016/j.jhsa.2013.03.047. Review. PubMed PMID: 23790425.

Weller A, Garg S, Larson AN, Fletcher ND, Schiller JR, Kwon M, Copley LA, Browne R, Ho CA. Management of the pediatric pulseless supracondylar humeral fracture: is vascular exploration necessary? J Bone Joint Surg Am. 2013 Nov 6;95(21):1906-12. doi: 10.2106/JBJS.L.01580. PubMed PMID: 24196459.

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2
Q
  1. Figure 6 is the radiograph of a 65-year-old right-hand-dominant woman with right upper extremity pain and deformity after falling down several steps. Her sensory functions are grossly intact, but motor strength is 4/5 for anterior interosseous nerve, posterior interosseous nerve, and ulnar nerve distributions distally. Her capillary refill is 2 seconds, and her skin is intact. Evaluation reveals no other major injuries. In addition to careful evaluation of the joint proximally and distally, what is the best next step?
  2. Traction radiographs to assess the fracture pattern
  3. MR imaging to fully evaluate for ligamentous injuries
  4. Electromyography (EMG)/nerve conduction studies to evaluate neurologic deficit
  5. Emergent surgical management
  6. Urgent surgical management sometime that evening
A
  1. Traction radiographs to assess the fracture pattern

RECOMMENDED READINGS

Doornberg J, Lindenhovius A, Kloen P, van Dijk CN, Zurakowski D, Ring D. Two and three-dimensional computed tomography for the classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy. J Bone Joint Surg Am. 2006 Aug;88(8):1795-801. PubMed PMID: 16882904.

Galano GJ, Ahmad CS, Levine WN. Current treatment strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg. 2010 Jan;18(1):20-30. Review. PubMed PMID: 20044489.

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3
Q

10.Figures 10a and 10b are the radiographs of a 6-year-old girl who fell on her outstretched right hand. What is the best next step?

1- Closed reduction and casting of the supracondylar humeral fracture

2- Closed reduction and pinning with 2 or 3 laterally introduced pins of the supracondylar humeral fracture

3- Closed reduction and pinning with 2 laterally introduced pins and 1 medially introduced pin of the supracondylar humeral fracture

4- Open reduction and pinning of the supracondylar humeral fracture with 2 or 3 laterally introduced pins

5- Open reduction and pinning of the supracondylar humeral fracture with 2 laterally introduced pins and 1 medially introduced pi

A

2- Closed reduction and pinning with 2 or 3 laterally introduced pins of the supracondylar humeral fracture

RECOMMENDED READINGS

American Academy of Orthopaedic Surgeons: The Treatment of Pediatric Supracondylar Humerus Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons, September 2011. Available at http://www.aaos.org/research/guidelines/guide.asp. Accessed September 8, 2015.

Mallo G, Stanat SJ, Gaffney J. Use of the Gartland classification system for treatment of pediatric supracondylar humerus fractures. Orthopedics. 2010 Jan;33(1):19. doi: 10.3928/01477447-20091124-08. PubMed PMID: 20055347.

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4
Q
  1. Figures 14a and 14b are the radiographs of a 6-year-old girl who fell on her outstretched right hand and is seen in the emergency department. She has decreased pulses and an under perfused hand. Closed reduction and pinning with 3 laterally introduced pins is performed. Pulses at the wrist are absent, and her hand is still under perfused. What is the best next step?
  2. Explore the antecubital fossa
  3. Add a medial pin with an open approach
  4. Immediately remove the pins and check the pulses
  5. Immediately remove the pins and perform an open reduction and internal fixation of the

fracture under direct vision.

  1. Remove the pins and repeat the closed reduction followed by repeat pinning
A
  1. Explore the antecubital fossa

RECOMMENDED READINGS

American Academy of Orthopaedic Surgeons: The Treatment of Pediatric Supracondylar Humerus Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons, September 2011. Available at http://www.aaos.org/research/guidelines/guide.asp. Accessed September 8, 2015.

Garbuz DS, Leitch K, Wright JG. The treatment of supracondylar fractures in children with an absent radial pulse. J Pediatr Orthop. 1996 Sep-Oct;16(5):594-6. PubMed PMID: 8865043.

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5
Q
  1. A 24-year-old man has a low-velocity gunshot wound to his right humerus. It is an isolated injury, and he has complete radial nerve palsy. Optimal treatment should consist of antibiotics and
  2. irrigation, debridement, and external fixation of the humerus, with exploration of the radial nerve.
  3. irrigation, debridement, and intramedullary nailing of the humerus, with exploration of the radial nerve.
  4. irrigation, debridement, and open reduction and internal fixation (ORIF) of the fracture using a plate and screws with exploration of the radial nerve.
  5. exploration of the radial nerve and immobilization in a coaptation splint.
  6. immobilization in a coaptation splint and observation of the radial nerve to see if function returns.
A
  1. immobilization in a coaptation splint and observation of the radial nerve to see if function returns.’

RECOMMENDED READINGS

Guo Y, Chiou-Tan FY. Radial nerve injuries from gunshot wounds and other trauma: comparison of electrodiagnostic findings. Am J Phys Med Rehabil. 2002 Mar;81(3):207-11. PubMed PMID: 11989518.

Vaidya R, Sethi A, Oliphant BW, Gibson V, Sethi S, Meehan R. Civilian gunshot injuries of the humerus. Orthopedics. 2014 Mar;37(3):e307-12. doi: 10.3928/01477447-20140225-66. PubMed PMID: 24762161.

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6
Q
  1. Figures 32a through 32e are the radiographs, CT scans, and arthroscopic view of a 26-year-old man who was hit by a car and sustained an injury to his right knee. Treatment of his injury should include
  2. open reduction and internal fixation (ORIF) of the medial tibial plateau with a locked plate.
  3. ORIF of the medial tibial plateau and repair or reconstruction of the lateral collateral ligament (LCL) and posterolateral corner.
  4. revascularization of the leg, ORIF of the medial tibial plateau, and repair or reconstruction of the LCL and posterolateral corner.
  5. revascularization of the leg and repair of the LCL and posterolateral corner.
  6. revascularization of the leg and ORIF of the lateral and medial tibial plateaus.
A
  1. revascularization of the leg, ORIF of the medial tibial plateau, and repair or reconstruction of the LCL and posterolateral corner.

RECOMMENDED READINGS

Cole P, Levy B, Schatzker J, Watson JT. Tibial plateau fractures. In: Browner B, Levine A, Jupiter J, Trafton P, Krettek C, eds. Skeletal Trauma: Basic Science Management and Reconstruction. Philadelphia, PA: Saunders Elsevier; 2009:2201-2287.

Chang SM, Zhang YQ, Yao MW, Du SC, Li Q, Guo Z. Schatzker type IV medial tibial plateau fractures: a computed tomography-based morphological subclassification. Orthopedics. 2014 Aug;37(8):e699-706. doi: 10.3928/01477447-20140728-55. PubMed PMID: 25102505.

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7
Q
  1. Figures 40a through 40d are the radiographs and CT scans of an 18-year-old woman who sustained a tibia/ fibula fracture. Prior to intramedullary nailing of the tibia, the physician should
  2. plate the fibula.
  3. place an external fixator.
  4. perform a 4-compartment fasciotomy.
  5. perform reduction and internal fixation of the intra-articular split.
  6. perform a stress examination to see if there is syndesmotic disruption.
A
  1. perform reduction and internal fixation of the intra-articular split.

RECOMMENDED READINGS

Tejwani N, Polonet D, Wolinsky PR. Controversies in the intramedullary nailing of proximal and distal tibia fractures. J Am Acad Orthop Surg. 2014 Oct;22(10):665-73. doi: 10.5435/JAAOS-22-10-665. PubMed PMID: 25281261.

