Trauma - RC Q's Flashcards

Question 1

Q

RC 2018 LRINEC components for nec fasc? High score assx with which organism? Comorbidities that increase risk of NF?

Answer

A

<ul> <li><b>Score >6 assx with Pseudomonas Aeruginosa</b></li><li><b>s</b>core > 6 has PPV of 92% of having necrotizing fasciitis </li> <ul> <li>think: CBC (Hb, WBC), lytes (Na, Cr), infx (CRP, glu)</li><li>CRP (mg/L) </li> <ul> <li>≥150: 4 points</li><li><150: 0 points</li> </ul> <li>WBC count (×10³/mm³) </li> <ul> <li><15: 0 points</li> <li>15–25: 1 point</li> <li>>25: 2 points</li> </ul> <li>Hemoglobin (g/dL) </li> <ul> <li>>13.5: 0 points</li> <li>11–13.5: 1 point</li> <li><11: 2 points</li> </ul> <li>Sodium (mmol/L) </li> <ul> <li><135: 2 points</li> </ul> <li>Creatinine (umol/L) </li> <ul> <li>>141: 2 points</li> </ul> <li>Glucose (mmol/L) </li> <ul> <li>>10: 1 point</li></ul></ul><li>Comorbidities:</li><li>DM</li> <li>Age</li> <li>Obesity</li> <li>AIDS</li> <li>Cancer</li> <li>PVD</li> <li>IV drug use</li> <li>Alcohol abuse</li> <li>Chronic immunosuppresion</li></ul>

<div>Notes</div>

<ul><li>Mortality 10% (6-76%) - RFs: time from admission to debridement, age>60, Streptococcal toxic shock, immunocompromised</li><li><div>Triad: swelling, erythema, pain (out of proportion) - most sensitive symptom</div></li><li><div>antibiotics<ul><li>initial antibiotics<ul><li>start empirically with penicillin, clindamycin, metronidazole, and and aminoglycoside</li></ul></li><li>definitive antibiotics<ul><li>penicillin G<ul><li>for strep or clostridium</li></ul></li><li>imipenemordoripenemormeropenem<ul><li>for polymicrobial</li></ul></li><li>addvancomycin<strong></strong>or<strong></strong>daptomycin<ul><li>if MRSA suspected</li></ul></li></ul></li></ul></div></li></ul>

<div><div> <div><u>Type</u></div> <div><u>Organism</u></div> <div><u>Characteristics</u></div> <div>Type 1</div> <div></div> <div>Polymicrobial</div> <div>Typical 4-5aerobic and anaerobicspecies cultured:</div> <div>•non-Group A Strep</div> <div>•anaerobes including Clostridia</div> <div>•facultative anaerobes</div> <div>•enterobacteria</div> <div>•Synergistic virulence between organisms</div> <div>• Most common (80-90%)</div> <div>• Seen in immunosuppressed (diabetics and cancer patients)</div> <div>• Postop abdominal and perineal infections</div> <div>Type 2</div> <div></div> <div>Monomicrobial</div> <div>• Group A β-hemolyticStreptococciis most common organism isolated</div> <div>• 5% of cases</div> <div>• Seen in healthy patients</div> <div>• Extremities</div> <div>Can cause infx within 24hrs of surgery</div> <div>Type 3</div> <div>Marine Vibrio vulnificus</div> <div>(gram negative rods)</div> <div>++ virulent</div> <div>• Marine exposure</div> <div>Type 4</div> <div>MRSA</div> <div></div><div><br></br></div> </div></div>

Question 2

Q

<div>RC 2012, 2011 - Distal radius; all of the following are risk factors for failure of non-op treatment except</div>

<div>B. Dorsal angulation</div>

<div>C. Metaphyseal Comminution </div>

<div>D. Radial shortening</div>

Answer

A

B.<div><br></br></div><div><div>Mackenney, McQueen (JBJS 2006) Prediction of instability in distal radius fractures</div> <ul> <li>Patient age, metaphyseal comminution of the fracture and ulnar variance were most consistent predictors of radiographic outcome</li> <li>Dorsal angulation not found to be a significant predictor</li></ul></div>

Question 3

Q

<div>RC 2018 - Regarding clavicle fractures, all have been shown to increase nonunion rates EXCEPT?</div>

<ol> <li>Fracture displacement</li> <li>Increasing age</li> <li>Female gender</li> <li>Ipsilateral scapula fracture</li></ol>

<div><div>RC 2014, 2015 What is a risk factor for mid-shaft clavicle non-union:</div> <div>A. Scapula fracture</div> <div>B. Male</div> <div>C. Younger age</div> <div>D. Degree of displacement</div></div>

Answer

A

Pt: female, age>60<div># pattern: displacement > 1.5cm, comminution</div>

Question 4

Q

RC 2013 - What has the highest chance of a clavicle non union <ul> <li>A. proximal 1/3 clavicle</li> <li>B. Middle 1/3 clavicle</li> <li>C. Distal 1/3 clavicle lateral to CC ligaments</li> <li>D. Distal 1/3 medial to CC ligaments</li></ul>

Answer

A

“D. Lateral 1/3rd - medial to CC ligament (type 2)<div>(lateral to CC is often undisplaced - type 1)</div><div><br></br></div><div>Nonunion rate 28-75% but only 20-34% are symptomatic</div><div><br></br></div><div><img></img><br></br></div>”

Question 5

Q

<div>RC 2013, 12, 11 - Clavicle fracture; what is NOT indication to fix?</div>

<div>A. Grade III open</div>

<div>B. Floating Shoulder</div>

<div>C. 5 mm displaced lateral clavicle</div>

<div>D. 1.5 cm shortening</div>

Answer

A

<div>Answer: C</div>

Shortening >1.5-2cm<div>Displacement >100%</div><div><br></br></div><div>Open #, polytrauma, early functional recovery</div><div><br></br></div><div>Union times 16 weeks vs 24 weeks</div>

Question 6

Q

RC 2017 - 50-year-old female with 3 part proximal humerus. All are accepted methods of fixation except <ol> <li>Percutaneous pinning with C-arm imaging</li><li>Open reduction with pins and tension bands</li> <li>ORIF with a plate</li> <li>Hemi</li></ol>

Answer

A

b.<div><ul> <li>CRPP beneficial for 2 part, 3 part, and valgus-impacted 4 part #s</li> <li>ORIF w/ plate = obvious</li> <li>Hemi = good option</li> <li>Open reduction w/ pins and tension band? Never seen it, never mentioned in JAAOS article…</li> <li>ANSWER: B</li></ul></div>

Question 7

Q

<div>RC 2013 - What is the first priority during reconstruction of a traumatic brachial plexus injury?</div>

<ol> <li>Shoulder stability</li> <li>Wrist extension</li> <li>Protective sensation of the hand</li> <li>Elbow flexion</li></ol>

Answer

A

<div><b>4. elbow flexion</b></div>

<b><div><b><br></br></b></div>1- elbow flexion (MCQ 2013)</b><div>2- Shoulder abduction</div><div>3 - hand sensation</div><div>4- wrist extension/finger flexion</div><div>5- wrist flexion and finger extension</div><div>6- intrinsic hand function</div>

Question 8

Q

RC 2012 - Components of SSSC?

Answer

A

Glenoid<div>Coracoid</div><div>CC ligaments</div><div>Clavicle</div><div>AC ligaments</div><div>Acromion</div>

Question 9

Q

<div>RC 2013 - What is true regarding a humeral nail vs. ORIF of a humerus fracture? </div>

<div>A. Humeral nail associated with more shoulder pain </div>

<div>B. ORIF has more malunion </div>

<div>C. Radial nerve palsy is contraindication to humeral nail </div>

<div>D. Varus angulation of 15 degrees is poorly tolerated</div>

Answer

A

Nail: higher nonunion 3-30%, higher delayed nonunion, re-op 10-40%, <b>shoulder impingement 15%</b><div>Plate: nonunion 3%, re-op 10%</div>

Question 10

Q

RC Oral - TT for radial nerve palsy?

Answer

A

“Wrist ext: PT -> ECRB<div>thumb ext: PL –> EPL</div><div>finger ext: FCR –> EDC</div><div><br></br></div><div><img></img> <div></div> <img></img> <img></img><br></br></div>”

Question 11

Q

RC 2017 - Picture of Type IV capitellum fracture (McKee variant), what is true? <ol> <li>The trochlea is intact</li> <li>The capitellum is intact</li> <li>An olecranon osteotomy must be done</li> <li>A direct midline anterior approach is not a good option</li></ol><div><div>RC 2016 - Which of the following is true? </div> <div>A. An olecranon osteotomy is required </div> <div>B. An anterior approach is contra-indicated </div> <div>C. The capitellum is fractured and the trochlea is intact </div> <div>D. The capitellum is intact and the trochlea is fractured</div></div><div><br></br></div><div><div>RC 2012 - Double Bubble XRAY showing coronal shear fracture of elbow. What is true</div> <ol> <li>Need to view trochlea</li> <li>Can fix from an antecubital approach</li> <li>MCL is torn</li> <li>Represents an Isolated capitellar fracture</li></ol></div>

Answer

A

“<div>RC 2017 - D; RC 2016 - B, RC 2012 - A</div><div><br></br></div>Type 1/4 –> ORIF with Posterior incision, lateral approach +/- medial approach or olecranon osteotomy<div><br></br></div><div><b>do not go anterior; go lateral</b></div><div><b>type 4s extend into trochlea - double bubble</b></div><div><img></img><b><br></br></b></div><div><img></img><b><br></br></b></div>”

Question 12

Q

<div>RC 2008 - After performing a radial head replacement, the elbow is still unstable when in supination. All the following are potential reasons except:</div>

<div>1 – Radial head implant is too large</div>

<div>2 – LUCL is avulsed off of lateral epicondyle</div>

<div>3 – Coranoid fracture that has not been fixed</div>

<div>4 – MCL rupture that was not recognized</div>

Answer

A

<div>1. RH is prob too small!</div>

Question 13

Q

RC 2016 - Technical Considerations for Fixing Coronoid?

Answer

A

-Exposure: medially, FCU split gives best visualization<div><br></br><div>-Reduction: flex elbow to reduce tension, ensure cortical read and articular read good</div><div>-Fixation: buttress plate, dorsal to volar screws, suture repair</div><div><br></br></div><div>-others: talk about algorithm for TT injury (ie can maybe fix coronoid through lateral approach with RH gone)</div></div>

Question 14

Q

RC 2014, 2012 List 3 ways to judge fragment size for RH replacement?

Answer

A

<div>-Clinical: assess lateral aspect of UH with and without trial head in place (<b>most sensitive)</b>; implant should be at the level of the lateral edge of coronoid (PRUJ <1mm proximal to lateral edge of coronoid), reconstruct fragments then downsize 2mm, stable through ROM<br></br></div>

<div>-X-ray: assymetry of medial UH articular (but this is bad: requires 6mm of overlengthing for this to change); cf contralateral side</div>

Question 15

Q

<div>RC 2018,2014 Which of the following is true regarding olecranon fractures:</div>

<ol> <li>A decrease in the proximal ulna dorsal angulation (PUDA) results in a decrease in elbow extension</li> <li>When performing an olecranon excision and triceps advancement for a comminuted fracture, attaching the triceps to the anterior aspect of the ulna results in increased extension strength</li> <li>It is sometimes acceptable to leave an articular gap or bone loss in severely comminuted fractures</li> <li>A tension band results in increased compressive strength at the fracture site compared to a pre-countered plate</li></ol>

Answer

A

<div>Answer: C</div>

Question 16

Q

<div>RC 2015, 2012 - What is the mechanism of injury in Bado I Monteggia fractures:</div>

<div>A. Forced supination</div>

<div>B. Forced pronation</div>

<div>C. Hyperextension</div>

<div>D. Fall on flexed elbow</div>

Answer

A

” <div> <div>B. hyperpronation</div><div><br></br></div><div>remember: type 2 has a posterior RH (think of supination pushing the RH out the back like in PLRI). so type 1 = anterior RH = forced pronation</div><div><img></img></div><div>Note: monteggia assx with 20% risk of PIN injury</div> </div>”

Question 17

Q

RC 2018 -<div>(1) What is the superficial muscle interval of the Henry approach to the distal radius?</div><div>(2) What neurovascular structures will you encounter in the middle and distal portions of this approach?</div><div>(3)Volar muscles to elevate off radius for plating?</div>

