OITE Review
Selected by
Waleed Awwad, MD, FRCSC
1997
Year:1997 Question # 7
Figure 2 shows the lateral radiograph of the left hindfoot and ankle
of a patient who fell 10 feet and landed on his left foot. The
most predictable advantage of open reduction and internal
fixation compared with closed management without reduction is
a. an earlier return to function.
b. decreased subtalar range arthrosis.
c. increased ankle dorsiflexion.
d. increased subtalar range of motion.
e. restoration of height and width of the heel.
Correct Answer: e
Explanation: Remember, when the calcaneus fractures it loses
height, widens, shortens, and falls into varus. None of the first
four answers are very "predictable" and that`s what they ask
for. In butress plating, you can restore much of the height and
width
Year:1997 Question # 10
What is the most appropriate biomechanical fixation
method/device for a reverse oblique intertrochanteric fracture?
a. Ender pins
b. Sliding hip screw
c. 95-degree fixed angle device
d. Cerclage wire with interfragmentary fixation
e. Medial displacement osteotomy with sliding hip screw
Correct Answer: c
Too proximal for Enders. The fracture line would be parallel to a
DHS screw; so that would be bad AO fundamentals. Cerlage
wiring and interfrags is a pretty weak construct. Medial
displacementosteotomies (Fig.18-31 attached) are done mainly
for intertrochs where the Gr. Troch is fractured off or where
there is no posteromedial bone (calcar) continuity. There is,
however, a "notching" that can be done to make a reverse
intertroch more stable. (Fig. 18-25 attached)
Year:1997 Question
Figure 5a shows the radiograph of a 22-year-old man 3 years
after undergoing reduction and fixation for a fracture of the
radius and ulna with two plates secured with 4.5 mm screws. A
postoperative radiograph after the plate removal is shown in
Figure 5b. Which of the following factors increases the risk of
re-fracture?
a. Young age
b. Incomplete healing
c. Use of a large plate
d. Bony overgrowth around the plate
e. Insufficient amount of time between fracture and plate removal
Correct Answer: c
Young age would decrease the risk (not #1). There`s no evidence
of incomplete healing (npt #2). They used 4.5 mm screws
where a 3.5 mm would have been adequate. Bony overgrowth
is evident and could potentially be a stress riser, but not nearly
as much as those empty 4.5 mm screw holes (not #4). 3 years
is plenty of time before plate removal can be done (not #5).
Year:1997 Question # 28
Figures 7a and 7b show the wound and radiograph of a 44-yearold man who underwent plating for a closed fracture of his tibia
7 months ago. The wound has been draining for 4 months, and
cultures are positive for Staphylococcus aureus. In addition to
antibiotics, metal removed, and debridement, treatment should
include
a. electrical stimulation and casting.
b. soft-tissue coverage and re-plating with a bone graft.
c. bone grafting, soft-tissue coverage, and application of a cast.
d. external fixation, staged soft-tissue coverage, and bone
grafting.
e. intramedullary rodding, staged soft-tissue coverage, and bone
grafting.
Correct Answer: d
Osteomyelitis, or inflammation of the bone, can result from
hematogenous seeding, from direct inoculation (ie, following
open fractures or following open reduction and internal fixation
of fractures), or from the contiguous spread of bacteria from
infected structures. Early diagnosis and effective surgical and
antibiotic management can control the infection; suppression of
its activity may last a lifetime. Basic treatment should include
thorough debridement, irrigation, wound management (external
fixation, staged soft-tissue coverage), and bone grafting.
Year:1997 Question # 32
Figures 10a and 10b show radiographs of a 27 year-old woman
who sustained an injury to her left, nondominant forearm as a
result of a motor vehicle accident. Under anesthesia, it is noted
that the distal radioulnar joint is unstable but reducible in
supination. Treatment should include
a. closed reduction, followed by splint immobilization with the limb
in supination.
b. closed reduction and external fixation of the radius, followed by
splint immobilization with the limb in supination.
c. open reduction and external fixation of the radius, with fixation
of the radioulnar joint.
d. open reduction and internal plate fixation of the radius, with
fixation of the distal radioulnar joint.
e. open reduction and internal plate fixation of the radius, with
immobilization of the distal radioulnar joint in supination.
Correct Answer: e
The Galeazzi eponym, originally defined as fracture of the distal
third of the radial shaft with an associated dislocation of the
distal radioulnar joint (DRUJ), has been applied when referring
to a fracture anywhere along the radial shaft as well as to
fractures to both radius and ulna that occur in conjunction with
a DRUJ injury. Monteggia and Galeazzi lesions require
anatomic reduction of the diaphyseal fracture component in
order to restore the normal axial interrelationship of the forearm
bones and allow reduction of the dislocation. Fracture fixation is
accompanied best by plating. Residual instability of a reduced
DRUJ after anatomic plating of the radius can usually be
addressed by immobilizing the limb in supination for 6 weeks
postoperatively. Temporary pin fixation of the DRUJ is rarely
required. Cast immobilization after surgical treatment of closed,
unstable single bone forearm injuries has not been shown to
have any detrimental effect on functional outcome.
Year:1997 Question # 37
The incidence of vascular injury after an anterior knee dislocation
is
a.
b.
c.
d.
e.
less than 5%.
10% to 25%.
30% to 50%.
60% to 80%
greater than 95%.
Correct Answer: c
Knee dislocation are classified relative to the position of the tibia,
and there are five types. Anterior knee dislocation occur most
frequently (40%), followed by posterior (33%), lateral (18%),
and other (5%). The incidence of vascular injury after an
anterior or posterior knee dislocation has been reported to be
20% - 35%. (Most studies quote 30%). Neurologic injuries most
frequently involve the common peroneal nerve nerve because
of its tethered proximity to the fibular head. Lateral and
posterolateral dislocations are the most frequent causes of
common peroneal nerve injury. Overall, incidence of neurologic
injuries varies between 16% and 40%. Less than 50% of
patients will have partial or complete recovery from a peroneal
nerve.
Year:1997 Question # 40
A 45-year-old man sustains an injury to his pelvic ring as a result
of a motor vehicle accident. Radiographs are shown in Figures
11a through 11c, and a CT scan is shown in Figure 11d.
Examination reveals that he is hemodynamically stable and has
no associated injuries. Management should include
a. anterior sacroiliac plate fixation.
b. anterior fixation of the pubic symphysis.
c. posterior fixation of the left sacroiliac joint.
d. early mobilization and weight bearing without internal fixation.
e. combined anterior fixation to the pubic symphysis and posterior
fixation of the left sacroiliac joint.
Correct Answer: b
Disruptions of the symphysis pubis are variable. The symphyseal
ligaments, the pubic meniscus, and the arcuate ligament may
be disrupted. For isolated disruptions of the symphysis pubis,
most authors advocate closed, nonsurgical management,
especially when the symphysis diastasis is less than 2.5 cm. In
cases where the diastasis exceeds this limit, stabilization
should be pursued.
Year:1997 Question # 41
Radiographs of a 24-year-old man who sustained an open tibial
frature 11 months ago are shown in Figures 12a and 12b.
Examination shows an anteromedial draining wound over the
midtibia. Which of the following methods will most accurately
identify the pathologic microorganisms?
a. Swab culture of the sinus tract
b. Operative sampling of the sinus tract
c. Operative sampling of the posterolateral sequestrum
d. Operative sampling of deep specimens from multiple foci
e. Needle aspiration of the distal tibial metaphyseal abscess
Correct Answer: d
In a recent study, pathogens that were identified on cultures of
material obtained by swabbing of the superficial aspect of a
wound and needle biopsy were compared with those that were
isolated from material that was obtained at debridement. The
cultures of material that was obtained by superficial swabbing
of the wound and needle biopsy were inadequate for prediction
of the presence of aerobic organisms. Moreover, the failure to
isolate anaerobies from the material obtained by needle biopsy
did not rule out the presence of anerobic organisms, nor does it
rule out the possibility that osteomyelitis may be reactivated
after intramedullary nailing with reaming. Therfore, tissue for
culture of aerobic and anerobic organisms must be obtained
during operative debridement in order to identify all pathogenic
organisms. Other studies have shown that cultures must be
taken from multiple sites in chronic osteomyelitis of long bones
in order to properly treat all varieties of bacteria present.
Year:1997 Question
A 37-year-old man who sustained a type IIIB open fracture of the
middle third of the tibia after a severe crush injury has
significant contusions and some necrosis of the posterior
muscles. Treatment consists of debridement and external
fixation. Which of the following muscle flaps should be used for
soft-tissue coverage of the exposed anteromedial tibia?
a. Soleus
b. Fasciocutaneous
c. Medial gastrocnemius
d. Lateral gastrocnemius
e. Free vascularized muscle
Correct Answer: e
Grade IIIB indicates initial soft-tissue loss and extensive areas of
denuded bone that make later flap coverage necessary. All
grade IIIB and many grade IIIC wounds require flap coverage.
For the proximal third of the leg, such coverage is best
achieved with a gastrocnemius flap; a soleus flap will cover
soft-tissue defects extending towards the mid-aspect of the
tibia, but a free flap is required for more distal defects. If the
solius or gastrocnemius muscles have been damaged, they are
unsuitable for local coverage and a free flap must be
substituted.
Year:1997 Question # 44
A previously active 36-year-old woman who fractured her right
ankle 10 years ago and was treated with 6 weeks of cast
immobilization now has had pain and swelling for the past year
and is no longer able to play tennis or jog. Examination shows
swelling and a 10-degree loss of dorsiflexion when compared
with the normal, contralateral ankle. Radiographs show
shortening of the fibula, widening of the ankle mortise, lateral tilt
of the talus, and slight narrowing of the tibiotalar joint space.
Treatment should include
a. ankle fusion.
b. osteotomy of the fibula.
c. deltoid ligament reconstruction.
d. a custom-made plastic shoe insert.
e. nonsteroidal anti-inflammatory drug therapy
Correct Answer: b
Patients who had reconstructive surgery for a malunion of a
displaced fracture of the fibula were evaluated. In these
patients who had pain, swelling of the ankle, and stiffness at an
average of six years after the injury, the malunions were
classified radiographically as either occult or overt. An occult
malunion was one in which the talus remained in its normal
position, but the lateral malleolus showed residual
displacement, characterized byexternal rotation and shortening.
In an overt malunion, there were similar changes in the lateral
malleolus to correct the external rotation and shortening, to
reduce the lateral subluxation or the anterior aspect of the
tibiofibular joint, and to restore the stability of the talus.
Year:1997 Question # 61
A 38-year-old woman who sustained multiple blunt injuries,
including a unilateral lateral compression injury to the pelvic
ring as a result of a motor vehicle accident, is awake, alert, and
normotensive; however, she has a decreased pulse pressure, a
pulse of 110/min and a urine output of 20 mL/hr. She responds
to an initial fluid bolus; however, after the fluids are slowed,
perfusion begins to deteriorate. An increase in fluids and blood
administration is instituted. To evaluate the abdomen as a
potential bleeding source, management should include
a. obtaining a CT scan of the abdomen.
b. obtaining lateral decubitus radiographs of the abdomen.
c. obtaining a crosstable lateral radiograph of the abdomen.
d. performing an exploratory laporatomy.
e. performing a supraumbilical diagnostic peritoneal lavage.
Correct Answer: e
This question is for the initial evaluation of hemodynamic
instability in a multitrauma patient with pelvic fractures. This
question specifically asks for the test to evaluate the abdomen
as a source of bleeding. While a CT scan can help us identify
the pelvic fracture, a DPL is the quickest way to identify intraabdominal bleeding, and the trauma surgeons can tell pretty
quickly whether a patient needs to go to OR based on the
outflow color from the DPL.
