This practice set contains high-yield board review questions covering key concepts in 2. Trauma. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 3601
Topic: 2. Trauma
Which of the following conditions associated with a closed fracture of the clavicle indicates the need for open reduction and internal fixation?
Correct Answer & Explanation
. Injury to the subclavian artery
Explanation
Injuries to underlying vascular structures associated with clavicle fractures require exploration and stabilization. Brachial plexus injuries recover spontaneously in two thirds of patients. Displaced and segmental fractures may undergo closed reduction. Open treatment of clavicle fractures have been discouraged secondary to technical difficulties and nonunion. A floating shoulder (displaced clavicle and scapular neck fractures is an indication for ORIF but not humeral neck fracture.)
Question 3602
Topic: 2. Trauma
A 41-year-old man is involved in a high-speed motor vehicle crash and sustains a closed femoral midshaft fracture and a unilateral pulmonary contusion with a hemothorax, requiring placement of a chest tube. He has an initial blood pressure of 90/50 mm Hg. After receiving two liters of crystalloid, he has a blood pressure of 115/70 mm Hg and a heart rate of 90 bpm. He has normal mentation and does not require ventilator support. An arterial blood gas reveals that his delta base is
Correct Answer & Explanation
. Skeletal traction
Explanation
The patient responded to crystalloid resuscitation and hemodynamic parameters and the base deficit indicate that he is adequately resuscitated for definitive fracture care. In a resuscitated patient, a reamed nail is not detrimental in the setting of a pulmonary injury and is favorable for fracture union. An unreamed nail has a higher nonunion rate than a reamed nail for femoral fractures. In a skeletally mature patient with a midshaft fracture, an intramedullary nail is preferred to open reduction and internal fixation. In an adult patient, skeletal traction should be considered only as a temporary treatment prior to surgical fixation of the femoral fracture.
Question 3603
Topic: 2. Trauma
An 8-year-old girl has a supracondylar fracture of the distal humerus. Her neurovascular status is intact. Radiographs show hyperextension of 10 degrees of the distal fragment and an angle between the humeral shaft and capitellar physis (Baumann’s angle) of 88 degrees. Management should consist of
Correct Answer & Explanation
. Olecranon pin traction
Explanation
Supracondylar fracture of the humerus accounts for 3 percent of childhood fractures. It is the commonest fracture of the elbow region in children and accounts for 80% of elbow injuries. Common complications include cubitus varus, ischemic contracture, and neurovascular lesions. This question chooses closed reduction with Kwire fixation as the correct method of treatment. However, the literature discusses olecranon screw traction and open reduction as legitimate options in treatment. This study recommends olecranon traction for severely displaced fractures left unstable by closed reduction.
Question 3604
Topic: 2. Trauma
A 56-year-old man who tripped and fell out of his golf cart onto his right shoulder 4 days ago now reports mild pain while chipping. Examination reveals mild bruising over the lateral clavicle but good shoulder range of motion and strength. A radiograph is shown in Figure 9. Appropriate treatment at this time should include which of the following?
Correct Answer & Explanation
. Intramedullary pinning
Explanation
Treatment of this minimally displaced distal clavicle fracture should begin with nonsurgical management consisting of sling therapy followed by gentle motion therapy. Any form of surgical intervention at this time is unnecessary because this fracture pattern has a high incidence of union. A bone stimulator may be used if healing becomes delayed.