Answer

A

“<ul> <li>What is the superficial muscle interval of the Henry approach to the distal radius?</li> <ul> <li>Distal: FCR (median) and brachioradialis (radial)</li> <li>Prox: PT (median) and BR (radial)</li> <li><img></img></li> </ul> </ul> <div></div> <ul> <li>What neurovascular structures will you encounter in the middle and distal portions of this approach?</li> <ul> <li>Proximal: PIN</li> <ul> <li>Supinate to incise supinator and protect PIN</li> </ul> </ul> </ul> <div><img></img></div> <div></div> <ul> <li>Middle: Superficial radial nerve, radial artery</li> <ul> <li>Pronate to take off PT</li> <li><img></img></li> </ul> <li>Distal: palmar cutaneous branch of median nerve, radial artery</li> <ul> <li><img></img></li> </ul> <li></li> </ul> <ul> <li>What 4 muscles must be taken/dissected off or divided to place a plate along the entire length of the volar radius?</li> <ul> <li>PQ, FPL, PT, FDS, supinator</li> <li><img></img></li> </ul> <li>When working in the proximal third of this approach, what nerve will you need to protect?</li> <ul> <li>PIN</li> <ul> <li><img></img></li> </ul> </ul></ul><div></div>”

Question 18

Q

<div>RC 2018 - Regarding the volar henry approach:</div>

<ul> <li>What is the superficial muscle interval of the Henry approach to the distal radius?</li><li><div>What neurovascular structures will you encounter in the middle and distal portions of this approach?</div></li><li><div><div>What 4 muscles must be taken/dissected off or divided to place a plate along the entire length of the volar radius?</div></div></li><li><div><div>When working in the proximal third of this approach, what nerve will you need to protect?</div></div></li></ul>

Answer

A

“<div><div><ul> <li>What is the superficial muscle interval of the Henry approach to the distal radius?</li> <ul> <li>Distal: FCR (median) and brachioradialis (radial)</li> <li>Prox: PT (median) and BR (radial)</li> <li><img></img></li> </ul> </ul> <div></div> <ul> <li>What neurovascular structures will you encounter in the middle and distal portions of this approach?</li> <ul> <li>Middle: Superficial radial nerve, radial artery</li> <ul> <li><img></img></li> </ul> <li>Distal: palmar cutaneous branch of median nerve, radial artery</li> <ul> <li><img></img></li> </ul> </ul> <li>What 4 muscles must be taken/dissected off or divided to place a plate along the entire length of the volar radius?</li> <ul> <li>PQ, FPL, PT, FDS, supinator</li> <li><img></img></li> </ul> <li>When working in the proximal third of this approach, what nerve will you need to protect?</li> <ul> <li>PIN</li> <ul> <li><img></img></li> </ul> </ul></ul></div></div>”

Question 19

Q

RC 2018 - RFs for synostosis after BBFA # and tx?

Answer

A

<div>injury: proximal, comminution, same level, large soft tissue injury, disruption of IOM, head injury</div>

<div>surgical: delay in tx >4weeks, single approach (Boyd), disruption of IOM (dissection, hardware, bony fragments), primary bone grafting</div>

<div>Treatment:</div>

<div>-operative(resection): anconeus or free fat interposition</div>

<div>-post-op: 700cGy radiation, Indomethacin 25 TID</div>

Question 20

Q

RC 2015 - Which of the following is not normal for distal radius <div> a. Ulnar variance -1mm</div> <div> b. Ulnar variance +1mm</div> <div> c. volar tilt 11 degrees</div> d. radial inclination of 18 degrees

Answer

A

<div>Answer: D</div>

<div>Normal parameters</div>

AP: radial height 12mm, <i>radial inclination 22 deg</i>, ulnar neutral (range -4 to +2)<div>Lat: volar inclication 11 deg, SL 45 deg</div><div><br></br></div><div><div> <div>View</div> <div>Measurement</div> <div>Normal</div> <div>Acceptable criteria</div> <div>AP</div> <div>Radial height</div> <div>13mm</div> <div>< 5mm shortening</div> <div></div> <div></div> <div>Radial inclination</div> <div>23°</div> <div>change < 5°</div> <div></div> <div></div> <div>Articular stepoff</div> <div>congruous</div> <div>< 2 mm stepoff</div> <div></div> <div>Lateral</div> <div>Volar tilt</div> <div>11°</div> <div>dorsal angulation < 5° or within20° of contralateral distal radius</div> <div></div> </div></div><div><br></br></div>

Question 21

Q

RC 2018, 2014 - After a distal radius fracture, a patient sustains a rupture of the EPL. What deficit will they have? <ol> <li>Thumb IP extension only</li> <li>Thumb IP extension and pronation</li> <li>Thumb IP extension and abduction</li> <li>Thumb IP extension and adduction</li></ol><div><div></div> <div>RC 2018, 2016 - Wrist 6 months post-ORIF. Patient returns unable to extend thumb DIP. What is the NEXT best step?</div> <ol> <li>Tendon transfer EIP to EPL</li> <li>Tendon transfer FDS to EPL</li> <li>Nerve conduction studies</li> <li>Thumb IP Joint Fusion</li></ol></div>

Answer

A

<div>A. Most common time period after a distal radius fracture for EPL rupture is 8 weeks after injury.</div>

<div>A.EIP is <i>ulnar to EDC</i></div>

Question 22

Q

RC 2018 -Regarding tension band wiring, all are true EXCEPT? <div>a.The medial malleolus is an example of a dynamic tension band</div> <div>b.Tension band wire can neutralize tensile forces, and in fact can convert them in compression forces with joint flexion</div> <div>c.A plate on the tension side of bone can act as a tension band</div> d.Using it on the tension side of a bone will lead to compression on the opposite cortex

Answer

A

<div>Answer: A</div>

-TBW can neutralize tensile forces and convert them to compressive forces at joint in flexion<div>-Plate on tension side can act as tension band</div><div>-medial mal tension band is considered <b>static (not dynamic) -</b> forces of fracture after applicaiton remain fairly constant</div><div><b><br></br></b></div>

Question 23

Q

RC 2018 - A 17 year old male is seen following an injury he sustained. After see his MRI (below), what is the recommended treatment? (the MRI shows root avulsion C8/T1) <div>a.Tendon transfers</div> <div>b.Nerve repair</div> <div>c.Neurotization</div> <div>d.Shoulder arthrodesis</div>

Answer

A

-<b>nerve transfer (neurotization) </b>should be done within 18 months for viability of motor end plate<div>-tendon transfer is back up for c8-t1</div><div>-cant do nerve repair (pre-ganglionic)</div>

Question 24

Q

RC 2018, 15, 12 - Open Fracture in Water tx?

Answer

A

-<b>delayed wound closure</b><div>-Fresh Water (Tx: FQ -<b>ciproflox)</b>: <b>Staph</b>, Vibrio, Aeromonas Hydrophilia (fresh air), Pseudomonas</div><div>-Salt water (Tx: doxy): mycobacterium marinum, clostridium</div>

Question 25

Q

<div>RC 2011 - Regarding compartment syndrome which will NOT help treat acute compartment syndrome:</div>

<div>A. Transfusing to keep HGB greater than 100</div>

<div>B. fixing hypotension</div>

<div>C. Giving O2 by mask</div>

<div>D. Cutting all circumferential dressings and casts</div>

Answer

A

emergent fasciotomy<div>transfusion for Hb>100</div><div>fixing hypotension</div><div>cutting casts</div><div><b>not giving O2 by mask (MCQ )</b></div>

Question 26

Q

RC 2015, 2010 Leadbetter Maneuver?

Answer

A

“FATI CABE<div>-flexion, adduction, Traction and IR hip</div><div>-Circumduction, ABduction, extension of hip while maintaining IR</div><div><img></img><br></br></div>”

Question 27

Q

RC 2015, 2013, 2010 What are three radiographic factors indicate adequate reduction of a displaced femoral neck?

Answer

A

“<div>-Standard parameters: Displacement <2mm, <5 deg angulation</div><div>-Specific parameters: Lovell’s lines (gentle S), Garden alignment index (>160 on AP, 180 on lat)</div><div>-‘overall impression’</div><div><br></br></div><div>-open approach - direct visualization<br></br></div>”

Question 28

Q

<div>RC 2014, 2012 - List 5 factors that increase the 30 day morbidity of a patient with a hip fracture</div>

Answer

A

Nottingham score (SAQ):<div>Age>65, >80</div><div>Male</div><div>Institutionalized<br></br></div><div>PMHX: MMSE<6, anemic (Hb<100), >2 comorbidities, malignancy</div><div><br></br></div><div>score >5 = high risk = 86% 30 day survival , 54% 1 year</div><div><br></br></div><div>Note:Current in-hospital mortality rates are approximately 6%, while 1-year mortality rates depending on the study are found to be between 20-30%</div>

Question 29

Q

RC 2013, 12 Elderly person suffers a Garden 3-4 fracture of the femoral neck. Concerning all arthroplasty (Hemi and THA) compared to fixation which of the following is NOT true? <div>A. Functional outcomes are better for arthroplasty</div> <div>B. Mortality is greater for fixation </div> <div>C. Revision is greater for fixation</div> <div>D. Blood loss is less for fixation</div>

Answer

A

<div><b>Answer: B.</b><b>increased early mortality for THA</b></div>

<div>THA has better fxnal outcome</div>

<div>fixation - less blood loss, greater risk of revision surgery</div>

Question 30

Q

<div>RC 2014 - The medial femoral circumflex travels anterior to all of the following except:</div>

<ol> <li>Obturator Internus</li> <li>Obturator externus</li> <li>Superior gemellus</li> <li>Inferior gemellus</li></ol>

Answer

A

“B.<div><br></br></div><div><img></img><br></br></div><div><br></br></div><div><img></img><br></br></div>”

Question 31

Q

<div>RC 2015 - In a severely displaced femoral neck fracture, what blood supply to the femoral head is likely preserved?</div>

<div> a. Medial femoral circumflex</div>

<div> b. Lateral femoral circumflex</div>

<div> c. Retinacular vessels</div>

<div> d. Obturator</div>

Answer

A

D<div><div>Supplies the artery of the ligamentum teres, has minimal blood supply to the head in adults, but the vessels running up the neck are disrupted in displaced femoral neck fractures</div></div>

Question 32

Q

RC 2011 - Clinical Features of varus malunion femoral neck # (list 4)?

Answer

A

<div>Pain, decreased walking distance</div>

Trendelenberg sign (Abductor weakness)<div>LLD, difference in rotation</div><div>prominent GT - bursitis</div><div>decreased ROM</div><div>Obligate external ROM with flexion (impingement)</div>

Question 33

Q

<div>RC Exam 2012: When performing a valgus intertrochanteric osteotomy and bone grafting for a nonunion of a femoral neck fracture in a 40 year old, all of the following are true, except?</div>

<div>A. Need to medialize the shaft as much as possible </div>

<div>B. It is best to leave at least 2 cm between entry point of blade plate and osteotomy </div>

<div>C. Aiming for angulation of fracture line to horizontal of 20-30 degrees </div>

<div>D. There is a high union rate but a limp persists</div>

Answer

A

<div>Answer: A</div>

-<b>Lateralize shaft</b>(VaLgus = Lateral) - MCQ 2012<div>-angle goal is 20-30 deg from horizontal</div><div>-leave 2cm between blade and osteotomy</div><div>-high union rate, but limp may persist</div>

Question 34

Q

RC 2017, 2013 - List 3 strategies for avoiding varus in subtroch?

Answer

A

-position: lateral to allow flexion, abd, IR<div>-Nail start point: medial or piriformis entry</div><div>-Closed reduction: crutch, cobb, F-tool</div><div>-Perc reduction: Schanz pin into neck, linea</div><div>-Open reduction: clamps, wires, unicortical plate</div><div>-Reaming: medial!</div>

Question 35

Q

<div>RC 2012 Inter-troch fractures. All are true EXCEPT</div>

<div>A. decreased failure with Tip to apex < 25 mm</div>

<div>B. decreased failure with 150 degree DHS</div>

<div>C. decreased failure with females</div>

<div>D. Fracture pattern</div>

Answer

A

<div>Answer: B</div>

<div>RFs for failure</div>

Tip Apex Distance > 25mm<div>Unstable fracture pattern</div><div>Poor reduction</div><div><b>150 degree DHS (MCQ 2012)</b></div><div>Superior and anterior/posterior screw placements (ie. Peripheral placements?) Older patient age (not associated in some)<br></br></div>

Question 36

Q

RC 2011 - Adv/Disadv for piriformis vs GT start nails?

Answer

A

Piriformis<div><b>-Adv (SAQ 2011):</b> less varus malunion, colinear trajectory with shaft, decrease risk of GT blowout</div><div>-Disadv: more difficult start point, less forgiving in A to P plane, risk of iatrogenic fem neck fracture, decreased blood supply to fem head in peds, increased dissection</div><div><br></br></div><div>GT</div><div>-adv: easier start point, less soft tissue damage</div><div>-disavantage: increase risk of varus malalignment, increase risk of fracture comminution (b/c you direct nail medially), GT blow out</div>

Question 37

Q

RC 2017, 2016, 2015 - Radiographic Strategies to determine femoral rotation during nailing shaft fracture?