Year:1997 Question # 64
An 18-year-old woman has a closed femoral shaft fracture and
facial trauma. Cervical spine radiographs are normal. Because
of moderate facial edema, internal fixation of the femur is
delayed. Two days later, the patient is noted to have mental
confusion and dyspnea. The lungs are clear to auscultation with
normal breath sounds. Vital signs are pulse, 100/min;
respiration, 35/min; blood pressure, 140/95 mm Hg. Arterial
blood gases are pO2, 70; pCO2, 45. The pH was 7.35. The
most likely diagnosis is
a. occult head injury.
b. pulmonary embolism.
c. spontaneous pneumothorax.
d. fat embolism.
e. upper airway obstruction
Correct Answer: d
This scenario is pointing to fat embolism from the beginning. This
is a young patient with a long bone fracture, two days out. The
abg suggests acute hyppoxemia, without a compensated
metabolic situation. While the confusion can be associated with
a head injury, the abg is not. Confusion from hypoxemia is
probably causal, and dyspnea too, is associated with fat
embolism. The three most worrisome problems are listed, being
PE, pneumothorax, and acute upper airway obstruction. The
breath sounds woulkd all be affected in these however.
Year:1997 Question # 74
A 25-year-old woman who has multiple injuries, including closed
femoral and tibial shaft fractures, is initially awake and alert, but
during resusitation she becomes somnolent. A chest radiograph
shows three rib fractures on the right side, and an AP view of
the pelvis shows a 3-cm pubic diastasis. She has a systolic
blood pressure of 220 mm Hg and a pulse rate of 38/min.
Treatment should include
a. pelvic angiography.
b. diagnostic peritoneal lavage.
c. emergency CT scan of the head and a neurosurgical
consultation.
d. administration of 2 L of crystalloid and blood type and
crossmatching.
e. insertion of a chest tube in the midclavicular line of the second
intercostal space.
Correct Answer: c
Although hypotension could be the cause of her somnolence, her
SBP is quite high indicating that this is not likely, also she is not
tachycardic which is a hallmark of hypovolemic shock. Cardiac
Tamponade or tension ptx is another thought but this is not
mentioned on the CXR. The only other source for somnolence
to consider is neurogenic. Choices 1,2,4 all pertain to diagnosis
of a hypovolemic origin. Choice 3 is best as it directly deals with
a neurogenic origin as is likely in this case scenario.
Year:1997 Question # 88
Initial radiographs of a 56-year-old man who sustained a closed
fractue of the distal tibia in a motor vehicle accident are shown
in Figures 24a and 24b. Figure 24c shows a clinical photograph
of the injured foot and ankle in the operating room 8 days later.
The chances of surgical wound complications are most likely to
be minimized by
a. avoiding plate fixation of the distal tibia.
b. keeping the incisions spread by more than 7 cm.
c. using low-profile malleable plates.
d. using a "pilon" fracture incision and a femoral distractor.
e. using a topical antibiotic cream and delaying surgery for 3 to 5
more days
Correct Answer: a
Several studies over the last several years have concluded that
limited internal fixation (usually lateral) combined with external
fixation reduce the risk of soft tissuue insult in pilon fxs. Choice
2, keeping the incisions 7 cm apart is correct but it is even
better to not make 2 incisions at all. Choice 3, using low profile
plates is also a good idea, but again, no plate is even better.
Choice 4, using a pilon fracture incision and a femoral distractor
indicates the intent for ORIF, which would be best avoided.
Choice 5, using a topical antibiotic cream and delaying surgery
for 3 to 5 more days is only partially true. Abx cream is not
recommende nor helpful. Most authors do recommend delaying
any open surgery until 10-14 days after the trauma to allow the
soft tissue swelling to subside. **JAAOS 1994 Nov./Dec. 297305**References:Keywords: Question 16 of 145
Year:1997 Question # 120
An 18-year-old active duty soldier sustains a 6-cm segmental loss
to the tibial diaphysis from an antipersonnel mine. Treatment
consists of a fine wire circular external fixator with bone
transport, and the immediate postopertive course is uneventful.
The patient is given instructions in advancing the frame during
a convalescent leave. A radiograph taken 5 weeks
postoperatively shows a gain of 4.5 cm and a radiolucent linear
area transversely through the middle of the regenerate bone.
This finding is most likely the result of
a. a fracture.
b. a pin tract infection.
c. advancing the frame too fast.
d. advancing the frame to slowly.
e. infection within the regenerate
Correct Answer: c
The Ilizarov method of distraction osteosynthesis typically calls for
lengthening/distracting at a rate of 1mm/day. At 7 weeks out,
the radiographs show 4.5cm of distraction. This is 1cm longer
than it should be distracted and accounts for the radiolucency in
the regenerate bone. There is no history which is consistent
with refracture or infection.
Year:1997 Question
A patient undergoes anatomic reduction and stable fixation of a
spiral distal fibula fracture that is 4.5 cm above the joint. With
which of the following concomitant injuries is the patient most
likely to benefit from placement of a syndesmosis screw?
a. Deltoid ligament rupture
b. Wagstaffes avulsion fracture
c. Rupture of the anterior inferior tibiofibular ligament
d. Oblique medial malleolus fracture that has been reduced and
stabilized
e. Transverse medial malleolus fracture that has been reduced
and stabilized
Correct Answer: a
In 1991, J Soleri, et al performed a biomechanical cadaveric study
to investigate the need for syndesmotic screws in a Weber C
ankle fracture. Their results supported earlier studies which
showed that the medial complex (medial malleolus and deltoid
ligament) is the primary stabilizer of the talus in the ankle
mortise. As a result, they recommended the placement of a
syndesmotic screw in Weber C ankle fractures with deltoid
ligament insufficiency.
Year:1997 Question
A 25-year-old man sustains multiple injuries, including a pelvic
ring disruption, in a motor vehicle accident. He is
hemodynamically stable. Attempts to pass a urinary catheter
are unsuccessful. What diagnostic test should be obtained
next?
a. CT scan
b. Cystogram
c. Urinalysis
d. Excretory urogram
e. Retrograde urethrogram
Correct Answer: e
In pelvic trauma, inability to pass a urinary catheter may be a sign
of urethral trauma. A retrograde urethrogram is sthe diagnositic
study of choice.
Year:1997 Question
A 35-year-old man sustains a closed Galeazzi fracture-dislocation
and a fracture of the ulnar styloid process as a result of a highspeed motor vehicle accident. The radius fracture is
anatomically fixed with a plate; however, the ulnar head
remains dislocated. What structure is most likely responsible for
preventing reduction?
a. Radioulnar capsule
b. Pronator Quadratus
c. Flexor carpi ulnaris
d. Extensor carpi ulnaris
e. Triangular fibrocartilage complex
Correct Answer: d
Difficulty with reduction of the ulnar head may be caused by
interposition of the ECU. Due to its firm attachment to the
triangular fibrocartilage complex by its fibro-osseous sheath, it
is usually the structure that prevents reduction
Year:1997 Question
Examination of a construction worker who received an accidental
electric shock while on the job reveals that he is awake, alert,
and holding his arm tightly against the chest and holding his
forearm tightly to the front of the trunk. External rotation and
abduction are severely limited and painful. Which of the
following injuries best accounts for these findings?
a. Luxatio erecta
b. Anterior dislocation of the glenhumeral joint
c. Superior dislocation of the glenhumeral joint
d. Posterior dislocation of the glenhumeral joint
e. Greater tuberosity fracture of the proximal humerus
Correct Answer: d
Common causes of failure to externally rotate shoulder are DJD,
adhesive capsulitis, and posterior dislocation. Seizures are the
most common cause of posterior dislocations.
Year:1997 Question
A 30-year-old soccor player has pain and swelling 4 hours after
being kicked in the anterior compartment of the leg. Which of
the following physical findings best indicates increased
compartment pressure?
a. Anterior compartment tenderness
b. Pain with active ankle dorsiflexion
c. Pain with passive flexion of the toes
d. Pain with passive extension of the toes
e. Decreased sensation on the dorsum of the foot
Correct Answer: c
Severe pain, out of proportion to the injury, with passive stretching
of a muscle is indicative of increased compartment pressures.
Toe flexion would stretch the EHL and EDC muscles which
reside in the anterior compartment. This compartment as well
as the deep post. compartment are the most commonly
involved. Generally speaking, compartment syndrome usually
occurs in less than 24 hours. Ischemic injury starts when the
pressures reach 10 - 20 mmHg below DBP. Paralysis and
sensory changes can occur within one hour of the ischemia.
Within the first 4 hours of ischemia only noepraxic injury occurs,
but after 8 hours there is axonotmesis which is irreversible.
Also, the area of highest pressure is not always palpable but is
generally at the level of the fracture.
Year:1997 Question
A 31-year-old woman has had instability of the right ankle for the
past 10 years. Stress radiographs show asymmetrical anterior
drawer translation, excess lateral opening, and a unilateral os
subfibulare on the affected side. In this patient, the os
subfibulare represents
a. a supernumary bone.
b. an unfused accessory ossification center.
c. a nonunion of an avulsion fracture of the talus.
d. a nonunion of an avulsion fracture of the fibula.
e. a nonunion of an avulsion fracture of the calcis.
Correct Answer: d
This patient has signs c/w a torn anterior talofibular ligament (the
most commonly ruptured ligament in the human body). It is
thought that an os subfibulare represents an avulsion fracture
of the anterior talofibular ligament and is not a normal variant.
Anatomic studies have shown that there is no secondary
ossification center at this site and when examined at the time of
surgery it was noted that these all represented an avulsion
fracture. An os subtibiale was noted in 20% of normal x-rays
and found to be bilateral 50% of the time.
Year:1997 Question
A 20-year-old man who sustains closed femoral and tibial shaft
fractures has mild distension of the abdomen, a systolic blood
pressure of 75 mm Hg, and a pulse rate of 135/min. His
neurovascular examination is normal. Lateral cervical spine,
chest, and AP pelvis radiographs are normal. After
administration of 2 L of crystalloid, he has a systolic blood
pressure of 95 mm Hg and a pulse rate of 120/min.
Management should now include
a. diagnostic peritoneal lavage.
b. immediate femoral nailing and splinting of the tibia.
c. immediate stabilization of both the femur and the tibia.
d. splinting the tibia and placing the femur in skeletal traction.
e. simultaneous retrograde femoral nailing and an exploratory
laparotomy
Correct Answer: a
Shock can be classified as hypovolemic, cardogenic, neurogenic,
and septic.
Class I.......% blood volume loss up to 15%.....HR < 100.......SBP
NI...........Pulse pressure NI
Class II......% blood volume loss 15-30%.........HR > 100.......SBP
NI...........Pulse pressure decreased
Class III.....% blood volume loss 30-40%.........HR > 120.......SBP
<90..........Pulse pressure decreased
Class IV.....% blood volume loss >40%...........HR > 140.......SBP
<90..........
Pulse pressure decreased In a study of 100 patients with femur
fractures (62 w/isolated fx and 38 w/additional fxs) no patient
had greater than class II shock. In a patient with a closed femur
fx and hypotension further work up is required to determine the
cause of the hypotension (ie DPL). Treatment of the fracture
immediately is indicated to decrease the risk of ARDS, and fat
emboli syndrome
Year:1997 Question # 244
A 29-year-old man who has an isolated knee injury following a
motor vehicle accident is neurovascularly intact, Plain
radiographs are shown in Figures 68a and 68b, and two cuts of
an axial CT scan are shown in Figures 68a and 68d. Reduction
and fixation would be best accomplished by
a. percutaneous reduction and hybrid external fixation.
b. arthroscopically assisted reduction and percutaneous screw
fixation from anterolateral to posterolateral.
c. open reduction and plating through an anterolateral approach
with meniscal elevation.
d. open reduction with screw fixation through a midline anterior
approach with tibial tubercle elevation.
e. open reduction and plating through an approach between the
medial head of the gastrocnemius and the semitenedinosus.
