Trauma - RC Q's Flashcards
1
Q
RC 2018 LRINEC components for nec fasc? High score assx with which organism? Comorbidities that increase risk of NF?
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>
2
Q
<div>RC 2012, 2011 - Distal radius; all of the following are risk factors for failure of non-op treatment except</div>
<div>A. Age > 80 </div>
<div>B. Dorsal angulation</div>
<div>C. Metaphyseal Comminution </div>
<div>D. Radial shortening</div>
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>
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>
A
<div>RC 2018:D</div>
<div>RC 2014: D</div>
<div><br></br></div>
Pt: female, age>60<div># pattern: displacement > 1.5cm, comminution</div>
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>
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>”
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>
<div></div>
A
<div>Answer: C</div>
<div><br></br></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>
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>
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>
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>
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>
8
Q
RC 2012 - Components of SSSC?
A
Glenoid<div>Coracoid</div><div>CC ligaments</div><div>Clavicle</div><div>AC ligaments</div><div>Acromion</div>
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>
A
<div>A.</div>
<div><br></br></div>
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>
10
Q
RC Oral - TT for radial nerve palsy?
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>”
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>
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>”
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>
A
<div>1. RH is prob too small!</div>
<div><br></br></div>
13
Q
RC 2016 - Technical Considerations for Fixing Coronoid?
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>
14
Q
RC 2014, 2012 List 3 ways to judge fragment size for RH replacement?
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>
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>
A
<div>Answer: C</div>
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>
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>”
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>
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>”
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>
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>”
19
Q
RC 2018 - RFs for synostosis after BBFA # and tx?
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><br></br></div>
<div>Treatment:</div>
<div>-operative(resection): anconeus or free fat interposition</div>
<div>-post-op: 700cGy radiation, Indomethacin 25 TID</div>
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
A
<div>Answer: D</div>
<div><br></br></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>
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>
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>
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
A
<div>Answer: A</div>
<div><br></br></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>
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>
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>
24
Q
RC 2018, 15, 12 - Open Fracture in Water tx?
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>
25
RC 2011 - Regarding compartment syndrome which will NOT help treat acute compartment syndrome:
A. Transfusing to keep HGB greater than 100
B. fixing hypotension
C. Giving O2 by mask
D. Cutting all circumferential dressings and casts
c.
transfusion for Hb>100
fixing hypotension
cutting casts
not giving O2 by mask (MCQ )
26
RC 2015, 2010 Leadbetter Maneuver?
"FATI CABE![]()
"
-flexion, adduction, Traction and IR hip
-Circumduction, ABduction, extension of hip while maintaining IR
27
RC 2015, 2013, 2010 What are three radiographic factors indicate adequate reduction of a displaced femoral neck?
"
-Standard parameters: Displacement <2mm, <5 deg angulation
-Specific parameters: Lovell's lines (gentle S), Garden alignment index (>160 on AP, 180 on lat)
-'overall impression'
-open approach - direct visualization
"
28
RC 2014, 2012 - List 5 factors that increase the 30 day morbidity of a patient with a hip fracture
Nottingham score (SAQ):
Age>65, >80
Male
Institutionalized
PMHX: MMSE<6, anemic (Hb<100), >2 comorbidities, malignancy
score >5 = high risk = 86% 30 day survival , 54% 1 year
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%
29
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?
A. Functional outcomes are better for arthroplasty
B. Mortality is greater for fixation
C. Revision is greater for fixation
D. Blood loss is less for fixation
Answer: B. increased early mortality for THA
THA has better fxnal outcome
fixation - less blood loss, greater risk of revision surgery
30
RC 2014 - The medial femoral circumflex travels anterior to all of the following except:
- Obturator Internus
- Obturator externus
- Superior gemellus
- Inferior gemellus
"B.
![]()
![]()
"
31
RC 2015 - In a severely displaced femoral neck fracture, what blood supply to the femoral head is likely preserved?
a. Medial femoral circumflex
b. Lateral femoral circumflex
c. Retinacular vessels
d. Obturator
D
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
32
RC 2011 - Clinical Features of varus malunion femoral neck # (list 4)?
Pain, decreased walking distance
Trendelenberg sign (Abductor weakness)LLD, difference in rotation
prominent GT - bursitis
decreased ROM
Obligate external ROM with flexion (impingement)
33
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?
A. Need to medialize the shaft as much as possible
B. It is best to leave at least 2 cm between entry point of blade plate and osteotomy
C. Aiming for angulation of fracture line to horizontal of 20-30 degrees
D. There is a high union rate but a limp persists
Answer: A
-angle goal is 20-30 deg from horizontal
-leave 2cm between blade and osteotomy
-high union rate, but limp may persist
34
RC 2017, 2013 - List 3 strategies for avoiding varus in subtroch?
-position: lateral to allow flexion, abd, IR
-Nail start point: medial or piriformis entry
-Closed reduction: crutch, cobb, F-tool
-Perc reduction: Schanz pin into neck, linea
-Open reduction: clamps, wires, unicortical plate
-Reaming: medial!
35
RC 2012 Inter-troch fractures. All are true EXCEPT
A. decreased failure with Tip to apex < 25 mm
B. decreased failure with 150 degree DHS
C. decreased failure with females
D. Fracture pattern
Answer: B
RFs for failure
Tip Apex Distance > 25mm Unstable fracture pattern
Poor reduction
150 degree DHS (MCQ 2012)
Superior and anterior/posterior screw placements (ie. Peripheral placements?) Older patient age (not associated in some)
36
RC 2011 - Adv/Disadv for piriformis vs GT start nails?
Piriformis
-Adv (SAQ 2011): less varus malunion, colinear trajectory with shaft, decrease risk of GT blowout
-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
GT
-adv: easier start point, less soft tissue damage
-disavantage: increase risk of varus malalignment, increase risk of fracture comminution (b/c you direct nail medially), GT blow out
37
RC 2017, 2016, 2015 - Radiographic Strategies to determine femoral rotation during nailing shaft fracture?
"-cortical step sign, width
![]()
![]()
![]()
![]()
"
-LT profile
-Tornetta technique (True anteversion angle), perfect lateral
Others: prep other limb to determine clinical rotation, intrinsic nail values, post-op CT
- 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.
- Results in rotational discrepancy under 8 degrees
- Most reliable
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)
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.
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. The 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). Distal fragment is rotated until the posterior aspect of the condyles line up perfectly on the image.
Figure 4. Patient's normal anteversion (angle A) has now been restored, and distal locking can be done by instrument protocol.
38
RC 2017 - Design features of reamers to decrease IM pressure during nailing?
- Sharp reamers
- Deeper reaming flutes
- Shallower flutes get clogged and act like a piston
39
RC 2014, 2012. List 4 complications associated with the hemi-lithotomy position and the fracture table when nailing a midshaft femur fracture
- Complications
- Malunion - rotational, angular
- Non-union - <10%
- LLD - 43% if comminuted
- Infection - 1-3.8%
- Well leg compartment syndrome - hemilithotomy
- HO
- Pudendal Nerve palsy - Most common symptoms are pain, numbness
- Can get incontinence and altered ejaculation
- Femoral Nerve - AP locking screw in retrograde nail (lock prox to LT to prevent)
- Vascular injury
- Erectile dysfunction 40% (mcq 2018)
- 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.
- Recommendations : Surgical time and/or traction time should be minimized.When surgical
time exceeds 120 minutes, intraoperative
traction should be released.
It has been shown that tissue
pressures of 70 mm Hg applied for
120 minutes result in microscopic
tissue damage.42 This idea is further
validated by the knowledge that
tourniquet times are commonly limited
to 120 minutes. Periodic release
of traction is required when traction
is prolonged
40
RC 2013 - advantages of locking plate over DCS for DF #s?
Better fixation in osteoporotic/comminuted bone (multiple points of fixation)
Ability to control multiple fracture fragments
Anatomic contour helps with reduction of joint
Biomechanically superior in cyclic load and ultimate strength
Preserves more distal bone stock
Less soft tissue stripping
Note: COTS 2016 - LISS vs DCS
-LISS: 52% healed without intervention, failures 28%, revisions 7/22
DCS: 91% healed, failures 12.5%, revisions 2/22
41
RC 2014 - For a 95 degree distal femoral locking plate, where should the first guidewire go?
A. Parallel to the joint line, proximal to Blumensaat’s line
B. Parallel to the joint line, distal to Blumensaat’s line
C. Perpendicular to the femoral shaft, proximal to Blumensaat’s line
D. Perpendicular to the femoral shaft, distal to Blumensaat’s line
"A.
![]()
"
-parallel to joint line, proximal to Blumensaat's
42
RC 2013, 11, 10 - LIst 8 Parameters to consider in a trauma patient for DCO vs Early total care
"Physiologic Factors
"
-MAP>60
-HR<100
-U/O>0.5cc/kg/hr
-PaO2/FiO2>300
-Temp>35
Acidosis Factors
-Lactate<2.5
-BE N= -2 to +2 (do not want >6-8) *best as per MCQ 2015
-pH>7.25
-gastric mucosal pH>7.3
Coag Factors
-Plts>90
-Fibrinogen>1
-low D-dimer, PTT
Conceptual framework: SSCC
-soft tissue: extremity, chest, abdo
-shock
-cold: low temp
-coag
43
RC 2014, 11 - List 4 signs of Class 4 hypovolemic shock?