Casstevens C, Le T, Archdeacon MT, Wyrick JD. Management of extra-articular fractures of the distal tibia: intramedullary nailing versus plate fixation. J Am Acad Orthop Surg. 2012 Nov;20(11):675-83. doi: 10.5435/JAAOS-20-11-675. PubMed PMID: 23118133.

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8
Q
  1. (Item Deleted)

Figures 57a and 57b are the CT scanograms of a 24-year-old man who was shot in the left thigh. He sustained an isolated comminuted femoral shaft fracture. After performing a locked intramedullary nail procedure, the scanogram was taken to check rotational alignment. After reading the scanogram, what is the best next step?

  1. The shaft needs to be internally rotated 25.94 degrees to correct the deformity; the right femoral anteversion is 43.33 degrees and the left is 17.39 degrees; the left leg is overrotated externally.
  2. The shaft needs to be externally rotated 25.94 degrees to correct the deformity; the right femoral anteversion is 43.33 degrees and the left is 17.39 degrees; the left leg is overrotated internally.
  3. The right femoral anteversion is 6.39 degrees and the left femoral anteversion is 7.17 degrees, so the result is good.
  4. The right femoral anteversion is 6.39 degrees and the left is 17.39 degrees; the deformity should be corrected by rotating the left leg externally 11 degrees.
  5. The right femoral anteversion is 6.39 degrees and the left is 17.39 degrees; the deformity should be corrected by rotating the left leg internally 11 degrees.
A
  1. The right femoral anteversion is 6.39 degrees and the left femoral anteversion is 7.17 degrees, so the result is good.

RECOMMENDED READINGS

Lindsey JD, Krieg JC. Femoral malrotation following intramedullary nail fixation. J Am Acad Orthop Surg. 2011 Jan;19(1):17-26. PubMed PMID: 21205764.

Gugala Z, Qaisi YT, Hipp JA, Lindsey RW. Long-term functional implications of the iatrogenic rotational malalignment of healed diaphyseal femur fractures following intramedullary nailing. Clin Biomech (Bristol, Avon). 2011 Mar;26(3):274-7. doi: 10.1016/j.clinbiomech.2010.11.005. Epub 2010 Nov 30. PubMed PMID: 21122956.

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9
Q
  1. Figure 63 is the CT scan of a 43-year-old woman who was involved in a motor vehicle collision and sustained multiple injuries including a pelvic fracture. The injury shown in the CT scan is most consistent with a (an)
  2. combined-mechanism (CM) injury with a VS mechanism with a completely unstable right hemipelvis and a LC injury resulting in a completely unstable left hemipelvis.
  3. anteroposterior compression (APC) mechanism resulting in a completely unstable right hemipelvis.
  4. APC mechanism resulting in a partially unstable right and left hemipelvis.
  5. vertical shear mechanism resulting in a partially unstable left hemipelvis internal rotation and a completely unstable right hemipelvis external rotation (open book).
  6. lateral compression mechanism type 3 resulting in a partially unstable left hemipelvis internal rotation and a partially unstable right hemipelvis external rotation (open book).
A
  1. lateral compression mechanism type 3 resulting in a partially unstable left hemipelvis internal rotation and a partially unstable right hemipelvis external rotation (open book).

RECOMMENDED READINGS

Pennal GF, Tile M, Waddell JP, Garside H. Pelvic disruption: assessment and classification. Clin Orthop Relat Res. 1980 Sep;(151):12-21. PubMed PMID: 7418295.

Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audigé L. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007 Nov-Dec;21(10 Suppl):S1-133. PubMed PMID: 18277234.

Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology. 1986 Aug;160(2):445-51. PubMed PMID: 3726125.

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10
Q
  1. Figure 73a is the radiograph of a healthy 50-year-old farmer who was driving a pickup truck when he was involved in a motor vehicle collision. He arrived at the hospital 3 hours after the injury with right hip pain. You elect to reduce and fix his hip. After obtaining informed consent, he is placed under general anesthesia and positioned on the fracture table. Figures 73b and 73c are the fluoroscopic figures after your best attempt at reduction. What is the best next step?
  2. Fix the hip in its current position.
  3. Change plans and do a hemiarthroplasty.
  4. Change plans and do a total hip arthroplasty.
  5. Perform an open reduction of the femoral neck and then fix it.
  6. Ask a partner to try to do a closed reduction and see if he or she can do a better job.
A
  1. Perform an open reduction of the femoral neck and then fix it.

RECOMMENDED READINGS

Pauyo T, Drager J, Albers A, Harvey EJ. Management of femoral neck fractures in the young patient: A critical analysis review. World J Orthop. 2014 Jul 18;5(3):204-17. doi: 10.5312/wjo.v5.i3.204. eCollection 2014 Jul 18. Review. PubMed PMID: 25035822.

Kregor PJ. The effect of femoral neck fractures on femoral head blood flow. Orthopedics. 1996 Dec;19(12):1031-6; quiz 1037-8. Review. PubMed PMID: 8972521.

Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br. 2004 Sep;86(7):1035-40. PubMed PMID: 15446534.3.

Gautam VK, Anand S, Dhaon BK. Management of displaced femoral neck fractures in young adults (a group at risk). Injury. 1998 Apr;29(3):215-8. PubMed PMID: 9709424.

Parker MJ. The management of intracapsular fractures of the proximal femur. J Bone Joint Surg Br. 2000 Sep;82(7):937-41. Review. PubMed PMID: 11041577.

Weinrobe M, Stankewich CJ, Mueller B, Tencer AF. Predicting the mechanical outcome of femoral neck fractures fixed with cancellous screws: an in vivo study. J Orthop Trauma. 1998 Jan;12(1):27-36; discussion 36-7. PubMed PMID: 9447516.

Bosch U, Schreiber T, Krettek C. Reduction and fixation of displaced intracapsular fractures of the proximal femur. Clin Orthop Relat Res. 2002 Jun;(399):59-71. Review. PubMed PMID: 12011695.

Garden RS. Malreduction and avascular necrosis in subcapital fractures of the femur. J Bone Joint Surg Br. 1971 May;53(2):183-97. PubMed PMID: 5578215.

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11
Q
  1. Figures 78a and 78b are the radiographs of a 62-year-old woman with long-standing type 1 diabetes mellitus who fell and injured her right ankle. Her HbA1c level is 8%, or 64 mmol/mol. She has loss of protective sensibility that is confirmed via testing with a 5.07 Semmes-Weinstein monofilament. What is the best next step?
  2. Nonsurgical treatment with a cast and prolonged nonweight-bearing activity
  3. Surgical delay until her HgA1c level is normalized
  4. Surgical treatment with minimal fixation and a prolonged period of postsurgical nonweight-bearing activity
  5. Surgical treatment including multiple syndesmotic screws and a prolonged period of postsurgical nonweight-bearing activity
  6. Surgical treatment without syndesmotic screws unless there is a syndesmotic injury and a prolonged period of postsurgical nonweight-bearing activity
A
  1. Surgical treatment including multiple syndesmotic screws and a prolonged period of postsurgical nonweight-bearing activity

RECOMMENDED READINGS

Rosenbaum AJ, Dellenbaugh SG, Dipreta JA, Uhl RL. The management of ankle fractures in diabetics: results of a survey of the American Orthopaedic Foot and Ankle Society membership. Foot Ankle Spec. 2013 Jun;6(3):201-5. doi: 10.1177/1938640013477132. Epub 2013 Feb 19. PubMed PMID: 23424187.

McCormack RG, Leith JM. Ankle fractures in diabetics. Complications of surgical management. J Bone Joint Surg Br. 1998 Jul;80(4):689-92. PubMed PMID: 9699839.

Wukich DK, Kline AJ. The management of ankle fractures in patients with diabetes. J Bone Joint Surg Am. 2008 Jul;90(7):1570-8. doi: 10.2106/JBJS.G.01673. Review. PubMed PMID: 18594108.