Answer

A

“-cortical step sign, width<div>-LT profile</div><div>-Tornetta technique (True anteversion angle), perfect lateral</div><div><br></br></div><div>Others: prep other limb to determine clinical rotation, intrinsic nail values, post-op CT</div><div><br></br></div><div><ul> <li>Tornetta Technique (1995): True anteversion angle. Anteversion determined off c-arm angles for perfect lateral of proximal femur and knee of non-injured limb, recreate with rotation of distal femur to match.</li> <ul> <li>Results in rotational discrepancy under 8 degrees</li> <li>Most reliable</li> </ul> </ul> <div><img></img></div> <div>Figure 1. true anteversion angle. c-arm is used to obtain a true lateral of the normal femoral neck and then rotated until the posterior aspect of the condyles lines up. Difference between these angles is the true anteversion angle (angle A)</div> <div><img></img></div> <div>Figure 2. Nail has been placed and locked proximally. c-arm is used to obtain a true lateral of the femoral neck. Current degree of anteversion is represented by angle B. In this example, the femur has an IR deformity.</div> <div><img></img></div> <div>Figure 3. c-arm is internally rotated to reproduce the correct anteversion for this patient, as measured on the normal side (angle A), and it is moved to the knee. T<b>he surgeon now stabilizes the proximal fracture fragment by holding the locking jig while an assistant rotates the distal fragment via the traction pin or foot holder (arrow</b>). Distal fragment is rotated until the posterior aspect of the condyles line up perfectly on the image.</div> <div><img></img></div> <div>Figure 4. Patient’s normal anteversion (angle A) has now been restored, and distal locking can be done by instrument protocol.</div></div>”

Question 38

Q

RC 2017 - Design features of reamers to decrease IM pressure during nailing?

Answer

A

<div><div><ol> <li>Sharp reamers</li> <li>Deeper reaming flutes</li> </ol><ul> <li>Shallower flutes get clogged and act like a piston</li> </ul> <li>Longer reamer heads</li> <li>Small diameter of reamer drive shaft</li> <li>Suction/irrigation reamer (RIA)</li> <li>Angled reamers (vs blunt reamers)</li> <li>smaller reamer sizes – this may be due to smaller reamer drive shaft diameter</li> <li>Technical point = faster reamer advancement and non-forceful advancement</li> <li>Distal vent hole</li></div></div>

Question 39

Q

<div><div>RC 2014, 2012. List 4 complications associated with the hemi-lithotomy position and the fracture table when nailing a midshaft femur fracture</div></div>

Answer

A

<ul><li><div>Complications</div></li><ul><li><div>Malunion - rotational, angular</div></li><li><div>Non-union - <10%</div></li><li><div>LLD - 43% if comminuted</div></li><li><div>Infection - 1-3.8%</div></li><li><div>Well leg compartment syndrome - hemilithotomy</div></li><li><div>HO</div></li><li><div>Pudendal Nerve palsy - Most common symptoms are pain, numbness</div></li><ul><li><div>Can get incontinence and altered ejaculation</div></li></ul><li><div>Femoral Nerve - AP locking screw in retrograde nail (lock prox to LT to prevent)</div></li><li><div>Vascular injury</div></li><li><div><b>Erectile dysfunction 40% (mcq 2018)</b></div></li><ul><li><div>Mallet R, Tricoire JL, Rischmann P, Sarramon JP, Puget J, Malavaud B. High prevalence of erectile dysfunction in young male patients after intramedullary femoral nailing. Urology. 2005;65(3):559-563.</div></li></ul></ul></ul>

<ul><ul><ul><li><div>Recommendations : Surgical time and/or traction time should be minimized.When surgical</div></li></ul></ul></ul>

<div>time exceeds 120 minutes, intraoperative</div>

<div>traction should be released.</div>

<div>It has been shown that tissue</div>

<div>pressures of 70 mm Hg applied for</div>

<div>120 minutes result in microscopic</div>

<div>tissue damage.42 This idea is further</div>

<div>validated by the knowledge that</div>

<div>tourniquet times are commonly limited</div>

<div>to 120 minutes. Periodic release</div>

<div>of traction is required when traction</div>

<div>is prolonged</div>

Question 40

Q

RC 2013 - advantages of locking plate over DCS for DF #s?

Answer

A

Better fixation in osteoporotic/comminuted bone (multiple points of fixation)<div>Ability to control multiple fracture fragments</div><div>Anatomic contour helps with reduction of joint</div><div>Biomechanically superior in cyclic load and ultimate strength</div><div>Preserves more distal bone stock</div><div>Less soft tissue stripping<br></br></div><div><br></br></div><div>Note: COTS 2016 - LISS vs DCS</div><div>-LISS: 52% healed without intervention, failures 28%, revisions 7/22</div><div>DCS: 91% healed, failures 12.5%, revisions 2/22</div>

Question 41

Q

<div>RC 2014 - For a 95 degree distal femoral locking plate, where should the first guidewire go?</div>

<div>A. Parallel to the joint line, proximal to Blumensaat’s line</div>

<div>B. Parallel to the joint line, distal to Blumensaat’s line</div>

<div>C. Perpendicular to the femoral shaft, proximal to Blumensaat’s line</div>

<div>D. Perpendicular to the femoral shaft, distal to Blumensaat’s line</div>

Answer

A

“A.<div><br></br><div>-parallel to joint line, proximal to Blumensaat’s</div><div><img></img><br></br></div></div>”

Question 42

Q

RC 2013, 11, 10 - LIst 8 Parameters to consider in a trauma patient for DCO vs Early total care

Answer

A

“<b><u>Physiologic Factors</u></b><div>-MAP>60</div><div>-HR<100</div><div>-U/O>0.5cc/kg/hr</div><div>-PaO2/FiO2>300</div><div>-Temp>35</div><div><br></br></div><div><b><u>Acidosis Factors</u></b></div><div><i>-Lactate<2.5</i></div><div><i>-BE N= -2 to +2 (do not want >6-8) *best as per MCQ 2015</i></div><div>-pH>7.25</div><div>-gastric mucosal pH>7.3</div><div><br></br></div><div><b><u>Coag Factors</u></b></div><div>-Plts>90</div><div>-Fibrinogen>1</div><div>-low D-dimer, PTT</div><div><br></br></div><div><b><u>Conceptual framework: SSCC</u></b></div><div>-soft tissue: extremity, chest, abdo</div><div>-shock</div><div>-cold: low temp</div><div>-coag</div><div><br></br></div><div><br></br></div>”

Question 43

Q

RC 2014, 11 - List 4 signs of Class 4 hypovolemic shock?

Answer

A

“-BL >2000cc (40% blood volume)<div>-decreased BP</div><div>-decrease PP</div><div>-HR>140</div><div>-U/O - none</div><div>-MS: comatose</div><div>-RR>35</div><div><br></br></div><div><img></img><br></br></div><div><br></br></div><div>MASSIVE TF protocol: 1:1:1 pRBC: plts:plasma</div>”

Question 44

Q

RC 2017, 16, 15 - 8 Xray signs of traumatic aortic rupture?

Answer

A

“<div><b><u>Stay organized! - aorta, trachea, esophagus, lungs, pleura, fractures</u></b></div><div><b><u><br></br></u></b></div><div><b><u>Findings from loss of aortic arch</u></b></div>-Widened mediastinum (more than 8cm)<div>-Obliteration of aortic knob i.e. Disuption of the calcium ring of the aortic knob (broken halo sign)</div><div>-Loss of outline of the descending aorta</div><div>-Loss of the aorto pulmonary window (the space between the pulmonary artery and the aorta)</div><div>-Widened paraspinal interfaces (this the line on xray that outlines the aorta on either side of the spine) <div></div> <div><b><u>Trachea and esophageal findings:</u></b></div>-Trachea deviated to right</div><div>-Deviation of the esophagus (or NG tube) to the right of the T4 spinous process (more than 1-2cm)</div><div>-Widened paratracheal stripe <div></div> <div></div> <div><b><u>Intra-pulmonary and chest wall findings:</u></b></div>-Presence of a left apical cap (indicates an apical pleural hematoma)</div><div>-Left hemothroax</div><div>-Depression of left mainstem bronchus of lung (more than 40 degrees)</div><div>-Elevation of right mainstem bronchus</div><div>-Fractures of the first or second rib or scapula<br></br></div><div><br></br></div><div><div> <div> <div><img></img></div> </div></div></div>”

Question 45

Q

RC 2017, 2014 - List 4 major and 4 minor criteria of FES?

Answer

A

<u>Major = cope = coma, oxygen, petechial rash, edema</u><div>-CNS depression</div><div>-Resp: Hypoxemia, pulm edema</div><div>-derm: petechial rash</div><div><br></br></div><div><u>Minor = FPRTTD</u></div><div>-fat in urine</div><div>-pyrexia</div><div>-retinal emboli</div><div>-tachycardia</div><div>-thrombocytopenia</div><div>-decrease hct</div><div><br></br></div><div>Tx: supportive, ICU, maybe steroids (no mortality benefit)</div>

Question 46

Q

<div>RC 2012 - A patient presents with a distal pole patella fracture with displacement and comminution. The patient has a large hemarthrosis and extensor mechanism disruption. What is the best treatment option?</div>

<div>A. Complete patellectomy</div>

<div>B. ORIF maintaining all fragments</div>

<div>C. Partial patellectomy with repair to posterior patella </div>

<div>D. Inferior pole patellectomy with repair to anterior patella</div>

Answer

A

<b><div><b><br></br></b></div>ORIF (</b>is better than partial patellectomy)<div>If resecting, then put patellar tendon anteriorly (Reduces contact stresses)</div><div><br></br></div><div><ol> <li>Vaselko M (JBJS 2005) Inferior Patellar Pole Avulsion Fractures: Osteosynthesis Compared with Pole Resection</li> </ol><ul> <li>Retrospective review of 14 vs 11 fractures</li> <li>Average patellofemoral score better in internal fixation group than resection with patellar ligament repair (94 vs 81)</li> <li>Normal patellar height in 10/11 ORIFs, 3/13 tendon advancements</li> </ul> <div></div> <ol> <li>JAAOS 2011 - Patellar Fractures in Adults</li> </ol><ul> <li>Partial Patellectomy and Inferior Pole Fracture</li> <ul> <li>Saltzman et al, Marder et all found that reattachment of the patellar tendon to the anterior surface of the remaining patella - which most resembles the native anatomy-substantially minimized contact stresses</li> <li>Saltzman –> 40 patients with partial patellectomy</li> <ul> <li>78% good or excellent, quads strength 85%</li> </ul> <li>Bostman –> poor outcomes if >40% of patella removed</li> <li>Marder –> increased PF contact forces with patellectomy</li> </ul> </ul></div>

Question 47

Q

<div>RC 2017 - Which defect filler will have the least subsidence with tibial plateau fractures?</div>

<ol> <li>Calcium sulfate</li> <li>Calcium phosphate</li> <li>Iliac crest autograft</li> <li>Cancellous allograft</li></ol>

Answer

A

b. Ca PO4<div>(equivalent union rates to iliac crest)</div>

Question 48

Q

<div>RC 2015, 2011 Regarding fixation of a tibial plateau fracture, which is true?</div>

<div> a. Locking plates have better outcomes and less complications than non-locking plates</div>

<div> b. Locking plates have better outcomes and more complications than non-locking plates</div>

<div> c. Locking plates have equal outcomes and less complications than non-locking plates</div>

<div> d. Locking plates have equal outcomes and equal complications as non-locking plates</div>

Answer

A

D. equivalent outcomes and complications

Question 49

Q

<div>RC 2013 Proximal tibia fracture. What has the lowest rate of ligament injury</div>

<div>A. Bicondylar</div>

<div>B. Lateral joint depression</div>

<div>C. Lateral joint split</div>

<div>D. Lateral joint split depression</div>

Answer

A

C. Lateral joint split (Schatzker 1) - least energy (MCQ 2013)

Question 50

Q

<div>RC 2016 Tibial external fixator is placed. In converting to definitive treatment all of the following are acceptable EXCEPT: </div>

<div>A. 2 weeks convert to IM nail </div>

<div>B. 2 weeks convert to plate </div>

<div>C. 5 weeks, curettage pin sites, IM nail </div>

<div>D. 5 weeks, curettage pin sites, delayed IM nail</div>

Answer

A

If >28 days, then remove ex-fix, curretage pin sites and delay IMN or plate<div>PIN SITE HOLIDAY</div><div>MCQ 2016</div>

Question 51

Q

RC 2018, 2015, 2012 - List 5 intra-op techniques to aid reduction of proximal tibial shaft fracture when nailing?

Answer

A

-position: semi-extended<div>-approach: supra-patellar</div><div>-start point: lateral</div><div>-perc: blocking screws, femoral distractor</div><div>-open: unicortical plate</div><div>-nail: increased Herzog angle (or more proximal)</div>

Question 52

Q

RC 2018 - 3 tibial fracture patterns that increase risk of distal ankle injury?