Correct Answer: e
Lateral plateau fractured 70-80% and medial plateau only 1020%. This is due to medial plateau being stronger, and when
fractured is usually a more violent injury w/more soft tissue
injuries (meniscal tear 50%, ligamentatous injury 30%, peroneal
neuropraxia, popliteal vessel injury, and compartment
syndrome. Schatzker Classification: Type I: Split fx of lateral
plateau. Type II: Split depression fx of lateral plateau. Type III:
Depression fx of lateral plateau. Type IV: Fracture of medial
plateau. Type V: Bicondylar fx. Type VI: Plateau fx w/separation
of metaphysis from diaphysis. RX of Types I - IV: lateral L
plates, Types V, and VI: ring or hybrid fixator. Rx of Type IV fx
cannot be performed by anterior approach and must be
exposed directly from posteromedial or posterolateral incisions.
Year:1997 Question # 253
A 35-year-old man sustained a comminuted type II open fracture
of the humeral shaft associated with a complete radial nerve
palsy as a result of a motor vehicle accident. Along with
administration of antibiotics and debridement, treatment should
include
a. skeletal traction, an electromyogram, and nerve conduction
studies.
b. immediate nerve exploration and application of a hanging arm
cast.
c. surgical fracture fixation and immediate nerve exploration.
d. surgical fracture fixation and nerve exploration if no recovery is
apparant after 4 months.
e. functional humeral bracing and nerve exploration in four months
if no recovery is apparant after 4 months.
Correct Answer: c
10-18% incidence. 90% neuropraxia w/95% of these recovering
spontaneously within 3-4 months. If no return evident clinically
EMG/NCS studies are indicated w/possible delayed
exploration. Injury to nerve that occurs during initial fracture
management may indicate laceration by bone fragments and
should be explored immediately. Other indications for primary
exploration are open fx, penetrating injuries, and spiral fx of mid
distal 1/3 (Holstein-Lewis Fx).
Year:1997 Question # 270
Radiographs of a fracture after a rotational injury are shown in
Figure 78. A mortise view shows no widening of the ankle
mortise. There is no swelling or tenderness over the medial
ankle. Which of the following treatment options will most rapidly
and effectively restore ankle function?
a. Removable fracture brace, and early mobilization
b. Closed reduction and nonweightbearing cast immobilization
c. Open reduction and plate fixation of the lateral malleolus
d. Open reduction of the lateral malleolus and repair of the torn
anterior tibiofibular ligament
e. Open reduction of the lateral malleolus, repair of the torn
anterior tibiofibular ligament, and repair of the deltoid ligament
Year:1997 Question # 272
Figures 79a and 79b show a fracture of the tibia in a 53-year-old
woman who fell down stairs. Management consists of closed
reduction, casting, and bracing. Which of the following factors is
most likely to compromise the outcome?
a. Early weightbearing
b. Age of the patient
c. The intact fibula
d. The initial angulation
e. Location of the fracture
1998
Year:1998 Question # 5
A 17-year-old boy who sustained a closed clavicle fracture after
he was ejected from an all-terrain vehicle was treated with a
figure-of-8 brace 1 year ago. He now reports continuous pain at
the site of the fracture and is unable to actively raise his arm
above his head. A radiograph is shown in Figure 1.
Management should now consist of
a. an onlay bone graft.
b. electrical stimulation.
c. resection of the distal clavicle.
d. plate fixation and a bone graft.
e. smooth wire fixation and a bone graft.
Correct Answer: d
The xray here reveals a midshaft non-united clavicle fx. The boy is
one year out and intervention of some sort is indicated at this
time. The recommended choice at this time is plate fixation with
bone graft. Bone graft alone or Kwires will not yield a stable
fixation allowing compression and healing.
Year:1998 Question # 8
What is the treatment of choice for an adult who has an isolated
fracture of the ulna at the junction of the distal and middle
thirds, with 5 degrees apex dorsal angulation and a 25%
displacement?
a. Intramedullary rodding
b. Functional bracing
c. Closed reduction and a long arm cast
d. Closed reduction and application of an external fixator
e. Open reduction and internal fixation with a dorsal plate
Correct Answer: b
Isolated fractures of the mid/distal ulna (nightstick variety) do not
always require ORIF as do their radial counterparts. Studies
have shown that functional bracing is as effective as ORIF if
there is <10degrees angulation and <50% displacement. A long
arm cast is not necessary as this only leads to elbow stiffness.
These pts should be followed radiographically for progressive
displacement which would necessitate ORIF. It is important
also to look for associated injuries about the elbow and wrist.
Year:1998 Question # 26
Which of the following provides the most stable fixation for
comminuted fractures of the posterior acetabular wall?
a. Cable
b. Buttress plate
c. Methylmethacrylate
d. Multiple lag screws
e. Multiple Kirschner wires
Correct Answer: b
Fractures of posterior wall occur more freq than any other type of
acetabular fracture. Nearly 33 % of isolated post. Wall fxs are
comminuted. Failure of fixation is devastating complication best
prevented by rigid fixation. Often comminuted fractures involve
fragments close to post rim such that attempts to fix these with
screws or pins would violate the articular surface. Study
referenced tested screws alone vs plate/screws (buttress)
under wt-bearing conditions and found plate much stronger.
Year:1998 Question # 28
What posterior pelvic ring injury is most commonly associated with
neurologic compromise?
a. Sacral fracture lateral to the foramina
b. Sacral fracture medial to the foramina
c. Sacroiliac fracture-dislocation
d. Sacroiliac dislocation
e. Iliac wing fracture
Correct Answer: b
Classification of Sacral fractures: Based on direction, location and
level of sacral fractures Each type has characteristic clinical
presentationsClassification of Sacral Fractures: Zone 1: region
of ala Occasionally associated with partial damage to L5 nerve
root MOI-lateral compression Zone 2: region of sacral foramina
Frequently assoc. with sciatica Zone 3: region of central canal
Frequently assoc. with saddle anesthesia and loss of sphincter
function High incidence (25%) seen in falls (Jumper`s fx)
Routine pelvic x-rays are useless Require: Ferguson views,
tomograms or CT scans
Year:1998 Question # 29
A patient has a noncomminuted displaced fracture of the radial
head with a distal radioulnar dissociation. What is the most
appropriate treatment for the radial head?
a. Allograft replacement
b. Radioulnar synostosis
c. Excision of the radial head
d. Open reduction and internal fixation
e. Silicone radial head replacement
Correct Answer: d
Radial head fractures account for 33% elbow fractures MOI-axial
load on pronated forearm Mason classification: Type I: nondisplaced or minimally displaced ( articular surface < 2mm)
Type II: displaced > 2 mm Type III: comminuted, not
reconstructable Type IV: fracture plus elbow dislocation EssexLopresti: fracture of radial head with DRUJ dissociation.
disruption of interosseous membrane Problem with silicone
implants-much less stiff than intact interosseous membrane
allowing for radial shortening over time. Problem with excision--same, radial shortening with loss of wrist motion In bad Type III
fxs, may require excision of head with implant, then if proximal
migration of radius occurs pt will require radioulnar synostosis
in future but not acutely.
Year:1998 Question # 31
Examination of a 45-year-old construction worker who was
crushed by falling dirt and buried to midchest level reveals
hemodynamic instability; however, radiographs of the chest are
normal, and results of a diagnostic peritoneal lavage are
negative. Despite the administration of a fluid bolus and packed
red blood cells, hemodynamic instability persist. A radiograph of
the pelvis is shown on Figure 4. The next step in the
management should be
a. application of a pelvic external fixator.
b. a pelvic sling.
c. angiography of the pelvis.
d. open reduction and internal fixation.
e. open packing of the pelvic hematoma.
Correct Answer: a
Pelvic ring injuries treatment requirements are related to degree of
osseous-ligamentous injury, displacement and treatment
requirements are related to degree of osseous-ligamentous
injury, displacement and presence of associated
pelvic/abd/thoracic/ or head injuries 20% have associated
hemodynamic instability 15% mortality rate Algorhythm:
Year:1998 Question # 53
Which of the following conditions associated with a closed fracture
of the clavicle indicates the need for open reduction and
internal fixation?
a. Injury to the subclavian artery
b. Injury to the brachial plexus
c. Segmented fracture
d. 100% displacement
e. Associated displaced surgical neck fracture of the humerus
Correct Answer: a
Indications for open reduction/internal fixation of acute clavicle
fractures include: Open fracture Skin tenting that fails to
respond to closed reduction "Floating shoulder" - Ipsilateral
clavicle and unstable scapula fracture Neurovascular injury that
is progressive or fails to respond to closed reduction: Brachial
plexus injuries do not necessitate ORIF as they are most likely
due to stretching of the plexus and unlikely to improve with
exploration. If subclavian artery or vein injury is suspected, an
anteriogram should be performed. Exploration is mandatory in
the event of a torn large vessel. Some type II distal clavicle
fractures
Year:1998 Question # 56
The Injury Severity Score (ISS), using point scores from five
different body systems, is a method that aids in predicting the
chances of mortality in a patient with multiple injuries by
a. adding the scores in all five body systems.
b. adding the squares of the scores in the three most severely
injured systems.
c. doubling the cumulative scores for head and chest systems.
d. combining the scores from the most and least injured systems.
e. correcting the score in the most severely injured system for
age.
Correct Answer: b
The Injury Severity Score (ISS) was developed in 1974 to help
predict morbidity and mortality of the multiply injured patient
and also for purposes of evaluating and directing emergency
and subsequent care. Injury scores until that time had failed to
take into account the importance of concomitant injuries to
different major body systems and their affect on mortality. Poor
correlation existed between injury score and mortality. The
Injury Severity score was developed as a modification of the
Abbreviated Injury Score (AIS) which assesses the severity of
injury to each of five different systems (head or neck, face,
chest, abdominal or pelvic contents, extremities or pelvic girdle
and general). Scores for each system ranged from 0-5.
Researchers found that if, instead of taking the cumulative
score (as in AIS) the squares of the scores in the three most
severely injured systems were added, mortality and morbidity
were closely predicted. Highest score possible 75.
Year:1998 Question # 74
A patient sustained a joint depression-type fracture of the
calcaneus that healed despite lack of treatment. The loss of
dorsiflexion the patient is now experiencing is most likely the
result of
a. widening and shortening of the heal.
b. weakness of the gastrocnemius-soleus complex.
c. anterior impingement from a horizontal talus.
d. unrecognized compartment syndrome of the foot.
e. degenerative arthritis of the tibiotalar joint.
Correct Answer: c
In a joint depression fracture, the calcaneus is driven upward
against the talus by the impact. A fracture line is created that
begins in the sinus tarsi near the lateral wall and propagates
obliquely across the posterior facet to the medial wall. This
fracture line is known as the primary fracture line. Because the
posterior facet is no longer under the talus, the talus settles into
a position parallel to the ground. Even though the foot is in a
neutral position, any attempt to dorsiflex the foot will cause the
talar neck to impinge on the anterior aspect of the tibia.
Year:1998 Question # 78
Which of the following injuries is most commonly associated with
a fracture of the scapular body?
a. Vascular injury
b. Tear of the rotator cuff
c. Injury to the brachial plexus
d. Fracture of an upper thoracic rib
e. Fracture of the proximal humerus
Correct Answer: d
96% of patients had associated injuries, with upper thoracic rib
fractures being most common. Most scapular fractures occur as
a result of direct impact over the scapular region. Other
associated injuries: hemopneumothorax 29%, pulmonary
contusion 8%, head injury 34%, ipsilateral clavicle fracture
25%, cervical spine injury 12%. Surgical indications: - scapular
neck fractures with more than 40 degrees of angulation in either
the transverse or coronal plane, or with 1 cm or more of
displacement - greater than 3 to 5 mm step-off of glenoid joint
surface - scapular spine fractures at the base of the acromion
and those with more than 5 mm displacement may be at risk for
the development of a nonunion
Year:1998 Question # 80
Figure 16 shows the AP radiograph of a 32-year-old man with a
fracture cephalad to the fovea of the femoral heat. A CT scan
shows a single head fragment. After closed reduction of the hip,
there is 5 mm of residual articular incongruity. Management
should now include
a. hybrid total hip arthroplasty.
b. noncemented hemiarthroplasty of the hip.
c. closed reduction and percutaneous pin fixation.
d. open reduction through an anterior approach to the hip.
e. excision of the head fragment.