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12
Q
  1. A 23-year-old African American mother of 2 children from a low-income household is seen in the emergency department with a subtrochanteric hip fracture. She has a history of frequent emergency room visits for chronic low-back pain, abdominal pain, a sleep disorder, and severe headaches. She most likely
  2. has lead poisoning.
  3. has Crohn’s disease.
  4. has osteogenesis imperfecta.
  5. has secondary hyperparathyroidism.
  6. is a victim of domestic violence.
A
  1. is a victim of domestic violence.

RECOMMENDED READINGS

Zillmer DA. Domestic violence: the role of the orthopaedic surgeon in identification and treatment. J Am Acad Orthop Surg. 2000 Mar-Apr;8(2):91-6. Review. PubMed PMID: 10799094.

AAOS Information Statement

Child Abuse or Maltreatment, Elder Maltreatment, and Intimate Partner Violence (IPV): The Orthopaedic Surgeon’s Responsibilities in Domestic and Family Violence http://www.aaos.org/about/papers/ advistmt/1030.asp Accessed September 8, 2015.

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13
Q
  1. Figures 91a and 91b are the current radiographs of a 60-year-old woman with type 1 diabetes mellitus who sustained a bimalleolar ankle fracture treated with open reduction and internal fixation 6 weeks ago. What is the best next step?
  2. Allow the patient to start weight-bearing activity as tolerated
  3. Remove the syndesmotic screws and start weight-bearing activity as tolerated
  4. Keep the patient in a cast and start weight-bearing activity as tolerated
  5. Keep the patient in a protective device and delay advancing weight-bearing status for an additional month
  6. Keep the patient in a protective device and advance weight-bearing status to weight-bearing activity as tolerated
A
  1. Keep the patient in a protective device and delay advancing weight-bearing status for an additional month

RECOMMENDED READINGS

Rosenbaum AJ, Dellenbaugh SG, Dipreta JA, Uhl RL. The management of ankle fractures in diabetics: results of a survey of the American Orthopaedic Foot and Ankle Society membership. Foot Ankle Spec. 2013 Jun;6(3):201-5. doi: 10.1177/1938640013477132. Epub 2013 Feb 19. PubMed PMID: 23424187.

Wukich DK, Kline AJ. The management of ankle fractures in patients with diabetes. J Bone Joint Surg Am. 2008 Jul;90(7):1570-8. doi: 10.2106/JBJS.G.01673. Review. PubMed PMID: 18594108.

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14
Q
  1. Figure 97 reveals a fracture sustained by a 60-year-old man 5 weeks after he underwent total hip arthroplasty. What is the most appropriate way to treat this fracture?
  2. Open reduction and internal fixation (ORIF) with locked-plate fixation
  3. ORIF with cortical strut graft and cable fixation
  4. Percutaneous submuscular locked-plate fixation
  5. Femoral component revision with cerclage cable fixation
  6. Revision to a proximal femoral replacement
A
  1. Femoral component revision with cerclage cable fixation

RECOMMENDED READINGS

Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res. 2004 Mar;(420):80-95. Review. PubMed PMID: 15057082.

Ko PS, Lam JJ, Tio MK, Lee OB, Ip FK. Distal fixation with Wagner revision stem in treating Vancouver type B2 periprosthetic femur fractures in geriatric patients. J Arthroplasty. 2003 Jun;18(4):446-52. PubMed PMID: 12820087.

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15
Q
  1. Figures 102a and 102b are the radiographs of a 60-year-old woman who slipped and fell and is unable to bear weight. In the emergency department, she was found to be neurologically intact and had good pulses. What is the most likely diagnosis?
  2. Bicondylar injury
  3. Fracture of the posterior and medial tibial plateau
  4. Split depression fracture of the anterolateral tibial plateau
  5. Split depression fracture of the posterolateral tibial plateau
  6. Split depression fracture of the posteromedial tibial plateau
A
  1. Split depression fracture of the posterolateral tibial plateau

RECOMMENDED READINGS

Sohn HS, Yoon YC, Cho JW, Cho WT, Oh CW, Oh JK. Incidence and fracture morphology of posterolateral fragments in lateral and bicondylar tibial plateau fractures. J Orthop Trauma. 2015 Feb;29(2):91-7. doi: 10.1097/BOT.0000000000000170. PubMed PMID: 24978940.

Marsh JL. Tibial plateau fractures. In: Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P, eds. Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:1787-1789.

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16
Q
  1. Figures 107a through 107c are the radiographs of a 9-year-old girl who is seen in the emergency department 1 hour after a fall from monkey bars. A gross deformity is noted at the left elbow, but there are no lacerations or open areas in the skin. She is further assessed and found to have delayed capillary refill, diminished radial artery pulsation in the ipsilateral hand, and decreased ability to flex her fingers and wrist (when compared to the contralateral side). What is the best next step?
  2. Perform an immediate closed reduction and percutaneous pinning
  3. Perform closed reduction and hyperflexion splinting
  4. Take the patient emergently to the operating room for open reduction and

nerve/artery exploration

  1. Obtain an emergent CT angiogram of the limb to assess location of arterial flow interruption
  2. Immediately elevate the extremity and splint at 40 degrees relative extension to decrease swelling and improve blood flow
A
  1. Perform an immediate closed reduction and percutaneous pinning

RECOMMENDED READINGS

Kelly DM, Meier J. Shoulder, upper arm, and elbow trauma: Pediatrics. In: Cannada LK, ed. Orthopaedic Knowledge Update 11. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2014:785-795.

Carter CT, Bertrand SL, Cearley DM. Management of pediatric type III supracondylar humerus fractures in the United States: results of a national survey of pediatric orthopaedic surgeons. J Pediatr Orthop. 2013 Oct-Nov;33(7):750-4. doi: 10.1097/BPO.0b013e31829f92f3. PubMed PMID: 24025582.

Abzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg. 2012 Feb;20(2):69-77. doi: 10.5435/JAAOS-20-02-069. 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. doi: 10.1097/ BPO.0b013e3181d213a6. PubMed PMID: 20357592.

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17
Q
  1. (Item Deleted)

A woman with multiple injuries is unconscious. Her injuries include a closed comminuted tibial shaft fracture for which there is concern for the development of compartment syndrome. As intracompartmental pressure (ICP), systolic blood pressure (sBP), and diastolic blood pressure (dBP) are monitored, at which point is fasciotomy indicated?

  1. When the ICP is elevated to 20 mm Hg
  2. When the ICP is elevated to 30 mm Hg
  3. When the ICP is elevated to 20 mm Hg below dBP
  4. When the ICP is elevated to 30 mm Hg below dBP
  5. Only when the ICP is equal to or greater than the dBP
A
  1. When the ICP is elevated to 20 mm Hg below dBP

RECOMMENDED READINGS

Whitesides TE, Heckman MM. Acute Compartment Syndrome: Update on Diagnosis and Treatment. J Am Acad Orthop Surg. 1996 Jul;4(4):209-218. PubMed PMID: 10795056.

Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg. 2005 Nov;13(7):436-44. Review.PubMed PMID: 16272268.

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18
Q
  1. Scapular fractures are noteworthy for their associated injuries. Which imaging modality would identify the injury most commonly associated with scapular fractures?
  2. CT of the head
  3. CT of the chest
  4. Focused assessment with sonography for trauma (FAST)
  5. Angiogram
  6. Anteroposterior pelvis radiograph
A
  1. CT of the chest

RECOMMENDED READINGS

Lunsjo K, Tadros, Czechowski Jk, Abu-Zidan. Scapular fractures and associated injuries in blunt trauma: a prospective study. J Bone Joint Surg Br. 2006;88:Supp 1:141.

Baldwin KD, Ohman-Strickland P, Mehta S, Hume E. Scapula fractures: a marker for concomitant injury? A retrospective review of data in the National Trauma Database. J Trauma. 2008 Aug;65(2):430-5. doi: 10.1097/TA.0b013e31817fd928. PubMed PMID: 18695481.