Answer

A

<ul> <li>A spiral pattern tibia fracture</li> <li>A distal one-third tibial shaft fracture location, </li> <li>Spiral pattern fibula fracture </li> <ul> <li></li> <li>JOT 2014 - Predictive Radiographic Markers for Concomitant Ipsilateral Ankle Injuries in Tibial Shaft Fractures</li> <li>Thirty-five of 71 (49.3%) tibial shaft fracture patients had a concomitant ipsilateral ankle injury. Of these, 31 (88.6%) ankle injuries occurred in patients with a spiral pattern tibia fracture of the distal third diaphysis (P , 0.001).</li> </ul></ul>

Question 53

Q

<div>RC 2013, 2015 In a grade IIIA open tibia fracture, which of the following is true?</div>

<div> a. Delayed closure results in decreased wound complications</div>

<div> b. Delayed closure results in increased wound complications</div>

<div> c. Delayed closure results in decreased infection</div>

<div> d. Delayed closure results in increased infection</div>

Answer

A

<b><u>increased infection </u></b>(MCQ 2013, 2015)<div><div><br></br></div>Primary Closure - 3% infection</div><div>Delayed Closure - 17% infection<br></br></div><div><br></br></div><div>JBJS 2014 Delayed Wound Closure Increases Deep Infection Rates Associated with Lower-Grade Open Fracture<br></br></div><div><br></br></div><div><div>Bhattacharyya (Plast Reconstr Surg 2008)</div> 12.5% infection for <7 days, 57% > 7 days<br></br></div>

Question 54

Q

<div>RC 2013, 12 “Type II” open tibia treated with bmp 2 at definitive procedure. What is NOT true? (These are the answers we were given; absolutely they meant type II open)</div>

<div>A. Lower rate of subsequent bone grafting procedures</div>

<div>B. Lower rate of subsequent soft tissue procedures</div>

<div>C. Higher infection</div>

<div>D. Lower infection</div>

Answer

A

-<b>lower infx (NOT higher)</b><div>-lower rate of subsequent bone grafting</div><div>-lower rate of subsequent soft tissue procedures</div><div><br></br></div><div><div>Govender S (JBJS 2002) Recombinant human BMP-2 for treatment of open tibial fracture</div> <ul> <li>94% follow up at 2 years (unreamed nail)</li> <li>BMP-2 group:</li> <ul> <li>44% reduction in risk of failure</li> <ul> <li>secondary intervention because of delayed union</li> </ul> <li>Fewer intervention</li> <li>Faster fracture healing</li> <li>Fewer hardware failures</li> <li>Fewer infections (type IIIA/B injuries)</li> <li>Faster wound healing</li> </ul></ul></div>

Question 55

Q

<div>RC 2016 - Proximal tibia fracture. Where do you place your blocking screws to prevent deformity?</div>

<div>A. Anterior and medial</div>

<div>B. Anterior and lateral</div>

<div>C. Posterior and medial</div>

<div>D. Posterior and lateral</div>

Answer

A

“<div>D.</div><div>At risk of valgus and procurvatum</div><div><br></br></div><div><ul> <li>Aids to reduction:</li> <ul> <li>Nail in extension</li> <li>Blocking screws</li> <ul> <li>Increase strength and rigidity of fixation</li> <li>Place on concave side of deformity</li> </ul> <li>Lateralize start point</li> <li>Increase Herzog angle</li> <li>Unicortical Plate at the fracture site</li> </ul></ul></div><div><img></img> <img></img><br></br></div>”

Question 56

Q

<div>RC 2015 - What is a described complication of antegrade nailing a proximal femur fracture using a lateral entry nail</div>

<div>A. varus malunion</div>

<div>B. valgus malunion</div>

<div>C. increased disruption of femoral head blood supply</div>

<div>D. Increased hoop stresses and fracture</div>

Question 57

Q

RC 2012 - List 4 principles of managing pilon excluding soft tissue?

Answer

A

“<div>LENGTH, ALIGNMENT, (ROTATION)</div>-reduce/fix fibula for length<div>-correct varus/valgus tibia</div><div>-ligamentotaxis to reduce anterolateral and posterior fragments</div><div>-anatomically reduce and fix articular block</div><div>-autologous bone grafting of metaphyseal defect</div><div>-buttress plating to prevent angulation</div>”

Question 58

Q

<div>RC 2014 - A patient suffers an open pilon fracture. You are shown an x-ray with a huge piece of the medial malleolus and distal articular surface. They tell you it is devoid of soft tissue attachment. How do you manage this patient?</div>

<ul> <li>A. Autoclave and reimplant</li> <li>B. Send to the bone bank for later reimplantation</li> <li>C. Discard</li> <li>D. Clean thoroughly and reimplant</li></ul>

Answer

A

D. clean thoroughly and re-implant<div><br></br></div><div><br></br></div><div><div>Van Winkle, on the other hand, advocated chlorhexidene lavage and antibiotic emersion as a 100% effective method of clearing microbial contamination. Case reports of total talar extrusion have succeeded with reimplantation through various techniques. Assal et al reported no infection with use of pulsatile normal saline lavage and emergent reimplantation. Smith reported on 27 cases of talar extrusion, all with use of Bacitracin baths and reimplantation. They averaged 6.7 hours before operative debridement and had one infection.</div></div>

Question 59

Q

RC 2017 - 5 indications for amputations after trauma? 2017 SAQ/CORF

Answer

A

“Near or complete amputation at presentation<div>-Complete anatomic disruption of tibial nerve</div><div>-Irreparable vascular injury</div><div>Crush injury w/ > 6 hrs warm ischemic time</div><div>Serious associated polytrauma</div><div>Severe ipsilateral foot trauma</div><div>Anticipated protracted reconstructive course<br></br></div><div><br></br></div><div>MESS score (not predictive in LEAP study)</div><div><img></img><br></br></div>”

Question 60

Q

RC 2016, 2013 - List 3 xray findings of syndesmosis injury?

Answer

A

“<div>clear space >6mm (AP/mortise) is ABNORMAL</div><div>overlap <6mm (AP) or <1mm (mortise) is ABNORMAL</div><div>medial clear space >6mm</div><div>PM fracture</div><div>—</div><div><br></br></div><div>AP Normal: overlap >6mm on AP, clear space <6mm</div><div>AP injury: overlap <6mm on AP, clear space >6mm</div><div><br></br></div><div>Mort Normal: overlap >1mm, clear space <6mm</div><div>Mort injury: NO overlap, clear space >6mm</div><div><br></br></div><div><br></br></div>AP: overlap>6mm, clear space<6mm<div>Mo: overlap>1mm, clear space<6mm, med clear space<6mm</div><div>Lat: avulsion off post mal</div><div>other: proximal spiral fibula fracture</div><div><img></img><br></br></div><div><br></br></div>”

Question 61

Q

<div>RC 2018, 2014 - What is the most common fracture associated with a talar neck fracture?</div>

<ol> <li>Medial malleolus</li> <li>Fibula</li> <li>Calcaneus</li> <li>Lisfranc</li></ol>

Answer

A

1.<div><div>In a study by Hawkins,8 15 of 57 patients (26%) had associated fractures of the medial malleolus.</div><div><br></br></div><div>Canale and Kelly9 found that 11 of 71 pa- tients (15%) with fractures of the talar neck had associated fractures of the medial and lateral malleoli (10 and 1, respectively).</div><div><br></br></div><div><br></br></div></div>

Question 62

Q

<div>RC 2016, 2013 - All of the following are true regarding a Hawkin’s sign following a talar neck fracture, except: </div>

<ol> <li>It is a radiolucent line underneath the subchondral surface on xray</li> <li>It is useful as evaluation for vascularity of the talus</li> <li>It usually shows up at 3 weeks post injury</li> <li>It is caused by osteopenia from bone resorption.</li></ol>

Answer

A

-evidence of preserved vascularity of talus<div>-radiolucency in subchondral bone (caused by osteopenia from bone resorption)</div><div><b>-6-8 weeks after #</b></div>

Question 63

Q

RC 2017 - Patient comes in with a talar dislocation, after anterolateral and anteromedial incisions you are still unable to reduce the talus. What is the next step?<ol> <ol> <li>Fibular osteotomy</li> <li>Medial malleolar osteotomy</li> <li>Inline traction</li> <li>Femoral Distractor</li> </ol></ol>

Answer

A

“4.<div><br></br></div><div>old answer: 2. MM osteotomy</div><div><ul> <li>Rockwood’s:</li> <ul> <li>Mentions distractor, and no mention of osteotomy</li> <li>Additional traction, if needed, can be performed with a Schanz pin or a mini-distractor. Associated osteochondral fragments are debrided.</li> </ul> <li>JAAOS on talar neck fracture said medial mal osteotomy should be last resort. First step after open reduction should include using shxantz pins and universal distractor)</li></ul></div>”

Question 64

Q

RC 2017, 2012 Talar neck goes onto <u> </u>malunion, best seen on <u> </u>xray. treatment may include <u> </u>given the affected <u> </u>motion<div><br></br></div><div>RC MCQ Young patient has talar neck fracture that is fixed but goes on the malunion, what is true:<div><ol> <ol> <li>Subtalar motion will not be affected</li> <li>AP radiograph is best for seeing it</li> <li>Varus Malunion</li> <li>Osteotomy is contra-indicated</li> </ol></ol></div></div>

Answer

A

“<b>varus malunion</b><div>Canale Xray - 15 deg inverted, 15 deg from vertical</div><div>Osteotomy (if no arthrosis)</div><div>subtalar motion is abnormal!</div><div><br></br></div><div><img></img><br></br></div><div><br></br></div><div>Answer: 3</div>”

Answer 64

A

“4 - Tarsal canal (From the post tib)<div><img></img><img></img><br></br></div><div><br></br></div>”

Answer 65

A

“<div>FOR TALAR NECK FRACTURE</div>casette under PF foot<div>15 deg pronation</div><div>15 deg from vertical (Tube at 75 deg from horizontal)</div><div><br></br></div><div><img></img><br></br></div>”

Answer 66

A

<div><div>ANSWER - B </div><div>ANSWER - B</div> <div>Lateral - its the (postero-) medial structures:</div><div>-tom dick and nervous harry</div><div>-Tib post</div><div>-<b>FHL</b>(MCQ 2012, 2014,2016)</div><div>-FDL</div></div>

Medial - its the lateral structures:<div>-Boney: Talar head fracture, navicular #</div><div>-soft-tissue: <b>TN capsule (MCQ 13,15,18)</b>, extensor retinaculum, EDB, peroneals, NVB</div><div><br></br></div><div><ul> <li>Associated fractures (Bibbo C (FAI 2003))</li> <ul> <li>Medial:</li> <ul> <li>Dorsomedial talar head</li> <li>Posterior tubercle of talus</li> <li>Lateral Navicular</li> </ul> <li>Lateral:</li> <ul> <li>Cuboid</li> <li>Anterior calcaneus</li> <li>Lateral process of talus</li> <li>Lateral mal (Fibula)</li> </ul> </ul></ul></div>

Answer 67

A

A. Build off sustentaculum

Answer 68

A

<b>A.</b>Better pain management with arthrodesis for primary ligamentous regardless of age

Answer 69

A

AP<div>-disruption of medial 2nd MT and medial cuneiform</div><div>-diastasis between MT1 and MT2</div><div>-flec sign (avulsion of 2nd MT or med cuneiform)</div><div><br></br></div><div>Oblique</div><div>-disruption of medial MT4 and medial cuboid</div><div><div>-disruption of medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)</div></div><div><br></br></div><div><br></br></div><div>Lateral</div><div>-collapse of mid arch (cant see MT5 base from medial cuneiform collapse)</div>

Answer 70

A

<ol> <li>Osseous Intrinsic Stability:</li> </ol>

<ul> <li>Trapezoidal shape of middle three MT bases and cuneiforms produces a stable arch</li> <li>Recessed 2nd MT keystone creating a stable mortise</li> <ul> <li>Recessed 8 mm proximal to med cuneiform and 4 mm proximal to lateral cuneiform</li> </ul> </ul>

<li>Ligaments:</li>

<ul> <li>Transverse intermetatarsal - D2-D5 base MTs </li> <li>Oblique:</li> <ul> <li>Dorsal, interosseous and plantar ligaments between medial cuneiforms and 2nd MT</li> <li>Interosseous > Plantar > Dorsal</li></ul></ul>

Answer 71

A

A<div><br></br></div><div><div>A - 7.3mm cannulated screws, so need at least 1-2 mm space around screw (moorhead)</div> <div>B - False, see below, in dysmorphic cases S2 is preferred</div> <div>C & D - False, Assuming this asks if its safe screw with 1.5 cm displacement, see below, substantial loss of space for screws with > 1 cm displacement</div></div>