"-BL >2000cc (40% blood volume)
![]()
-decreased BP
-decrease PP
-HR>140
-U/O - none
-MS: comatose
-RR>35
MASSIVE TF protocol: 1:1:1 pRBC: plts:plasma
"
44
RC 2017, 16, 15 - 8 Xray signs of traumatic aortic rupture?
"
![]()
"
Stay organized! - aorta, trachea, esophagus, lungs, pleura, fractures
Findings from loss of aortic arch
-Widened mediastinum (more than 8cm) -Obliteration of aortic knob i.e. Disuption of the calcium ring of the aortic knob (broken halo sign)
-Loss of outline of the descending aorta
-Loss of the aorto pulmonary window (the space between the pulmonary artery and the aorta)
-Widened paraspinal interfaces (this the line on xray that outlines the aorta on either side of the spine)
Trachea and esophageal findings:
-Trachea deviated to right -Deviation of the esophagus (or NG tube) to the right of the T4 spinous process (more than 1-2cm)
-Widened paratracheal stripe
Intra-pulmonary and chest wall findings:
-Presence of a left apical cap (indicates an apical pleural hematoma) -Left hemothroax
-Depression of left mainstem bronchus of lung (more than 40 degrees)
-Elevation of right mainstem bronchus
-Fractures of the first or second rib or scapula
45
RC 2017, 2014 - List 4 major and 4 minor criteria of FES?
DX: 2 maj + 1 min or 1 maj + 4 min
Major = cope = coma, oxygen, petechial rash, edema-CNS depression
-Resp: Hypoxemia, pulm edema
-derm: petechial rash
Minor = FPRTTD
-fat in urine
-pyrexia
-retinal emboli
-tachycardia
-thrombocytopenia
-decrease hct
Tx: supportive, ICU, maybe steroids (no mortality benefit)
46
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?
A. Complete patellectomy
B. ORIF maintaining all fragments
C. Partial patellectomy with repair to posterior patella
D. Inferior pole patellectomy with repair to anterior patella
B.
If resecting, then put patellar tendon anteriorly (Reduces contact stresses)
- Vaselko M (JBJS 2005) Inferior Patellar Pole Avulsion Fractures: Osteosynthesis Compared with Pole Resection
- Retrospective review of 14 vs 11 fractures
- Average patellofemoral score better in internal fixation group than resection with patellar ligament repair (94 vs 81)
- Normal patellar height in 10/11 ORIFs, 3/13 tendon advancements
- JAAOS 2011 - Patellar Fractures in Adults
- Partial Patellectomy and Inferior Pole Fracture
- 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
- Saltzman --> 40 patients with partial patellectomy
- 78% good or excellent, quads strength 85%
- Bostman --> poor outcomes if >40% of patella removed
- Marder --> increased PF contact forces with patellectomy
47
RC 2017 - Which defect filler will have the least subsidence with tibial plateau fractures?
- Calcium sulfate
- Calcium phosphate
- Iliac crest autograft
- Cancellous allograft
b. Ca PO4
(equivalent union rates to iliac crest)
48
RC 2015, 2011 Regarding fixation of a tibial plateau fracture, which is true?
a. Locking plates have better outcomes and less complications than non-locking plates
b. Locking plates have better outcomes and more complications than non-locking plates
c. Locking plates have equal outcomes and less complications than non-locking plates
d. Locking plates have equal outcomes and equal complications as non-locking plates
D. equivalent outcomes and complications
49
RC 2013 Proximal tibia fracture. What has the lowest rate of ligament injury
A. Bicondylar
B. Lateral joint depression
C. Lateral joint split
D. Lateral joint split depression
C. Lateral joint split (Schatzker 1) - least energy (MCQ 2013)
50
RC 2016 Tibial external fixator is placed. In converting to definitive treatment all of the following are acceptable EXCEPT:
A. 2 weeks convert to IM nail
B. 2 weeks convert to plate
C. 5 weeks, curettage pin sites, IM nail
D. 5 weeks, curettage pin sites, delayed IM nail
C.
PIN SITE HOLIDAY
MCQ 2016
51
RC 2018, 2015, 2012 - List 5 intra-op techniques to aid reduction of proximal tibial shaft fracture when nailing?
-position: semi-extended
-approach: supra-patellar
-start point: lateral
-perc: blocking screws, femoral distractor
-open: unicortical plate
-nail: increased Herzog angle (or more proximal)
52
RC 2018 - 3 tibial fracture patterns that increase risk of distal ankle injury?
- A spiral pattern tibia fracture
- A distal one-third tibial shaft fracture location,
- Spiral pattern fibula fracture
- JOT 2014 - Predictive Radiographic Markers for Concomitant Ipsilateral Ankle Injuries in Tibial Shaft Fractures
- 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).
53
RC 2013, 2015 In a grade IIIA open tibia fracture, which of the following is true?
a. Delayed closure results in decreased wound complications
b. Delayed closure results in increased wound complications
c. Delayed closure results in decreased infection
d. Delayed closure results in increased infection
D.
increased infection (MCQ 2013, 2015)Delayed Closure - 17% infection
JBJS 2014 Delayed Wound Closure Increases Deep Infection Rates Associated with Lower-Grade Open Fracture
Bhattacharyya (Plast Reconstr Surg 2008)
12.5% infection for <7 days, 57% > 7 days
54
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)
A. Lower rate of subsequent bone grafting procedures
B. Lower rate of subsequent soft tissue procedures
C. Higher infection
D. Lower infection
C
-lower infx (NOT higher)-lower rate of subsequent bone grafting
-lower rate of subsequent soft tissue procedures
Govender S (JBJS 2002) Recombinant human BMP-2 for treatment of open tibial fracture
- 94% follow up at 2 years (unreamed nail)
- BMP-2 group:
- 44% reduction in risk of failure
- secondary intervention because of delayed union
- Fewer intervention
- Faster fracture healing
- Fewer hardware failures
- Fewer infections (type IIIA/B injuries)
- Faster wound healing
55
RC 2016 - Proximal tibia fracture. Where do you place your blocking screws to prevent deformity?
A. Anterior and medial
B. Anterior and lateral
C. Posterior and medial
D. Posterior and lateral
"
![]()
![]()
"
D.
At risk of valgus and procurvatum
- Aids to reduction:
- Nail in extension
- Blocking screws
- Increase strength and rigidity of fixation
- Place on concave side of deformity
- Lateralize start point
- Increase Herzog angle
- Unicortical Plate at the fracture site
56
RC 2015 - What is a described complication of antegrade nailing a proximal femur fracture using a lateral entry nail
A. varus malunion
B. valgus malunion
C. increased disruption of femoral head blood supply
D. Increased hoop stresses and fracture
A.
57
RC 2012 - List 4 principles of managing pilon excluding soft tissue?
"
LENGTH, ALIGNMENT, (ROTATION)
-reduce/fix fibula for length-correct varus/valgus tibia
-ligamentotaxis to reduce anterolateral and posterior fragments
-anatomically reduce and fix articular block
-autologous bone grafting of metaphyseal defect
-buttress plating to prevent angulation
"
58
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?
- A. Autoclave and reimplant
- B. Send to the bone bank for later reimplantation
- C. Discard
- D. Clean thoroughly and reimplant
D. clean thoroughly and re-implant
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.
59
RC 2017 - 5 indications for amputations after trauma? 2017 SAQ/CORF
"Near or complete amputation at presentation
![]()
"
-Complete anatomic disruption of tibial nerve
-Irreparable vascular injury
Crush injury w/ > 6 hrs warm ischemic time
Serious associated polytrauma
Severe ipsilateral foot trauma
Anticipated protracted reconstructive course
MESS score (not predictive in LEAP study)
60
RC 2016, 2013 - List 3 xray findings of syndesmosis injury?
"
AP: overlap>6mm, clear space<6mm![]()
"
clear space >6mm (AP/mortise) is ABNORMAL
overlap <6mm (AP) or <1mm (mortise) is ABNORMAL
medial clear space >6mm
PM fracture
---
AP Normal: overlap >6mm on AP, clear space <6mm
AP injury: overlap <6mm on AP, clear space >6mm
Mort Normal: overlap >1mm, clear space <6mm
Mort injury: NO overlap, clear space >6mm
Mo: overlap>1mm, clear space<6mm, med clear space<6mm
Lat: avulsion off post mal
other: proximal spiral fibula fracture
61
RC 2018, 2014 - What is the most common fracture associated with a talar neck fracture?
- Medial malleolus
- Fibula
- Calcaneus
- Lisfranc
1.
In a study by Hawkins,8 15 of 57 patients (26%) had associated fractures of the medial malleolus.
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).
62
RC 2016, 2013 - All of the following are true regarding a Hawkin’s sign following a talar neck fracture, except:
- It is a radiolucent line underneath the subchondral surface on xray
- It is useful as evaluation for vascularity of the talus
- It usually shows up at 3 weeks post injury
- It is caused by osteopenia from bone resorption.
C.
-radiolucency in subchondral bone (caused by osteopenia from bone resorption)
-6-8 weeks after #
63
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?
- Fibular osteotomy
- Medial malleolar osteotomy
- Inline traction
- Femoral Distractor
"4.
"
old answer: 2. MM osteotomy
- Rockwood's:
- Mentions distractor, and no mention of osteotomy
- Additional traction, if needed, can be performed with a Schanz pin or a mini-distractor. Associated osteochondral fragments are debrided.