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19
Q
  1. Figures 120a and 120b are the sagittal MR images of a man who injured his knee after he slipped and fell on ice 2 days ago. He has severe knee pain and instability. Examination is difficult because of swelling, guarding, and apprehension. What is the indicated treatment?
  2. Hinged knee brace
  3. Anterior cruciate ligament (ACL) reconstruction
  4. Open posterior cruciate ligament (PCL) reconstruction
  5. Patellar tendon repair
  6. Arthroscopic medial meniscectomy
A
  1. Patellar tendon repair

RECOMMENDED READINGS

Matava MJ. Patellar Tendon Ruptures. J Am Acad Orthop Surg. 1996 Nov;4(6):287-296. PubMed PMID: 10797196.

Volk WR, Yagnik GP, Uribe JW. Complications in brief: Quadriceps and patellar tendon tears. Clin Orthop Relat Res. 2014 Mar;472(3):1050-7. doi: 10.1007/s11999-013-3396-6. Epub 2013 Dec 12. Review. PubMed PMID: 24338040; PubMed Central PMCID: PMC3916631

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20
Q
  1. Figure 123 is the anteroposterior radiograph of a 69-year-old active woman who fell off of a ladder and is unable to ambulate. Which treatment offers the best long-term solution?
  2. Hemiarthroplasty
  3. Total hip arthroplasty (THA)
  4. 3 cannulated screws
  5. A cephalomedullary device
  6. A dynamic hip screw with side plate
A
  1. Total hip arthroplasty (THA)

RECOMMENDED READINGS

Healy WL, Iorio R. Total hip arthroplasty: optimal treatment for displaced femoral neck fractures in elderly patients. Clin Orthop Relat Res. 2004 Dec;(429):43-8. PubMed PMID: 15577464.

Yu L, Wang Y, Chen J. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures: meta-analysis of randomized trials. Clin Orthop Relat Res. 2012 Aug;470(8):2235-43. doi: 10.1007/s11999-012-2293-8. Epub 2012 Mar 1. PubMed PMID: 22395872; PubMed Central PMCID: PMC3392403.

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21
Q
  1. A 54-year-old man sustained a closed tibial shaft fracture that was treated with open reduction and internal fixation using an intramedullary nail. On his follow-up visit, he noted that his foot was rotated differently than the contralateral foot. Which imaging modality can be used to best evaluate the deformity?
  2. Ultrasound
  3. MR imaging
  4. Stress radiograph
  5. Standing radiograph
  6. Computed tomography
A
  1. Computed tomography

RECOMMENDED READINGS

Puloski S, Romano C, Buckley R, Powell J. Rotational malalignment of the tibia following reamed intramedullary nail fixation. J Orthop Trauma. 2004 Aug;18(7):397-402. PubMed PMID: 15289683.

Theriault B, Turgeon AF, Pelet S. Functional impact of tibial malrotation following intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 2012 Nov 21;94(22):2033-9. doi: 10.2106/JBJS.K.00859. PubMed PMID: 23172320.

22
Q
  1. Which malunion is most commonly associated with intramedullary nailing (IMN) fixation of proximal tibial shaft fractures?
  2. Procurvatum, varus
  3. Procurvatum, valgus
  4. Recurvatum, varus
  5. Recurvatum, valgus
  6. Recurvatum, internal rotation
A
  1. Procurvatum, valgus

RECOMMENDED READINGS

Ricci WM, O’Boyle M, Borrelli J, Bellabarba C, Sanders R. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma. 2001 May;15(4):264-70. PubMed PMID: 11371791.

Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, Schrick JL, Sangeorzan BJ. Intramedullary nailing of proximal quarter tibial fractures. J Orthop Trauma. 2006 Sep;20(8):523-8. PubMed PMID: 16990722.

Hiesterman TG, Shafiq BX, Cole PA. Intramedullary nailing of extra-articular proximal tibia fractures. J Am Acad Orthop Surg. 2011 Nov;19(11):690-700. Review. PubMed PMID: 22052645

23
Q
  1. Figures 135a through 135c are the radiographs of a 78-year-old woman who sustained an elbow injury to her nondominant arm after a fall from a standing height. If considering total elbow arthroplasty vs internal fixation, the preferred surgical approach is
  2. medial through a flexor-pronator split.
  3. straight posterior through an olecranon osteotomy.
  4. anterolateral between the brachialis and biceps.
  5. lateral column, elevating off of common extensors and the capsule.
  6. posterior triceps sparing.
A
  1. posterior triceps sparing.

RECOMMENDED READINGS

Sørensen BW, Brorson S, Olsen BS. Primary total elbow arthroplasty in complex fractures of the distal humerus. World J Orthop. 2014 Jul 18;5(3):368-72. doi: 10.5312/wjo.v5.i3.368. eCollection 2014 Jul 18. PubMed PMID: 25035841; PubMed Central PMCID: PMC4095031.

McKee MD, Veillette CJ, Hall JA, Schemitsch EH, Wild LM, McCormack R, Perey B, Goetz T, Zomar M, Moon K, Mandel S, Petit S, Guy P, Leung I. A multicenter, prospective, randomized, controlled trial of open reduction–internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):3-12. doi: 10.1016/j. jse.2008.06.005. Epub 2008 Sep 26. PubMed PMID: 18823799.

24
Q
  1. Figures 137a and 137b are the radiographs of a 35-year-old man who has an elbow injury. What is the best surgical approach for this fracture?
  2. Medial through the flexor-pronator split
  3. Straight posterior, through an olecranon osteotomy
  4. Anterolateral between the brachialis and biceps
  5. Lateral column, elevating off of common extensors and the capsule
  6. Limited Kocher approach between the anconeus and extensor carpi ulnaris
A
  1. Lateral column, elevating off of common extensors and the capsule

RECOMMENDED READINGS

McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am. 1996 Jan;78(1):49-54. PubMed PMID: 8550679.

Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Coronal plane partial articular fractures of the distal humerus: current concepts in management. J Am Acad Orthop Surg. 2008 Dec;16(12):716-28. Review. PubMed PMID: 19056920.

25
Q

139.

A 19-year-old man broke his radius and ulna in the mid forearm. Following closed reduction and splinting, his ulna is translated 20% with less than 5 degrees of angulation, and the radius is well aligned with only 5 degrees of apex-volar angulation. The physician should recommend

  1. an above-elbow splint for 3 weeks followed by a forearm fracture brace.
  2. an above-elbow cast for 6 weeks.
  3. open reduction and internal fixation (ORIF) of the ulna.
  4. ORIF of the radius.
  5. ORIF of the radius and ulna.
A
  1. ORIF of the radius and ulna.

RECOMMENDED READINGS

Schulte LM, Meals CG, Neviaser RJ. Management of adult diaphyseal both-bone forearm fractures. J Am Acad Orthop Surg. 2014 Jul;22(7):437-46. doi: 10.5435/JAAOS-22-07-437. Review. PubMed PMID: 24966250.

Anderson LD, Sisk D, Tooms RE, Park WI 3rd. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am. 1975 Apr;57(3):287-97. PubMed PMID: 1091653.

26
Q
  1. Figure 145 is the radiograph of a 34-year-old man who sustained a clavicle fracture after a dirt bike accident. When considering benefits, risks, and costs, the most cost-effective treatment method that minimizes morbidity is
  2. figure-of-8 bracing.
  3. open reduction plate fixation.
  4. locked intramedullary fixation.
  5. sling management with delayed surgery (if required).
  6. multiple percutaneous thread Kirschner wire fixation.
A
  1. sling management with delayed surgery (if required).

RECOMMENDED READINGS

Rehn CH, Kirkegaard M, Viberg B, Larsen MS. Operative versus nonoperative treatment of displaced midshaft clavicle fractures in adults: a systematic review. Eur J Orthop Surg Traumatol. 2014 Oct;24(7):1047-53. doi: 10.1007/s00590-013-1370-3. Epub 2013 Dec 10. Review. PubMed PMID: 24322539.