Correct Answer: d
Pipkin classification of femoral head fractures: - Type I: occurs
below the fovea - Type II: occurs above the fovea,
consequently the blood supply through the foveal artery may be
intact - Type III: associated with femoral neck fracture - Type
IV: associated with an acetabular fracture - With fractures
involving the fovea or involving the superior weightbearing
dome, anatomic reduction is mandatory. If this is not achieved
through a closed reduction and confirmed by CT, open
reduction is carried out through a Smith-Petersen anterior
approach to the hip. Stabilization of the fracture through
interfragmental screw compression techniques is required.
Year:1998 Question # 81
Figure 17a shows the postoperative AP hip radiograph of a 35year-old woman who sustained an isolated fracture of the
femoral neck while skiing 7 months ago. Treatment consisted of
open reduction and screw fixation. She now reports continuous
pain in the groin and an inability to bear weight. AP and lateral
radiographs shown in Figures 17b and 17c reveal no evidence
of healing of the fracture. Management at this time should
consist of
a. a quadratus femoris pedicle bone graft.
b. a proximal femoral allograft.
c. intertrochanteric osteotomy.
d. total hip arthroplasty.
e. hip hemiarthroplasty
Correct Answer: c
An abduction osteotomy at the intertrochanteric level, converts
shearing forces into compressive forces. The compression
promotes healing of the fracture
Year:1998 Question # 84
Which of the following surgical approaches to the hip is
associated with the highes incidence of heterotopic
ossification?
a. Ilioinguinal
b. Extended iliofemoral
c. Combined ilioinguinal and Kocher-Langenbeck (posterior)
d. Kocher-Langenbeck (posterior)
e. Kocher-Langenbeck (posterior) with trochanteric osteotomy
Correct Answer: b
Heterotopic ossification after an acetabular fracture has been
shown to be related to the surgical exposure, male sex,
associated head injury, and the fracture type. The incidence of
Brooker III and IV heterotopic ossification in the KocherLangenbeck exposure was 10.5%; for the ilioinguinal exposure,
2%; extended iliofemoral, 35%; combined KocherLangenbeck/ilioinguinal exposures, 27%.
Year:1998 Question # 108
Which of the following radiographic views best shows the size and
displacement of a posterior wall fracture of the acetabulum?
a. Inlet view of the pelvis
b. Outlet view of the pelvis
c. AP view of the hip
d. Iliac oblique view (external oblique) of the hip
e. Obturator oblique view (internal oblique) of the hip
Correct Answer: e
Obturator Oblique (internal oblique) inlet view best shows A/P
displacement of the pelvis (not acetabulum) outlet view shows
superior displacement posteriorly and both superior or inferior
displacement anteriorly (PELVIS) AP of hip-shows : 1. Pelvic
brimCanterior border of anterior column 2. Ileoischial lineborder of posterior column 3. Roof of acetabulum 4. Medial wall
of acetabulum 5. Posterior border of acetabulum Iliac oblique
(external oblique)-45 degree external rotation with beam
centered on hip. Shows posterior column, anterior border of
acetabulum and iliac wing Obturator oblique (internal oblique)elevate affected hip up 45 degrees. Shows obturator foramen,
anterior column, posterior lip
Year:1998 Question # 113
Figure 25a shows the initial postoperative AP radiograph, and
FIgures 25b and 25c show the current AP and lateral
radiographs of a 46-year-old woman who underwent open
reduction and internal fixation of a distal fibula fracture and
placement of a syndesmosis screw 15 months ago. She has full
function, but the ankle swells with activity. Th radiographs
reveal that
a. fixation of the syndesmosis has failed.
b. widening of the ankle mortise has led to failure of fixation.
c. infection around the syndesmosis screw has led to
osteomyelitis.
d. the syndesmosis screw is broken.
e. motion between the tibia and fibula has caused loosening of the
syndesmosis screw
Correct Answer: e
1. fixation failure is incorrect because the mortise is not wide 2.
mortise is not widened 3. osteomyelitis would not have the
uniform sclerotic margin 4. the screw isn=t broken 5. only three
cortices are crossed and this allows motion at the syndesmosis
which causes the lucency References:
Year:1998 Question # 127
A healed fracture of the tibia that demonstrates 25 degrees apex
posterior angulation and 28 degrees varus angulation on AP
and lateral radiographs is most accurately described as a
a. complex deformity with angulation in two planes.
b. single deformity less than 20 degrees, apex posterolateral.
c. single deformity greater than 30 degrees, apex posterolateral.
d. single deformity less than 20 degrees, apex posterolmedial
e. single deformity greater than 30 degrees, apex posteromedial
Correct Answer: c
Single deformity greater than 30deg, apex posterolateral. To accurately
describe post-traumatic long bone deformities (fractures, malunions or
nonunions) with regards to angulation and/or translation it is important to
realize that the actual deformity is rarely in a pure apex anterior, posterior,
valgus of varus direction. Instead the true plane of the apex is tangential to
the points of reference given by the radiographs. This plane, described as
the apex of the deformity, can be precisely calculated using trigonometric
formulae or crudely assessed by extrapolating from two films at 90deg to
each other (AP & lat). For example, a tibial angulation that appears apex
posterior on the lateral view and in varus on the AP is actually a single
deformity with a posterolaterally directed apex. Similarly, an apex that is
anterior and valgus is not two separate deformities but rather a single
deformity with an apex that is directed anteromedially. The true angle of this
deformity is always greater than that seen on either the AP or lateral views;
there are mathematical tables available for determining this, or you can
estimate. Finally, angulation and translation should be regarded and
described separately since they are often in different planes.
Year:1998 Question # 134
Which of the following methods of treatment of a displaced
Lisfranc fracture-dislocation will most reliably lead to good
functional results?
a. Weightbearing short leg cast
b. Nonweightbearing short leg cast
c. Removable splint and early motion
d. Open reduction and internal fixation
e. Elastic compression bandage with full weightbearing
Correct Answer: d
lisfranc injuries occur at the midfoot with damage to the articulation between the
metatarsals and cuneiforms. The Lisfanc ligament courses obliquely
between the second metatarsal and medial cuneiform. As many as 95% of
patients with Lisfanc joint dislocations have been shown to have associated
metatarsal fractures. Fractures of the midtarsal bones (cuneiforms, cuboid
and navicular) have been seen in up to 39% of these patients. Diagnosis
requires adequate radiographs (AP, lateral and oblique films) with close
attention to anatomic relationships. The medial border of the second
metatarsal should line up with the medial border of the middle cuneiform on
the AP film while the medial border of the fourth metatarsal should be
aligned with the medial border of the cuboid on the oblique film.
Nondisplaced fractures without ligament instability (stress radiographs) can
be treated in non-weightbearing cast for six weeks. In displaced or unstable
injuries, open anatomic reduction and fixation is indicated. With severe
comminution, the tarsometatarsal joints within the medial column can be
fused acutely.
Year:1998 Question # 144
A patient is in respiratory distress as a result of a high-speed
motor vehicle accident. After emergency intubationm the
arterial blood is poorly oxygenated, and examination shows leftsided trachael deviation, absence of breath sounds on the right
sidem and tympany on percussion over the right side of the
chest. Management should include
a. positive-pressure ventilation.
b. an immediate radiograph of the chest.
c. adjustment of the position of the endotrachael tube.
d. insertion of a large-bore needle into the pericardial space.
e. insertion of a large-bore needle in the right second intercostal
space, midclavicular line
Correct Answer: e
These are classic signs of a tension pneumothorax. A tension
PTX results when there is damage to the lung parenchyma
allowing inspired air to escape into the pleural space. This
leads to an increase in intrapleural pressure and a shift in the
mediastinum to the contralateral side, resulting in narrowing or
occlusion of the vena cava at the diaphragm. Immediate
thoracic decompression is mandatory to prevent death. This is
performed by placing a large-bore needle into the second
intercostal space in the midlavicular line . This should be
followed immediately by tube thoracostomy
Year:1998 Question # 145
The axial stability of a 4-pin uniplanar external fixator used to treat
a patient who has a transverse midthird fracture of the tibia with
a 5-mm fracture gap can be most greatly increased by
a. allowing the ends of the fracture to touch.
b. adding a second connecting bar.
c. adding one pin to each fracture fragment.
d. increasing the pin diameter from4 mm to 6 mm.
e. decreasing the connecting bar-to-bone distance from 6 cm to 4
cm.
Correct Answer: a
Bone contact allows load sharing between bone and fixator for
compressive, torsional, and certain bending loads. Without
bone contact, the external fixator must support full load, and
this can have a significant effect on fracture healing. With
transverse fx`s, application of compression across the fracture
site can greatly increase the stiffness of the frame-bone
system.
Year:1998 Question # 157
Figure 35 shows the postoperative radiograph of a femur fracture
proximal to a total knee prosthesis that was treated by open
reduction and plate fixation 9 months ago. What is the most
likely reason the previously well-seated screw has backed out
of the central portion of the plates?
a.
b.
c.
d.
e.
Infection
Nonunion
Improper screw length
Osteonecrosis of the distal fragment
Use of a cortical screw instead of a cancellous screw
•
Correct Answer: b
Failure of fx healing is the most common clinical complication of fx`s. The
factors that influence fx healing differ from case to case. Morphologic studies
of ununited fx`s have described 2 different types of nonunions: (1) those with
unmineralized fibrous and fibrocartilaginous tissue bridging the fx gap, and
(2) those with a cleft or gap between the ends of the fx`d bone, which are
usually covered with similar fibrous tissue or fibrocartilage. The former
situation, which is clinically the more common one, is called a nonunion; the
latter is called pseudarthrosis. An analysis of 95 human tissue specimens of
nonunions and pseudarthroses demonstrated that in extraarticular fx`s, all
cases of delayed healing are first nonunions. Subsequently, microscopic
clefts may appear within the tissues that compose the nonunion, and, in time
and only in certain cases, a dominant cleft may propagate to form a
practically complete separation of the fx ends, ie., pseudarthrosis. *See
attached article
Year:1998 Question # 192
To prevent injury to the posterior interosseous nerve during the
approach for reduction and fixation of a fracture of the radial
head, anterior retraction should be performed with the
forearm
a.
b.
c.
d.
e.
maximally pronated and the elbow extended.
maximally pronated and the elbow flexed.
maximally supinated and the elbow flexed.
maximally supinated and the elbow extended.
in neutral rotation, with the elbow extended.
Correct Answer: b
The posterior interosseous nerve is vulnerable to injury during the
posterolateral approach to the radial head as it winds around
the neck of the radius within the substance of the supinator
muscle. Maximal pronation and flexion at the elbow moves the
nerve medially out of the operative field so that the supinator
and the underlying joint capsule can be incised without danger.
Year:1998 Question # 213
In patients older than age 50 years who experience shoulder
dislocation or proximal humerus fracture, the incidence of
associated neurologic abnormality documented by
electromyogram is as high as
a.
b.
c.
d.
e.
10%
20%
50%
70%
90%
Correct Answer: C
Several complications can occur with glenohumeral dislocations
and humeral neck fractures including rotator cuff tear, vascular
injuries, osteonecrosis, and nerve injuries. When diagnosed by
EMG the incidence of axillary and other types of nerve lesions
is 20-30% for all age groups. Blom and Dahlback found that
patients over 50 are considerably more affected. In this age
range the incidence of nerve injury documented by EMG may
be as high as 50% (23 of 53 patients).
Year:1998Question # 241
A 37-year-old laborer sustained a fracture of the posterior
acetabular wall. Two years following operative management,
the patient reports severely limited hip motion, and back pain.