- 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)
64
RC 2017, 2012 Talar neck goes onto malunion, best seen on xray. treatment may include given the affected motion
RC MCQ Young patient has talar neck fracture that is fixed but goes on the malunion, what is true:
- Subtalar motion will not be affected
- AP radiograph is best for seeing it
- Varus Malunion
- Osteotomy is contra-indicated
"varus malunion
![]()
Canale Xray - 15 deg inverted, 15 deg from vertical
Osteotomy (if no arthrosis)
subtalar motion is abnormal!
Answer: 3
"
65
RC EXAM - A 35-year-old woman is involved in a head-on collision while driving and suffers a Hawkings 3 talus. Injury to what vessel increases the risk for osteonecrosis of the injured bone?
1- Dorsalis pedis artery
2- PerforaFng peroneal artery
3- Lateral tarsal artery
4- Artery of the tarsal canal
5- Artery of the tarsal sinus
"4 - Tarsal canal (From the post tib)![]()
![]()
"
66
RC 2016 - Canale view position?
"
![]()
"
FOR TALAR NECK FRACTURE
casette under PF foot15 deg pronation
15 deg from vertical (Tube at 75 deg from horizontal)
67
RC 2018, 2014, 2012 - A patient with a lateral subtalar dislocation, what is a block to reduction?
- Tib ant
- FHL
- EHL
- TN capsule
RC 2018, 2015, 2013 - What is a block to reduction in a medial subtalar dislocation:
- FHL
- TN capsule
- FDL
- Talar body impaction fracture
ANSWER - B
ANSWER - B
Lateral - its the (postero-) medial structures:
-tom dick and nervous harry
-Tib post
-FHL (MCQ 2012, 2014,2016)
-FDL
-Boney: Talar head fracture, navicular #
-soft-tissue: TN capsule (MCQ 13,15,18), extensor retinaculum, EDB, peroneals, NVB
- Associated fractures (Bibbo C (FAI 2003))
- Medial:
- Dorsomedial talar head
- Posterior tubercle of talus
- Lateral Navicular
- Lateral:
- Cuboid
- Anterior calcaneus
- Lateral process of talus
- Lateral mal (Fibula)
68
RC Exam 2012, 2015 - What is the most important part of your surgical plan in a depressed calcaneal fracture?
a. Build off the sustentaculum
b. Elevate joint with graft or substitute
c. Must use locking plate
d. Must use two approaches
A. Build off sustentaculum
69
RC 2018 - Regarding ligamentous lisfranc injuries, what has the best outcomes in terms of patient pain (yes, they said pain)?
- Midfoot arthrodesis
- ORIF
- Casting
- CRPP
A. Better pain management with arthrodesis for primary ligamentous regardless of age
70
RC 2016, 13, 11, 10 List 4 radiographic features you study when assessing for Lis Franc injury?
AP
-disruption of medial 2nd MT and medial cuneiform
-diastasis between MT1 and MT2
-flec sign (avulsion of 2nd MT or med cuneiform)
Oblique
-disruption of medial MT4 and medial cuboid
-disruption of medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)
Lateral
-collapse of mid arch (cant see MT5 base from medial cuneiform collapse)
71
RC 2018, 2014 List 4 important bony or ligamentous stabilizers of the lisfranc joint.
- Osseous Intrinsic Stability:
- Trapezoidal shape of middle three MT bases and cuneiforms produces a stable arch
- Recessed 2nd MT keystone creating a stable mortise
- Recessed 8 mm proximal to med cuneiform and 4 mm proximal to lateral cuneiform
- Transverse intermetatarsal - D2-D5 base MTs
- Oblique:
- Dorsal, interosseous and plantar ligaments between medial cuneiforms and 2nd MT
- Interosseous > Plantar > Dorsal
72
RC 2016 - What is true about SI screw placement?
A. To place an S2 screw, 1 cm distance between the S1 and S2 foramens is required
B. You cannot place an S2 screw if there is sacral dysmorphism
C. Can place screw if displacement in the AP plane of 1.5cm
D. Can place screw if displacement in the cranial-caudal plane of 1.5cm
A
A - 7.3mm cannulated screws, so need at least 1-2 mm space around screw (moorhead)
B - False, see below, in dysmorphic cases S2 is preferred
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
73
RC 2018 - RFs for arterial injury in pelvic fractures?
-Patient (list 1)
-Clinical/Lab (List 4)
-Xray (list 2)
-Patient (list 1): increasing age, multiply injured (ISS score)
-Clinical/Lab (List 4): sBP<100, severe acidosis, BD<6mmol/L, change in BD>2mmol/L
-Xray (list 2): SI joint widening. APC II/III, LCII/III, VS, combined
Mortality with bleed: 47%
Mortality without bleed: 2%
74
RC 2018 - RF failure of acetabular ORIF, all except:
- Age <40
- Initial displacement
- Impaction
- Associated femoral head injury
A. Age >40 (NOT <40 yrs)
initial displacement
impaction
associated fem head injury
---
RF breakdown:
-patient factors: age>40, high BMI
-injury factors: fem head impaction, displacement >2cm, PW, anterior dislocation
-surgical factors: non-anatomic reduction, roof incongruence, EIL approach
75
RC 2015, 2013- isolated PW #, all of the following are indications for ORIF EXCEPT:
a-Intra-articular fragment b-Roof arc less than 20
c-Positive stress test
d-40% wall involvement
B - do not use RA angles for PW fractures
PW can only be treated nonop if hip is stable and congruent (ie likely need EUA)
old rule that <20% PW involvement is stable is not necessarily true
76
RC 2017 - 30 year old male is involved in an MVC and sustains a posterior wall acetabular fracture. What is true about the outcomes following a 6 weeks course of indomethacin
- Indomethacin is important for prevention of HO
- It will increase the non-union risk
- ..
B.
Sagi JOT 214
- 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.
JAAOS Feb 2017 HO in acetabular surgery
- Sufficient literature indicates NSAIDs are ineffective
- Sufficient literature supports a significant increase in fracture non-union
77
RC 2016 Elderly acetabular fracture, which of the following is true?
A. Most need posterior approach
B. Gull sign is representative of interposed fragment
C. Most have an anatomic reduction
D. 20% or more go on to total hip with long term outcome
D - true
A - false
B - false - gull sign = superomedial dome impaction (AC-PHT)
C-false
78
RC 2016 - Which approach gives best access for reduction and fixation to quadrilateral plate?
A. Medial window ilioinguinal
B. Stoppa
C. Kocher-langenbeck
D. Hardinge
B. Stoppa
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 the quadrilateral surface.
79
RC 2012 - What type of acetabular fracture can you not use a roof angle in?
1-Associated two column (worded this way) 2-Transverse posterior wall
3-Posterior column
4-T type
1 or 2 - both are true (prism says 1)
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
80
RC 2013 Posterior wall fractures (2nd question) all are true EXCEPT:
1)5 of Letournels lines are intact 2)> 50% of posterior wall involvement requires fixation
3)Marginal impaction requires disimpaction and bone grafting
4)Intra-articular split requires fixation
4
Isolated posterior wall fractures have all other lines intact - YES
Posterior wall fractures >40% are associated with hip instability --> should go on to fixation
Articular steps associated with poor outcomes --> therefore should be disimpacted- Not necessarily splits
81
RC 2015 - What is the best approach to fix an associated both column acetabular fracture:
- Iliofemoral
- Triradiate
- Kocher-Langenbach
- Ilioinguinal/Stoppa
"D. ilioinguinal/stoppa (if injury pattern starts with 'A' so go Anterior)"
82
RC 2016 - What are 4 features of post-tourniquet syndrome? How to minimize complications if you anticipate prolonged TT?
weakness without paralysis
edema
stiffness
pallor
subjective numbness to extremity without objective anesthesia
Resolves over weeks to months
Times: Thigh 300-350min, arm 250-300
---
Minimize comp (list 3):
-allow intermittent reperfusion
-alternating cuffs
-wider cuff, lower inflation pressures
-hypothermia of limb
83
RC 2016 - list 6 Modifiable RFs for non-union?
"
![]()
"
PMHx: DM, hypoT, malnutrition (VitD/Ca), anemia
Meds: NSAIDS, steroids/immunosupp
SocHx: smoking, EtOH
Surgical factors: soft tissue stripping, fixation rigidity/stability
84
RC 2017 - Regarding driving guidelines in orthopedic surgery, all of the following are TRUE except?
a. You shouldn’t drive with a cast or air boot on the right leg
b. Orthopedic surgeons have a good knowledge of the law in regard to driving
c. Braking ability returns to normal at 3-4 weeks post arthroscopy
d. You can drive 4-6 weeks after THA
B
- 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
- 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.
- Patients may safely drive 4-6 weeks after right total hip arthroplasty
85
RC 2013 - Young female with polytrauma. Shown an xray with bilateral inf and sup ramus # but perfect SI joints. Been to OR for splenectomy and found a large retroperitoneal hematoma. Still hypotense 95/50 and 90bpm. What to do next?
A. Angio with embolization
B. “External fixator or C – clamp”
C. Return to OR for re-exloration and packing
D. Pelvic binder
A
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.