Question 3605
Topic: 2. Trauma
A 21-year-old woman is struck by a car and sustains a Gustillo IIIB fracture of the tibia. The wound was debrided and immobilized with an external fixator. Radiographs are shown in Figure A. The soft tissue defect was covered with a free flap. Her recovery was complicated by wound infection with Klebsiella pneumoniae and Escherichia coli. One month after her injury, she underwent intramedullary nailing and placement of an antibiotic spacer measuring 15cm in length. Radiographs are shown in Figure B. At the next stage of surgery 6 weeks later, the surgeon should plan to do all of the following:
Correct Answer & Explanation
. Excise the spacer
Explanation
The second stage of the Masquelet technique requires removal of the cement bolus, incision into the induced membranes and bone grafting. The existing hardware is preserved where possible as the fracture is still not stable. Bone graft is inserted INTO the membranous cavity, AROUND the nail.The Masquelet staged technique of induced membranes is an option for filling large bone defects up to 25cm in length. This technique protects against autograft resorption, stimulates mesenchymal cell-to-osteoblast differentiation, maintains graft position, and prevents soft tissue interposition. Cement impregnation achieves high local antibiotic concentration without risk of systemic toxicity.Ashman et al. discussed the techniques of addressing bone defects. Options include:(1) acute limb shortening (up to 4cm in the tibia and humerus, and 7cm in the femur);(2) distraction osteogenesis for defects up to 10cm long (at 1mm/day with consolidation period of 5days per mm, or total treatment time of up to 60days/cm), (3) autograft (up to 25cm of vascularized fibula, or 3cm of nonvascularized iliac crest),and (4) Masquelet technique.Taylor et al. reviewed the induced membranes technique. They found that the membrane is well vascularized and composed of type I collagen with fibroblasts with an inner epithelial cell layer. There is a high concentration of VEGF, RUNX2 (CBFA1), TGFß1, and BMP2. The membrane is sutured over bone graft to create a closed pouch. When a nail is present, they note a second internal membrane around the nail, potentially increasing local vascularity and osteoinductive factor concentration.Figure A shows a Gustillo IIIB tibia fracture with a large bone defect held in a temporizing external fixator. Figure B shows the same defect following intramedullary nailing and with a cement spacer placed circumferentially around the nail in the defect.Incorrect Answers
Question 3606
Topic: 2. Trauma
Figures A and B are post-operative radiographs of a 54-year-old female. In the first 6 months after this procedure, what is the most likely factor for functional impairment in this patient?
Correct Answer & Explanation
. Osteonecrosis
Explanation
A residual deficit in muscle performance and anterior knee pain are expected in the majority of patients at 6 months after surgical fixation of their patella fractures.Anterior knee pain is reported to be a common symptom following treatment of patellar fractures. A likely contributing factor to the anterior knee pain is scarring and tightness of the structures surrounding the knee, as well as patella maltracking due to quadricep/hamstring weakness and/or poor muscle synchrony. Other factors for anterior knee pain may include symptomatic hardware, which may be treated with removal of fixation after union has been achieved.Lazaro et al. looked at the outcome data on thirty patients with isolated unilateral patellar fractures. Anterior knee pain during activities of daily living was experienced by twenty-four (80%) of the patients. The knee extensor mechanism on the injured side had deficits in strength (-41%), power (-47%), and endurance (-34%) as compared with the uninjured side.Lebrun et al. reviewed a series of 40 operatively treated patella fractures and found that at over 6 years postoperatively, significant symptomatic complaints and functional deficits persisted based on validated outcome measures as well as objective physical evaluations. Removal of symptomatic fixation was required in 52% of the patients treated with osteosynthesis, whereas 38% of those with retained fixation self-reported implant-related pain at least some of the time.Figure A and B show AP and lateral radiographs of a comminuted patella fracture treated with a tension band repair construct. The articular surface looks well reduced.Incorrect Answers:
Question 3607
Topic: 2. Trauma
A patient has a displaced complex intra-articular distal humeral fracture. What factor is considered most important when deciding on what surgical approach to use?
Correct Answer & Explanation
. Visualization of the articular surface
Explanation
DISCUSSION: When managing a complex intra-articular fracture, it is imperative that there is adequate visualization of the joint; this usually means an extensile approach. At the elbow, this is usually through a transolecranon osteotomy. The recent addition of a muscle-sparing approach as described by Bryan and Morrey has gained popularity, but it is difficult to maintain soft-tissue viability and it may put the ulnar nerve at risk. A triceps-splitting approach, which can be used for simple single articular splits into the joint where extra-articular reduction is available, is possible and good results have been reported. To date, there is minimal data on these alternative approaches for comminuted intra-articular distal humeral fractures.REFERENCES: McKee MD, Mehne DK, Jupiter JP: Fractures of the distal humerus: Part II, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1483-1522McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR: Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82:1701-1707.Patterson SD, Bain GI, Mehta JA: Surgical approaches to the elbow. Clin Orthop2000;370:19-33.Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: A triceps-sparing approach. Clin Orthop 1982;166:188-192.
Question 3608
Topic: 2. Trauma
Figure 91 shows the radiograph of a 57-year-old man who fell 6 feet off a ladder. He is neurovascularly intact but reports shoulder pain. What is the most appropriate acute treatment for this patient?
Correct Answer & Explanation
. Physical therapy for range of motion, advancing to strengthening as tolerated
Explanation
The patient has sustained a traumatic surgical neck fracture of the humerus. Sling immobilization and a recheck in 1 week with radiographs is appropriate to check for maintenance of alignment. The fracture is minimally displaced and therefore does not require surgical stabilization or further diagnostic imaging. Surgical reduction and plating is not indicated in this nondisplaced fracture. Physical therapy and activity as tolerated at this point are contraindicated because of the acuity of the fracture.