Robinson CM, Goudie EB, Murray IR, Jenkins PJ, Ahktar MA, Read EO, Foster CJ, lark K, Brooksbank AJ, Arthur A, Crowther MA, Packham I, Chesser TJ. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial. J Bone Joint Surg Am. 2013 Sep 4;95(17):1576-84. doi: 10.2106/JBJS.L.00307. PubMed PMID: 24005198.

Walton B, Meijer K, Melancon K, Hartman M. A cost analysis of internal fixation versus nonoperative treatment in adult midshaft clavicle fractures using multiple randomized controlled trials. J Orthop Trauma. 2015 Apr;29(4):173-80. doi: 10.1097/BOT.0000000000000225. PubMed PMID: 25233160.

27
Q
  1. When compared to compression plating, antegrade intramedullary nailing (IMN) of humeral shaft fractures in adults is associated with increased risk for
  2. implant failure.
  3. fracture nonunion.
  4. radial nerve palsy.
  5. periprosthetic fracture.
  6. rotational shoulder stiffness.
A
  1. rotational shoulder stiffness.

RECOMMENDED READINGS

Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults. Cochrane Database Syst Rev. 2011 Jun 15;(6):CD005959. doi: 10.1002/14651858.CD005959.pub2. Review. PubMed PMID: 21678350.

Li Y, Wang C, Wang M, Huang L, Huang Q. Postoperative malrotation of humeral shaft fracture after plating compared with intramedullary nailing. J Shoulder Elbow Surg. 2011 Sep;20(6):947-54. doi: 10.1016/j.jse.2010.12.016. Epub 2011 Mar 26. PubMed PMID: 21440461.

28
Q
  1. A 38-year-old patient sustained the isolated left foot injury seen in Figure 157 after falling from a ladder. Which treatment will most likely produce the best clinical outcome and lowest risk for revision surgery?
  2. Arthrodesis
  3. Arthroplasty
  4. Closed reduction and casting
  5. Closed reduction and percutaneous pinning
  6. Open reduction and internal fixation (ORIF)
A
  1. Arthrodesis

RECOMMENDED READINGS

Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006 Mar;88(3):514-20. PubMed PMID: 16510816.

Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009 Oct;30(10):913-22. doi: 10.3113/FAI.2009.0913. PubMed PMID: 19796583

29
Q
  1. A 40-year-old man sustains a low-velocity gunshot wound to the pelvis. The entry wound is on his right flank, resulting in a fracture of the right ilium and left acetabulum. The bullet is lodged in his left hip. He is hemodynamically stable and has good peripheral pulses, decreased motor and sensory function of the right sciatic nerve, and rebound tenderness of the abdomen. The next step is to
  2. perform a sigmoidoscopy.
  3. order an electromyography/nerve conduction studies (EMG/NCS) to assess if the sciatic nerve

has a neurapraxia.

  1. order an angiography to assess for an internal iliac injury.
  2. take him for a laparotomy.
  3. remove the bullet from his left hip.
A
  1. take him for a laparotomy.

RECOMMENDED READINGS

Bartkiw MJ, Sethi A, Coniglione F, Holland D, Hoard D, Colen R, Tyburski JG, Vaidya R. Civilian gunshot wounds of the hip and pelvis. J Orthop Trauma. 2010 Oct;24(10):645-52. doi: 10.1097/ BOT.0b013e3181cf03ea. PubMed PMID: 20871253.

Najibi S, Matta JM, Dougherty PJ, Tannast M. Gunshot wounds to the acetabulum. J Orthop Trauma. 2012 Aug;26(8):451-9. doi: 10.1097/BOT.0b013e31822c085d. PubMed PMID: 22357085.

30
Q
  1. Figures 161a and 161b are the axial-cut CT scans of a patient with an acetabular fracture. The arrow is pointing to which structure?
  2. Femoral vein
  3. Femoral artery
  4. Femoral nerve
  5. Iliopsoas tendon
  6. Iliopectineal fascia
A
  1. Femoral nerve

RECOMMENDED READINGS

Standring S (ed): Gray’s Anatomy: The Anatomical Basis of Clinical Practice. JAMA 2009;301(17):1825- 1831.

Hoppenfeld S, deBoer P (eds): Surgical Exposures in Orthopaedics: The Anatomic Approach. 2nd ed. Philadelphia, PA: JB Lippincott;1994:368-375.

31
Q
  1. To be most effective, poller screws should be placed at which location when treating a proximal third tibial shaft fracture that tends to adopt a valgus position?
  2. Medial to the nail in the metaphyseal segment
  3. Medial side of the nail in the diaphyseal segment
  4. Medial to lateral in the metaphyseal segment posterior to the nail
  5. Lateral to the nail in the metaphyseal segment
  6. Lateral side of the nail in the diaphyseal segment
A
  1. Lateral to the nail in the metaphyseal segment

RECOMMENDED READINGS

Stedtfeld HW, Mittlmeier T, Landgraf P, Ewert A. The logic and clinical applications of blocking screws. J Bone Joint Surg Am. 2004;86-A Suppl 2:17-25. PubMed PMID: 15691104.

Stinner DJ, Mir H. Techniques for intramedullary nailing of proximal tibia fractures. Orthop Clin North Am. 2014 Jan;45(1):33-45. doi: 10.1016/j.ocl.2013.09.001. Epub 2013 Oct 5. Review. PubMed PMID: 24267205.

Hiesterman TG, Shafiq BX, Cole PA. Intramedullary nailing of extra-articular proximal tibia fractures. J Am Acad Orthop Surg. 2011 Nov;19(11):690-700. Review. PubMed PMID: 22052645.

32
Q
  1. A 25-year-old Hispanic man with a gunshot wound to his right humerus and femur is seen in the trauma bay. He is neurovascularly intact throughout and has had both fractures immobilized with splints in preparation for surgery. The nurse says that he has received pain medication but is requesting more. In addition to assessing for compartment syndrome, the physician should
  2. counsel the patient that he will feel better after surgery.
  3. order a toxicology screen to assess for recent narcotic use.
  4. be aware that pain medication dosing may be influenced by implicit bias.
  5. assume the nurse may have a racial bias and order more pain medication for the patient.
  6. ignore the request for increased pain medicine.
A
  1. be aware that pain medication dosing may be influenced by implicit bias.

RECOMMENDED READINGS

Mir HR, Rao RD. Patient-centered care: communication skills and cultural competence. In: Cannada LK, ed. Orthopaedic Knowledge Update 11. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2014:91-101.

Stone J, Moskowitz GB. Non-conscious bias in medical decision making: what can be done to reduce it? Med Educ. 2011 Aug;45(8):768-76. doi: 10.1111/j.1365-2923.2011.04026.x. PubMed PMID: 21752073.

Sabin J, Nosek BA, Greenwald A, Rivara FP. Physicians’ implicit and explicit attitudes about race by MD race, ethnicity, and gender. J Health Care Poor Underserved. 2009 Aug;20(3):896-913. doi: 10.1353/ hpu.0.0185. PubMed PMID: 19648715; PubMed Central PMCID: PMC3320738.