86
RC 2017 - After extended bisphosphonate therapy, which of the following patients are at highest risk of atypical femur fracture:
- Female, >70 y/o, active, independent
- Male, > 70 y/o, active, independent
- Male, <70 y/o, inactive, dependent
- Female, <70 y/o, active, independent
A.
The mean age of the 27 patients at time of fracture was 75.6 years (52 to 91 years) and 23 (85%) were female
87
RC 2013 - Which of the following is a reason NOT to put O2 on an old person in trauma
A. Chronic lung disease with increased PaCO2 B. Chronic lung disease with decrease PaCO2
C. Heart disease
D. No reason to not put O2 on
"D"
""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""
88
RC 2013 - 23 yo woman in a MVC. Presents with C7 complete cord lesion and a closed femur fracture. She has received 2 L of crystalloid. Heart rate is 110 and BP is 86/55. The cause of her hypotension is
A. Hypovolemia due to unrecognized abdominal bleeding B. Hypovolemia due to her femur fracture
C. Spinal shock
D. Neurogenic shock
"B
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"
not C/D - this is hypovolemic shock
89
RC 2014 - A patient presents to ER with C5/6 jumped facets and complete quadriplegia following an MVC (or some other similar trauma). It is an isolated injury. The patient is bradycardic (HR 60?) and hypotensive (80/45 mmHg). So far the patient has been given 6L of crystalloid. What should you do now?
- A. Slow IV to maintenance rate
- B. Start transfusing blood
- C. Give albumin
- D. Rapid bolus with IV crystalloid
a.Maintenance fluids!
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
Management of Neurogenic shock
Trendelenburg 10-20 deg
Address fluid deficit
Maintenance fluids (RC EXAM)
Pressor support/ICU
Swan Ganz catheter for monitoring fluid status
Supplemental oxygen
90
RC 2009 - Woman post CRPP distal radius #. Pain and dysaesthesia over thumb & 1st dorsal webspace. What is the most effective form of treatment?
Type I + stellate ganglion block Type I + antidepressants & gabapentin
Type II + stellate ganglion block
Type II + antidepressants & gabapentin
D
Type 1- No identifiable peripheral nerve study on current objective testing methods
Type 2- Clinical presence of signs of peripheral nerve injury (i.e. nerve conduction study findings) - causalgia, no evidence for stellate ganglion block however
91
RC 2018 MCQ - When doing a hemiarthroplasty for a 4 part proximal humerus fracture, what is an important technical consideration:
- Head should be 0.5-1.5cm above GT
- Uncemented prosthesis should be used
- Prosthesis should be 3.5cm above the pec insertion
- Prosthesis should be in 50 degrees of retroversion
A
- HTD: head to tuberosity distance should be ~10mm
- B - false--> use cement to maintain humeral component height
- C - false--> should be 5.6cm above pec
- D - false --> should be 20 deg retroverted
92
RC 2018 - In setting of tuberosity malunion what is True
a. Tuberosity malunion <1.5cm subacromial decompression is good option
b. In setting of AVN humeral head you should not use short stem implant
c. Hemiarthroplasty and osteotomy of the tuberosities
"Answer: A![]()
"
- <15 mm of GT displacement considered as positive criterion for an acromioplasty indication
- Arthroplasty with tuberosity osteotomy drastically decreases constant scores post-op
- Most common is hemi with a humeral stem, but now RTSA becoming more common
- Osteotomy often is also indication to allow implantation of the new stem
- Short stem for AVN of HH
93
RC 2018 - In RTSA for fracture, healing of the tuberosities helps with what motion?
- External Rotation
- Adduction
- Abduction
- Internal rotation
A
94
RC 2018 - Regarding non-rigid/dynamic syndesmotic fixation (tight rope) which is true:
a. Tightrope more likely to lose reduction than screw
b. Tightrope is less likely to lose reduction than screw
c. Clinically the outcomes are the same
B
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. 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. Neither the incidence of ankle joint osteoarthritis nor functional outcome significantly differed between the fixation methods.
A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography.
95
RC 2018 - You decide you want to do an ORIF of both the glenoid (?neck) and scapular body (because it’s Tuesday and you’re feeling wild). What is the best surgical approach to accomplish this?
- Anterior deltopect (Henry’s)
- Acromion osteotomy
- Modified judet approach between posterior deltoid and infraspinatous (it gave this specific interval)
- Axillary approach utilizing the interval between infraspinatous and teres minor
C.
Modified Judet Approach and Minifragment Fixation of Scapular Body and Glenoid Neck Fractures
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.
96
RC 2013 - What is most true with regards to the treatment of glenoid neck fractures?
- Patients with extra-articular fractures do well with non-operative treatment
- Stable injuries if no other fractures or ligamentous injuries
- Usually plated through a deltopectoral approach
- Patients with <1cm medialization should be treated operatively
Answer: B
JAAOS 2012. Cole et al. Management of scapular fractures
- Indications for surgery often include such parameters as:
- medialization (>25 mm),
- 25°to 45° angulation on a lateral radiograph,
- GPA <20°, and
- Displaced double lesions of the SSSC.
- Some of the papers described ligamentous injury as part of the double lesions
- 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.
- 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
97
RC 2018 Which is NOT a complications of femoral nailing in traction table
a. Erectile dysfunction
b. Femoral nerve palsy
c. Malrotation
d. Well leg compartment syndrome
B
JAAOS 2009 Intramedullary Nailing of Femoral Shaft Fractures
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 neurological injuries (pudendal nerve palsy, sciatic nerve palsy, common peroneal nerve palsy, erectile dysfunction), soft tissue contusions, pressure ulcers, compartment syndrome, crush syndrome and vascular injuries (by-pass graft occlusion, inferior epigastric artery avulsion)
98
RC 2018- A patient presents with a posterior hip dislocation that is not reducible by closed means. What is the block to reduction?
a. Labrum
b. Sciatic nerve
c. Obturator internus
d. Psoas
A
99
RC 2018. When comparing outcomes for the surgical treatment of hip fractures in the elderly between using an IM device and a SHS device, the SHS device has:
a. Higher failure rate
b. Greater mortality at 1 year
c. The same rate of transfusion
d. Higher reoperation rates with SHS
C
ANSWER: C
· Nails may have less blood loss intraoperatively but that does not translate to lower transfusion rates than SHS
· 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
o CMN – Shorter OR and longer fluoroscopy time
o No difference noted – Functional recovery, reoperation and mortality
Specifically – no difference in the transfusion requirements b/w CMN and SHS
· 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
o No Significant Differences between IMN and SHS devices
· Rate of implant cut out
· Device failure
· Nonunion
· Infection – both superficial & deep
· Mobility scores
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
100
RC 2018 - A 25M was water-skiing and sustains a higher grade open both-bone forearm fracture in fresh water. Optimal treatment includes irrigation & debridement, ORIF, and what else?
a. Delayed wound closure and ciprofloxacin
b. Delayed wound closure and doxycycline
c. Immediate wound closure and cloxicillin
d. Immediate wound closure and clindamycin
A
Fresh water = Fluoroquinolone (ciproflox)
Salt water = doxycycline
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
JAAOS 2005 Extremity Trauma and Related Infections Occurring in the Aquatic Environment
- Cover with floroquonolone
- Cipro, levoflox
- Stabilize fracture
- Tetanus
- Explore wound, DO NOT cover primarily, leave it oepen or loosely approximate
- Small wounds, secondary healing
- Large wounds
- Delayed closure 3-7 days
Orthobullets
- Freshwater - Flouroquinolone or 3rd or 4th gen cepholosporin
- Saltwater - doxy + ceftazidime or flouroquonolone
101
RC 2018, 2016 - Wrist 6 months post-ORIF. Patient returns unable to extend thumb DIP. What is the NEXT best step?
- Tendon transfer EIP to EPL
- Tendon transfer FDS to EPL
- Nerve conduction studies
- Thumb IP Joint Fusion
A
102
RC 2018 List 2 complications of RIA and 4 for IC-BG other than infx and pain
RIA
-intraop fracture or cortical performation requring fixation
-blood loss, transfusion risk
IC-BG
-minor: infx, hematoma, seroma, post-op pain, merlagia paresthetica
-major: pseudoaneursym, AV fistula, pelvic fracture, hernia
ALWAYS: INFECTION, BLEEDING, PAIN
103
RC 2018 List principles of management for an INTERprosthestic fracture
-ensure component stability
-preserve endosteal blood supply
-fixed angle plate fixation that spans both components by 2 cortical widths
-use screws AND wire fixation around implants
-augment with allograft, autograft
104
RC 2018 Given a terrible triad elbow fracture WITH a type 3 coronoid fracture, describe the recommended order of fixation.
START Lateral - see if you can get to coronoid through radial fracture, if not, do combo approach
-Lateral approach: fix RH and LUCL repair (90 deg flexion and pronation)
-Stress elbow: fix MCL if needed, then Ex-fix if needed
105
RC 2017 All of the following intra-operative findings are poor prognosticators with acetabular fractures, EXCEPT:
- Articular margin impaction
- Femoral head fracture
- Labral tear
- Cartilage “abrasion”
C.
RF breakdown:
-patient factors: age>40, high BMI
-injury factors: fem head impaction, displacement >2cm, PW, anterior dislocation
-surgical factors: non-anatomic reduction, roof incongruence, EIL approach
106
RC 2011 - Give 2 advantages of doing a piriformis starting point vs. a trochanteric starting point for an antegrade femoral nail.
