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2. Trauma MCQs

Practice Set 183 of 640

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 3641

Topic: 2. Trauma

Which of the following best characterizes the injury shown in Figure 53? Review Topic

. Stable tear drop extension injury
. Facet dislocation
. Unstable flexion compression injury
. Stable axial load injury
. Burst fracture

Correct Answer & Explanation

. Stable tear drop extension injury

Explanation

The injury shown is a flexion compression injury also known as "tear drop" fracture. It is characterized by the large anteroinferior fragment off the vertebral body and the retrolisthesis seen in this image. It is considered an unstable injury and should be distinguished from the more stable and minor extension tear drop avulsion where there is no vertebral malalignment and the anteroinferior fracture is a small avulsion of the annulus attachment. Other axial load injuries can be stable but have more of a compression or even burst pattern with loss of body height rather than the anteroinferior fragment. The radiograph does not demonstrate facet malalignment that would be seen with a facet dislocation.

Question 3642

Topic: 2. Trauma

Figure 48 shows a current lateral radiograph of a 23-year-old man who sustained a closed femoral diaphyseal fracture 5 months ago. Treatment consisted of placement of a retrograde femoral nail for the femoral fracture. The patient now reports a sudden onset of pain in the midthigh and cannot bear weight on his leg. Management should consist of

. an onlay iliac crest bone graft.
. limited weightbearing and observation.
. removal of the implant and limited weightbearing.
. removal of the implant and insertion of a reamed femoral nail.
. removal of the implant and insertion of an unreamed femoral nail.

Correct Answer & Explanation

. an onlay iliac crest bone graft.

Explanation

Moed’s article basically discusses the application of retrograde unreamed femoral nailing in selected multiply injured patients. He reports higher rates of non-union and longer time to union than antigrade with and without reaming and retrograde nailing without reaming. Despite this, the article maintains its advantages: elimination of need for fracture table; decrease in intraopperative manipulation; shortened duration of procedure; and decreased blood loss. The author discusses treatment of non-unions with this technique insofar as he describes conversion of statically locked nails of the three delayed unions (N=22) to dynamic constructs by removal of the proximal locking screw.In Webb, et al. one hundred five consecutive patients with a diagnosis of delayed union (61 patients) or nonunion (44 patients) of the femoral shaft from February 1968 to November 1983 were managed by intramedullary reaming and nailing. The procedure was accomplished by closed techniques in 82 of the cases. Adequate follow-up study was obtained in 101 patients; all but four showed clinical and radiologic union at an average of 20 weeks following the procedure, with an overall union rate of 96%. The four patients whose fractures failed to consolidate with this treatment had repeat procedures with placement of thicker nails, and all subsequently healed.The fracture pictured for this question is an oblique, distal 1/3 diaphyseal femur fracture with a butterfly fragment, an axially and rotationally unstable fracture configuration. The clinical history and x-ray are consistent with delayed union, therefore response #4 is the only sensible management option.

Question 3643

Topic: 2. Trauma

Figures 18a through 18c show injuries sustained by a 22-year-old woman after falling 45 feet while mountain climbing. After being airlifted to the nearest trauma center, her arterial blood gas was 7.21, pO2 84, pCO2 48, and delta base -11 mmol/L. Her Hgb is 8.7 and her resuscitation is ongoing. Based on this data, what would be the best management of her orthopaedic injuries?

. External fixation of the pelvis, external fixation of the distal femur, and splinting of the humerus
. External fixation of the pelvis, external fixation of the distal femur, and intramedullary nailing of the humerus
. External fixation of the pelvis, open reduction and internal fixation of the distal femur, and splinting of the humerus
. Open reduction and internal fixation of the pelvis, open reduction and internal fixation of the distal femur, and intramedullary nailing of the humerus
. Open reduction and internal fixation of the pelvis, open reduction and internal fixation of the distal femur, and open reduction and internal fixation of the humerus

Correct Answer & Explanation

. External fixation of the pelvis, external fixation of the distal femur, and splinting of the humerus

Explanation

The patient is under-resuscitated and would benefit from minimally invasive stabilization of the pelvic ring and long bone fractures in a "damage-control" approach. External fixation of the pelvis and femur can be performed quickly and with minimal blood loss which should limit the "second hit" associated with moreprolonged, invasive surgery. Upper extremity fractures are best managed acutely with splints in this clinical setting. Definitive fracture fixation should be delayed until the patient is adequately resuscitated.