33
Q
  1. A 90-year-old woman sustained a spontaneous left femur fracture at the tip of a cemented revision total hip arthroplasty femoral stem, as seen in Figures 173a through 173d. Prior to her fracture, she reported no hip problems but had intermittent midthigh pain for 5 years and had seen a hip surgeon 3 years ago to discuss this pain (Figures 173e through 173h). The revision arthroplasty was performed 18 years ago with a long trochanteric osteotomy. Her comorbidities include mild chronic obstructive pulmonary disease, coronary artery disease, S/P 3-vessel coronary artery bypass grafting, hypertension, and type II diabetes mellitus. What is the best next step in treatment?
  2. Open reduction and internal fixation with a long anatomically contoured locking femoral plate, use of monocortical locking screws and cables adjacent to the femoral stem, and hip arthroplasty implant retention
  3. Open reduction and internal fixation with a long proximal femoral locking plate bypassing the fracture by 4 holes, use of monocortical locking screws adjacent to the femoral stem, and hip arthroplasty implant retention
  4. Open reduction and internal fixation with an 8-hole compression plate, use of cables adjacent to the femoral stem and screws below the stem, and hip arthroplasty implant retention
  5. Open reduction and internal fixation with a cortical strut allograft secured with cables and hip arthroplasty implant retention
  6. Removal of all implants and hip arthroplasty revision using a long modular femoral stem that passes the fracture site
A
  1. Open reduction and internal fixation with a long anatomically contoured locking femoral plate, use of monocortical locking screws and cables adjacent to the femoral stem, and hip arthroplasty implant retention

RECOMMENDED READINGS

Wood GC, Naudie DR, McAuley J, McCalden RW. Locking compression plates for the treatment of periprosthetic femoral fractures around well-fixed total hip and knee implants. J Arthroplasty. 2011 Sep;26(6):886-92. doi: 10.1016/j.arth.2010.07.002. Epub 2010 Sep 3. PubMed PMID: 20817391.

Bryant GK, Morshed S, Agel J, Henley MB, Barei DP, Taitsman LA, Nork SE.Isolated locked compression plating for Vancouver Type B1 periprosthetic femoral fractures. Injury. 2009 Nov;40(11):1180-6. doi: 10.1016/j.injury.2009.02.017.Epub 2009 Jun 18. PubMed PMID: 19539924

Fulkerson E, Koval K, Preston CF, Iesaka K, Kummer FJ, Egol KA. Fixation of periprosthetic femoral shaft fractures associated with cemented femoral stems: a biomechanical comparison of locked plating and conventional cable plates. J Orthop Trauma. 2006 Feb;20(2):89-93. PubMed PMID: 16462560.

Ricci WM, Bolhofner BR, Loftus T, Cox C, Mitchell S, Borrelli J Jr. Indirect reduction and plate fixation, without grafting, for periprosthetic femoral shaft fractures about a stable intramedullary implant. J Bone Joint Surg Am. 2005 Oct;87(10):2240-5. PubMed PMID: 16203889.

34
Q
  1. After hip hemiarthroplasty to address a fracture, use of which test can help surgeons best predict the need for a walking aid 2 years after surgery?
  2. Shuttle run
  3. Illinois agility
  4. 1-leg stance
  5. Timed up and go (TUG)
  6. Timed stair ascent
A
  1. 1-leg stance

RECOMMENDED READINGS

Springer BA, Marin R, Cyhan T, Roberts H, Gill NW. Normative values for the unipedal stance test with eyes open and closed. J Geriatr Phys Ther. 2007;30(1):8-15. PubMed PMID: 19839175.

Laflamme GY, Rouleau DM, Leduc S, Roy L, Beaumont E. The Timed Up and Go test is an early predictor of functional outcome after hemiarthroplasty for femoral neck fracture. J Bone Joint Surg Am. 2012 Jul 3;94(13):1175-9. doi: 10.2106/JBJS.J.01952. PubMed PMID: 22760384.

Kristensen MT, Henriksen S, Stie SB, Bandholm T. Relative and absolute intertester reliability of the timed up and go test to quantify functional mobility in patients with hip fracture. J Am Geriatr Soc. 2011 Mar;59(3):565-7.doi: 10.1111/j.1532-5415.2010.03293.x. PubMed PMID: 21391955.

35
Q
  1. A 40-year-old man sustained a low-velocity gunshot wound to his right ilium and acetabulum. What is the most common associated injury?
  2. Bladder injury
  3. Perforated viscus
  4. Major venous injury
  5. Major arterial injury
  6. Major peripheral nerve injury
A
  1. Perforated viscus

RECOMMENDED READINGS

Bartkiw MJ, Sethi A, Coniglione F, Holland D, Hoard D, Colen R, Tyburski JG, Vaidya R. Civilian gunshot wounds of the hip and pelvis. J Orthop Trauma. 2010 Oct;24(10):645-52. doi: 10.1097/ BOT.0b013e3181cf03ea. PubMed PMID: 20871253.

Najibi S, Matta JM, Dougherty PJ, Tannast M. Gunshot wounds to the acetabulum. J Orthop Trauma. 2012 Aug;26(8):451-9. doi: 10.1097/BOT.0b013e31822c085d. PubMed PMID: 22357085.

36
Q
  1. Figures 196a and 196b are the radiographs of a 3-year-old child with an elbow injury. Pulses are not palpable at the wrist, but the child’s fingers are pink with sluggish capillary refill. Treatment should consist of
  2. splinting and observation for return of pulses.
  3. reduction and fixation of the fracture with reassessment of perfusion.
  4. exploration of the brachial artery after reduction and fixation.
  5. exploration of the brachial artery before reduction and fixation.
  6. angiogram to assess arterial flow before reduction and fixation.
A
  1. reduction and fixation of the fracture with reassessment of perfusion.

RECOMMENDED READINGS

Weller A, Garg S, Larson AN, Fletcher ND, Schiller JR, Kwon M, Copley LA, Browne R, Ho CA. Management of the pediatric pulseless supracondylar humeral fracture: is vascular exploration necessary? J Bone Joint Surg Am. 2013 Nov 6;95(21):1906-12. doi: 10.2106/JBJS.L.01580. PubMed PMID: 24196459.

Scannell BP, Jackson JB 3rd, Bray C, Roush TS, Brighton BK, Frick SL. The perfused, pulseless supracondylar humeral fracture: intermediate-term follow-up of vascular status and function. J Bone Joint Surg Am. 2013 Nov 6;95(21):1913-9. doi: 10.2106/JBJS.L.01584. PubMed PMID: 24196460.

37
Q
  1. Figures 204a and 204b are the 3-dimensional CT scan and CT scan of a 23-year-old basketball player who fell on his left elbow 7 days ago. Current motion is 80 to 110 degrees in flexion-extension, 5 degrees of supination, and 20 degrees of pronation limited by pain in the area of the mobile wad. Aspiration of 7 ml of blood from the joint and a lidocaine injection do not improve his motion. What is the best next step?
  2. Radial head replacement
  3. Open reduction and internal fixation of the radial head
  4. Splint for 7 to 10 days and re-examine
  5. Sling and gradual increase of activities to tolerance
  6. A 2-week trial of physical therapy to restore motion
A
  1. Open reduction and internal fixation of the radial head

RECOMMENDED READINGS

Ikeda M, Sugiyama K, Kang C, Takagaki T, Oka Y. Comminuted fractures of the radial head. Comparison of resection and internal fixation. J Bone Joint Surg Am. 2005 Jan;87(1):76-84. PubMed PMID: 15634816.

Businger A, Ruedi TP, Sommer C. On-table reconstruction of comminuted fractures of the radial head. Injury. 2010 Jun;41(6):583-8. doi: 10.1016/j.injury.2009.10.026. Epub 2009 Nov 22. PubMed PMID: 19932475.

38
Q
  1. When performing the initial evaluation of an injured patient in the emergency department, adherence to the Advanced Trauma Life Support (ATLS) protocol has been shown to
  2. decrease the amount of time to initial patient imaging.
  3. decrease the cost associated with providing Level I trauma care.
  4. increase the number of patients receiving head CT scans.
  5. improve patient satisfaction with emergency department care.
  6. improve patient outcomes and decrease initial management errors.
A
  1. improve patient outcomes and decrease initial management errors.

RECOMMENDED READINGS

van Olden GD, Meeuwis JD, Bolhuis HW, Boxma H, Goris RJ. Clinical impact of advanced trauma life support. Am J Emerg Med. 2004 Nov;22(7):522-5. PubMed PMID: 15666253.