"
- JAAOS - Intramedullary Nailing of femoral shaft fractures
Piriformis Entry Nails
Advantages:
- Has a colinear trajectory with the femoral shaft (i.e. it's a more “straight shot”, in line with the shaft”
- Decreased risk of varus malreduction (remember, more lateral start point = varus malreduction, too medial = valgus malreduction)
- Decreased risk of iatrogenic fracture comminution
- Decreased risk of GT fracture (i.e. GT “blow out”)
107
RC 2018 - AC separation what is true
- Hook plate provide better radiographic and function outcomes
- Hook plate provide better early function
- Non-operative provide better early function
- Non-operative provide better function but higher rate of needing surgery
"C.
"
J Orthop Trauma. 2015 Nov;29(11):479-87. doi: 10.1097/BOT.0000000000000437.
Multicenter Randomized Clinical Trial of Nonoperative Versus Operative Treatment of Acute Acromio-Clavicular Joint Dislocation.
RTW:
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).
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.
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.
108
RC 2015 - Given AP x-ray of an extra-articular supracondylar elbow fracture. 65yo lady. Best treatment?
A. Olecranon osteotomy with orthogonal plating
B. Extra-articular parallel plating
C. Early ROM
D. TEA
B.
109
"![]()
RC 2016 - Shown a lateral x-ray of the elbow with a “double bubble” sign
Which of the following is true?
A. An olecranon osteotomy is required
B. An anterior approach is contra-indicated
C. The capitellum is fractured and the trochlea is intact
D. The capitellum is intact and the trochlea is fractured
"
"
(double bubble - ie fracture of the capitellum and trochlea - type 4)
B
do a lateral approach, may need a medial approach to help reduce the trochlea as well, but DON'T go anterior
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110
RC 2012 - Double Bubble XRAY showing coronal shear fracture of elbow. What is true
- Need to view trochlea
- Can fix from an antecubital approach
- MCL is torn
- Represents an Isolated capitellar fracture
A.
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.
111
RC 2018 - Approach to terrible triad fixation?
- Position: supine with arm over chest, lateral with bolster
- Incision: posterior, then raise lateral fasciocutaneous flap only and do your lateral approach first; may not need a medial approach at all if you can access coronoid fracture through your radial head defect
- Fix RH (or replace)
- Fix Coronoid (cannulated screws, mini plates, suture repair through trans osseous tunnels created with ACL guide)/anterior capsule
- Repair lateral ligs (LCL) at 90 deg flexion with suture anchor
- Evaluate stability of medial side (repair MCL)
- Ex-fix if still unstable
112
RC 2012 - Components of the terrible triad?
RH #
Coronoid #
Elbow Dislocation
113
RC 2013 - After performing a radial head replacement, the elbow is still unstable when in supination. All the following are potential reasons except:
- Radial head implant is too large
- LUCL is avulsed off of lateral epicondyle
- Coronoid fracture that has not been fixed
- MCL rupture that was not recognized
A.
- Too small of radial head will lead to instability è DJ: I don’t know about this…
- JHS Reference points for radial head prosthesis size DOORNBERG
- “A prosthesis that is too large also may contribute to persistent elbow instability after surgical repair”
114
RC 2015 - Elbow injury with large coronoid fracture and comminuted radial head. What is not part of the usual surgical plan?
a. Repair LUCL
b. ORIF coronoid
c. Repair or replace the radial head
d. Repair MCL
"D."
- Pugh DMW (JBJS 2004) Standard surgical protocol to treat elbow dislocations with radial head and coronoid fracture
- ""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""
115
RC 2017 - What is true regarding radial head arthroplasty that is 4mm too large
- They will get wrist pain
- 4mm short will have equal functional outcomes
- Increased radiocapitellar contact pressures
- Increased tightness of the IOM
C.
- Doornberg JHS Jan 2006
- an implant that is too large and causes widening of the lateral side of the ulnotrochear joint space and radiocapitellar wear
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)
116
RC 2008 - Radial Neck # with 1cm shortening, most likely outcome?
- Wrist pain
- OA
- PIN palsy
- Myositis ossificans
A.
- JBJSBr 2006 undiagnosed essex-lopresti - wrist scores were worse than elbow scores preop
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.
117
RC 2016 - A patient has a radial head fracture. 2 fragments. What is the best management plan?
- ORIF with screws and/or plate
- CRPP
- Replacement
- Resection
A. ORIF for < 3 pieces
- Review of 56 patients at 2 years with type 4 radial head #
- Most patients with Mason III fractures with >3 fragments had poor results (13/14)
- 12 patients with < 3 --> no non-union, early failure or severe loss of ROM
- Greater than 3 fragments should be excised or replaced
118
RC 2013, 2011 - List 4 long term complications of radial head fractures.
- Elbow stiffness
- Radiocapitellar arthrosis
- Loss of pronation/supination
- Longitudinal forearm instability
- Weaker:
- Infection
- PIN injury
- HO/Synostosis
- Elbow Instability
119
RC Exam - Which accurately describes the anatomy of the distal humerus?
A . 30o anteversion, 6o valgus, internal rotation
B. 30o anteversion, 6o varus, internal rotation
C. 5o anteversion, 6o valgus, 5o internal rotation
D. 5o anteversion, 6o varus, 5o external rotation
"A.![]()
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120
RC 2012 - GSW with anteromedial axillary entry wound. ORIF through anterolateral brachialis muscle splitting approach. Post-op, inability to flex elbow, with sensation numbness lateral forearm and dorsolateral hand. Wrist flexion and extension normal. Hand function normal. Cause of injury?
a. musculocutaneous injury
b. radial nerve injury
c. compartment syndrome
d. Muscle stripping from plate dissection
A
Internervous plane (none)
- between the brachialis (musculocutaneous n. and radial n.) and brachioradialis (radial n.)
121
RC 2014 - All are true regarding MFCA, except?
- Both the MFCA and LFCA come off the profunda
- During capsular exposure, it is protected by staying cephaled to the piriformis
- It anastomoses with the superior gluteal artery
- …something else true
"C.
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"
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. As described above, the supra-acetabular branch of the SGA anastomosed with the ascending branch of the LFCA in thirty-two specimens. Additionally, the SGA anastomosed with the proximal deep branch of the IGA on the posterior surface of the acetabulum in thirty specimens.
122
RC 2014 - Which of the following is true regarding humeral shaft fractures?
- A. Approximately 5% nonunion rate
- B. 15 degrees varus is poorly tolerated
- C. Radial nerve palsy is a contraindication to conservative management
- D. 2cm of shortening is a contraindication to non-operative treatment
A.
<20 deg sagital plane
<30 deg varus/valgus
<3cm shortening
Union rate 90-95%
123
RC 2013 - Which of the following is a reason NOT to put O2 on an old person in trauma
- A. Chronic lung disease with increased PaCO2
- B. Chronic lung disease with decrease PaCO2
- C. Heart disease
- D. No reason to not put O2 on
"D"
""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""
124
RC 2012 - Best indication for Ex fix in a BBFA:
A. Grade IIIB
B. Grade IIIC
C. Comminuted
D. Segmental
"B. "
- 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
- 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
- AO Surgery Reference
- ""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""
125
RC 2013 - What is the best indication for external fixation in an open diaphyseal radius and ulna fracture?
A. Segmental bone loss
B. Ipsilateral wrist injury
C. Grade IIIC Injury
D. Elbow instability
C
- Another shit question. I would have chosen C
- 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
- Some argument that primary shortening is an option in the forearm
- JAAOS - Adult Diaphyseal Forearm Fractures
- The use of external fixation for forearm fractures is indicated in rare cases of severe soft-tissue injury or contamination
126
Methods to increase stability with Ex-Fix
" ![]()
"
Femur: 5 or 6mm pins
Tibia: 4 or 5 mm pins
127
How to Decrease pin site infection in Ex-fix?
- Stable construct
- Sterile technique
- Soft tissue protector
- HA pins
- Sterile bandage
128
RC 2016, 2013 - Motorcycle crash 2 hours ago with hypotension, unstable. Tibia fracture with large soft tissue defect, 12cm bone on road (in paper bag with EMS), vascular injury with no pulses, insensate foot. Ipsilateral femur and acetabular fractures. How will you treat the leg?
A. I+D, Vascular repair, replace extruded tibia and unreamed nail
B. I+D, Vascular repair, discard extruded tibia and unreamed nail
C. I+D, Vascular repair, discard extruded tibia and ring fixator
D. Below knee amputation
"D."
Leap Study Group - Amputation vs reconstruction
- Impact on decision to amputate limb
- Severe soft tissue injury - Highest impact on decision-making process**
- Absence of plantar sensation
- Second highest impact on surgeon’s decision making process
- Not an absolute contraindication to reconstruction
- Plantar sensation can recover by long-term f/u
- 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.
- Outcome measures – same 2 and 7 year outcomes in ppl with amputation vs salvage
- Sickness impact profile
- Return to work
- Not significantly different b/w amputation and reconstruction at 2 and 7 years
129
RC 2014 - Open femur fracture with 3cm bone loss. I+D and ex-fix are done. What is the next step?
A. Convert to IM nail and shorten
B. IM nail then wait 16-20 weeks and bone graft if no union
C. Bone graft 2 weeks later when you IM nail
D. Bone transport at 8 weeks once soft tissue envelope is optimized
B.