Radiographs reveal extensive mature heterotopic ossification
with preservation of the hip joint space. Management should
now consist of
a.
b.
c.
d.
e.
resection arthroplasty and local radiation.
in situ fusion of the hip.
excision of heterotopic bone, total hip arthroplasty, and oral
indomethacin.
excision of heterotopic bone, and local radiation.
excision of heterotopic bone, hemiarthroplasty, and oral
indomethacin.
Correct Answer: d
The use of various prophylactic measures to decrease the incidence of ectopic bone formation has
been reported in the literature. One suggested approach is to minimize surgical osteotomies
and the amount of subperiosteal stripping and pericapsular trauma during operation. Many
surgeons seek to maximize the use of the ilioinguinal and Kocher-Langenbeck approaches.
these approaches, however, remain inadequate for certain T shaped and both column
fractures, as well as old fractures that require the extended iliofemoral approach for reduction.
Another approach to prophylactic therapy is low dose radiation immediately after hip surgery;
several authors have reported success in reducing the incidence and severity of HO.
Prophylactic use of diphosphonate to reduce the amount of ectopic bone formation after total
hip arthroplasty has been shown to be ineffective. Diphosphonate compounds prevent
mineralization of the osteoid matrix, but not the production of the matrix. Moreover,
diphosphonate must be administered systemically, and mineralization of the osteoid can
proceed once it is discontinued. Anti-inflammatory drugs such as indomethacin, ibuprofen, and
fluriprofen have been shown to be potentially effective in reducing ectopic bone formation and
appear to present fewer risks compared to other forms of prophylactic therapy. However, well
designed, prospective, controlled studies are needed go evaluate the long term effects of these
drugs. It is important to note that there are four factors found to highly correlate with Grade 1
ectopic bone formation were identified and may be considered predictive of Grade 1 HO. They
are: 1) the extended iliofemoral approach; 2) multiple (two or more) perifracture operative
findings; 3) T type fractures; and 4) the presence of associated injuries to the chest and
abdomen. The incidence of HO in patients with these risk factors can be greater than 30% with
greater than 8% developing restriction of hip motion.
Year:1998 Question # 255
Which of the following plain radiographic views of the shoulder
best reveals a Hill-Sachs lesion of the humeral head?
a.
b.
c.
d.
e.
Lateral Y
Scapular AP
Neutral rotation AP
Internal rotation AP
External rotation AP
Correct Answer: d
A Hill-Sachs lesion is found in greater than 80% of the patients
with recurrent anterior dislocations. The lesion is found at the
posterolateral margin of the humeral articular surface. The
lesion will have articular cartilage lateral to it and a raw,
cancellous surface. The normal sulcus will be smooth with
vascular channels. The Hill-Sachs lesion is best viewed with the
arm in marked internal rotation with an AP radiograph of the
shoulder. This places the lesion in the most visible view by
rotating the lesion out laterally from behind the humeral head. A
scapular AP view places the scapula flat on the plate of the
cassette. This view shows the glenohumeral joint space well,
and will also show fractures of the humerous and glenoid lip.
Year:1998 Question # 258
Following closed reduction for the injury shown in Figures 69a and
69b, treatment should consist of
a.
b.
c.
d.
e.
repair or reconstruction of the medial collateral ligament.
repair or reconstruction of the medial and lateral collateral
ligaments.
immobilization for 5 days or less.
immobilization for 14 days.
immobilization for 25 days.
Correct Answer: c
Elbow dislocation is commonly due to a fall on the outstretched hand and is the second
most common dislocation to shoulder dislocation. Articular injuries occur in 25-50%
of these injuries. Clinically with stress tests and in surgical exploration, it has been
shown that the medial collateral ligament is damaged in ALL fracture-dislocations.
Residual calcification has been show to occur in the substance of the medial coll.
Ligament in 85% of patients, and in the lat coll lig in 75% of cases. Desired treatment
is reduction and early range of motion. If there is instability, an arc of motion in the
stable ranges should be initiated should begin within 5 days and should continue for
1 week. Gradual resumption of flexion and extension should continue for 3-4 weeks.
A fracture-dislocation should be treated with immediate fracture elbow reduction, and
repair of the fracture according to its own characteristic. Prolonged immobilization
should be avoided at all costs. Residual flexion contractures should be treated with a
hyperextension splint at night with physical rehabilitation. Surgical repair/intervention
in simple dislocations (ie no fracture) has been shown to have worse results than
nonoperative intervention with less flexion contracture being observed in the
nonoperative groups. 10% compared to 15%. Therefore, in the nonathlete, early
reduction and early ROM is the preferred mode of therapy.
Year:1998 Question # 273
The radiographs shown in Figures 71a through 71c, and the CT
scan shown in Figure 71d reveal an acetabular fracture that
should be classified as
a.
b.
c.
d.
e.
t-type.
both column.
transverse.
anterior column.
anterior column posterior hemitransverse.
Correct Answer: b
Acetabular fractures are classified in the following manner: Type A Partial
Articular One Column · A1-posterior wall · A2-posterior column · A3-Anterior
wall and/or anterior column Type B Partial Articular Transverse Oriented
Fracture · B1-Tranverse + posterior wall · B2-T-types · B3-Anterior with
posterior hemitransverse Type C Complete Articular, Both Column Fracture
Both columns are fractured, and all articular segments including the roof are
detached from the remaining segment of ilium. This is the "FLOATING
ACETABULUM", which is s form of T-fracture with the horizontal limb
proximal to the acetabulum. · C1-both column with ant column fracture
extending to iliac crest (high variety) · C2-both column with ant. column
fracture extending to the anterior border of the ilium (low variety) · C3-both
column, ant fracture enters the SI joint Image 71c shows an obturator
oblique view which clearly shows an anterior column fracture and that the
ilium is separated from the acetabulum. Figure 71b is and iliac oblique which
shows the posterior column fracture and a significant protrusio, the classic
spur sign is also seen in this figure.
Year:1998 Question # 274
What is the most common nerve injury following a Monteggia
fracture-dislocation of the forearm in adults?
a.
b.
c.
d.
e.
Posterior interosseous
Anterior interosseous
Radial
Median
Ulnar
Correct Answer: a
Monteggia Fracture consists of an ulna fracture associated with dislocation of the radial
head. It occurs <5% of all forearm fractures. Bado classified Monteggia fractures:
Type 1- Anterior dislocation of the radial head with anteriorly angulated fracture of
the ulna Type II- Posterior dislocation of the radial head with posterior angulated
fracture of the ulna Type III-Lateral or anterolateral dislocation of the radial head with
a fracture of the ulnar metaphysis Type IV-Anterior dislocation of the radial head with
a fracture of the radius and ulna The most common nerve injury involved in
Moteggia`s fractures involve the deep branch of the radial nerve or the posterior
interosseous nerve. The usual course is is spontaneous recovery, and exploration is
not warranted unless full function does not return within 6-8 weeks. However, a good
neurologic exam is warranted prior to reduction attempts. Several cases of post.
interosseous entrapment have been documented where the nerve is actually
wrapped around the radial head and impedes reduction. The answer given, posterior
interosseous, is a branch of the radial nerve, and is the most common neurologic
structure damaged in a Monteggia fracture. The anterior interosseous can be
damaged but is not very common. The radial, median and ulnar nerves proper are
rarely involved.
Year:1998 Question # 275
Which of the following conditions is associated with the highest
mortality rate in patients with a pelvic fracture?
a.
b.
c.
d.
e.
Shock from hypovolemia
Associated rupture of the bladder
Arterial bleeding on pelvic angiogram
Presence of a hematoma in the perineum and scrotum
Fractures of both the anterior and posterior pelvic ring
Correct Answer: a
Pelvic fracture patients outcome has been shown to be directly
linked to degree of hemodynamic instability. Mortality rates
were 3.4% in stable patients versus 42% in unstable patients. It
should also be noted that the patients who were
hemodynamically unstable were older, had more severe pelvic
trauma, greater multisystem trauma, and, as expected, much
higher mortality. Therefore, the primary goal in initial
management of trauma victims (not just with pelvic fractures) is
hemodynamic stability
2001
Year:2001 Question # 1
A 49-year-old man has a persistent Trendelenburg gait after
undergoing open reduction and internal fixation of a posterior
wall acetabular fracture 6 months ago. The radiographs
reveal a normal joint space with no heterotopic ossification
and no signs of osteonecrosis. Weakenss in what muscle
group is the most likely cause of his limp?
a.
b.
c.
d.
e.
Gluteus maximus
Gluteus medius
Tensor fascia lata
Iliopsoas
Vastus lateralis
Correct Answer: b
References:Hoppenfeld S, deBoer P (eds): Surgical Exposures in
Orthopaedics: The Anatomic Approach. Philadelphia, PA,
Lippincott Williams & Wilkins, 1984, pp 353-386.
Year:2001 Question # 8
After plating of a both-bone forearm fracture in an adult, which of
the following actions is most important to achieve maximal
forearm rotation?
a.
b.
c.
d.
e.
Early motion
Surgery within 7 days
Restoration fo the radial bow
Compression fixation of both bones
Repair of the interosseous ligament
Correct Answer: c
References:Schemitsch EH, Richards RR: The effect of malunion
on functional outcome after plate fixation of fractures of both
bones of the forearm in adults. JBJS Am 1992;74:1068-1078.
Year:2001 Question # 27
Which of the following is considered a typical feature of a T-type
acetabular fracture?
a.
b.
c.
d.
e.
Disruption of the iliac wing
Disruption of the obturator ring
A spur sign
Secondary congruence
Predominantly anterior column displacement
Correct Answer: b
References:Letournel E, Judet R: T-shaped fractures, in
Fractures of the Acetabulum. Springer-Verlag, 1981, pp 163179. Saterbak AM, Marsh JL, Brandser E, Turbett T: Acetabular
fractures classification of Letournel and Judet: A systematic
approach. Iowa Orthop J 1995;15:184-196.
Year:2001 Question # 31
A 30-year-old man sustained multiple injuries in a motor vehicle
accident, including bilateral femoral shaft fractures a pelvic
ring fracture, and a floating right elbow. Following stabilization
of the life-threatening injuries, treatment of the right humerus
should consist of
a.
b.
c.
d.
e.
closed reduction and application of a cast
closed reduction and placement of a reamed humeral nail
closed reduction and percutaneous pinning
open reduction and internal fixation
application of an external fixation device
Correct Answer: d
References:Johnson KD: Management of fractures of the
femur,tibia, and upper extremity in the multiply injured patient.
Instr Course Lect 1990;39:565-576. Dabezies EJ, Banta CJ II,
Murphy CP, d`Ambrosia RD: Plate fixation of the humeral shaft
for acute fractures, with and without radial nerve injuries. J
Orthop Trauam 1992;6:10-13.
Year:2001 Question # 36
A 23-year-old woman who was struck by a motor vehicle has a Glasgow Coma
Scale score of 15 and a systolic blood pressure of 110mm Hg on arrival in
the emergency department. Examination reveals a rotationally unstable
pelvic ring injury and multiple long bone fractures. Initial management
consists of IV administration of 3L of lactated Ringer`s solution over 2
hours. Reexamination now reveals that the patient is tachycardic and her
systolic blood pressure has dropped to 60mmHg. What is the most likely
cause of this event?
a.
b.
c.
d.
e.
Insufficient fluid resuscitation
Unrecognized spinal trauma
Unrecognized brain injury
Myocardial infarction
Failure to stabilize the pelvic ring injury
Correct Answer: a
References:Browner BD, Jupter JB, Levine AM, Trafton PB (eds):
Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998,
pp 141-148.
Year:2001 Question # 50
A 19-year-old man sustained multiple puncture wounds to his
side, neck, and posterior and anterior chest wall following
explosion of a homemade pipe bomb 6 weeks ago. The
patient now reports difficulty with overhead activity.