Ali J, Adam R, Butler AK, Chang H, Howard M, Gonsalves D, Pitt-Miller P, Stedman M, Winn J, Williams JI. Trauma outcome improves following the advanced trauma life support program in a developing country. J Trauma. 1993 Jun;34(6):890-8; discussion 898-9. PubMed PMID: 8315686.

39
Q
  1. In a patient with a high-energy comminuted femoral shaft fracture, which ipsilateral fracture is present as often as 10% of the time and initially missed up to 50% of the time?
  2. Talus
  3. Calcaneus
  4. Tibial spine
  5. Tibial plafond
  6. Femoral neck
A
  1. Femoral neck

RECOMMENDED READINGS

Tornetta P 3rd, Kain MS, Creevy WR. Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol. J Bone Joint Surg Am. 2007 Jan;89(1):39-43. PubMed PMID: 17200308.

Riemer BL, Butterfield SL, Ray RL, Daffner RH. Clandestine femoral neck fractures with ipsilateral diaphyseal fractures. J Orthop Trauma. 1993;7(5):443-9. PubMed PMID: 8229381.

Swiontkowski MF, Hansen ST Jr, Kellam J. Ipsilateral fractures of the femoral neck and shaft. A treatment protocol. J Bone Joint Surg Am. 1984 Feb;66(2):260-8.

PubMed PMID: 6693453.

40
Q
  1. Which factor is associated with increased failure rates for the treatment of stable intertrochanteric femur fractures with a dynamic hip screw (DHS)?
  2. Long barrel
  3. Early weight bearing
  4. Younger patient age
  5. 2-hole plate instead of a 4-hole plate
  6. Tip-apex distance exceeding 25 mm
A
  1. Tip-apex distance exceeding 25 mm

RECOMMENDED READINGS

Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995 Jul;77(7):1058-64. PubMed PMID: 7608228.

Bolhofner BR, Russo PR, Carmen B. Results of intertrochanteric femur fractures treated with a 135-degree sliding screw with a two-hole side plate. J Orthop Trauma. 1999 Jan;13(1):5-8. PubMed PMID: 9892117.

41
Q
  1. Figures 219a through 219c are the postreduction radiographs of a 28-year-old man who had left ankle pain after falling down a flight of stairs. He underwent closed reduction in the emergency department. To maximize rotational stability of the distal fibula, fixation should include
  2. intramedullary fixation of the fibula.
  3. screw-and-suture button fixation of the syndesmosis.
  4. quadricortical screw fixation of the syndesmosis over a 4-hole plate.
  5. locking plate fixation of the fibula and deltoid ligament repair.
  6. plate fixation of the fibula and fixation of the posterior malleolus.
A
  1. plate fixation of the fibula and fixation of the posterior malleolus.

RECOMMENDED READINGS

Irwin TA, Lien J, Kadakia AR. Posterior malleolus fracture. J Am Acad Orthop Surg. 2013 Jan;21(1):32- 40. doi: 10.5435/JAAOS-21-01-32. Review. PubMed PMID: 23281469.

Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res. 2006 Jun;447:165-71. PubMed PMID: 16467626.

Hartford JM, Gorczyca JT, McNamara JL, Mayor MB. Tibiotalar contact area. Contribution of posterior malleolus and deltoid ligament. Clin Orthop Relat Res. 1995 Nov;(320):182-7. PubMed PMID: 7586825.

42
Q
  1. Which imaging method is optimal when attempting to determine displacement of a medial humeral epicondyle fracture?
  2. Distal humeral axial view
  3. External oblique radiographs
  4. Internal oblique radiographs
  5. Standard anteroposterior and lateral elbow radiographs
  6. Fluoroscopic examination of the elbow
A
  1. Distal humeral axial view

RECOMMENDED READINGS

Edmonds EW. How displaced are “nondisplaced” fractures of the medial humeral epicondyle in children? Results of a three-dimensional computed tomography analysis. J Bone Joint Surg Am. 2010 Dec 1;92(17):2785-91. doi: 10.2106/JBJS.I.01637. PubMed PMID: 21123608.

Souder CD, Farnsworth CL, McNeil NP, Bomar JD, Edmonds EW. The Distal Humerus Axial View: Assessment of Displacement in Medial Epicondyle Fractures. J Pediatr Orthop. 2015 Jul- Aug;35(5):449-54. doi: 10.1097/BPO.0000000000000306. PubMed PMID: 25171678.

43
Q
  1. Titanium is often described as the best implant for fracture internal fixation because its elastic modulus is closest to that of bone. Cortical bone has an approximate modulus of elasticity of 15 (in megapascals [MPa], range 7 to 30). What is the approximate modulus of elasticity of titanium?
  2. 20 MPa
  3. 40 MPa
  4. 60 MPa
  5. 80 MPa
  6. 100 MPa
A
  1. 100 MPa

RECOMMENDED READINGS

Rho JY, Ashman RB, Turner CH. Young’s modulus of trabecular and cortical bone material: ultrasonic and microtensile measurements. J Biomech. 1993 Feb;26(2):111-9. PubMed PMID: 8429054.

Niinomi M. Mechanical properties of biomedical titanium alloys. Materials Science and Engineering: A. 1998;243(1-2):231-6.

44
Q
  1. What is the in-hospital mortality and 1-year mortality after hip fracture among elderly people in the United States?
  2. 6%; 15%
  3. 6%; 30%
  4. 15%; 30%
  5. 15%; 40%
  6. 6%; 40%
A
  1. 6%; 30%

RECOMMENDED READINGS

Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009 Oct 14;302(14):1573-9. doi:10.1001/jama.2009.1462. PubMed PMID: 19826027; PubMed Central PMCID: PMC4410861.

Jiang HX, Majumdar SR, Dick DA, Moreau M, Raso J, Otto DD, Johnston DW.Development and initial validation of a risk score for predicting in-hospital and 1-year mortality in patients with hip fractures. J Bone Miner Res. 2005 Mar;20(3):494-500. Epub 2004 Nov 29. PubMed PMID: 15746995.

45
Q
  1. A healthy 70-year-old man has an isolated high-energy open bimalleolar ankle fracture after a fall from a bicycle. Compared to a 30-year-old man with the same injury, his postsurgical course will be associated with a (an)
  2. higher infection rate.
  3. shorter time to union.
  4. equivalent complication rate.
  5. increased incidence of nerve injury.
  6. increased rate of nonunion.
A
  1. equivalent complication rate.

RECOMMENDED READINGS

Herscovici D Jr, Scaduto JM. Management of high-energy foot and ankle injuries in the geriatric population. Geriatr Orthop Surg Rehabil. 2012 Mar;3(1):33-44. doi: 10.1177/2151458511436112. PubMed PMID: 23569695; PubMed Central PMCID: PMC3617904.

Pagliaro AJ, Michelson JD, Mizel MS. Results of operative fixation of unstable ankle fractures in geriatric patients. Foot Ankle Int. 2001 May;22(5):399-402. PubMed PMID: 11428758.

46
Q
  1. What is the current U.S. Food and Drug Administration (FDA) indication for recombinant human bone morphogenetic protein-2 (rhBMP-2) implantation after a fracture occurs?
  2. Aseptic tibial nonunion repair
  3. Acute open tibial shaft fracture
  4. Acute open femoral fracture after intramedullary nail (IMN) fixation
  5. Acute open femoral fracture with segmental bone loss after IMN
  6. There is currently no FDA indication for use of rhBMP-2 after fracture
A
  1. Acute open tibial shaft fracture

RECOMMENDED READINGS

Govender S, Csimma C, Genant HK, Valentin-Opran A, Amit Y, Arbel R, Aro H, Atar D, Bishay M, Börner MG, Chiron P, Choong P, Cinats J, Courtenay B, Feibel R, Geulette B, Gravel C, Haas N, Raschke M, Hammacher E, van der Velde D, Hardy P, Holt M, Josten C, Ketterl RL, Lindeque B, Lob G, Mathevon H, McCoy G, Marsh D, Miller R, Munting E, Oevre S, Nordsletten L, Patel A, Pohl A, Rennie W, Reynders P, Rommens PM, Rondia J, Rossouw WC, Daneel PJ, Ruff S, Rüter A, Santavirta S, Schildhauer TA, Gekle C, Schnettler R, Segal D, Seiler H, Snowdowne RB, Stapert J, Taglang G, Verdonk R, Vogels L, Weckbach A, Wentzensen A, Wisniewski T; BMP-2 Evaluation in Surgery for Tibial Trauma (BESTT) Study Group. Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients. J Bone Joint Surg Am. 2002 Dec;84-A(12):2123-34. PubMed PMID: 12473698.