- JAAOS 2015 - Management of Segmental Bone Defects:
- Autologous bone grafting an option up to 5cm
- Bone transport a good option for infected defects, but usually only used in longer defects
- Acute shortening an option up to 3-5cm (vascular kinking after this), but more common in upper extremity
- Pipitone PS (Orthop Clin NA 2014) Management of Traumatic Bone Loss in the Lower Extremity
- Critically sized defects - defect is 2-3x the diameter of the bone
- Autogenous iliac crest bone graft if <4cm
- Shortening/lengthening with 2-10cm
- Tibia/humerus --> immediate shortening of 3-4cm tolerated
- Femur --> 5-7cm
- If defect is >3cm can get venous congestions and edema --> necrosis/infection
- Defects > 10cm consider vascularized fibular grafting, distraction osteogenesis
130
RC 2015 - What is true regarding bone loss of 6cm:
- A. More common in diaphyseal fractures
- B. More common in the femur
- C. Should amputate if >10cm
- D. Must plate it to maintain alignment and rotation
"A.
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131
RC 2016 Obese patient with large open tibia fracture. Severe diabetes for 20 years. Heavy smoker. Which factor reduces the risk of infection the most?
A. Poor diabetic sugar control
B. Smoking history
C. Administering antibiotics in < 1 hour
D. Early operative debridement
C.
- JAAOS 2010 - Open Tibial Fracture
- Early antibiotics shown to reduce infection (<3 hours)
- Smoking and diabetes are risk factors for infection
- Quality of debridement is important for infection risk, but no evidence for timing of debridement
132
RC 2013 - What is true about compartment syndrome:
- A. Most common in males <35yo
- B. Open fractures are less likely to have a compartment syndrome
- C. Compartment pressure measurements are necessary for diagnosis
- D. Forearm fractures are not a common cause of compartment syndrome
A.
133
RC 2018 - A male trauma patient has a pelvic fracture that is stabilized with an In-Fix implant which is placed subcutaneously. What is the most commonly seen complication with this method of fixation?
a. Femoral nerve injury
b. Injury to the spermatic cord
c. Lateral femoral cutaneous nerve of the thigh injury
d. Bladder perforation
"C."
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 % [5, 8, 10]. The most common complication reported is lateral femoral cutaneous nerve palsy, reported to occur temporarily in 0–30 % and permanently in 0–1 % [5, 8]. Heterotopic ossification has been reported in 0–25 % [5, 8].
134
RC 2018 - A 17 year old male is seen following an injury he sustained. After see his MRI (below - c-spine root avulsion), what is the recommended treatment? (the MRI given is essentially exactly what we were actually given, and the stem was just as vague as this - you had to figure out what the pathology is)
a. Tendon transfers
b. Nerve repair
c. Neurotization
d. Shoulder arthrodesis
A. Dhaliwal agrees
McGill: C
135
RC 2014 - A 50yo male falls from a horse. You are shown an x-ray which demonstrates 2-3cm pubic diastasis and slight right SI joint widening but no vertical instability. What was the mechanism?
A. Vertical shear
B. Anterior posterior compression
C. Lateral compression
D. Open book
B.
136
RC 2016 - When utilizing the Kocher-Langenbeck approach for acetabular fractures, everything is true about positioning EXCEPT?
A. Lateral: useful for transverse fractures
B. Lateral: useful for ipsilateral pubic symphysis fractures
C. Prone: useful to decrease sciatic nerve tension
D. Prone: useful to palpate the quadrilateral plate
"A - prone for T type and transverse
"
B-true
In summary, Kocher-Langenbeck in the prone position:
- Less tension on sciatic nerve (easy to extend hip with cushion under knee, and more under tibia for knee flexion)
- Better reduction (not statistically significant, but gravity doesn't displace fracture)
- Better ability to assess quadrilateral plate through greater sciatic notch
Lateral position:
- Can fix ipsilateral symphysis fractures, maybe
137
RC 2017, 2012 - 5 indications for ORIF of midshaft humerus
- Open Fractures
- Failure of conservative management, inability to brace
- Floating Elbow
- Poly-trauma/early mobilization
- Brachial plexus injury/flail extremity
- Pathologic Fracture
- Vascular Injury
- High energy GSW (low E GSW can be treated non-op)
138
RC 2012 - Old lady with an olecranon fracture tension banded. Decent reduction. Pins penetrating anterior cortex. Next image on follow-up shows the transverse olecranon piece is proximal to the construct by 5 cm or so. Why did this happen?
A. Took off splint too early
B. You physio to do Passive ROM too early
C. She didn’t stop smoking
D. The wire construct was passed superficial to the triceps
"D."
- JAAOS 2000 - Olecranon Fractures
- ""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""
- ""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""
139
RC Exam - Distal radius fracture; what is a risk factor for negative prognosis of the radiocarpal joint AND the DRUJ
- 2 mm articular displacement
- “greater than” 5 mm shortening of distal radius
- incongruity of the sigmoid notch
- radial inclination of 10
2.
- Articular displacement does correlate with radiocarpal radiographic arthritic change but has no effect on DRUJ
- Similarly incongruity of sigmoid notch impacts DRUJ but not radiocarpal joint
- Radial inclination impacts lunate contact forces
140
RC 2014, 2008 - What is the best indication for performing a distal radius osteotomy?
- 1 mm intra-articular step
- 2mm radial shortening
- Less than 10 degrees radial inclination on PA view
- 5 degrees of dorsal tilt
"C.
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141
RC 2014 - Regarding a hip fracture patient on Plavix (clopidogrel), which of the following is true?
A. The effects can be reversed with vitamin K and plasma transfusion
B. Multiple transfusions will be required if the patient goes to the OR within 48 hours
C. There will be no major complications if the patient is taken to the OR before 24-48 hours
D. It is safer to wait 3-5 days before operative intervention to avoid perioperative complications
C.
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
142
RC 2013 - Regarding a DHS placement. Which of the following is NOT true:
A. Peripheral placement makes no difference
B. Tip apex is D(ap) x D(lat) (Yup, it was X, not plus)
C. Screws placed in the superior aspect of the head are more likely to cut out
"A, B are FALSE Statements
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143
RC 2012 - 65 yr F , non-pathological, with transverse fracture at the level of the LT. How do you treat it?
A. Blade plate
B. Centromedullary nail (interlocking)
C. Cephalomedullary nail (recon)
D. Retrograde nail
C.Inter-locking nail is designed to bring the nail medial in the canal as second screw is placed
144
"RC Exam - ![]()
75 year old female suffers a subtrochanteric fracture and is treated with a blade plate as seen in the XR. (This XR is nearly identical to what we were shown). What is true?
A. It will fail because it is not anatomically fixed with absolute stability of the cortical fragments.
B. It will not fail because the load is spread over a long length of plate
C. It will fail because it was not bone grafted
D. It will fail because of osteoporosis and delayed fracture healing.
"
B.
145
RC 2018 - List 3 patient factors that lead to failure of a distal femoral locking plate. List 3 technical or fracture related factors that contribute to failure of a distal femoral locking plate.
- Independent risk factors for reoperation (nonunion, infx)
- Patient: diabetes, BMI smoking,
- Injury: open fracture, metaphyseal comminution
- Surgery: Shorter plate length
146
RC 2013 - What is associated with highest rate of non-union of a distal femur fracture treated with a locking plate?
- Previous smoker that quit 4 years ago
- Shorter plate length
- Oblique fracture extending into metaphysis
- Fracture extending into the diaphysis
B.
- 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.
Ricci JOT 2014 – Risk factors for failure of locked plate fixation
- Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length.
Rodriguez JOT 2016 Mechanical construct characteristics predisposing to non-union after locked lateral plating of distal femur fractures
- 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
147
RC 2013 - In an adult femur supracondylar fracture, intraarticular and metaphyseal comminution what are 3 advantages of a distal femoral locking plate over a 95 degree sliding dynamic condylar screw.
- Better fixation in osteoporotic/comminuted bone (multiple points of fixation)
- Ability to control multiple fracture fragments
- Anatomic contour helps with reduction of joint
- Biomechanically superior in cyclic load and ultimate strength
- Preserves more distal bone stock
- Less soft tissue stripping
148
RC 2014 - You are shown an x-ray of a periprosthetic oblique distal femur fracture just above a well fixed TKA. Bone quality is good. The patient is otherwise healthy. What is the best treatment?
A. Cast
B. Revision with long stems
C. ORIF
D. Distal femur-replacing prosthesis and revision of the tibial component
C.
149
RC 2012 - You are given a coronal CT slice mid joint of a Schatzker II split depression lateral plateau fracture. The arrow points to the impacted joint depression fragment. What is the best way to reduce this fragment at the time of the operation?
A. Ligamentotaxis with X-Fix
B. Direct visualization and manipulation of fragment
C. Indirect reduction using raft screws
D. Indirect reduction using k-wires
B.
- Buckley 2018. A sub-meniscal arthrotomy improves the medium-term patient outcome of tibial plateau fractures
- Prospective ORIF (submeniscal arthrotomy) vs CRIF (x-ray guided)
- 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.
150
RC 2011, 2015 Regarding fixation of a tibial plateau fracture, which is true?
a. Locking plates have better outcomes and less complications than non-locking plates
b. Locking plates have better outcomes and more complications than non-locking plates
c. Locking plates have equal outcomes and less complications than non-locking plates
d. Locking plates have equal outcomes and equal complications as non-locking plates
D.