Examination reveals loss of scapular stability with the scapula
retracted and the inferior pole rotated medially. Winging is
increased with attempts to elevate the arm.
Electromyography confirms the diagnosis of what type of
nerve palsy?
a.
b.
c.
d.
e.
Spinal accessory
Suprascapular
Long thoracic
Axillary
Musculocutaneous
Correct Answer: c
References:Connor PM, Yamaguchi K, Manifold SG, Pollock RG,
Flatow EL, Bigliani LU: Split pectoralis major transfer for
serratus anterior palsy. Clin Orthop 1997;341:134-142.
Year:2001 Question # 64
What nerve is most commonly injured during an ilioinguinal
approach to the acetabulum?
a.
b.
c.
d.
e.
Femoral
ilioinguinal
obturator
L5 nerve root
lateral femoral cutaneous
Correct Answer: e
References:Hoppenfeld S, deBoer P (eds): Surgical Exposures in
Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA,
JB Lippincott, 1994, pp 323-401.
Year:2001 Question # 74
Which of the following is considered a contraindication to the
treatment of a humeral shaft fracture with functional bracing?
a.
b.
c.
d.
e.
Radial nerve palsy
Transverse fracture
Distal third fracture
Low-velocity gunshot fracture
Ipsilateral brachial plexus palsy
Correct Answer: e
References:Brien WW, Gellman H, Becker V, Garland DE,
Waters RL, Wiss DA: Managment of fractures of the humerus in
patients who have an injury of the ipsilateral brachial plexus.
JBJS Am 1990;72:1208-1210. Sarmiento A, Zagorski JA, Zych
GA, Latta LL, Capps CA: Functional bracing for the treatment of
fractures of the humeral diaphysis. JBJS Am 2000;82:478-486.
Year:2001 Question # 82
Which of the following factors will have the greatest affect on the
stability of the hip after closed reduction of a posterior wall
fracture-dislocation?
a.
b.
c.
d.
e.
Magnitude of the posterior capsular disruption
Length of time until reduction occurs
Size of the wall fragment
Presence of femoral head depression
Presence of loose bodies in the fovea of the hip joint
Correct Answer: c
References:Beaty JH (ed): OKU 6, Rosemont, IL, AAOS, 1999,
pp 441-453. Matta JM: Fractures of the acetabulum: Accuracy
of reduction and clinical results in patients managed operatively
within three weeks after the injury. JBJS Am 1996;78:16321645
Year:2001 Question # 123
What type of major pelvic ring injury has the greatest average
transfusion requirement?
a.
b.
c.
d.
e.
Lateral compression
Vertical sheer
Anteroposterior compression
Fractures through the sacrum
Fractures through the iliac wing
Correct Answer: c
References:Turen CH, Dube MA, LeCroy MC: Approach to the
polytraumatized patient with musculoskeletal injuries. J Am
Acad Orthop Surg 1999;7:154-165. Dalal SA, Burgess AR,
Siegel JH, et al: Pelvic fracture in multiple trauma: Classification
by mechanism is key to pattern of organ injury, resuscitative
requirements, and outcome. J Trauma 1989;29:981-1002.
Year:2001 Question # 124
Where does the nutrient artery to the tibia most commonly enter
the bone?
a.
b.
c.
d.
e.
Aneriorly above the pes anserinus
Anteriorly 4 cm above the ankle
Laterally above the fibular head
Posteriorly below the posterior cruciate ligament insertion
Posterior in the medial malleolus
Correct Answer: d
References:Brinker MR, Cook SD, Dunlap JN, Christakis P, Elliot
MN: Early changes in nutrient artery blood flow following tibial
nailing with and without reaming: A preliminary study. J Orthop
Trauma 1999;13:129-133.
Year:2001 Question # 129
Which of the following is considered the most important factor in
fracture healing in adults?
a.
b.
c.
d.
e.
Age of the patient
Gender of the patient
Neurologic status of the extremity
Blood supply
Fracture pattern
Correct Answer: d
References:Buckwalter JA, Einhorn TA, Simon SR (eds):
Orthopaedic Basic Science: Biology and Biomechanics of the
Musculoskeletal System, ed 2. Rosemont, IL, AAOS, 2000, pp
372-399.
Year:2001 Question # 142
When treating tibial plateau fractures, the most important reason
that proximal tibial transfixation wires should be placed at
least 14 mm from the articular surface is to
a.
b.
c.
d.
e.
obtain good fixation in subchondral bone
allow radiographic visualization of the joint reduction
minimize the risk that septic arthritis will develop
increase the range of knee flexion
compress the articular fragments
Correct Answer: c
References:DeCoster TA, Crawford MK, Kraut MA: Safe
extracapsular placement of proximal tibia transifxation pins.
JOT 1999;13:236-240. Reid JS, Van Slyke MA, Moulton MJ,
Mann TA: Safe placement of proximal tibial transifxation wires
with resepct to intracapsular penetration. JOT 2001;15:10-17
Year:2001 Question # 150
What structures are located within the femoral canal as it passes
beneath the inguinal ligament?
a.
b.
c.
d.
e.
Femoral artery, femoral vein, and femoral nerve
Femoral artery and femoral vein
Femoral artery, femoral vein, and lymphatics
Femoral artery, femoral vein, femoral nerve, and lymphatics
Internal iliac artery, internal iliac vein, and femoral nerve
Correct Answer: c
References:Hoppenfeld S, deBoer P (eds): Surgical Exposures in
Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA,
JB Lippincott, 1994, pp 362-375.
Year:2001 Question # 161
A 35-year-old laborer sustains an irreparable fracture of the radial
head after falling 12 feet. Examination reveals tenderness at
the elbow and wrist and pain with manipulation of the distal
radioulnar joint. In addition to resection of the radial head,
management should include
a.
b.
c.
d.
e.
hinged bracing of the elbow.
immobilization in a long arm cast.
prosthetic replacement of the radial head.
repair of the distal radioulnar joint.
application of a hinged external fixator.
Correct Answer: c
References:Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ,
Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2.
Rosemont, IL, American Academy of Orthopaedic Surgeons,
2000, pp 39-51. Hotchkiss RN, An KN, Sowa DT, Basta S,
Weiland AJ: An anatomic and mechanical study of the
interosseous membrane of the forearm: Pathomechanics of
proximal migration of the radius. J Hand Surg Am 1989;14:25661.
Year:2001 Question # 173
What portion of the calcaneus typically maintains a normal
relationship to the talus in displaced intra-articular calcaneus
fractures?
a.
b.
c.
d.
e.
Sustentaculum tali
Tuberosity
Anterolateral
Posterior facet
Lateral wall
Correct Answer: a
References:Olexa TA, Ebraheim NA, Haman SP: The
sustentaculum tali: Anatomic, radiographic, and surgical
considerations. Foot and Ankle Int 2000;21:400-403. Sanders
R: Intra-articular fractures of the calcaneus: Present state of the
art. J Orthop Trauma 1992;6:252-265.
Year:2001 Question # 179
What is the most likely cause of mortality within the first 48 hours
in patients who sustain a pelvic fracture from a lateral
compression mechanism?
a.
b.
c.
d.
e.
Aortic rupture
Pelvic arterial injury
Pelvic venous injury
Hollow viscous injury
Head injury
Correct Answer: e
References:Dalal SA, Burgess AR, Siegel JH, et al: Pelvic
fracture in multiple trauma: Classification by mechanism is key
to pattern of organ injury, resusitative requirements, and
outcome. J Trauma 1989;29:981-1002.
Year:2001 Question # 190
Concurrent injuries to which of the following structures results in
an increased osteogenic response to fracture?
a.
b.
c.
d.
e.
Head
Liver
Chest
Major artery
Bladder
Correct Answer: a
References:Kushwaha VP, Garland DG: Extremity fractures in
the patient with a traumatic brain injury. J Am Acad Orthp Surg
1998;6:298-307. Spencer RF: The effect of head injury on
fracture healing: A quantitative assessment. J Bone Joint Surg
Br 1987;69:525-528.
Year:2001 Question # 199
When compared to plate fixation, antegrade intramedullary nailing
of humeral shaft fractures results in
a.
b.
c.
d.
e.
better elbow function.
a higher rate of union.
a higher rate of complications.
a higher rate of infection.
longer surgical time.
Correct Answer: c
References:Farragos AF, Schemitsch EH, McKee MD:
Complications of intramedullary nailing for fractures of the
humeral shaft: A review. J Orthop Trauma 1999; 13:258-267.
McCormack RG, Brien D, Buckley RE, McKee MD, Powell J,
Schemitsch EH: Fixation of fractures of the shaft of the
humerus by dynamic compression plate or intramedullary nail:A
prospective randomized trial. J Bone Joint Surg Br
2000;82:336-339.
Year:2001 Question # 202
An ankle fracture heals with an anatomically aligned mortise and 2
mm of displacement of the distal fibula fracture. What affect
will these findings have on the tibiotalar joint?
a.
b.
c.
d.
e.
Decreased contact loading
Increased contact loading
Increased external rotation
Increased medial-lateral translation
Normal loading, rotation, and translation
Correct Answer: e
References:Brown TD, Hurlbut PT, Hale JE, et al: Effects of
imposed hindfoot constraint on ankle contact mechanics for
displaced lateral malleolar fractures. J Orthop Trauma
1994;8:511-519. Michelson JD: Fractures about the ankle. J
Bone Joint Surg Am 1995;77:142-152.
Year:2001 Question # 211
Which of the following factors has been shown to be an
independent risk factor for infection after open reduction and
internal fixation of the calcaneus through an extensile lateral
incision?
a.
b.
c.
d.
e.
Age of greater than 50 years
History of smoking
A comminuted posterior facet
Extension of the fracture into the sustentaculum
Use of phenytoin
Correct Answer: b
References:Folk JW, Starr AJ: Early wound complications of
operative treatment of calcaneus fractures: Analysis of 190
fractures. J Orthop Trauma 1999;13:369-372
Year:2001 Question # 215
In the treatment of femoral shaft fractures, the lowest union rate
has been reported after which of the following types of
nailing?
a.
b.
c.
d.
e.
Reamed antegrade locked
Reamed antegrade unlocked
Reamed retrograde locked
Unreamed antegrade locked
Unreamed retrograde locked
Correct Answer: e
References:Moeb BR, Watson JT, Cramer KE, Karges DE,
Teefey JS: Unreamed retrograde intramedullary nailing of
fractures of the femoral shaft. J Orthop Trauma 1998;12:334342. Moeb BR, Watson JT: Retrograde intramedullary nailing,
without reaming, of fractures of the femoral shaft in multiply
injured patients. J Bone Joint Surg Am 1995;77:1520-1527.
Year:2001 Question # 218
A 35-year-old man sustained an isolated closed displaced
bicondylar tibial plateau fracture after being struck by a car.
Reduction and internal fixation of both condyles can be most
safely achieved using which of the following surgical
approaches?
a.
b.
c.
d.
e.
Isolated anterior midline
Isolated lateral parapatellar
Isolated posteromedial
Combined anterolateral and posteromedial
Combined anterior midline and posterior transpopiteal
Correct Answer: d
References:Georgiadis GM: Combined anterior and posterior
approaches for complex tibial plateau fixations. J Bone Joint
Surg Am 1989;71:273-277.
Year:2001 Question # 225
Which of the following is considered the most important factor in
preventing failure of fixation of displaced femoral neck
fractures?
a.
b.
c.
d.
e.
Use of a compression screw and side plate
Use of cannulated screws
Accuracy of reduction
Reduction on a traction table
Release of a capsular hematoma
Correct Answer: c
References:Chua D, Jaglal SB, Schatzker J: Predictors of early
failure of fixation in the treatment of displaced subcapital hip
fractures. J Orthop Trauma 1998;12:230-234. Swiontkowski
MF: Intracapsular fractures of the hip. J Bone Joint Surg Am
1994;76:129-138.
Year:2001 Question # 228
What type of knee dislocation is most likely to be irreducible by
closed means?
a.
b.
c.
d.
e.