Question 3609
Topic: 2. Trauma
An elderly woman with osteoporosis falls from a standing height, sustaining a low-energy fracture of the acetabulum. What structures are most likely fractured?
Correct Answer & Explanation
. Posterior column and posterior wall
Explanation
Epidemiologic studies suggest that 4,000 acetabular fractures occur in elderly patients each year in the United States. This accordingly may become the most common age group to present with this fracture. In elderly patients with considerable osteoporosis, a typical fracture pattern may present with intrapelvic dislocation of the femoral head with compromise to the anterior column and "medial wall." The resulting fractures are often complex fracture patterns with extensive comminution and displacement. Thesemay present as atypical fracture patterns not always conforming to classic injury patterns described by Judet and associates. This fracture pattern seen commonly in geriatric patients results from low-energy falls with force directly applied to the greater trochanter. Fractures involving the posterior column and/or wall and transverse fracture patterns involving both the anterior and posterior columns occur infrequently in this age group. They are, however, more commonly encountered in younger age groups as a result of higher energy trauma.
Question 3610
Topic: 2. Trauma
A 35-year-old man who is involved in an improvised explosive device attack is hit by a piece 57 of shrapnel. He has a solitary penetrating wound in his left tibia. Radiographs show no fracture. He has significant pain and his calf is grossly swollen. He has good sensation and palpable dorsalis pedis and tibialis posterior pulses. He has elevated pressure in all 4 compartments. When performing a 4-compartment fasciotomy using the 2-incision technique, which structure is at risk when opening the deep posterior compartment?
Correct Answer & Explanation
. Anterior tibial artery
Explanation
DISCUSSIONCompartment syndrome is commonly seen in lower-extremity trauma, especially in blast injuries or high-energy trauma to the lower extremity. It is important to recall the neurovascular structures present in each of the 4 compartments. The posterior tibial artery is in the deep posterior compartment along with the tibial nerve, the peroneal artery and vein, and the posterior tibial vein. The lateral compartment contains the superficial peroneal nerve.The anterior compartment contains the deep peroneal nerve and the anterior tibial artery and vein. The superficial posterior compartment does not have any neurovascular structures. The saphenous nerve is superficial.RECOMMENDED READINGSThompson JC, ed. Netter’s Concise Atlas of Orthopaedic Anatomy. Teterboro: NJ: Icon Learning Systems; 2002.Mubarak SJ, Owen CA. Double-incision fasciotomy of the leg for decompression in compartment syndromes. J Bone Joint Surg Am. 1977 Mar;59(2):184-7. PubMed PMID: 15455478.View Abstract at PubMed
Question 3611
Topic: 2. Trauma
A patient with a transverse femur fracture undergoes statically locked antegrade intramedullary nailing. Postoperatively, the patient appears to have a
Correct Answer & Explanation
. Settle the case because the surgeon made an error that resulted in unnecessary surgery, and thus the case is indefensible.
Explanation
To establish negligence, certain criteria must be met. 1) A duty was owed by the surgeon (in this case, yes, a relationship was established). 2) The duty was breached, where the provider failed to meet the standard of care (there was a technical error, but it was corrected). 3) The breach caused an injury. In this case, the patient had an outcome that was very acceptable, as documented with outcome studies, for femur fractures. Also, the rotational error and locking distally would have had little impact on the hip, whereas antegrade nailing itself is expected to result in some objective impairment of the hip in some patients. 4) Damages were incurred as a result. In this case, the patient returned to work and could not rock climb which could be reasonably expected with a femur fracture in some patients, and cannot be causally linked to the corrective surgery. For all practical purposes, the patient had a very acceptable outcome. Thus, settling the case for an error would be rather permissive and the important issue is that the surgeon recognized the problem, addressed it, and fulfilled his or her postoperative responsibility. The case is very defendable, and thus it is unlikely to be lost. Defending the case and alleging no error is incorrect because there was an error. The surgeon should never function outside of his or her legal counsel once a suit is filed.
Question 3612
Topic: 2. Trauma
The teardrop shape marked with an asterisk in Figure 61 represents what anatomic structure?
