Trauma 2016 Flashcards
- What is the most biomechanically optimal fixation method to address the fracture shown in Figures 2a
and 2b?
- Bicortical lag screws
- Partially threaded cancellous screws
- Tension band construct with smooth wires
- Medial antiglide plate
- Precontoured lateral locking plate
- Medial antiglide plate
RECOMMENDED READINGS
Hak DJ, Egol KA, Gardner MJ, Haskell A. The “not so simple” ankle fracture: avoiding problems and pitfalls to improve patient outcomes. Instr Course Lect. 2011;60:73-88. PubMed PMID: 21553763.
Ricci WM, Tornetta P, Borrelli J Jr. Lag screw fixation of medial malleolar fractures: a biomechanical, radiographic, and clinical comparison of unicortical partially threaded lag screws and bicortical fully threaded lag screws. J Orthop Trauma. 2012 Oct;26(10):602-6. PubMed PMID: 22437423.
- A 25-year-old man had a severe pronation external rotation ankle injury with an oblique fibular fracture above the joint line and a 10% posterior malleolar fracture. After restoring fibular length and rotation after performing plate fixation, the approach to the posterior malleolar fracture and the optimal syndesmosis closure can be achieved by applying the clamp at which position?
- Proximal to the syndesmosis level with midmedial tibial and fibular placement with reduction
and fixation of the posterior malleolus
- A point distal to the syndesmosis level with the medial clamp at the mid anteroposterior (AP)
tibia and fibular diameter, with no reduction and fixation of the posterior malleolus
- At the syndesmosis level with the clamp applied to the anterior medial tibia and lateral malleolar ridge, with reduction and fixation of the posterior malleolus
- At the syndesmosis level with midmedial tibial and fibular placement with no reduction and fixation of the posterior malleolus
- At the syndesmosis level with the midmedial tibia and fibular ridge, with reduction and fixation of the posterior malleolus
- At the syndesmosis level with the midmedial tibia and fibular ridge, with reduction and fixation of the posterior malleolus
RECOMMENDED READINGS
Gardner MJ, Graves ML, Higgins TF, Nork SE. Technical Considerations in the Treatment of Syndesmotic Injuries Associated With Ankle Fractures. J Am Acad Orthop Surg. 2015 Aug;23(8):510-8. doi: 10.5435/ JAAOS-D-14-00233. PMID: 26209146.
Phisitkul P, Ebinger T, Goetz J, Vaseenon T, Marsh JL. Forceps reduction of the syndesmosis in rotational ankle fractures: a cadaveric study J Bone Joint Surg Am. 2012 Dec 19;94(24):2256-61. doi: 10.2106/ JBJS.K.01726. PMID: 23318616.
Miller AN, Carroll EA, Parker RJ, Boraiah S, Helfet DL, Lorich DG. Direct visualization for syndesmotic stabilization of ankle fractures. Foot Ankle Int. 2009 May;30(5):419-26. doi: 10.3113/FAI.2009.0419. PMID: 19439142.
10.
Figures 10a and 10b are the emergency department radiographs of a 32-year-old healthy man who is involved in a motor vehicle collision. He has an isolated injury. What is the best next step?
- Anterior total hip arthroplasty (THA)
- Open reduction and internal fixation (ORIF)
- Closed reduction percutaneous pinning
- Posterior THA
- Hemiarthroplasty
- Open reduction and internal fixation (ORIF)
RECOMMENDED READINGS
Callaghan JJ, Liu SS, Haidukewych GJ. Subcapital fractures: a changing paradigm. J Bone Joint Surg Br. 2012 Nov;94(11 Suppl A):19-21. doi: 10.1302/0301-620X.94B11.30617. Review. PubMed PMID: 23118374.
Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P 3rd, Obremskey W, Koval KJ, Nork S, Sprague S, Schemitsch EH, Guyatt GH. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am. 2003 Sep;85-A(9):1673-81. PubMed PMID: 12954824.
- Loss of active knee extension after use of an anterior subcutaneous internal fixator in the surgical treatment of unstable pelvic fractures is attributable to
- lateral femoral cutaneous nerve injury.
- obturator nerve injury.
- saphenous nerve injury.
- femoral nerve injury.
- thrombosis of the femoral artery.
- femoral nerve injury.
RECOMMENDED READINGS
Hesse D, Kandmir U, Solberg B, Stroh A, Osgood G, Sems SA, Collinge CA. Femoral nerve palsy after pelvic fracture treated with INFIX: a case series. J Orthop Trauma. 2015 Mar;29(3):138-43. doi: 10.1097/ BOT.0000000000000193. PubMed PMID: 24983430.
Lewallen DG. Neurovascular injury associated with hip arthroplasty. Instr Course Lect. 1998;47:275-83. Review. PubMed PMID: 9571429.