Alt V, Borgman B, Eicher A, Heiss C, Kanakaris NK, Giannoudis PV, Song F. Effects of recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) in grade III open tibia fractures treated with unreamed nails-A clinical and health-economic analysis. Injury. 2015 Nov;46(11):2267-72. doi: 10.1016/j. injury.2015.07.013. Epub 2015 Aug 13. PubMed PMID: 26374949.

Wei S, Cai X, Huang J, Xu F, Liu X, Wang Q. Recombinant human BMP-2 for the treatment of open tibial fractures. Orthopedics. 2012 Jun;35(6):e847-54. doi: 10.3928/01477447-20120525-23. Review. PubMed PMID: 22691656.

47
Q

250.

Electrical stimulation of bone is thought to promote bone healing through 1. downregulation of osteoclasts.

  1. micromechanical stimulation of osteoblasts.
  2. upregulation of growth factors transforming growth factor-beta and other bone

morphogenetic proteins.

  1. induced mechanical microtrauma at boundary tissues.
  2. enhancement of intracellular calcium and signal transduction.
A
  1. upregulation of growth factors transforming growth factor-beta and other bone

RECOMMENDED READINGS

Nauth A, Kuzyk PR, Einhorn TA, Schemitsch EH. Advances in the enhancement of bone healing and bone graft substitutes. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:133-143.

Aaron RK, Boyan BD, Ciombor DM, Schwartz Z, Simon BJ. Stimulation of growth factor synthesis by electric and electromagnetic fields. Clin Orthop Relat Res. 2004 Feb;(419):30-7. Review. PubMed PMID: 15021128.

48
Q
  1. Figures 259a and 259b are the radiograph and clinical photograph of a 50-year-old woman who fell and sustained a distal humeral fracture. You opt to perform an osteotomy to expose the injury. What is the best option?
  2. A transverse osteotomy 1 cm distal to the triceps insertion in the bare area of the ulna
  3. A transverse osteotomy 2 cm distal to the triceps insertion in the bare area of the ulna
  4. A Chevron osteotomy 2 cm distal to the triceps insertion in the bare area of the ulna
  5. A Chevron osteotomy 3 cm distal to the triceps insertion in the bare area of the ulna
  6. An oblique osteotomy that completely avoids the articular surface of the ulnohumeral joint
A
  1. A Chevron osteotomy 2 cm distal to the triceps insertion in the bare area of the ulna

RECOMMENDED READINGS

Wang AA, Mara M, Hutchinson DT. The proximal ulna: An anatomic study with relevance to olecranon osteotomy and fracture fixation. J Shoulder Elbow Surg. 2003 May-Jun;12(3):293-6. PubMed PMID: 12851585.

Elmadag M, Erdil M, Bilsel K, Acar MA, Tuncer N, Tuncay I. The olecranon osteotomy provides better outcome than the triceps-lifting approach for the treatment of distal humerus fractures. Eur J Orthop Surg Traumatol. 2014 Jan;24(1):43-50. doi: 10.1007/s00590-012-1149-y. Epub 2012 Dec 21. PubMed PMID: 23412273.

49
Q
  1. A 19-year-old woman was a pedestrian when she was hit by a car. She arrives in the emergency department confused and anxious. Her heart rate (HR) is 125 beats per minute (BPM) and her blood pressure (BP) is 90/50 mm Hg. Two large-bore intravenous lines are started, and 2 liters of normal saline are given. She can move all 4 extremities on command and has good pulses in all 4 limbs. Radiographs reveal pelvic and bilateral tibia fractures. According to the Advanced Trauma Life Support for Doctors (ATLS) handbook, her hemorrhage meets criteria for which class?
  2. I
  3. II
  4. III
  5. IV
  6. V
A
  1. III

RECOMMENDED READINGS

ATLS: Advanced Trauma Life Support for Doctors (Student Course Manual). Chicago9, IL: American College of Surgeons.

Guly HR, Bouamra O, Spiers M, Dark P, Coats T, Lecky FE; Trauma Audit and Research Network. Vital signs and estimated blood loss in patients with major trauma: testing the validity of the ATLS classification of hypovolaemic shock. Resuscitation. 2011 May;82(5):556-9. doi: 10.1016/j.resuscitation.2011.01.013. Epub 2011 Feb 23. PubMed PMID: 21349628.

50
Q
  1. An 85-year-old woman with mild dementia fell and is taken to a hospital. She is unable to bear weight on her right leg, and diagnostics reveal a displaced intertrochanteric right femur fracture. To improve short-and intermediate-term outcomes for this patient,
  2. her pain should be controlled primarily with meperidine instead of morphine.
  3. she should be transported to the operating room emergently without any medical evaluation within 12 hours for fracture fixation.
  4. she should be admitted to the geriatric service or a hospitalist (if available) for medical optimization in preparation for surgical fracture management.
  5. she should undergo a neurology service consultation for evaluation of dementia in preparation for surgical fracture management.
  6. she should undergo a routine echocardiogram with a cardiology consultation to address risk stratification in advance of surgical fracture management.
A
  1. she should be admitted to the geriatric service or a hospitalist (if available) for medical optimization in preparation for surgical fracture management.

RECOMMENDED READINGS

Friedman SM, Mendelson DA, Kates SL, McCann RM. Geriatric co-management of proximal femur fractures: total quality management and protocol-driven care result in better outcomes for a frail patient population. J Am Geriatr Soc. 2008 Jul;56(7):1349-56. doi: 10.1111/j.1532-5415.2008.01770.x. Epub 2008 May 22. PubMed PMID: 18503520.

Kates SL, Mendelson DA, Friedman SM. The value of an organized fracture program for the elderly: early results. J Orthop Trauma. 2011 Apr;25(4):233-7. doi: 10.1097/BOT.0b013e3181e5e901. PubMed PMID: 21399474.

Ricci WM, Della Rocca GJ, Combs C, Borrelli J. The medical and economic impact of preoperative cardiac testing in elderly patients with hip fractures. Injury. 2007 Sep;38 Suppl 3:S49-52. PubMed PMID: 17723792.

Potter JF. The older orthopaedic patient: general considerations. Clin Orthop Relat Res. 2004 Aug;(425):44-9. Review. PubMed PMID: 15292786.

51
Q
  1. A 76-year-old man has a Vancouver type C periprosthetic fracture. What is the best option to fix this fracture?
  2. A plate with the proximal extent 2 canal diameters above the tip of the femoral prosthesis
  3. A plate with the proximal extent 2 canal diameters below the tip of the femoral prosthesis
  4. A plate that stops adjacent to the tip of the femoral prosthesis
  5. A long-stem revision of the prosthesis
  6. A long-stem revision of the prosthesis with a plate placed 2 canal diameters above the tip of the prosthesis.
A
  1. A plate with the proximal extent 2 canal diameters above the tip of the femoral prosthesis

RECOMMENDED READINGS

Masri BA, Meek RM, Duncan CP. Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res. 2004 Mar;(420):80-95. Review. PubMed PMID: 15057082.

Wolff LH III, Berry DJ. Periprosthetic fractures of the lower extremity. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction. Vol 2. 4th ed. Philadelphia, PA: Saunders Elsevier; 2011:2843-2858.

52
Q
A

5. OITE (41 decks)

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