Correct Answer & Explanation
. Anterior superior iliac spine
Explanation
DISCUSSION: The teardrop can be visualized on the obturator outlet view of the pelvis and represents a thick column of bone that runs from the AIIS to the PSIS. Half pins for eternal fixation frames or screws can be inserted into this column for fixation of fractures.REFERENCES: Gardner MJ, Nork SE: Stabilization of unstable pelvic fractures with supra-acetabular compression external fixation. J Orthop Trauma 2007;21:269-273.Haidukewych GJ, Kumar S, Prpa B: Placement of half-pins for supra-acetabular external fixation: An anatomic study. Clin Orthop Relat Res 2003;411:269-273.Kim WY, Hearn TC, Seleem O, et al: Effect of pin location on stability of pelvic external fixation. Clin Orthop Relat Res 1999;361:237-244.
Question 3613
Topic: 2. Trauma
All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:
Correct Answer & Explanation
. Can be protective to an injured spine
Explanation
DISCUSSION: Based on the references provided, the advantages of the lateral position include: facilitates the retraction of the vastus lateralis, allows hip flexion to aid reduction, improves access to the proximal segment (easier to get starting point). Disadvantages of the lateral position include: intraoperative imaging may be more difficult, rotation is more difficult to judge, and lateral positioning may not be practical in the polytraumatized patient.Advantages of the supine position include: may help protect a potentially unstable spine, facilitates access to sites other than the injured femur, shorter setup time, rotational and angulatory deformities may be more easily appreciated. Disadvantages of the supine position include: starting point localization may be more difficult.
Question 3614
Topic: 2. Trauma
The flexor hallucis longus tendon is at greatest risk of injury with a lateral-to-medial drill or screw during fixation of what structure?
Correct Answer & Explanation
. Lisfranc fracture-dislocation
Explanation
DISCUSSION: A drill bit or screw that penetrates the subchondral area of the posterior facet of the calcaneus can lead to direct injury of the flexor hallucis longus as it runs just inferior to the sustentaculum tali on its way to its insertion on the first phalanx of the great toe. A medial calcaneal groove is seen where this structure runs from superior to inferior. Injury to the flexor hallucis longus tendon can be acute or attritional. Bajammal et al investigated intra-articular calcaneus fractures and reported that patients who were NOT receiving Workers' Compensation, were younger (less than twenty-nine years old), had a moderately lower Böhler angle (0 degrees to 14 degrees ), a comminuted fracture, a light workload, or an anatomic reduction or a step-off of < or =2 mm after surgical reduction (p = 0.04) scored significantly higher on the scoring scales after surgery compared with those who were treated nonoperatively.
Question 3615
Topic: 2. Trauma
Figures 87a and 87b are the radiographs of an 18-year-old pedestrian who was struck by a car. During intramedullary nailing, it is difficult to maintain proper alignment. Poller blocking screws placed in the proximal fragment at which position(s) relative to the nail can help prevent the typical deformity?
Correct Answer & Explanation
. Anterior only
Explanation
This is a proximal one third tibial shaft fracture. Typically nailing of this fracture creates a valgus and procurvatum malalignment that must be addressed. This can be difficult when using an intramedullary nail in the wide metaphyseal bone of the proximal tibia. To help direct and center the nail in the metaphysis, blocking screws can be used. Blocking screws should be placed where the nail should not travel. If the nail was passed with the proximal fragment in this position, it would occupy the lateral and posterior aspects of the metaphyseal fragment. To prevent this, blocking screws should be placed in the lateral and posterior aspects of the proximal fragment.
Question 3616
Topic: 2. Trauma
Figure 36a shows the current radiograph of a 65-year-old woman who slipped and fell. History reveals that prior to the fall she was actively functioning without pain. Figure 36b shows a radiograph obtained 1 year ago. Based on the fracture pattern, the failure is most likely related to
Correct Answer & Explanation
. repetitive loading and fatigue failure.
Explanation
DISCUSSION: The radiograph shows a fracture distal to the prosthesis in a stable, apparently well-fixed prosthetic stem. The well-fixed prosthesis-bone composite is stiff, creating a modulus mismatch between the proximal and distal femur. Therefore, the risk of fracture, particularly in osteoporotic bone, is increased at this level. Revision of the stem to a longer construct is unnecessary, and standard plate and screw fixation has been shown to yield union rates of greater than 90%. Nonsurgical treatment of fractures distal to the tip of the prosthesis results in high nonunion rates, reported to be from 25% to 42%.REFERENCES: Johansson JE, McBroom R, Barrington TW, Hunter GA: Fracture of the ipsilateral femur in patients with total hip replacement. J Bone Joint Surg Am 1981;63:1435-1442.Bethea JS III, DeAndrade JR, Fleming LL, Lindenbaum SD, Welch RB: Proximal femoral fractures following total hip arthroplasty. Clin Orthop 1982;170:95-106.Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242.