Answer 72

A

-Patient (list 1): increasing age, multiply injured (ISS score)<div>-Clinical/Lab (List 4): sBP<100, severe acidosis, BD<6mmol/L, change in BD>2mmol/L</div><div>-Xray (list 2): SI joint widening. APC II/III, LCII/III, VS, combined</div><div><br></br></div><div>Mortality with bleed: 47%</div><div>Mortality without bleed: 2%</div>

Answer 73

A

<b>A. Age >40 (NOT <40 yrs)</b><div>initial displacement</div><div>impaction</div><div>associated fem head injury</div><div>—</div><div><u>RF breakdown:</u></div><div>-patient factors: <b>age>40</b>, high BMI</div><div>-injury factors: fem head impaction, displacement >2cm, PW, anterior dislocation</div><div>-surgical factors: non-anatomic reduction, roof incongruence, EIL approach</div>

Answer 74

A

B - do not use RA angles for PW fractures<div><br></br></div><div>PW can only be treated nonop if hip is stable and congruent (ie likely need EUA)</div><div>old rule that <20% PW involvement is stable is not necessarily true</div>

Answer 75

A

B.<div><br></br></div><div><div>Sagi JOT 214</div> <ul> <li>Treatment with 6 weeks of indomethacin does not appear to have a therapeutic effect for decreasing HO formation after acetabular fracture surgery and appears to increase the incidence of nonunion. Treatment with 1 week of indomethacin may be beneficial for decreasing the volume of HO formation without increasing the incidence of nonunion.</li></ul> <div>JAAOS Feb 2017 HO in acetabular surgery</div> <ul> <li>Sufficient literature indicates NSAIDs are ineffective</li> <li>Sufficient literature supports a significant increase in fracture non-union</li></ul></div>

Answer 76

A

<b>D - true</b><div>A - false</div><div>B - false - gull sign = superomedial dome impaction (AC-PHT)</div><div>C-false</div>

Answer 77

A

B. Stoppa<div><br></br></div><div><div>JOT 2014 - The modified Stoppa approach allows for exposure of most (79%) of the inner true bony pelvis including the entire pelvic brim and 80% of thequadrilateralsurface.</div></div>

Answer 78

A

1 or 2 - both are true (prism says 1)<div>Cannot use roof arc measurements for associated both column since there is no intact portion of the acetabulum to measure BUT you also can’t use it in B either because of the posterior wall component<br></br></div>

Answer 79

A

4<div><br></br></div><div>Isolated posterior wall fractures have all other lines intact - YES</div><div>Posterior wall fractures >40% are associated with hip instability –> should go on to fixation</div><div>Articular <b><u>steps</u></b> associated with poor outcomes –> therefore should be disimpacted- Not necessarily splits<br></br></div>

Answer 80

A

“D. ilioinguinal/stoppa (if injury pattern starts with ‘A’ so go Anterior)”

Answer 81

A

weakness without paralysis<div>edema</div><div>stiffness</div><div>pallor</div><div>subjective numbness to extremity without objective anesthesia</div><div><br></br></div><div>Resolves over weeks to months</div><div>Times: Thigh 300-350min, arm 250-300<br></br></div><div><br></br></div><div>—</div><div><br></br></div><div>Minimize comp (list 3):</div><div>-allow intermittent reperfusion<br></br></div><div>-alternating cuffs</div><div>-wider cuff, lower inflation pressures</div><div>-hypothermia of limb</div><div><br></br></div>

Answer 82

A

“<div>PMHx: DM, hypoT, malnutrition (VitD/Ca), anemia</div><div>Meds: NSAIDS, steroids/immunosupp</div><div>SocHx: smoking, EtOH</div><br></br><div>Surgical factors: soft tissue stripping, fixation rigidity/stability</div><div><br></br></div><div><div> <div> <div><img></img></div> </div></div></div>”

Answer 83

A

B<div><br></br></div><div><ul> <li>Braking function returns to normal 4 weeks after knee arthroscopy, 9 weeks after surgical management of ankle fracture, and 6 weeks after the initiation of weight bearing following major lower extremity fracture</li> <ul> <li>It describes driving 3 weeks after full weightbearing in ankle fractures, so the 9 week mark is because people typically prevent weightbearing until 6 weeks.</li> </ul> <li>Patients may safely drive 4-6 weeks after right total hip arthroplasty</li></ul></div>

Answer 84

A

A<div><div>There is level 1 evidence that patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out should have pelvic angiography/embolization.</div></div>

Answer 85

A

A.<div><div>The mean age of the 27 patients at time of fracture was 75.6 years (52 to 91 years) and 23 (85%) were female</div></div>

Answer 86

A

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

Answer 87

A

“B<div><br></br></div><div>not C/D - this is hypovolemic shock</div><div><img></img><br></br></div>”

Answer 88

A

<div>a.Maintenance fluids!</div>

<div>Patients in neurogenic shock typically have a heart rate between 50 and 70 beats per minute and a systolic pressure 30-50mm Hg below normal Treatment of neurogenic shock includes an initial fluid challenge, Trendelenberg positioning, vasopressors after central line insertion and atropine for treatment of bradyarrhythmias<br></br></div>

<div>Management of Neurogenic shock</div>

<div>Trendelenburg 10-20 deg</div>

<div>Address fluid deficit</div>

<div>Maintenance fluids (RC EXAM)</div>

<div>Pressor support/ICU</div>

<div>Swan Ganz catheter for monitoring fluid status</div>

<div>Supplemental oxygen<br></br></div>

Answer 89

A

D<div><br></br><div><br></br></div><div>Type 1- No identifiable peripheral nerve study on current objective testing methods</div><div>Type 2- Clinical presence of signs of peripheral nerve injury (i.e. nerve conduction study findings) - causalgia, no evidence for stellate ganglion block however<br></br></div></div>

Answer 90

A

A<div><ul> <li>HTD: head to tuberosity distance should be ~10mm</li> <li>B - false–> use cement to maintain humeral component height</li> <li>C - false–> should be 5.6cm above pec</li> <li>D - false –> should be 20 deg retroverted</li></ul></div>

Answer 91

A

“Answer: A<div><b><ul><li><div><15 mm of GT displacement considered as positive criterion for an acromioplasty indication</div></li></ul><ul><li><div>Arthroplasty with tuberosity osteotomy drastically decreases constant scores post-op</div></li><ul><li><div>Most common is hemi with a humeral stem, but now RTSA becoming more common</div></li><li><div>Osteotomy often is also indication to allow implantation of the new stem</div></li></ul><li><div>Short stem for AVN of HH</div></li></ul></b><div><img></img><br></br></div><div><br></br></div></div>”

Answer 92

A

B<div><br></br></div><div><b><div>A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography.</div><div><br></br></div><div> </div>Conclusion: Syndesmotic screw and TightRope had similar postoperative malreduction rates. However, intraoperative CT scanning of ankles with TightRope fixation was misleading due to dynamic nature of the fixation. <u>After at least 2 years of follow-up, malreduction rates may slightly increase when using trans-syndesmotic screw fixation, but reduction was well maintained when fixed with TightRope</u>. Neither the incidence of ankle joint osteoarthritis nor functional outcome significantly differed between the fixation methods.</b><br></br></div><div><br></br></div>

Answer 93

A

<div><b>Modified Judet Approach and Minifragment Fixation of Scapular Body and Glenoid Neck Fractures<div>The ‘‘L-’’shaped incision was carried down to the shoulder girdle fascia. An extrafascial plane was created from the distal tip of the acromion, along the lateral border of the scapula, to the inferior scapular angle. The inferior border of the deltoid was identified. A 1- to 2-cm vertical incision in the area bisecting the superior angle and the midportion of the lateral border was made. The deltoid muscle was incised sharply from the scapular spine cephalad and bluntly from the infraspinatus deep laterally until reaching the lateral scapular border. </div></b><br></br></div>

Answer 94

A

<div>Answer: B</div>

<div>JAAOS 2012. Cole et al. Management of scapular fractures</div>

<ul> <li>Indications for surgery often include such parameters as:</li> <ul> <li>medialization (>25 mm), </li> <li>25°to 45° angulation on a lateral radiograph,</li> <li>GPA <20°, and </li> <li>Displaced double lesions of the SSSC.</li> <li>Some of the papers described ligamentous injury as part of the double lesions</li> </ul> <li>Fractures involving the neck and body the staff to make up approximately 80 to 90% of surgical injury patterns. They are addressed or post your approach.</li> <li>I didn’t find a good study to look at nonoperative treatment however Herrera et al recorded a mean disability of the arm, shoulder and hand score 14 and 26 month follow-up as well symmetric motion and your complete recovery of strength</li></ul>

Answer 95

A

B<div><br></br></div><div><div> </div><div>JAAOS 2009 Intramedullary Nailing of Femoral Shaft Fractures</div><div>In addition to the time taken to set up the traction table and position the patient, complications may be seen associated with the traction table use, such as <b>neurological injuries (pudendal nerve palsy, sciatic nerve palsy, common peroneal nerve palsy, erectile dysfunction)</b>, soft tissue contusions, pressure ulcers, compartment syndrome, crush syndrome and vascular injuries (by-pass graft occlusion, inferior epigastric artery avulsion)</div><br></br></div>

Answer 96

A

C<div><br></br></div><div><b><div>ANSWER: C</div><div>· Nails may have less blood loss intraoperatively but that does not translate to lower transfusion rates than SHS</div><br></br><div>· Strategies Trauma Limb Recon 2012 – Dual lag screw cephalomedullary nail versus the classic sliding hip screw for stabilization of intertrochanteric fractures. A prospective randomized study</div><div>o CMN – Shorter OR and longer fluoroscopy time</div><div>o No difference noted – Functional recovery, reoperation and mortality</div><div>Specifically – no difference in the transfusion requirements b/w CMN and SHS</div><div>· Injury 2017 – Sliding Hip Screw vs Intramedullary Nail for trochanteric hip fractures: A Randomized Trial of 100 Patients with presentation of results related to fracture stability</div><div>o No Significant Differences between IMN and SHS devices </div><div>· Rate of implant cut out</div><div>· Device failure</div><div>· Nonunion</div><div>· Infection – both superficial & deep</div><div>· Mobility scores</div>o Significant Difference – the only difference found - Lower pain among patients with an AO type 3 fracture treated with an IMN versus a SHS at 9 months</b><br></br></div>

Answer 97

A

A<div><br></br></div><div>Fresh water = Fluoroquinolone (ciproflox)</div><div>Salt water = doxycycline</div><div><br></br></div><div><div>Contraindications for immediate closure of wounds include gross contamination with feces, dirt, stagnant water, farm injuries, fresh water injuries, delay to initiation of antibiotics >12 hours, and questionable tissue viability at initial surgery</div> <div></div> <div>JAAOS 2005 Extremity Trauma and Related Infections Occurring in the Aquatic Environment</div> <ul> <li>Cover with floroquonolone</li> <ul> <li>Cipro, levoflox</li> </ul> <li>Stabilize fracture</li> <li>Tetanus</li> <li>Explore wound, DO NOT cover primarily, leave it oepen or loosely approximate</li> <ul> <li>Small wounds, secondary healing</li> <li>Large wounds</li> <ul> <li>Delayed closure 3-7 days</li> </ul> </ul> </ul> <div>Orthobullets</div> <ul> <li>Freshwater - Flouroquinolone or 3rd or 4th gen cepholosporin</li> <li>Saltwater - doxy + ceftazidime or flouroquonolone</li></ul></div>

Answer 98

A

<u>RIA</u><div>-intraop fracture or cortical performation requring fixation</div><div>-blood loss, transfusion risk</div><div><br></br></div><div><u>IC-BG</u></div><div>-minor: infx, hematoma, seroma, post-op pain, merlagia paresthetica</div><div>-major: pseudoaneursym, AV fistula, pelvic fracture, hernia</div><div><br></br></div><div><u>ALWAYS</u>: INFECTION, BLEEDING, PAIN</div>

Answer 99

A

-ensure component stability<div>-preserve endosteal blood supply<br></br><div>-fixed angle plate fixation that spans both components by 2 cortical widths</div><div>-use screws AND wire fixation around implants</div><div>-augment with allograft, autograft</div></div>

Answer 100

A

<div>START Lateral - see if you can get to coronoid through radial fracture, if not, do combo approach</div>

-Medial approach: fix coronoid<div>-Lateral approach: fix RH and LUCL repair (90 deg flexion and pronation)</div><div>-Stress elbow: fix MCL if needed, then Ex-fix if needed</div><div><br></br></div>

Answer 101

A

C.<div><br></br></div><div><div><u>RF breakdown:</u></div><div>-patient factors:<b>age>40</b>, high BMI</div><div>-injury factors: fem head impaction, displacement >2cm, PW, anterior dislocation</div><div>-surgical factors: non-anatomic reduction, roof incongruence, EIL approach</div></div>