Posterior
Anterior
Lateral
Posterolateral
Posteromedial
Correct Answer: d
References:Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ,
Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2.
Rosemont, IL, American Academy of Orthopaedic Surgeons,
2000, pp 151-155. Quinlan AG, Sharrard WJW: Posterolateral
dislocation of the knee with capsular interposition. J Bone Joint
Surg Br 1958;40:660-663.
Year:2001 Question # 233
In trauma patients older than 60 years, mortality most closely
correlates with
a.
b.
c.
d.
e.
the injury severity score (ISS).
the extremity abbreviated injury score (AIS).
the need for orthopaedic surgery.
the timing of orthopaedic surgery.
a history of type I diabetes mellitus.
Correct Answer: a
Tornetta G, Mostafavi H, Riina J, et al: Morbidity and morality in
elderly trauma patients. J Trauma 1999;46:702-706.
Year:2001 Question # 237
What is the most common complication at a minimum of 1 year
after treatment with a reamed antegrade nail for a femoral
shaft fracture?
a.
b.
c.
d.
e.
Nonunion
Malunion
Trendelenburg gait
Hip discomfort
Osteonecrosis of the femoral head
Correct Answer: d
References:Bain GI, Zacest AC, Paterson DC, Middleton J, Pohl
AP: Abduction strength following intramedullary nailing of the
femur. J Orthop Trauma 1997;11:93-97.
Year:2001 Question # 249
A varus malreduction of a comminuated talar neck fracture will
result in
a.
b.
c.
d.
e.
varus hindfoot and decreased subtalar motion.
increased contact loading of the posterior facet.
subtalar instability.
anterior ankle impingement.
talonavicular subluxation.
Correct Answer: a
References:Daniels TR, Smith JW, Ross TI: Varus malalignment
of the talar neck: Its effect on the position of the foot and on
subtalar motion. J Bone Joint Surg Am 1996;78:1559-1567.
Sangeozan BJ, WagnerUA, HArrington RM, Tencer AF:
Contact characteristics of the subtalar joint: The effects of talar
neck misalignment. J Orthop Res 1992;10:544-551.
Year:2001 Question # 255
The poor results following surgical treatment of posterior wall
acetabular fractures are most commonly associated with
a.
b.
c.
d.
e.
sciatic nerve injury.
articular comminution.
heterotopic ossification.
deep venous thrombosis.
osteonecrosis of the femoral head.
Correct Answer: b
References:Browner BD, Jupiter JB, Levine AM, Trafton PB
(eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders
1998, pp 1204-1208. Matta JM: Fractures of the acetabulum:
Accuracy of reduction and clinical results in patients managed
operatively within three weeks after the injury. J Bone Joint
Surg Am 1996;78:1632-1645. Saterbak AM, Marsh JL, Nepola
JV, Brandser EA, Turbett T: Clinical failure after posterior wall
acetabular fractures: The influence of initial fracture patterns. J
Orthop Trauma 2000;14:230-237.
Year:2001 Question # 257
When comparing women who sustained a pelvic ring fracture with
women who have multiple injuries without a pelvic ring
fracture, those with a pelvic ring fracture have been found to
have a higher subsequent rate of
a.
b.
c.
d.
e.
miscarriage.
infertility.
depression.
failure to achieve physiologic sexual arousal.
urinary difficulties.
Correct Answer: e
References:Copeland CE, Bosse MJ, McCarthy ML, et al: Effect
of trauma and pelvic fracture on female genitourinary, sexual,
and reproductive function. J Orthop Trauma 1997;11:73-81.
Year:2001 Question # 270
During intramedullary tibial nailing, compartment pressures in the
leg are most elevated by the use of
a.
b.
c.
d.
e.
reaming.
continuous traction.
a medial starting point.
a lateral starting point.
a solid nail.
Correct Answer: b
References:Shakespeare DT, Henderson NJ: Compartmental
pressure changes during calcaneal traction in tibial fractures. J
Bone Joint Surg Br 1982;64:498-499. McQueen MM, Christie J,
Court-Brown CM: Compartment pressures after intramedullary
nailing of the tibia. J Bone Joint Surg Br 1990;72:395-397.
2002
Year:2002 Question # 8
When performing open reduction and internal fixation of a
displaced fracture of the scapular neck, which of the following
peripheral nerves is at the greatest risk of injury?
a.
b.
c.
d.
e.
Axillary
Musculocutaneous
Upper Subscapular
Radial
Dorsal scapular
Correct Answer: a
Anatomically the axillary nerve wraps underneath the glenoid,
through the quadrangular space (a frequent test question!!!)
and then laterally to innervate the deltoid. The posterior
approach to the shoulder (which is usually how you fix the
scapula) goes b/t the infraspinatus (suprascapular nerve) and
the teres minor (axillary nerve). Excessive traction on the teres
minor can cause damage to the axillary nerve. The
quadrangular space is made up of the teres minor (superior),
the Long head of the triceps (medial), the humerus (lateral) and
the teres major (inferior) and the axillary nerve and the posterior
humeral circumflex artery run in this space.
Year:2002 Question # 45
A patient with an isolated femur fracture has an injury severity
score (ISS) of 9. A patient with bilateral femur fractures and
no other injuries has an ISS of
a.
b.
c.
d.
e.
9
16
18
25
81
Correct Answer: 1
This question is interesting because it attempts to see if you have a
rudamentary knowledge of the ISS system. They don`t expect you to know
the actual numbers - just the concepts. The ISS incorporates anatomic
indices w/ severity indices.The ISS uses injury severity developed in the
abbreviated injury scale (AIS)(AIS-90). The ISS uses the highest AIS-90
score from the three most severely injured anatomic areas for any given
patient. These AIS-90 values (1 to 5) are each squared, and then summed
for a total ISS score. For example, a patient with a flail chest has an AIS-90
thorax of 4, a closed femur fracture AIS-90 skeletal system of 3, a ruptured
spleen AIS-90 abdomen of 4; the ISS score for this patient would be 41. The
ISS considers only the highest AIS-90 score from any single anatomic site.
This decreases the ability of this score to predict injury severity in patients
with multiple injuries within the same anatomic area. Nonetheless, the ISS
has become an important predictor of injury severity and mortality and is one
of the national standards for injury severity assessment. An ISS of 16 or
more has been shown to be associated with a mortality of 10%
Year:2002 Question # 59
Which of the following factors has the greatest influence on
achieving a good outcome following surgical treatment of
tibial plateau fractures?
a.
b.
c.
d.
e.
obtaining anatomic reduction of the articular surface
restoring mechanical alignment and stability
using minimally invasive stabilization techniques
initiating early knee range of motion
intiating early weight bearing
Correct Answer: b
Despite old studies claims that anatomic articular reduction is of the utmost importance
to good outcome in tibial plateau fractures, newer better research focusing on
functional outcomes suggest that as much as 5mm of articular step off may be
acceptable and much more important is that there be no malalignment or residual
instability of the tibia. It is not uncommon for recent studies on tibial plateau fractures
to suggest that a step-off of £2 mm in the articular surface, even under the lateral
meniscus, is necessary to achieve a good outcome. However, a number of studies
have indicated that articular incongruity following a tibial plateau fracture, particularly
a lateral plateau injury, is well tolerated and that the amount of articular congruity
plays a small role in determining the outcome following management of these
fractures. Effect of Factors Other than Articular Reduction Instability of the knee has
been shown by many investigators to be strongly associated with a poor clinical
outcome 43-46 . Malalignment of the proximal part of the tibia with the shaft also
contributes to a poor outcome following a tibial plateau fracture. Rasmussen 36
found that osteoarthritis had developed in nineteen (13%) of 146 patients with
proximal tibial valgus angulation of <10° at seven years of follow-up, whereas it had
developed in six of eleven patients with valgus angulation of >10°. Varus angulation
of any amount was poorly tolerated. Meniscal injury is frequently associated with a
tibial plateau fracture, with a reported prevalence of 20% to 47% 47,48 . Either
medial or lateral meniscectomy at the time of surgical treatment of a tibial plateau
fracture is strongly associated with a high prevalence of osteoarthritis and a poor
Year:2002 Question # 67
A healthy cognitively intact 70 year old woman sustains an
unstable intertrochanteric fracture that is stabilized with a well
placed sliding hip screw. Allowing immediate unrestricted
weight bearing will result in
a.
b.
c.
d.
e.
a decreased time to functional return
an increased risk of postoperative hip dislocation
an increased risk of sideplate breakage
an increased risk of implant cutout
an increased risk of wound healing problems
Correct Answer: a
The answer is clear, the faster you get an elderly individiual
ambulating the better. The question tells you that the fracture
was stabilised with a WELL PLACED sliding screw. Early
ambulation would provude a compressive force to the fracture
speeding the healing process. All of this in addition to the
multitude of medical benfits from early mobilisation (dec PE,
dec MI etc..)References:Koval KJ, Aharonoff GB, Su ET,
Zuckerman JD. Effect of acute inpatient rehab on outcome after
fracture of the femoral neck or intertroch fractures. JBJS
1998;80:357-364.
Year:2002 Question # 75
In an obtunded patient with a tibial fracture and suspected
compartment syndrome, fasciotomy should be performed
when intracompartment pressure are
a.
b.
c.
d.
e.
> 30mm Hg
> 40mm Hg
within 40mm Hg of systolic pressure
within 30 mm Hg of diastolic pressure
within 30 mm Hg of mean arterial blood pressure
Correct Answer: d
Compartment syndrome is an elevation of interstitial pressure in closed fascial
compartment that results in microvascular compromise. Necrosis of tissue
may begin at interstitial pressure as low as 30 mm. Many surgeon use 30
mm Hg as the cut off for performing fasciotomy. compartment
measurements within 20 mm Hg of diastolic pressure is an indication for
fasciotomy (DBP - compartment pressure is a relative indicator of tissue
perfusion). Measurements should be taken as close to the fracture site as
possible to achieve the highest readings. Clinical signs/symptoms: pain out
of proportion, pain with passive ROM, pallor, paresthesias, loss of pulses.
References:McQueen MM:Compartment monitoring in tibial fractures JBJS
1998;78:99-104 Nassif JM: Effect of acute reamed vs unreamed IMN on
compartment syndrome when traeating closed tibial shaft fractures. JOT
2000;14:554-558
Year:2002 Question # 108
What is the best indication for intramedullary nailing of the
humerus?
a.
b.
c.
d.
e.
Impending pathologic fracture from metastatic disease
Open fracture
Closed fracture with and associated femur fracture
Closed fracture with radial nerve palsy
Nonunion of a midshaft fracture
Correct Answer: 1
Indications for surgical management of humeral shaft fractures: open fracture, except
low-energy handgun wound; associated vascular injury; floating elbow; segmental
fracture; pathologic fracture; bilateral humeral fractures; humeral fracture in
polytrauma patient; neurologic loss after lacerating injury; neurologic loss during
closed fracture alignment; inability to maintain acceptable alignment; displaced intraarticular fracture extension. Indications for use of IM nails include segmental
fractures in which plate placement would require considerable soft-tissue dissection,
fractures in osteopenic bone, pathologic fractures, and humeral shaft fractures in
polytrauma patients who may need to use the injured arm for mobilization and
ambulation. A randomized prospective study comparing intramedullary nails versus
plates demonstrated no statistically significan differences in healing outcomes
assessed between humeral diaphyseal fractures treated with IM nails and those
treated with plates. Antegrade IM nails were associated with a higher incidence of
shoulder pain and stiffness. Plating was associated with a higher incidence of elbow
pain and stiffness as well as slightly higher incidence of nonunion and
infection.References:Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont,
IL, AAOS, 2002, pp 263-271. Chapman JR, Hanley MB, Agel J, Benca PJ:
Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails
versus plates. JOT 2000;14:162-6.
Year:2002 Question # 123
Nonsurgical management is most appropriate for which of the
following transverse patellar fractures?
a.
b.
c.
d.
e.