- Figures 18a and 18b are the clinical photographs of a 30-year-old man seen 1 year after undergoing locked antegrade intramedullary nailing for a comminuted right femoral fracture. He has pain over his right hip. What is the most likely diagnosis?
- A decrease in femoral anteversion on the right during surgery
- A malreduction externally rotating the proximal right femur during nailing
- A malreduction internally rotating the distal right femur during nailing
- An increase in femoral anteversion on the right during surgery
- An acceptable outcome
- A decrease in femoral anteversion on the right during surgery
RECOMMENDED READINGS
Dimitriou D, Tsai TY, Yue B, Rubash HE, Kwon YM, Li G. Side-to-side variation in normal femoral morphology: 3D CT analysis of 122 femurs. Orthop Traumatol Surg Res. 2016 Feb;102(1):91-7. doi: 10.1016/j.otsr.2015.11.004. Epub 2016 Jan 19. PubMed PMID: 26867707.
Karaman O, Ayhan E, Kesmezacar H, Seker A, Unlu MC, Aydingoz O. Rotational malalignment after closed intramedullary nailing of femoral shaft fractures and its influence on daily life. Eur J Orthop Surg Traumatol. 2014 Oct;24(7):1243-7. doi: 10.1007/s00590-013-1289-8. Epub 2013 Aug 11. PubMed PMID: 23934503.
Espinoza C, Sathy AK, Moore DS, Starr AJ, Reinert CM. Use of inherent anteversion of an intramedullary nail to avoid malrotation in femur fractures. J Orthop Trauma. 2014 Feb;28(2):e34-8. doi: 10.1097/ BOT.0b013e318298e48c. PubMed PMID: 23689227.
- A 72-year-old woman sustained a displaced femoral neck fracture after a fall. She is a community ambulator and plays tennis and golf weekly. What is the best functional treatment option for her hip?
- Total hip arthroplasty (THA)
- Hemiarthroplasty
- Hip resurfacing
- Internal fixation with sliding hip and antirotation screws
- Internal fixation with cannulated screws
- Total hip arthroplasty (THA)
RECOMMENDED READINGS
Florschutz AV, Langford JR, Haidukewych GJ, Koval KJ. Femoral neck fractures: current management. J Orthop Trauma. 2015 Mar;29(3):121-9. doi: 10.1097/BOT.0000000000000291. Review. PubMed PMID: 25635363.
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 four year follow-up of a randomized trial. J Bone Joint Surg Am. 2011 Mar 2;93(5):445-50. PubMed PMID: 21368076.
- When comparing sliding hip screw fixation to intramedullary nailing (IMN) in the management of transverse/reverse oblique trochanteric and subtrochanteric fractures, sliding hip screw fixation is associated with
- higher revision surgery rates.
- lower pain.
- better satisfaction.
- better quality of life.
- better mobility.
- higher revision surgery rates.
RECOMMENDED READINGS
Matre K, Havelin LI, Gjertsen JE, Vinje T, Espehaug B, Fevang JM. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register. Injury. 2013 Jun;44(6):735-42. doi: 10.1016/j.injury.2012.12.010. Epub 2013 Jan 8. PubMed PMID: 23305689.
Miedel R, Ponzer S, Törnkvist H, Söderqvist A, Tidermark J. The standard Gamma nail or the Medoff sliding plate for unstable trochanteric and subtrochanteric fractures. A randomised, controlled trial. J Bone Joint Surg Br. 2005 Jan;87(1):68-75. PubMed PMID: 15686240.
- Which variable is associated with poor outcomes and early need for arthroplasty in the setting of acetabulum fracture?
- Anatomical fracture reduction
- Posterior hip dislocation
- Femoral head cartilage lesion
- Initial displacement of the articular surface of less than 20 mm
- Postsurgical congruence of the acetabular roof
- Femoral head cartilage lesion
RECOMMENDED READINGS
Tannast M, Najibi S, Matta JM. Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures. J Bone Joint Surg Am. 2012 Sep 5;94(17):1559-67. PubMed PMID: 22992846.
Liebergall M, Mosheiff R, Low J, Goldvirt M, Matan Y, Segal D. Acetabular fractures. Clinical outcome of surgical treatment. Clin Orthop Relat Res. 1999 Sep;(366):205-16. PubMed PMID: 10627737.
- A healthy 24-year-old woman who is identified as American Society of Anesthesiologists (ASA) class I has a Gustilo-Anderson grade I open bimalleolar ankle fracture. Antibiotics, irrigation with low-flow cystoscopy tubing, irrigation and debridement, open reduction and internal fixation (ORIF), and primary wound closure are associated with
- a high probability of wound healing.
- a high probability of wound necrosis.
- a higher probability of wound necrosis than if pulsatile lavage were used.
- no difference in wound necrosis for healthy patients and those with medical comorbidities.
- none of these; wounds should never be primarily closed in open fractures.