Answer 102

A

“<ul><li>JAAOS - Intramedullary Nailing of femoral shaft fractures</li> </ul> <div>Piriformis Entry Nails</div> <div>Advantages:</div> <ol> <li>Has a colinear trajectory with the femoral shaft (i.e. it’s a more “straight shot”, in line with the shaft”</li> <li>Decreased risk of varus malreduction (remember, more lateral start point = varus malreduction, too medial = valgus malreduction)</li> <li>Decreased risk of iatrogenic fracture comminution</li> <li>Decreased risk of GT fracture (i.e. GT “blow out”)</li></ol>”

Answer 103

A

“C.<div><br></br></div><div><div><a>J Orthop Trauma.</a>2015 Nov;29(11):479-87. doi: 10.1097/BOT.0000000000000437.</div> <div>Multicenter Randomized Clinical Trial of Nonoperative Versus Operative Treatment of Acute Acromio-Clavicular Joint Dislocation.</div> <div><a>Canadian Orthopaedic Trauma Society</a>.</div> <div></div> <div>RTW: </div> <div>Patients in the nonoperative group returned to work earlier than those in the operative group. At 3 months after injury, 76% of patients in the nonoperative group had returned to work versus only 43% in the operative group. This was statistically significant (P = 0.004). By 1 year after injury, patients in both groups had almost all return to work (Fig. 5). </div> <div></div> <div>Although hook plate fixation resulted in superior radiographic alignment, it was not clinically superior to nonoperative treatment of acute complete dislocations of the AC joint. </div> <div>The nonoperative group had better early scores, although both groups improved from a significant level of initial disability to a good or excellent result (mean DASH score, 5-6; mean constant score, 91-95) at 2 years. At present, there is no clear evidence that operative treatment with the currently available hook plate improves short-term outcome for complete AC joint dislocations.</div></div>”

Answer 104

A

B.<div><br></br></div><div><br></br></div>

Answer 105

A

“<div>B</div><div><br></br></div>(double bubble - ie fracture of the capitellum and trochlea - type 4)<div><br></br></div><div>do a lateral approach, may need a medial approach to help reduce the trochlea as well, but DON’T go anterior<br></br><div><br></br></div><div><img></img> <br></br></div></div>”

Answer 106

A

A.<div><br></br></div><div><div>Assess LCL functional disruption of the LUCL secondary to capitellar comminution with lateral epicondylar fragmentation or avulsion is more common than is an intrasubstance tear of the ligament.</div></div>

Answer 107

A

<ul> <li>Position: supine with arm over chest, lateral with bolster</li> <li>Incision: posterior, then raise lateral fasciocutaneous flap only and <b>do your lateral approach first;</b> may not need a medial approach at all if you can access coronoid fracture through your radial head defect</li> <li>Fix RH (or replace)</li> <li>Fix Coronoid (cannulated screws, mini plates, suture repair through trans osseous tunnels created with ACL guide)/anterior capsule</li> <li>Repair lateral ligs (LCL) at 90 deg flexion with suture anchor</li> <li>Evaluate stability of medial side (repair MCL)</li> <li>Ex-fix if still unstable</li></ul>

Answer 108

A

RH #<div>Coronoid #</div><div>Elbow Dislocation</div>

Answer 109

A

A.<div><br></br></div><div><ul> <li>Too small of radial head will lead to instability è DJ: I don’t know about this…</li> <li>JHS Reference points for radial head prosthesis size DOORNBERG</li> <ul> <li>“A prosthesis that is too large also may contribute to persistent elbow instability after surgical repair”</li> </ul></ul></div>

Answer 110

A

“D.<div><ul> <li>Pugh DMW (JBJS 2004) Standard surgical protocol to treat elbow dislocations with radial head and coronoid fracture</li> <ul> <li>"”protocol included fixation or replacement of the radial head, fixation of the coronoid fracture and repair of associated capsular and lateral ligamentous injuries, in selected cases repair of MCL””</li> </ul></ul></div>”

Answer 111

A

C.<div><ul> <li>Doornberg JHS Jan 2006</li> <li>an implant that is too large and causes widening of the lateral side of the ulnotrochear joint space and radiocapitellar wear</li> </ul> <div>I couldn’t find any evidence that they will get wrist pain or increased tightness of the interosseous membrane or that for sure will have equal functional outcomes. However, according to Cohn et al. (radiocapitellar joint contact pressures following radial head arthroplasty Journal of hand surgery American 2014) over stuffing the real head causing malalignment of the radiocapitellar joint and lateral gapping of the ulnar humoral increases pressures or alter kinematics that could ultimately result hyaline cartilage erosion, synovitis and osteoarthritis)</div></div>

Answer 112

A

A.<div><ul> <li>JBJSBr 2006 undiagnosed essex-lopresti - wrist scores were worse than elbow scores preop</li> </ul> <div></div> <div>JAAOS, 2007, RH, RN# - With injury to or excision of the radial head, normal load sharing at the radiocapitellar joint no longer occurs, and all compressive loads are transferred from the distal radius to the ulna through the interosseous membrane and the distal radioulnar joint. Longitudinal radioulnar dissociation may follow when radial head fracture occurs in association with damage to any of these stabilizing soft-tissue structures, particularly the interosseous membrane.</div></div>

Answer 113

A

A. ORIF for <u><</u>3 pieces<div><ul> <li>Review of 56 patients at 2 years with type 4 radial head #</li> <li>Most patients with Mason III fractures with >3 fragments had poor results (13/14)</li> <li>12 patients with < 3 –> no non-union, early failure or severe loss of ROM</li> <li>Greater than 3 fragments should be excised or replaced</li></ul></div>

Answer 114

A

<ul> <li>Elbow stiffness</li> <li>Radiocapitellar arthrosis</li> <li>Loss of pronation/supination</li> <li>Longitudinal forearm instability</li> <li>Weaker:</li> <ul> <li>Infection</li> <li>PIN injury</li> <li>HO/Synostosis</li> <li>Elbow Instability</li> </ul></ul>

Answer 115

A

“A.<div><img></img><br></br></div>”

Answer 116

A

A<div><br></br></div><div>Internervous plane (none)<ul><li>between the brachialis (musculocutaneous n. and radial n.) and brachioradialis (radial n.)</li></ul></div>

Answer 117

A

“C.<div><div>No direct contribution from the SGA to the femoral head was identified in any specimen (C is not true). The SGA contributed indirectly to femoral head vascularity by taking part in a periacetabular vascular ring (15, 16) which was formed by contributions from the gluteal vessels proximally and circumflex femoral vessels distally. <b>As described above, the supra-acetabular branch of the SGA anastomosed with the ascending branch of the LFCA in thirty-two specimens</b>. Additionally, the SGA anastomosed with the proximal deep branch of the IGA on the posterior surface of the acetabulum in thirty specimens.</div></div><div><br></br></div><div><img></img><br></br></div>”

Answer 118

A

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

Answer 119

A

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

Answer 120

A

“B.<div><ul> <li>DJ: Shit question, you would do an ex fix in BOTH Grade IIIB and IIIC. No one is going to wait for you to plate a forearm before doing the vascular repair</li> <li>Previous years argue that IIIB you need soft tissue coverage and therefore you should ex fix and not plate because you will have exposed hardware. In reality, you would plate and get early flap coverage. Based on this logic, IIIC you are more likely to ex fix than IIIB</li> </ul> <div></div> <ul> <li>AO Surgery Reference</li> <ul> <li>"”In general, external fixation is only used as a temporary treatment in forearm shaft fractures. It is often indicated in the presence of severe soft-tissue injuries and in poly-trauma patients whose definitive treatment may have to be delayed””</li> </ul></ul></div>”

Answer 121

A

C<div><ul> <li>Another shit question. I would have chosen C</li> <li>Really difficult choice –> for a grade IIIC injury in the forearm need disruption of both ulnar and radial arteries therefore would need a big wound….however, in order to get segmental bone loss you also need a big wound</li> <li>Some argument that primary shortening is an option in the forearm</li> <li>JAAOS - Adult Diaphyseal Forearm Fractures</li> <ul> <li>The use of external fixation for forearm fractures is indicated in rare cases of severe soft-tissue injury or contamination</li> </ul></ul></div>

Answer 122

A

“<div> <div> <div><img></img></div><div><div> <div> <div> <div>Femur: 5 or 6mm pins</div> <div>Tibia: 4 or 5 mm pins</div> </div> </div></div></div> </div></div>”

Answer 123

A

<ul> <li>Stable construct</li> <li>Sterile technique</li> <li>Soft tissue protector</li> <li>HA pins</li> <li>Sterile bandage</li></ul>

Answer 124

A

“D.<div><div>Leap Study Group - Amputation vs reconstruction</div> <ol> <li>Impact on decision to amputate limb</li> </ol><ul> <li>Severe soft tissue injury - Highest impact on decision-making process**</li></ul> <ul> <li>Absence of plantar sensation</li> <ul> <li>Second highest impact on surgeon’s decision making process</li> <li>Not an absolute contraindication to reconstruction</li> <li>Plantar sensation can recover by long-term f/u</li> <li>The LEAP study showed that there was no difference in outcomes in ppl with sensate vs insensate foot at time of presentation for amputation vs limb salvage.</li> </ul> <li>Outcome measures – same 2 and 7 year outcomes in ppl with amputation vs salvage</li> <ul> <li>Sickness impact profile</li> <li>Return to work</li> <li>Not significantly different b/w amputation and reconstruction at 2 and 7 years</li> </ul></ul></div>”

Answer 125

A

B.<div><ul> <li>JAAOS 2015 - Management of Segmental Bone Defects:</li> <ul> <li>Autologous bone grafting an option up to 5cm</li> <li>Bone transport a good option for infected defects, but usually only used in longer defects</li> <li>Acute shortening an option up to 3-5cm (vascular kinking after this), but more common in upper extremity</li></ul></ul> <ul> <li>Pipitone PS (Orthop Clin NA 2014) Management of Traumatic Bone Loss in the Lower Extremity</li> <ul> <li>Critically sized defects - defect is 2-3x the diameter of the bone</li> <li>Autogenous iliac crest bone graft if <4cm</li> <li>Shortening/lengthening with 2-10cm</li> <ul> <li>Tibia/humerus –> immediate shortening of 3-4cm tolerated</li> <li>Femur –> 5-7cm</li> <li>If defect is >3cm can get venous congestions and edema –> necrosis/infection</li> </ul> <li>Defects > 10cm consider vascularized fibular grafting, distraction osteogenesis</li> </ul></ul></div>

Answer 126

A

“A.<div><br></br></div><div><img></img><br></br></div>”

Answer 127

A

C.<div><ul> <li>JAAOS 2010 - Open Tibial Fracture</li> <ul> <li>Early antibiotics shown to reduce infection (<3 hours)</li> <li>Smoking and diabetes are risk factors for infection</li> <li>Quality of debridement is important for infection risk, but no evidence for timing of debridement</li> </ul></ul></div>

Answer 128

A

A.<div><br></br></div><div><br></br></div>

Answer 129

A

“C.<div><div>Level 4 evidence available as case series have reported positive initial results with loss of reduction occurring in 0–2 %, revision surgery in 0–7 % and wound infection in 0–4 % [<a>5</a>,<a>8</a>,<a>10</a>]. The most common complication reported is lateral femoral cutaneous nerve palsy, reported to occur temporarily in 0–30 % and permanently in 0–1 % [<a>5</a>,<a>8</a>]. Heterotopic ossification has been reported in 0–25 % [<a>5</a>,<a>8</a>].</div></div>”

Answer 130

A

A. Dhaliwal agrees<div>McGill: C</div>

Answer 131

A

“A - prone for T type and transverse<div><br></br></div><div>B-true</div><div><br></br></div><div><div> <div> <div> <div>In summary, Kocher-Langenbeck in the prone position:</div> <ul> <li>Less tension on sciatic nerve (easy to extend hip with cushion under knee, and more under tibia for knee flexion)</li> <li>Better reduction (not statistically significant, but gravity doesn’t displace fracture)</li> <li>Better ability to assess quadrilateral plate through greater sciatic notch</li> </ul> <div></div> <div>Lateral position:</div> <ul> <li>Can fix ipsilateral symphysis fractures, maybe</li> </ul> </div> </div></div></div>”

Answer 132

A

<ul> <li>Open Fractures</li> <li>Failure of conservative management, inability to brace</li> <li>Floating Elbow</li> <li>Poly-trauma/early mobilization</li> <li>Brachial plexus injury/flail extremity</li> <li>Pathologic Fracture</li> <li>Vascular Injury</li> <li>High energy GSW (<b>low E GSW can be treated non-op)</b></li></ul>

Answer 133

A

“D.<div><ul> <li>JAAOS 2000 - Olecranon Fractures</li> <ul> <li>"”if the bent end of the Kirschner wire is left superficial to the triceps fibres routine post-operative elbow extension may cause the wire to back out””</li> <li>"”The most important factor in preventing wire migration is ensuring that the bent proximal end of the wire is buried beneath the fibres of the triceps””</li> </ul></ul></div>”