Nondisplaced fracture in an active 25 y/o laborer who can
perform a straight leg raise
Minimally displaced fracture in a 40 y/o patient who cannot
perrform a straight leg raise
Displaced fracture in an 80 y/o retired farmer
Displaced fracture in a patient on renal dialysis
Displaced fracture in a patient with diabetes mellitus
Correct Answer: A
Nonsurgical treatment is indicated for all nondisplaced patellar fx
and for minimally displaced fractured associated with an intact
extensor mechanism. The latter group includes patients with 23 mm of fx displacement as well as patients with extra articular
distal fractures and intact ability to perform a straight leg raise.
Surgical treatment has become the accepted standard for the
management of displaced patellar fractures, and fractures that
have no extensor mechanism (straight leg raise).
Year:2002 Question # 155
A 19-year-old man is combative, confused, and requires
intubation after a motor vehicle accident. An AP radiograph of
the pelvis reveals 3cm of symphyseal separation and bilateral
anterior widening of the sacroiliac joints. Abdominal
ultrasound reveals no obvious pathology. After administration
of IV crystalloid, the patient is normotensive. What is the most
appropriate next step in management?
a.
b.
c.
d.
e.
External fixation of the pelvis
Open reduction and Internal fixation of the pubic symphysis
CT of the head
CT of the abdomen
Exploratory laparotomy
Correct Answer: C
This question goes back to basic ATLS. While the obvious answer
to the open book pelvis (for definitive management) is external
fixation or ORIF, the more pressing issue is the patients overall
condition. After establishing the ABC`s (intubated, on a
ventilator, and normotensive), the secondary survey ensues.
The abdominal US serves in this regard to rule out any gross
abdominal abnormalities (free fluid, etc) and is a tool becoming
more often utilized acutely instead of CT. This is discussed in
the referenced chapter from OKU 6. Since there is no obvious
pathology and the patient is stable, answer d and e are not
correct. Any mental status changes warrants ruling out of
intracranial abnormalities in the acute setting. This is best done
with a head CT.
Year:2002 Question # 158
Following surgical treatment of an intertrochanteric femur fracture
with a fixed angle dynamic hip screw, what factor has the
greatest effect on the rate of implant cutout?
a.
b.
c.
d.
e.
Length of the side plate
Length of the barrel
Angle of the device
Use of a compression screw
Tip-apex distance
Correct Answer: E
Cutout is related most strongly to the distance of the screw tip
from the chondral surface. The length of the side plate and
barrel have no bearing on this nor does the angle of the device.
Compression screw has not been shown to affect failure of the
implant. The 2nd reference is a paper that investigates 19 DHS
screw cutouts. The tip-apex distance is the sum of the distance
from the tip of the screw to the apex of the femoral head on an
AP and a lateral (the 2 are added). In the article, the average
distance for those that did not cut out was 24 mm compared to
38 mm in the cutout group. There was a strong relationship
between and increasing tip-apex distance and rate of cutout.
Thus, the ideal position of the screw tip is around 1 cm from the
joint.References:OKU Trauma 2 Baumgaertner MR et al: The
value of the tip-apex distance in predicting failure of fixation of
peritrochanteric fractures of the hip. JBJS 1995;77:1058-1064.
Year:2002 Question # 169
A 40yo man who sustained multiple injuries in a MVC is in class III
hemorrhagic shock. Which of the following findings would be
most likely to be present in this patient ?
a.
b.
c.
d.
e.
normal mental status
normal systolic blood pressure
urine output of 15 ml/hr
respiratory rate of 20 breaths/min
pulse rate of less than 100 beats/min
Correct Answer: c
SHOCK EBL(% bld vol) P SBP UOP(ml/hr) Class I- <750cc (15%
BV) <100 nl >30 Class II- 750-1500cc (15-30%) >100 nl 20-30
ClassIII- 1500-2000cc(30-40%) >120 decr 5-15 Class IV>2000cc (40%) >140 decr negligible Some KEY POINTS !! Normotensive pelvic injury patients have a 3% mortality;
patients with a SBP <90 have a 38% mortality rate. -Most pelvic
bleeding is venous (90% cancellous bone & retroperitoneal
lumbar venous plexus). -Most common pelvic arterial injury at
time of angio is internal pudendal artery. -APC pelvic injuries
are associated with signif greater transfusion requirements than
LC injuries.References:Kellam JF, Fischer TJ, Tornetta P III,
Bosse MJ, Harris MB (eds): OKU: Trauma 2. Rosemont, IL,
AAOS, 2000. p229-237.
Year:2002 Question # 189
A 23 year old man sustains a nondisplaced clavicle fracture and
an ipsilateral scapular neck fracture with 1 cm of
displacement. Definitive treatment should consist of
a.
b.
c.
d.
e.
nonsurgical management
open reduction and internal fixation of the clavicle
open reduction and internal fixation of the scapula
open reduction and internal fixation of the scapula and
clavicle
resection of the acromioclavicular joint
Correct Answer: 1
Up until recent studies showing that nonoperative tx for floating shoulder
injuries with minimal displacement did well all of these injuries were treated
with open reduction and internal fixation of the simple fracture (clavicle or
scapula depending on pattern). The perceived risks until recently were
abduction weakness, decreased range of motion, chronic pain, malunion,
and nonunion with nonoperative treatment. These risks have been shown as
less a concern than suspected with recent studies from Edwards showing
comparable results to ORIF for floating shoulder injuries. The superior
shoulder suspensatory complex is an osseous and soft-tissue ring supported
by superior and inferior osseous struts. This ring is composed of the glenoid
process, the coracoid process, the coracoclavicular ligament, the distal part
of the clavicle, the acromioclavicular joint, and the acromial process. The
superior strut is the middle part of the clavicle, and the inferior strut is the
lateral part of the scapular body and the scapular spine.References:1.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, Il, American
Academy of Orthopaedic Surgeons, 2002, pp264-267. 2. Edwards SG:
Nonoperative treatment of ipsilateral fractures of the scapula and clavicle.
JBJS Am 2000; 82: 774-780
Year:2002 Question # 199
A young healthy patient sustains a severe crush injury resulting in
a comminuted midshaft tibia fracture and an 8 * 10 cm medial
soft-tissue difect with exposed bone. There is no associated
vascular injury. Which of the following procedures will most
predictably result in successful coverage?
a.
b.
c.
d.
e.
Split thickness skin graft
Fasciocutaneous flap
Soleus Flap
Gastrocnemius flap
Free Tissue transfer
Correct Answer: 5
Gustillo/Anderson GIIIB or higher injuries of the tibia has been Rotational flaps for the
proximal 1/3 of the tibia (Gastroc specifically), Rotational flap (Soleus specifically) or
free flap for fractures of the middle third, and free flap for fractures of the distal third.
Obviously these guidelines were not hard and fast, and other local wound
characteristics needed to be considered (i.e vasc. supply, infection, size of defect,
etc.) but these principles could and probably still can be generalized to treatment of
these tibial wounds. Therefore most of us should have narrowed this question down
to choice 3 and 5, because the other flaps do not provide the coverage needed (i.e.
muscle over bone in choice 1 and 2), or their vascular pedicle and location makes it a
poor choice for midshaft tibia soft tissue coverage (i.e choice 4). To come to the final
answer of choice five the reference article below reports that in their study the
treatment of an acute traumatic soft-tissue defect of the tibia, a free flap is
significantly less likely to have a short-term wound complication than is treatment
with a rotational flap. This is why the answer is choice 5. It does bring up the
question of whether this is applicable to the proximal tibia because it is implied in
there study, however I have found conflicting data regarding coverage of the
proximal tibia and imagine that this would not be on the test. For the proximal tibia
rotational flaps and free flaps are both viable options, although trends seem to be
going towards free flaps. Remember: free flaps is always the choice for middle and
distal third tibial coverage, and would be the likely choice for proximal as well,
although controversial.
Year:2002 Question # 207
A 19-year-old man sustains an isolated, displaced transcervical
femoral neck fracture in a motor vehicle accident. An urgent
closed reduction attempt in the operating room results in
ersidual varus angulation and 1 cm of displacement.
Appropriate management should now consist of
a.
b.
c.
d.
e.
in situ fixation.
bipolar hemiarthroplasty.
total hip arthroplasty.
open reduction and internal fixation.
in situ fixation and bone grafting.
Correct Answer: 4
Fractures of the femoral neck in young patients are extremely
rare. The results of treatment are poorer than octogenarians. In
addition, the force required to fracture the femoral neck in
young patients is much higher than in the old and represents
and high-angle, shear-type frature that extends to the lesser
tuberosity. As expected, the rates of non-union (0- 65%) and
AVN (19- 90%) are higher. It is imperative to fix these ASAP,
within 8-12 hours, depending on the author. If closed reduction
fails to restore anatomic alignment, proceed to open reduction
through an anterior approach. If closed recution is successful,
the fracture is internally fixed with multiple cannulated screws or
6.5 mm A-O cancellous screws.
Year:2002 Question # 217
A 32-year-old man has a displaced radial head fracture with an
associated posterolateral elbow dislocation. Examination
reveals pain and swelling throughout the elbow, forearm, and
wrist. In addition to closed redution of the elbow dislocation,
management should include
a.
b.
c.
d.
e.
a long arm cast.
a hinged elbow brace.
an external fixator with articulated hinge.
radial head resection.
open reduction and internal fixation of the radial head
Correct Answer: e
Pain throughout his forearm and wrist represents an injury to the
interosseous membrane (IOM) and DRUJ, a variant of the
Essex-Lopresti lesion. (The original Essex- Lopresti lesion was
described as a radial head fracture and DRUJ disruption
without an associated elbow dislocation.) You need to restore
the lateral buttress proximally to retain axial stability of the
forearm, either with ORIF of the radial head or else metal or
allograft head implant. If you do not restore the buttress,
proximal migration of the radius can occur. Temporary pin
fixation of the DRUJ in neutral position may be added to
neutralize the tendency toward proximal migration. None of the
other choices restore the proximal buttress of the radius.
Year:2002 Question # 220
A 24-year-old man sustains a displaced trancervical femoral neck
fracture and is treated with multiple cannulated screws. Five
months after the injury, the patient reports continued hip pain
and is unable to bear weight. Sequential radiographs and a
CT scan reveal 10 deg. of varus angualtion. Management
should now consist of
a.
b.
c.
d.
e.
continued obsevation with weight bearing.
valgus intertrochanteric osteotomy.
bipolar hemiarthroplasty.
electrical stimulation.
cancellous autologous bone grafting to the femoral neck
Correct Answer: b
References:Marti RK, Schuller HM, Raaymakers EL:
Intertrochanteric osteotomy for non-union of the femoral neck. J
Bone Joint Surg Br 1989;71:782-787. Kellam JF, Fischer TJ,
Tonetta P III, Bosse MHJ, Harris MB (eds): Orthopaedic
Knowledge Update: Trauma 2. Rosemont, IL, American
Academy of Orthopaedic Surgeons, 2000, pp 115-124.
Year:2002 Question # 262
What type of displaced unstable posterior pelvic ring injury will
benefit most from open reduction and internal fixation?
a.
b.
c.
d.
e.
Transforaminal sacral fracture
Sacral alar fracture
Iliac fracture
Sacroiliac fracture-dislocation
Sacroiliac dislocation
Correct Answer: 5
Pure sacroiliac lesions are associated with poor outcomes,
especially of exact reduction is not achieved. Fractures of the
iliac wing, sacroiliac fracture-dislocation, or mixed fractures with
SI propagation have the best prognoses, but the outcomes do
not correlate to the quality of reduction. References:Starr AJ:
Long-term functional prognosis of posterior injuries in highenergy pelvic disruption. J Orthop Trauma 1998;12:592-593.
Koval KJ (ed): OKU 7. Rosemont, IL, AAOS, 2002, pp 395-403.