- a high probability of wound healing.
RECOMMENDED READINGS
Ovaska MT, Madanat R, Mäkinen TJ. Predictors of Postoperative Wound Necrosis Following Primary Wound Closure of Open Ankle Fractures. Foot Ankle Int. 2016 Apr;37(4):401-6. doi: 10.1177/1071100715609182. PubMed PMID: 26830839.
Jenkinson RJ, Kiss A, Johnson S, Stephen DJ, Kreder HJ. Delayed wound closure increases deep-infection rate associated with lower-grade open fractures: a propensity-matched cohort study. J Bone Joint Surg Am. 2014 Mar 5;96(5):380-6. doi: 10.2106/JBJS.L.00545. PubMed PMID: 24599199.
- Impingement and penetration of the anterior cortex of the distal femur during intramedullary nailing (IMN) in the setting of proximal femur fractures are seen in patients with
- a posterior starting point.
- a small radius of curvature of the nail.
- tall stature.
- decreased femoral bow.
- an anterior starting point.
- a posterior starting point.
RECOMMENDED READINGS
Roberts JW, Libet LA, Wolinsky PR. Who is in danger? Impingement and penetration of the anterior cortex of the distal femur during intramedullary nailing of proximal femur fractures: preoperatively measurable risk factors. J Trauma Acute Care Surg. 2012 Jul;73(1):249-54. doi: 10.1097/ TA.0b013e318256a0b6. PubMed PMID: 22743391.
Ostrum RF, Levy MS. Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures: a report of three cases. J Orthop Trauma. 2005 Oct;19(9):656-60. PubMed PMID: 16247312.
- During the classic Henry approach to the right forearm (Figure 78), where is the radial artery located?
- Above retractor A
- Between retractors A and C
- Below retractors B and C
- Below the pronator terres
- The artery is not seen in this approach
PREFERRED RESPONSE: 3
- Below retractors B and C
RECOMMENDED READINGS
Campbell WS, Canale ST, Beaty JS, eds. Campbell’s Operative Orthopaedics. Philadelphia, PA: Elsevier/ Mosby; 2013:120.
Catalano LW 3rd, Zlotolow DA, Hitchcock PB, Shah SN, Barron OA. Surgical exposures of the radius and ulna. J Am Acad Orthop Surg. 2011 Jul;19(7):430-8. Review. PubMed PMID: 21724922.
- Which soft-tissue structure associated with the fracture seen in Figures 82a through 82c is most
commonly injured?
- Medial collateral ligament
- Medial meniscus
- Popliteus tendon
- Lateral meniscus
- Lateral collateral ligament
- Lateral meniscus
RECOMMENDED READINGS
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.
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.
- Figure 91 depicts the external rotation stress test performed after open reduction and internal fixation on the lateral malleolus of a bimalleolar-equivalent ankle fracture. What is the best next step?
- Close the wounds and place a below-knee plaster splint
- Reduce the syndesmosis with a king tong clamp and fix it with 2- x 3.5-mm screws with 4 cortexes each
- Reduce the syndesmosis with a king tong clamp and fix it with a 3.5-mm screw with 4 cortexes
- Reduce the syndesmosis with a king tong clamp and fix it with a 4.5-mm screw with 4 cortexes
- Repair the deltoid ligament
- Close the wounds and place a below-knee plaster splint
RECOMMENDED READINGS
Lower extremity fractures. In: Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics. Vol 2. 12th ed. Philadelphia, PA: Elsevier-Mosby; 2013:3044.
van den Bekerom MP. Diagnosing syndesmotic instability in ankle fractures. World J Orthop. 2011 Jul 18;2(7):51-6. doi: 10.5312/wjo.v2.i7.51. PubMed PMID: 22474636.
- When comparing intramedullary nailing (IMN) to percutaneous plating for the treatment of distal tibial metaphyseal fractures, IMN is associated with
- longer surgical time.
- more radiation.
- difficult implant removal.
- shorter surgical time.
- lower pain scores.
- shorter surgical time.
RECOMMENDED READINGS
Guo JJ, Tang N, Yang HL, Tang TS. A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. J Bone Joint Surg Br. 2010 Jul;92(7):984-8. doi: 10.1302/0301-620X.92B7.22959. PubMed PMID: 20595119.
Im GI, Tae SK. Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. J Trauma. 2005 Nov;59(5):1219-23; discussion 1223. PubMed PMID: 16385303.
- Figures 102a through 102d are the anteroposterior and lateral radiographs and axial and sagittal CT scans of a 40-year-old woman who was mowing her lawn when she slipped on wet grass and sustained an ankle injury. When performing open reduction and internal fixation, which interval is best used to expose and reduce the structure marked by the arrow?