Answer 134

A

2.<div><ol> <li>Articular displacement does correlate with radiocarpal radiographic arthritic change but has no effect on DRUJ</li> <li>Similarly incongruity of sigmoid notch impacts DRUJ but not radiocarpal joint</li> <li>Radial inclination impacts lunate contact forces</li></ol></div>

Answer 135

A

“C.<div><br></br></div><div><div><br></br></div><div><img></img><br></br></div></div>”

Answer 136

A

C.<div><br></br></div><div><div>CPG from JAAOS 2018 state the following: Evidence supports not delaying hip fracture surgery for pa- tients on aspirin and/or clopidogrel (recommendation level limited</div></div>

Answer 137

A

“A, B are FALSE Statements<div><br></br></div><div><img></img><br></br></div>”

Answer 138

A

C.Inter-locking nail is designed to bring the nail medial in the canal as second screw is placed

Answer 139

A

<ul> <li>Independent risk factors for reoperation (nonunion, infx) </li> <ul> <li>Patient: diabetes, BMI smoking, </li> <li>Injury: open fracture, metaphyseal comminution</li> <li>Surgery: Shorter plate length</li> </ul></ul>

Answer 140

A

B.<div><ul><li>Gardner et al. reported that non-unions of the distal femur occur most often after open and extensively comminuted fractures. According to our review, the most common fracture pattern associated with nonunion is metaphyseal comminution.</li> </ul> <div></div> <div>Ricci JOT 2014 – Risk factors for failure of locked plate fixation</div> <ul> <li>Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length.</li> </ul> <div></div> <div>Rodriguez JOT 2016 Mechanical construct characteristics predisposing to non-union after locked lateral plating of distal femur fractures</div> <ul> <li>No significant univariate differences with respect to number of proximal screws (P = 0.50), plate length (P = 0.17), total screw density (P = 0.56), and proximal screw density (P = 0.92) were observed between healed fractures and those with a nonunion</li></ul></div>

Answer 141

A

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

Answer 142

A

B.<ul> <li>Buckley 2018. A sub-meniscal arthrotomy improves the medium-term patient outcome oftibialplateau fractures</li> <ul> <li>Prospective ORIF (submeniscal arthrotomy) vs CRIF (x-ray guided)</li> <li>Postoperative CT scans showed that reductions were better with the ORIF group especially in the posterolateral quadrant as compared to the CRIF group. The frequency of mal-reductions was higher in the CRIF group. The KOOS, at two years, showed that the CRIF had significantly less good outcomes in the subcategories of SPORT (p = 0.03) and QOL (p = 0.01) measurements.</li> </ul></ul>

Answer 143

A

C.<div><br></br></div><div><ul> <li>Randomized, Prospective Comparison of Plate versus Intramedullary Nail Fixation for Distal Tibia Shaft Fractures. Vallier, Cureton and Patterson. JOT. 2011</li> <ul> <li>High primary union rates were noted after surgical treatment of distal tibia shaft fractures with both plates and nails</li> <li>Rates of infection and secondary procedures were similar when the two groups were compared.</li> <li>Open fractures were associated with increased rates of infection, nonunion, and malunion. </li> <li>Intramedullary nailing was associated with more malalignment versus plating. </li> <li>Fibula fixation may facilitate anatomic reduction of the tibia at the time of surgery, particularly when performing tibial nailing. The effect of retained fibula fixation on tibia healing deserves further study, because we observed a trend for more tibial non-unions with distal fibula fixation.</li> <li>In our combined analysis, nonunion of the tibia was more frequent after nails versus plates.</li> </ul></ul></div>

Answer 144

A

C.<div><ul> <li>Ostrum RF (JOT 1996) Posterior Plating of Displaced Weber B Fibular Fractures</li> <ul> <li>Benefits of posterior plating:</li> <ul> <li>Bicortical screws –> better fixation</li> <li>Stronger and stiffer construct</li> <li>Lag screw stronger as it is done through the plate (acts as a stronger cortex)</li> </ul> </ul></ul><div><br></br></div></div>

Answer 145

A

B.<div><br></br></div><div><div>Fixation of Posterior Malleolar Fractures Provides Greater Syndesmotic Stability. Gardner et. al. Clinical Orthopaedics and Related Research. 2006 </div> <ul> <li>PER Stage 4 ankle fracture with a deltoid ligament tear and posterior malleolus fracture</li> <ul> <li>After fracture creation, five specimens were assigned randomly to receive posterior malleolar fixation…The remaining five specimens received trans-syndesmotic fixation. </li> </ul> <li>Each specimen first was tested intact to determine its baseline stability for later use as its own internal control. </li> <li>Specimens were tested again after fixation to determine the effect of fracture creation and fixation on syndesmotic stability. </li> <li>Posterior malleolar fixation provided better rotational stability than syndesmosis fixation. </li> <ul> <li>Specimens with posterior malleolar fixation had a decrease in stiffness of 30% compared with the intact stiffness of each specimen</li> <li>Patients who had traditional syndesmosis stabilization had a 60% (SD, 20%) decrease in stiffness compared with intact rotation (40% of intact stiffness was restored)</li> <ul> <li>These are confusing statements</li> <li>Basically they mean more stiffness was restored with posterior mal fixation</li> </ul> </ul></ul></div>

Answer 146

A

a.<div><br></br></div><div>variation of repeat</div>

Answer 147

A

C.<div><div>The Weber and Lauge-Hansen fracture classifications suggest that the interosseous membrane (IOM) is torn with certain fracture patterns. In a recent study that evaluated ankle fractures with MRI, Nielson and associates identified 30 patients with IOM tears. Ten of the tears did not correspond with the level of the fibular fracture. The authors concluded that stability of the syndesmosis should not be based on the level of the fibular fracture alone but should also include an intraoperative stress test. Transsyndesmotic fixation should be considered for those fractures where the intraoperative stress test demonstrates instability. A widened medial clear space may occur with a deltoid injury and distal fibular fracture in the absence of a significant tear of the interosseous membrane.</div> <div>PREFERRED RESPONSE: 3</div> <div>REFERENCE: Nielson JH, Sallis JG, Potter HG, et al: Correlation of interosseous membrane tears to the level of the fibular fracture. J Orthop Trauma 2004;18:68-74.</div></div>

Answer 148

A

“C.<div><ul> <li>Lozano-Calderon/Doornberg/Ring (JBJS 2006) Fractures of the dorsal articular margin of the distal part of the radius with dorsal radiocarpal subluxation</li> <ul> <li>Dorsal Barton = subluxation of the distal radius consequent to a fracture through the articular surface of the carpal extremity of the radius, the fragment, usually is quite small and is broken from the dorsal end of the radius”</li> <li>Case series of 19 operative patients</li> <ul> <li>11 had dorsal alone, 7 combined, 1 volar alone</li> <li>“In conclusion, fractures of the dorsal margin of the articular surface of the distal part of the radius associated with dorsal radiocarpal subluxation or dislocation should be carefully evaluated for the presence of volar ligament injury or volar avulsion fracture, central articular impaction, and impaction of the majority of the articular surface as a large volar fragment. A combined dorsal and volar exposure is often necessary for these injuries because the central articular impaction and the dorsal marginal shearing fracture may be best treated through a dorsal exposure in internal fixation and the volar ligament injuries or avulsion fracture require a volar exposure and fixation. Despite the relative complexity of these injuries, satisfactory wrist function can be achieved in most patients.”</li> </ul> </ul><li><div><img></img></div> <div></div> <div><img></img></div></li></ul></div>”

Answer 149

A

<div><div>ANSWER: A</div> <ul> <li>2014, 2016, 2018</li> <li>Skaggs DL (JBJS 2005) Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children</li> <ul> <li>Analysis of 554 open fractures</li> <li>No difference between I&D before 6 hours and after 6 hours</li> </ul> <li>Patzakis and Wilkins</li> <ul> <li>1025 open fractures</li> <li>Infection rate 4.7% with abx before 3 hours and 7.4% antibiotics after 4 hours</li> </ul></ul></div>

Answer 150

A

“<b><br></br><div>Answer A (perforators)</div><br></br><div>Can’t be B (superficial and medial structure)</div><div>Can’t be C (distal structure)</div><div>D highly unlikely, much more proximal and posterior</div></b>”

Answer 151

A

<div> <i>JAAOS 2008 - Complications of Ankle Fractures in Patients with Diabetes</i></div>

<div>· <b>Increased risk of infection</b></div>

<div>· <b>Delayed wound healing</b></div>

<div>· <b>Delayed time to union</b></div>

<div>· <b>Non-union</b></div>

<div>· <b>Mal-union/loss of reduction</b></div>

<div>· <b>Increased hardware failure</b></div>

<div>· <b>Charcot neuroarthropathy</b></div>

<div>· <b>Amputation</b></div>

Answer 152

A

B.<div><br></br></div><div><div>o No evidence in young patients for SHS + antirotation screw vs 3 cannulated</div> <div>o Definitely would try and avoid a cephalomedullary nail in young patient (removing proximal bone stock, violating abductors)</div> <div><i></i></div> <div><i>Optimal Internal Fixation for Femoral Neck Fractures: Multiple Screws or Sliding Hip Screws? Bhandari, et al. J Orthop Trauma. 2009</i></div> <div>§ A meta-analysis by Parker and Blundell evaluated 28 trials (N = 5547 patients) and reported no advantage of any internal fixation technique over any other. </div> <div>§ The pooled estimate for displaced fractures revealed a trend in favor of the sliding hip screw in reducing the need for revision surgery.</div> <div>§ In summary, both indirect and direct comparisons suggest a possible benefit for a sliding hip screw over multiple cancellous screws in reducing the need for revision surgery</div></div>

Answer 153

A

A.<div><br></br></div><div>deformity starts at PIP</div><div><br></br></div><div>B-correct with centralization at PIP with tenotomy at DIP</div>

Answer 154

A

<div>• <b><i>Major</i></b></div>

<div>1. No or minimal trauma (fall from standing height or less) (<b>low energy</b>)</div>

<div>2. Fracture line <b>originates at the lateral cortex</b> and is substantially <b>transverse</b> in its orientation, although it may become oblique as it progresses medially</div>

<div>3. Complex fractures extend through both cortices and may be associated with a <b>medial spike</b></div>

<div>4. <b>Non-comminuted</b> or minimally comminuted</div>

<div>5. Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site (“<b>lateral beaking</b>” or “flaring”)</div>

<div>• <b>Minor</b></div>

<div>1. Generalized increase in cortical thickness of diaphysis</div>

<div>2. Unilateral or bilateral prodromal symptoms</div>

<div>3. Bilateral incomplete or complete fractures</div>

<div>4. Delayed healing</div>

Answer 155

A

“<div><i>Ref: AAOS review Ewing Sarcoma Family of Tumours - Feb 2010</i><i></i></div> <div>• X-ray: sclerosis present in ~40% of cases</div> <div>• 20-28% have fever on presentation</div> <div>• Common to have elevated ESR</div> <div>• Delay very common (studies with 50% of patients w/ symptoms for 6 months before diagnosis)</div> <div><span>• </span><span>Patients with metastatic disease <b>confined to the lung have a better prognosis</b> than do patients with extrapulmonary metastases</span></div>”

Answer 156

A

“<div><span>Ref: Journal of Bone and Mineral Research, Vol. 29, No. 1, January 2014, pp 1–23.</span><img></img></div><ul><li><div><span>Major</span></div></li></ul><ol><li><div>No or minimal trauma (fall from standing height or less)</div></li><li><div>Fracture line originates at the lateral cortex and is substantially transverse in its orientation, although it may become oblique as it progresses medially</div></li><li><div>Complex fractures extend through both cortices and may be associated with a <span>medial spike</span></div></li><li><div>Non-comminuted or minimally comminuted</div></li><li><div>Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site (“<span>lateral beaking</span>” or “flaring”)</div></li></ol><ul><li><div><span>Minor</span></div></li></ul><ol><li><div>Generalized increase in cortical thickness of diaphysis</div></li><li><div>Unilateral or bilateral prodromal symptoms</div></li><li><div>Bilateral incomplete or complete fractures</div></li><li><div>Delayed healing</div></li></ol>”

Answer 157

A

“<div><div>Answer: D</div><br></br><div><span>JBJS 2008. 90: 1738-43</span></div><ul><li><div>Five LE rating scores: MESS, LSI, PSI, NISSSA, HFS-98 are not predictive of outcome and therefore cannot be used to determine limb salvage vs recon</div></li></ul><ul><li><div>Conclusion states that currently available injury severity scores are not predictive of functional recovery of patients who undergo successful limb salvage surgery<br></br><br></br></div></li></ul><div><span>LEAP study</span></div>Helps with some prognostication but no good/useful score available<br></br></div>”