Question 3617
Topic: 2. Trauma
A 30-year-old man sustains a head injury as well as a femur and pelvis fractures as the result of a rollover motor vehicle accident. He is initially comatosed, but recovers cognitive function after 10 days in the hospital. Soon after awakening he complains of wrist pain and an x-ray demonstrates a distal radius fracture. What is the most likely explanation for this delayed diagnosis?
Correct Answer & Explanation
. wrist x-ray not initially obtained
Explanation
DISCUSSION: According to the cited article by Born et al, who prospectively studied the incidence of delayed recognition of skeletal injury at a Level I trauma center over an 18-month period, the majority of missed skeletal injuries result from failure to image the affected extremity. These authors identified 39 fractures in 26 of 1,006 consecutive blunt trauma patients that were not diagnosed in a timely fashion (delays ranging from 1-91 days). Although other factors contributed to the diagnostic failure (23% were visible on admission films and not recognized; 10% were not visible due to inadequate x-rays of appropriate limb; 13% had adequate x-rays but diagnosis could not be made from initial studies), 55% of the fractures that were delayed in diagnosis resulted from failure to image the affected extremity. They went on to conclude that, “although the delay of fracture identification was not felt to contribute to additional long-term cosmetic, functional, or neurologic problems,” continued radiographic surveillance is necessary to prevent diagnostic failure.
Question 3618
Topic: 2. Trauma
An otherwise healthy 13-year-old boy sustains the fracture shown in Figure 40 while throwing a fastball. Management should consist of
Correct Answer & Explanation
. an arm sling.
Explanation
DISCUSSION: Nonsurgical management such as a functional brace, hanging arm cast, or sugar tong splint is the treatment of choice for a fracture of the humeral shaft that is the result of throwing. The fracture surface typically is wide and the degree of displacement is not large; therefore, surgery is not indicated in most patients.REFERENCES: Ogawa K, Yoshida A: Throwing fracture of the humeral shaft: An analysis of 90 patients. Am J Sports Med 1998;26:242-246.Kaplan H, Kiral A, Kuskucu M, et al: Report of eight cases of humeral fracture following the throwing of hand grenades. Arch Orthop Trauma Surg 1998;117:50-52.
Question 3619
Topic: 2. Trauma
A paraplegic 32-year-old man was pulling himself up in bed by grasping the headboard rails when he felt a pop and immediate pain. A radiograph and CT scan are shown in Figures 2a and 2b. Based on these findings, management should consist of
Correct Answer & Explanation
. rest and a sling for 3 to 6 weeks.
Explanation
DISCUSSION: The coracoid process is an essential component of the superior shoulder suspensory complex and must be maintained. Open reduction and internal fixation is recommended if the fragment is large and displaced more than 1 cm.REFERENCES: Froimson AI: Fracture of the coracoid process of the scapula. J Bone Joint Surg Am 1978;60:710-711.Gil JF, Haydar A: Isolated injury of the coracoid process: Case report. J Trauma1991;31:1696-1697.
Question 3620
Topic: 2. Trauma
A 58-year-old African-American female who sustained an injury to her upper arm six months ago presents with persistent arm pain. She was initially treated with splinting, with conversion to fracture bracing. She is neurovascularly intact. An injury radiograph and a current radiograph are shown in Figures A and B respectively. What nutritional or metabolic disturbance is the most likely associated with this patient's diagnosis? Review Topic
Correct Answer & Explanation
. Vitamin A deficiency
Explanation
This patient has sustained a humeral diaphyseal fracture that has gone on to an atrophic nonunion. Vitamin D deficiency is the most likely associated metabolic disturbance.The incidence of nonunion with non-operative management of humeral shaft injuries ranges from 2-10%. Risk factors include vitamin D deficiency (most common), open fractures, segmental injuries, smoking and obesity. The optimal treatment is compression plating with bone grafting, which has been shown to be superior to intramedullary nailing with bone grafting or compression plating alone.Ring et al. reviewed factors that contributed to humeral diaphyseal nonunion after fracture bracing. Fractures in the proximal to middle one-third of the shaft or fractures with a spiral/oblique pattern were more likely to go on to nonunion.Brinker et al. reviewed 37 low-energy fractures that went onto nonunion. These patients were evaluated by clinical endocrinologists for evaluation of metabolic abnormalities. Thirty-one of the 37 patients (84%) had a metabolic issue, with 68% (25 of 37 patients) having Vitamin D deficiency.Figure A demonstrates a humeral shaft fracture. Figure B demonstrates an atrophic nonunion of the humeral shaft fracture.Incorrect Answers:
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