151
RC 2015 - 45yo male sustains a bicondylar tibial plateau fracture. What is the most important part of management?
A. articular reduction
B. early ROM
C. use of a locking plate
D. Alignment
D.
152
RC 2015 - All are true regarding fixation of distal tibial fracture, EXCEPT?
A. Fixation of fibula is associated with higher nonunion rate
B. Open fractures have higher rates of malunion and nonunion
C. Plate fixation is associated with higher rate of malunion
D. No difference in union rates between plate and IM nail fixation
C.
- Randomized, Prospective Comparison of Plate versus Intramedullary Nail Fixation for Distal Tibia Shaft Fractures. Vallier, Cureton and Patterson. JOT. 2011
- High primary union rates were noted after surgical treatment of distal tibia shaft fractures with both plates and nails
- Rates of infection and secondary procedures were similar when the two groups were compared.
- Open fractures were associated with increased rates of infection, nonunion, and malunion.
- Intramedullary nailing was associated with more malalignment versus plating.
- 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.
- In our combined analysis, nonunion of the tibia was more frequent after nails versus plates.
153
RC 2014 - 30 yr dude with posterior mall and lateral mall fracture. No medial mall facture. Talus 40% subluxated posterior. Lateral Mall is oblique at the joint line. What provides the most stable fixation?
A. One lag screw and lateral plate
B. Two lag screws
C. One lag screw and posterior plate
D. Tension band Wire
C.
- Ostrum RF (JOT 1996) Posterior Plating of Displaced Weber B Fibular Fractures
- Benefits of posterior plating:
- Bicortical screws --> better fixation
- Stronger and stiffer construct
- Lag screw stronger as it is done through the plate (acts as a stronger cortex)
154
RC 2018, 2015 - What is true about posterior malleolus fractures:
- A. 5% of spiral tibia fractures extend intra-articularly
- B. Posterior malleolus fixation provides more stability than syndesmosis fixation
- C. 10% involvement results in posterior subluxation
- D. Often starts posterolaterally and extends into the medial malleolus
B.
Fixation of Posterior Malleolar Fractures Provides Greater Syndesmotic Stability. Gardner et. al. Clinical Orthopaedics and Related Research. 2006
- PER Stage 4 ankle fracture with a deltoid ligament tear and posterior malleolus fracture
- After fracture creation, five specimens were assigned randomly to receive posterior malleolar fixation…The remaining five specimens received trans-syndesmotic fixation.
- Each specimen first was tested intact to determine its baseline stability for later use as its own internal control.
- Specimens were tested again after fixation to determine the effect of fracture creation and fixation on syndesmotic stability.
- Posterior malleolar fixation provided better rotational stability than syndesmosis fixation.
- Specimens with posterior malleolar fixation had a decrease in stiffness of 30% compared with the intact stiffness of each specimen
- Patients who had traditional syndesmosis stabilization had a 60% (SD, 20%) decrease in stiffness compared with intact rotation (40% of intact stiffness was restored)
- These are confusing statements
- Basically they mean more stiffness was restored with posterior mal fixation
155
RC 2014 - When fixing a syndesmotic injury with tibiofibular screws versus with an ORIF of the posterior malleolus, which of the following is true?
A. Stiffer syndesmosis with posterior malleolar fixation
B. External rotation of fibula can occur with posterior malleolar fixation
C. They both have the same rates of sural nerve injury
D. They both have the same rates of syndesmotic malreduction
a.
variation of repeat
156
RC exam - A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most reliable method of predicting a tear of the interosseous membrane?
1- Level of the fibular fracture
2- Lauge-Hansen fracture class
3- Intraoperative stress testing
4- Widening of the medial clear space
5- Talar dislocation
C.
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.
PREFERRED RESPONSE: 3
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.
157
RC 2016, 14 - What is true about dorsal barton fracture with dorsal subluxation of carpus?
- treat with closed reduction and casting
- volar radiocarpal ligaments not injured
- usually need volar and dorsal approach
- Teardrop angle (TDA) will be ?increased/decreased due to volar impaction
"C."
- Lozano-Calderon/Doornberg/Ring (JBJS 2006) Fractures of the dorsal articular margin of the distal part of the radius with dorsal radiocarpal subluxation
- 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”
- Case series of 19 operative patients
- 11 had dorsal alone, 7 combined, 1 volar alone
- “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.”
158
RC 2018 - An obese gentleman with type 1 diabetes presents to your emergency department with an open tibia fracture. What is the most important factor in preventing infection?
a. Early IV Abx in the ED
b. Glycemic control
c. Timely I+D
d. Wound care
ANSWER: A
- 2014, 2016, 2018
- Skaggs DL (JBJS 2005) Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children
- Analysis of 554 open fractures
- No difference between I&D before 6 hours and after 6 hours
- Patzakis and Wilkins
- 1025 open fractures
- Infection rate 4.7% with abx before 3 hours and 7.4% antibiotics after 4 hours
159
"
RC 2018 - During an OR, you place a Hohmann retractor posterior to the femur during lateral exposure of the proximal third of the thigh. You encounter brisk bleeding. What did you damage?
a. Profunda femoral artery
b. Superficial femoral artery
c. Popliteal artery
d. Superior gluteal artery"
"
Answer A (perforators)
Can't be B (superficial and medial structure)
Can't be C (distal structure)
D highly unlikely, much more proximal and posterior
"
160
RC 2011, 2010 - List 3 complications of doing an ankle ORIF in a patient with DM
JAAOS 2008 - Complications of Ankle Fractures in Patients with Diabetes
· Increased risk of infection
· Delayed wound healing
· Delayed time to union
· Non-union
· Mal-union/loss of reduction
· Increased hardware failure
· Charcot neuroarthropathy
· CRPS
· Amputation
161
RC 2014 - A 25yo male is involved in a MVC. You are shown an x-ray of a basicervical fracture, fairly horizontal pattern, displaced. GT is intact. What is the optimal treatment?
A. Cephalomedullary nail
B. Sliding hip screw with anti-rotation screw
C. Short threaded screws with 1 superior and 2 inferior
D. Short threaded screws with 2 superior and 1 inferior
B.
o No evidence in young patients for SHS + antirotation screw vs 3 cannulated
o Definitely would try and avoid a cephalomedullary nail in young patient (removing proximal bone stock, violating abductors)
Optimal Internal Fixation for Femoral Neck Fractures: Multiple Screws or Sliding Hip Screws? Bhandari, et al. J Orthop Trauma. 2009
§ 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.
§ The pooled estimate for displaced fractures revealed a trend in favor of the sliding hip screw in reducing the need for revision surgery.
§ 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
162
RC 2015 - What is true about Boutonierre deformity in RA:
A. Not associated with MCP and DIP pathology
B. Can be corrected with tenotomy over PIP
C. An arthrodesis is contraindicated with a stiff PIP joint
D. Caused by dorsal subluxation of the lateral cords
A.
deformity starts at PIP
B-correct with centralization at PIP with tenotomy at DIP
163
All are major criteria for AFF, based on the ASBMR 2013 consensus, except?
A. Generalized diaphyseal cortical thickening
B. Non-comminuted
C. Lateral beaking
D. Complete fracture extend through both cortices and may be associated with a medial spike
ANS A
• Major
1. No or minimal trauma (fall from standing height or less) (low energy)
2. Fracture line originates at the lateral cortex and is substantially transverse in its orientation, although it may become oblique as it progresses medially
3. Complex fractures extend through both cortices and may be associated with a medial spike
4. Non-comminuted or minimally comminuted
5. Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site (“lateral beaking” or “flaring”)
• Minor
1. Generalized increase in cortical thickness of diaphysis
2. Unilateral or bilateral prodromal symptoms
3. Bilateral incomplete or complete fractures
4. Delayed healing
164
What is true about Ewing Sarcoma?
a. Extrapulmonary mets are worse than only pulmonary mets
b. Not associated with sclerosis on x-ray
c. Rarely presents with fever, high WBC and high ESR
d. It is uncommon for a delay in symptoms and diagnosis
"
Ref: AAOS review Ewing Sarcoma Family of Tumours - Feb 2010
• X-ray: sclerosis present in ~40% of cases
• 20-28% have fever on presentation
• Common to have elevated ESR
• Delay very common (studies with 50% of patients w/ symptoms for 6 months before diagnosis)
• Patients with metastatic disease confined to the lung have a better prognosis than do patients with extrapulmonary metastases
"
165
"
RC 2019 - All are major criteria for AFF, based on the ASBMR 2013 consensus, except?
- Generalized diaphyseal cortical thickening
- Non-comminuted fracture
- Lateralized thickening or beaking
- Complete fracture extending through both cortices, and may be associated with a medial spike
"
Ref: Journal of Bone and Mineral Research, Vol. 29, No. 1, January 2014, pp 1–23.![]()
- Major
- No or minimal trauma (fall from standing height or less)
- Fracture line originates at the lateral cortex and is substantially transverse in its orientation, although it may become oblique as it progresses medially
- Complex fractures extend through both cortices and may be associated with a medial spike
- Non-comminuted or minimally comminuted
- Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site (“lateral beaking” or “flaring”)
- Minor
- Generalized increase in cortical thickness of diaphysis
- Unilateral or bilateral prodromal symptoms
- Bilateral incomplete or complete fractures
- Delayed healing
166
What is true about prospective lower extremity injury severity scores?