Answer 158

A

“<div>Answer: B</div><br></br><div><span>Ref: Clin Orthop Relat Res. 2004. 399:78-86</span></div><ul><li><div>58% of all complications include fem neck/shaft non-union were from single antegrade IM nails</div></li><li><div>Concluded that single device had worst results</div></li><li><div>Improved outcomes with reamed IM nail/lag screw combo</div></li></ul><br></br><div><span>Ref: Diagnosis and Management of Ipsilateral Femoral Neck and Shaft Fractures. JAAOS 2019</span></div><ul><li><div>Ostrum et al reported a multicenter series of 95 patients who underwent retrograde nailing for the femoral shaft fracture and either cannulated screws or a sliding hip screw for the femoral neck fracture. The authors reported union rates of 98% for the femoral neck fracture and 91.3% for the femoral shaft fracture.</div></li><ul><li><div><span>No difference was noted between cannulated screws and sliding hip screw with regard to femoral neck union.</span></div></li></ul><li><div>In patients with a displaced femoral neck fracture, surgical management typically consists of ORIF of the neck fracture with either a SHS or cannulated screws, followed by retrograde IMN of the femoral shaft.</div></li><li><div>Selection of proximal implants is based on the femoral neck fracture pattern, degree of comminution, and bone quality.</div></li><li><div>An open reduction of the femoral neck is performed through an anterior approach using joysticks, clamps, and preliminary wire fixation.</div></li><li><div>Using a lateral approach, either a SHS with one or two anti-rotational screws or cannulated screws in an inverted triangle pattern are placed. The screws of either construct are placed in the posterior half of the shaft such that the retrograde nail is able to pass anterior to them.</div></li><li><div>The femoral shaft fracture is then reduced, and a retrograde IMN is placed with the tip of the nail passing anterior to the screws of the proximal implant.</div></li></ul>”

Answer 159

A

“<div>Answer: A</div><br></br><div><span>JBM: This question is based from: van den Bekerom MPJ. Diagnosing syndesmotic instability in ankle fractures. World J Orthop. 2011</span></div><div><span>Ref: van den Bekerom. Diagnosing syndesmotic instability in ankle fractures. World J Orthop 2011</span></div><ul><li><div>On the basis of a biomechanical cadaveric study, Stoffel et al. concluded that use of the lateral (bone hook) stress test or Cotton test. and examination of the tibiofibular clear space on stress radiographs intra-operatively is more reliable, because of the greater displacement when performing this test, than the exorotation stress test.</div></li></ul><ul><li><div><span>The “Hook” or “Cotton” test is more reliable than the exorotation stress test.</span></div></li></ul><br></br><div><span>Ref: JAAOS 2015</span></div><div><span>Ref: Matuszewski PE, et al. Prospective Intraoperative Syndesmotic Evaluation During Ankle Fracture Fixation: Stress External Rotation Versus Lateral Fibular Stress. J Orthop Trauma. 2015;29(4):4.</span></div><ul><li><div>Presented a prospective series of 28 patients undergoing ankle fracture fixation and compared intraoperative testing methods of the syndesmosis.</div></li></ul><ul><li><div><span>They reported that compared with the Cotton test, stress external rotation demonstrated a 35% increase in medial clear space widening.</span></div></li></ul><br></br><br></br><div><span>Ref: Stoffel et al. Comparison of two intraoperative assessment methods for injuries to the ankle syndesmosis. A cadaveric study. J Bone Joint Surg Am 2009;91(11):2646-2652.</span></div><ul><li><div><span>Lateral stress produced a significantly greater increase in the tibiofibular clear space than did the external rotation test for Weber C injuries and Weber C plus deltoid ligament injuries.</span></div></li><li><div><span>For the detection of syndesmotic instability at the site of ankle fractures on stress radiographs, the lateral stress test appeared to be superior to the external rotation stress test in this cadaver model.</span></div></li></ul><br></br><br></br><div><span>Ref: Gardner M, et al. Technical Considerations in the Treatment of Syndesmotic Injuries Associated With Ankle Fractures. JAAOS 2015</span></div><ul><li><div>According to the Lauge-Hansen classification system, pronation external rotation, supination external rotation, and pronation abduction fractures hold the highest risk of syndesmotic injury.</div></li><li><div>The intraoperative evaluation of syndesmotic stability should occur after all other points of instability have been addressed.</div></li><li><div>It should be noted that, on radiography, the syndesmosis may have a nonpathologic appearance because of the variability of the incisura contour (eg, flat or cupped). Specifically, a tibiofibular overlap of 0 mm, which has traditionally been considered to be indicative of an injured syndesmosis, may be a normal finding in a patient with a flat incisura; however, it may rep- resent pathology in a patient with a cupped incisura.</div></li></ul><ul><li><div><span>The position of the ankle should be standardized during testing, and the </span><span>tibiofibular clear space</span><span> on the AP view reveals the least amount of variability attributable to rotation</span></div></li></ul><ul><li><div>If the contralateral ankle is uninjured, comparison radiographic views should be obtained</div></li><li><div>Standard intraoperative stress mechanisms include an <span>external rotation stress test of the dorsiflexed ankle</span> or <span>direct translation of the fibula via a clamp or hook</span> (modified Cotton test)</div></li></ul><ul><li><div><span>The </span><span>absolute increase in tibiofibular clear space is greater for the same injury pattern when using a laterally directed translational force with a hook than with an ER stress test.</span></div></li></ul>”

Answer 160

A

“<div><div>Answer: A</div><br></br><div><span>Ref: JOT 2015 16(3): 185 Canadian paper Toronto, Edmonton</span></div><ul><li><div>RF for development of LE acute compartment syndrome:</div></li><ul><li><div><span>Younger patients</span></div></li></ul><li><div>Not associated with compartment syndrome</div></li></ul><ul><li><div>Male</div></li><li><div>Open fracture</div></li><li><div>IM nail fixation</div></li><li><div>Segmental tibias less likely</div></li></ul></div><div><br></br></div>”

Answer 161

A

“Answer: A<div><br></br></div><div><div><span>Ref: JBJS 2004 86(12)2629.</span></div><ul><li><div>Cadaveric study</div></li></ul><ul><li><div><b>Increase of 2.5 mm in length significantly increases contact pressures</b></div></li><li><div>Decrease of 5 mm decreased contact pressures substantially</div></li></ul><ul><li><div><b>Ultimately increases contact pressures and leads to early development of OA</b></div></li><li><div><b>Loss of flexion</b></div></li></ul></div>”

Answer 162

A

“<div><span>Answer: B</span></div><br></br><ul><li><div><span>Terrible triad are not </span><span>always </span><span>operative.</span></div></li><ul><li><div><span>Indications for non-op management (rare):</span></div></li><ul><li><div><span>UH and RC joints must be concentrically reduced</span></div></li><li><div><span>Radial head fracture must not meet surgical indications</span></div></li><li><div><span>Coronoid fracture must be small</span></div></li><li><div><span>Elbow must be stable enough to allow early ROM</span></div></li></ul></ul></ul><div><span>REF: Matthew al. JAAOS 2009 & JBJS Am 2006;88:2216-2224.</span></div><ul><li><div><span>Coronoid tip fractures (O’Driscoll Type I) are most frequently seen in association with terrible triad injuries.</span></div></li></ul><ul><li><div><span>Coronoid fracture classification according to O’Driscoll et al.: The three types are tip (A), anteromedial facet (B), and basal (C) fractures.</span></div></li><ul><li><div><span>Tip fractures are subclassified into two groups, either ≤2 mm or >2 mm in size.</span></div></li><li><div><span>Anteromedial facet fractures are subclassified into three subtypes (anteromedial rim, rim plus tip, and rim and tip plus the sublime tubercle).</span></div></li><li><div><span>Basal fractures are subclassified into two groups (coronoid body and base, and transolecranon basal coronoid fractures).</span></div></li></ul></ul><ul><li><div><span>The anterior bundle of the MCL is postulated to be the last to fail.</span></div></li></ul>”

Answer 163

A

“<div><span>Answer: A</span><span><br></br><br></br></span></div><ul><li><div>Specific term forinferior dislocation of the GH joint trapped underneath the coracoid and glenoid.</div></li><li><div><span>Has greatest incidence of neurovascular injury</span>of all types of shoulder dislocations.</div></li><ul><li><div>Vascular injury <span>40%</span>, neurologic injury <span>60%</span> (axillary)</div></li></ul><li><div>Hyperabduction force applied to arm, levering the proximal humerus onto the acromion, injuring inferior capsule/labrum, which subsequently allows for disengagement of HH inferiorly from glenoid.</div></li></ul>”

Answer 164

A

“<div><span>Answer: B</span></div><br></br><div><span>Yaw</span> refers to the rotation of the nose of the bullet away from the line of flight.</div><ul><li><div><img></img></div></li></ul><br></br><div><span>Ref: JAAOS 2000 - Ballistics and GSW</span></div><div>Efficiency of Energy Transfer is dependent on:<br></br><br></br></div><div>(1) The amount of kinetic energy possessed by the projectile at the time of impact, such that the longer the range, the lower the velocity at impact.</div><div>(2) The stability and entrance profile of the projectile.</div><ul><li><div>At a yaw of 90° (sideways), maximal energy transfer is achieved.</div></li><li><div>Yaw tends to decrease over longer distances, allowing the bullet to hit its target nose on; at impact, however, wobbling and then tumbling occurs.</div></li></ul><div>(3) <span>The caliber, construction, and configuration of the bullet, which can be by far the most important factors predicting its effects.</span></div><div>(4) The distance and path traveled within the body.</div><ul><li><div>Penetrating (not exiting) missiles deliver their total contained kinetic energy.</div></li><li><div>Perforating (exiting) missiles transfer significantly less.</div></li></ul><div>(5) The biologic characteristics of the tissues impacted.</div><div>(6) The mechanism of tissue disruption (e.g., stretching, tearing, crushing)</div><br></br><div>Greater tissue damage to inelastic tissues (liver, spleen) than elastic ones (lung)</div><div><span>Low-velocity, but close range are high energy wounds and should be treated as per high velocity</span></div><div><span>Low velocity <2,000ft/s (handguns, shotguns), high velocity >2,000 ft/s (rifles, military weapons)</span></div><br></br><div><span>Ref: Kuhajda I, et al. Penetrating trauma. </span>‎<span>2014. </span>‎</div><ul><li><div><span>Dense organs, such as bone and liver, absorb more energy resulting in more </span><span>injury</span><span>. </span><span>Lungs</span><span>, which have a much lower density, absorb less energy and fortunately suffer less of an </span><span>injury</span><span>.</span></div></li></ul>”

Answer 165

A

“<div><span>Answer: A</span></div><br></br><div><span>REF: Sagi et al. Indomethacin Prophylaxis for Heterotopic Ossification after Acetabular Fracture Surgery <b>Increases the Risk for Nonunion</b> of the Posterior Wall. JOT 2014.</span></div><ul><li><div>The incidence of clinically significant HO after acetabular fracture surgery has been reported to be <span>as high as 40%</span> depending on the surgical approach and various patient/fracture characteristics.</div></li><li><div>Patients who consented to take part in the study preoperatively were randomly assigned to 1 of 4 postoperative treatment groups:</div></li></ul><ol><li><div>placebo for 6 weeks</div></li><li><div>3 days of indomethacin 75 mg PO daily followed by placebo for a total of 5.5 weeks</div></li><li><div>1 week of indomethacin 75 mg PO daily, followed by 5 weeks of placebo</div></li><li><div>6 weeks of indomethacin 75 mg PO daily</div></li></ol><ul><li><div>Patients were followed clinically and radiographically at 6 weeks, 3 months, 6 months, and 1 year.</div></li><li><div>While there were no statistically significant differences between placebo and 6 weeks of indomethacin with respect to the total number of patients with HO, Brooker classes of HO, or the volume of HO, <span>patients in the 6 week treatment group demonstrated a significantly higher rate of radiographic </span><span>nonunion </span><span>(62%) of either the posterior wall or one of the columns.</span><span></span></div></li><li><div>Patients in group 3 (1 week of IM) demonstrated a statistically significant lower incidence and volume of HO when compared to placebo, without a higher incidence in radiographic nonunion.</div></li></ul>”

Answer 166

A

Posterior dislocation. Piriformis tendon, gluteus maximus, capsule, ligamentum teres, posterior wall, bony fragment, iliofemoral ligament, labrum.<div><br></br></div><div>2. Anterior dislocation. Capsule, rectus femoris, labrum, psoas tendon.</div>

Answer 167

A

“<div>Answer: A</div> <ul> <li>Letournel and Judet noted that highest incidence of sciatic nerve palsy was in association with a posterior fracture dislocation.</li> <li>Sciatic nerve injury seen in 10-15% of dislocations</li> <li>Peroneal branch more commonly involved</li> <li>At least partial return of function in 60-70%</li> <li>Sciatic nerve injury <span>caused</span> by a reduction attempt warrants open reduction</li></ul>”

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