- Anterior tibial tendon and extensor hallucis longus
- Peroneus brevis and peroneus tertius
- Peroneus brevis and fibula
- Flexor hallucis longus and peroneus longus
- Flexor hallucis longus and flexor digitorum longus
- Flexor hallucis longus and peroneus longus
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.
Tornetta P 3rd, Ostrum RF, Trafton PG. Trimalleolar ankle fracture. J Orthop Trauma. 2001 Nov;15(8):588-90. PubMed PMID: 11733680.
- Figures 107a and 107b are the radiographs of a 45-year-old patient. Which fixation method can most effectively prevent malalignment?
- Intramedullary nailing (IMN)
- IMN with fibular fixation
- IMN with polar screws
- Plating of the distal tibia
- External fixation
- Plating of the distal tibia
RECOMMENDED READINGS
Kwok CS, Crossman PT, Loizou CL. Plate versus nail for distal tibial fractures: a systematic review and meta-analysis. J Orthop Trauma. 2014 Sep;28(9):542-8. doi: 10.1097/BOT.0000000000000068. Review. PubMed PMID: 24464094.
Vallier HA, Cureton BA, Patterson BM. Randomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fractures. J Orthop Trauma. 2011 Dec;25(12):736-41. doi: 10.1097/BOT.0b013e318213f709. PubMed PMID: 21904230.
- The appropriate entry for an intramedullary tibia nail being used for fixation of a central third diaphyseal tibial fracture is ideally positioned at which point in Figure 111?
- A
- B
- C
- D
- E
- B
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.
- Figure 114 is the radiograph of a 23-year-old man who is seen in the emergency department after a motor vehicle collision. He is hemodynamically stable, alert, and oriented, but he has pain in his left leg and hip. An examination should reveal that the limb is
- short and internally rotated.
- short and in neutral alignment.
- short and externally rotated.
- long and externally rotated.
- normal length and internally rotated.
- short and externally rotated.
RECOMMENDED READINGS
Canale ST, Beaty JH, Campbell WC. Fractures and dislocations. In: Campbell WS, Canale ST, Beaty JS, eds. Campbell’s Operative Orthopaedics. Philadelphia, PA: Mosby/Elsevier; 2013:3249.
Dislocations of the Hip. In: Rockwood CA, Green DP, Heckman JD, Bucholz RW, eds. Rockwood and Green’s Fractures in Adults. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1789.
- A 33-year-old man injures his right wrist and left leg in a motorcycle collision. He has a closed left midshaft tibia fracture and a closed comminuted right intra-articular distal radius fracture. Prior to treatment, he reports mild paresthesias in his right hand but can identify light touch on all digits. The surgeon performs closed reduction and splinting of both injuries, and the patient reports resolution of the median nerve paresthesias. Eight hours later, the surgeon is called to evaluate the patient because of increasing pain in his right arm. He appears agitated and uncomfortable, with a heart rate of 120 and blood pressure of 135/90 mm Hg. The surgeon opens his splint, and his right forearm compartments are soft. His fingers are pink and well perfused with brisk capillary refill. He cannot identify light touch to his thumb, index, or long finger, but can identify light touch to his small finger. He can actively flex and extend the digits through a small arc of motion with pain and has discomfort with passive stretch. What is the best next step?
- Measure forearm compartment pressures
- Obtain a stat complete blood count (CBC) and electrocardiogram (EKG)
- Obtain electromyography (EMG) study
- Emergent forearm fasciotomies
- Emergent carpal tunnel release
- Emergent carpal tunnel release
RECOMMENDED READINGS
Niver GE, Ilyas AM. Carpal tunnel syndrome after distal radius fracture. Orthop Clin North Am. 2012 Oct;43(4):521-7. doi: 10.1016/j.ocl.2012.07.021. Epub 2012 Sep 4. Review. PubMed PMID: 23026468.
Davis DI, Baratz M. Soft tissue complications of distal radius fractures. Hand Clin. 2010 May;26(2):229- 35. doi: 10.1016/j.hcl.2009.11.002. Review. PubMed PMID: 20494749.
- Figures 123a and 123b are the radiographs of a 37-year-old man who was the front-seat passenger in a motor vehicle collision. He is unable to move his knee and describes a shifting sensation. An examination reveals limited range of motion and the appearance as shown in the clinical photograph in Figure 123c. Foot pulses are palpable with an ankle-brachial index of 0.95. Several unsuccessful attempts at closed reduction are made. What is the best next step?
- Skeletal traction using a proximal tibial pin in the emergency room
- Skeletal traction using a calcaneal pin in the emergency room
- Open reduction through a posterior approach
- Open reduction through an anteromedial approach
- Closed reduction in the operating room using femoral distraction.
- Open reduction through an anteromedial approach
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.
Wand JS. A physical sign denoting irreducibility of a dislocated knee. J Bone Joint Surg Br. 1989 Nov;71(5):862. PubMed PMID: 2584265.