- High specificity but low sensitivity
- Highly specific
- There is minimal clinical utility to these scores
"
"
Answer: D
JBJS 2008. 90: 1738-43
- 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
- Conclusion states that currently available injury severity scores are not predictive of functional recovery of patients who undergo successful limb salvage surgery
LEAP study
Helps with some prognostication but no good/useful score available
167
Best treatment for femoral neck shaft fracture combo in 50 yo F?
A. One perfect antegrade IM nail
B. Retrograde IM nail and DHS
C. DHS and distal femoral plate
D. Hemiarthroplasty and distal femoral plate
"
Answer: B
Ref: Clin Orthop Relat Res. 2004. 399:78-86
- 58% of all complications include fem neck/shaft non-union were from single antegrade IM nails
- Concluded that single device had worst results
- Improved outcomes with reamed IM nail/lag screw combo
Ref: Diagnosis and Management of Ipsilateral Femoral Neck and Shaft Fractures. JAAOS 2019
- 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.
- No difference was noted between cannulated screws and sliding hip screw with regard to femoral neck union.
- 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.
- Selection of proximal implants is based on the femoral neck fracture pattern, degree of comminution, and bone quality.
- An open reduction of the femoral neck is performed through an anterior approach using joysticks, clamps, and preliminary wire fixation.
- 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.
- 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.
168
What is the best way to assess the syndesmosis intra-operatively?
A. Cotton test
B. External rotation
C. Gravity test
D. Dorsiflexion test
"
Answer: A
JBM: This question is based from: van den Bekerom MPJ. Diagnosing syndesmotic instability in ankle fractures. World J Orthop. 2011
Ref: van den Bekerom. Diagnosing syndesmotic instability in ankle fractures. World J Orthop 2011
- 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.
- The “Hook” or “Cotton” test is more reliable than the exorotation stress test.
Ref: JAAOS 2015
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.
- Presented a prospective series of 28 patients undergoing ankle fracture fixation and compared intraoperative testing methods of the syndesmosis.
- They reported that compared with the Cotton test, stress external rotation demonstrated a 35% increase in medial clear space widening.
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.
- 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.
- 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.
Ref: Gardner M, et al. Technical Considerations in the Treatment of Syndesmotic Injuries Associated With Ankle Fractures. JAAOS 2015
- According to the Lauge-Hansen classification system, pronation external rotation, supination external rotation, and pronation abduction fractures hold the highest risk of syndesmotic injury.
- The intraoperative evaluation of syndesmotic stability should occur after all other points of instability have been addressed.
- 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.
- The position of the ankle should be standardized during testing, and the tibiofibular clear space on the AP view reveals the least amount of variability attributable to rotation
- If the contralateral ankle is uninjured, comparison radiographic views should be obtained
- Standard intraoperative stress mechanisms include an external rotation stress test of the dorsiflexed ankle or direct translation of the fibula via a clamp or hook (modified Cotton test)
- The 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.
169
What is the biggest risk of compartment syndrome? (RC 2019)
A. Young Age
B. Segmental tibia
C. Gustillo classification
D. Something else wrong
"
"
Answer: A
Ref: JOT 2015 16(3): 185 Canadian paper Toronto, Edmonton
- RF for development of LE acute compartment syndrome:
- Younger patients
- Not associated with compartment syndrome
- Male
- Open fracture
- IM nail fixation
- Segmental tibias less likely
170
What is the consequence of oversizing a radial head replacement by 4 mm? (RC 2019)
A. Increased contact pressures
B. Increased tightness in IOM
C. Same effect as undersizing 4mm
D. Decreased pronation/supination by 30o
"Answer: A
"
Ref: JBJS 2004 86(12)2629.
- Cadaveric study
- Increase of 2.5 mm in length significantly increases contact pressures
- Decrease of 5 mm decreased contact pressures substantially
- Ultimately increases contact pressures and leads to early development of OA
- Loss of flexion
171
Terrible triad, what is true? (RC 2019)
A. LUCL torn from supinator crest
B. MCL often torn
C. It is always operative
D. Basal type 3 coronoid often
"
Answer: B
- Terrible triad are not always operative.
- Indications for non-op management (rare):
- UH and RC joints must be concentrically reduced
- Radial head fracture must not meet surgical indications
- Coronoid fracture must be small
- Elbow must be stable enough to allow early ROM
REF: Matthew al. JAAOS 2009 & JBJS Am 2006;88:2216-2224.
- Coronoid tip fractures (O’Driscoll Type I) are most frequently seen in association with terrible triad injuries.
- Coronoid fracture classification according to O’Driscoll et al.: The three types are tip (A), anteromedial facet (B), and basal (C) fractures.
- Tip fractures are subclassified into two groups, either ≤2 mm or >2 mm in size.
- Anteromedial facet fractures are subclassified into three subtypes (anteromedial rim, rim plus tip, and rim and tip plus the sublime tubercle).
- Basal fractures are subclassified into two groups (coronoid body and base, and transolecranon basal coronoid fractures).
- The anterior bundle of the MCL is postulated to be the last to fail.
172
"Patient has luxatio erecta (inferior dislocation ). All are true except? (RC 2019)
A. The long head of the biceps tendon can be a block to reduction
B. The humeral shaft is often abducted
C. The humerus is locked inferior to the glenoid
D. Proper reduction includes direct traction in-line with the humerus
"
"
Answer: A
- Specific term for inferior dislocation of the GH joint trapped underneath the coracoid and glenoid.
- Has greatest incidence of neurovascular injury of all types of shoulder dislocations.
- Vascular injury 40%, neurologic injury 60% (axillary)
- 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.
173
"
GSW - what is true? (RC 2019)
- A high velocity weapon at long range is worse than a low velocity weapon at close range
- Increased yaw results in increased damage
- Decreased damage if hits lung tissue first, compared to muscle
- Solid bullets are worse than Hollow points
"
Answer: B
Yaw refers to the rotation of the nose of the bullet away from the line of flight.
Ref: JAAOS 2000 - Ballistics and GSW
Efficiency of Energy Transfer is dependent on:
(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.
(2) The stability and entrance profile of the projectile.
- At a yaw of 90° (sideways), maximal energy transfer is achieved.
- Yaw tends to decrease over longer distances, allowing the bullet to hit its target nose on; at impact, however, wobbling and then tumbling occurs.
(3) The caliber, construction, and configuration of the bullet, which can be by far the most important factors predicting its effects.
(4) The distance and path traveled within the body.
- Penetrating (not exiting) missiles deliver their total contained kinetic energy.
- Perforating (exiting) missiles transfer significantly less.
(5) The biologic characteristics of the tissues impacted.
(6) The mechanism of tissue disruption (e.g., stretching, tearing, crushing)
Greater tissue damage to inelastic tissues (liver, spleen) than elastic ones (lung)
Low-velocity, but close range are high energy wounds and should be treated as per high velocity
Low velocity <2,000ft/s (handguns, shotguns), high velocity >2,000 ft/s (rifles, military weapons)
Ref: Kuhajda I, et al. Penetrating trauma. 2014.
- Dense organs, such as bone and liver, absorb more energy resulting in more injury. Lungs, which have a much lower density, absorb less energy and fortunately suffer less of an injury.
174
"
30M is involved in an MVC and sustains a posterior acetabular wall fracture. What is true about the outcomes following a 6-week course of indomethacin?
- Increase risk of nonunion
- Less HO
- Increases AVN risk
"
Answer: A
REF: Sagi et al. Indomethacin Prophylaxis for Heterotopic Ossification after Acetabular Fracture Surgery Increases the Risk for Nonunion of the Posterior Wall. JOT 2014.
- The incidence of clinically significant HO after acetabular fracture surgery has been reported to be as high as 40% depending on the surgical approach and various patient/fracture characteristics.
- Patients who consented to take part in the study preoperatively were randomly assigned to 1 of 4 postoperative treatment groups:
- placebo for 6 weeks
- 3 days of indomethacin 75 mg PO daily followed by placebo for a total of 5.5 weeks
- 1 week of indomethacin 75 mg PO daily, followed by 5 weeks of placebo
- 6 weeks of indomethacin 75 mg PO daily
- Patients were followed clinically and radiographically at 6 weeks, 3 months, 6 months, and 1 year.
- 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, patients in the 6 week treatment group demonstrated a significantly higher rate of radiographic nonunion (62%) of either the posterior wall or one of the columns.
- 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.
175
What structures can result in an irreducible dislocation?
1. Posterior dislocation. Piriformis tendon, gluteus maximus, capsule, ligamentum teres, posterior wall, bony fragment, iliofemoral ligament, labrum.
2. Anterior dislocation. Capsule, rectus femoris, labrum, psoas tendon.
176
"
With respect to hip dislocations and sciatic nerve injury, which of the following is true? (RC 2019)
- Nerve injury is not an indication for open reduction
- Is more common with pure dislocation vs fracture dislocation.
- EMG at 3 months can influence management
- No return of function at 6 months requires surgery
"
Answer: A
- Letournel and Judet noted that highest incidence of sciatic nerve palsy was in association with a posterior fracture dislocation.
- Sciatic nerve injury seen in 10-15% of dislocations
- Peroneal branch more commonly involved
- At least partial return of function in 60-70%
- Sciatic nerve injury caused by a reduction attempt warrants open reduction