Question 3644

Topic: 2. Trauma

A 26-year-old man was thrown from a car and sustained the injury seen in Figures 44a and 44b. Nonsurgical management of this injury is recommended. Which of the following factors increases the risk of nonunion?

. Male gender
. Diaphyseal location
. Comminuted displaced fracture
. Young age
. Associated injuries

Correct Answer & Explanation

. Male gender

Explanation

DISCUSSION: The patient has a displaced comminuted clavicle middle one third fracture from a high-energy mechanism.  Recent literature on high-energy clavicular fractures suggests a higher rate of nonunion than previously reported.  A nonunion rate of 30% has been reported by Hill and associates when the fracture fragments are displaced more than 1.5 cm.  In addition, several patients had neurologic symptoms related to the injury.  Robinson and associates reported an increased risk of nonunion in women, elderly patients, comminuted fractures, and injuries with a lack of cortical contact.REFERENCES: Hill JM, McGuire MH, Crosby LA: Closed treatment of displaced middle-third fractures of the clavicle gives poor results.  J Bone Joint Surg Br 1997;79:537-539.Wick M, Muller EJ, Kollig E: Midshaft fractures of the clavicle with a shortening of more than2 cm predispose to nonunion.  Arch Orthop Trauma Surg 2001;121:207-211.Robinson CM, Court-Brown CM, McQueen MM, et al: Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture.  J Bone Joint Surg Am2004;86:1359-1365.

Question 3645

Topic: 2. Trauma

A 35-year-old man is seen in the emergency department with a bullet wound to the foot that occurred 2 hours ago. Examination reveals a 0.5-cm entrance wound on the dorsum of the foot and a 1.5-cm exit wound on the plantar aspect. Exploration of the plantar wound in the emergency department reveals bone and metal fragments. Radiographs reveal a comminuted, unstable fracture of the base of the first metatarsal and cuneiform. Management should consist of tetanus toxoid, and

. surface irrigation, sterile dressing, and a short leg cast.
. surface irrigation, sterile dressing, a short leg cast, and oral antibiotics.
. surface irrigation, sterile dressing, a short leg cast, and IV antibiotics.
. surgical debridement, a short leg cast, and IV antibiotics.
. surgical debridement, external or internal fixation, and IV antibiotics.

Correct Answer & Explanation

. surface irrigation, sterile dressing, and a short leg cast.

Explanation

DISCUSSION: The patient sustained a type I unstable fracture that requires debridement of superficial fragments from the sole and surgical stabilization.  Low-velocity wounds less than 8 hours old are considered type I open fractures.  In contrast, gunshot wounds with associated fractures more than 8 hours old are considered type II open fractures using the Gustilo and Anderson classification.  Gustilo type I stable fractures due to gunshot wounds and seen within 8 hours can be treated with tetanus toxoid (if no history of immunization or booster within 5 years), surface irrigation, and casting or a hard sole shoe.  Antibiotics are not required unless gross contamination is present.  However, if the extent of contamination is unclear, or if a joint is penetrated, then routine antibiotic prophylaxis is recommended.  Indications for surgery include: articular involvement, unstable fractures, presentation 8 or more hours after injury, tendon involvement, and superficial fragments in the palm or sole.  Type I unstable fractures may be stabilized with internal or external fixation.  Type II unstable fractures should be treated with external fixation and repeat debridements until clean.REFERENCES: Holmes GB Jr: Gunshot wounds of the foot.  Clin Orthop Relat Res2003;408:86-91.Bartlett CS, Helfet DL, Hausman MR, et al: Ballistics and gunshot wounds: Effects on musculoskeletal tissues.  J Am Acad Orthop Surg 2000;8:21-36.

Question 3646

Topic: 2. Trauma

An 84-year-old female community ambulator with a history of hypertension undergoes a right hip hemiarthroplasty for a femoral neck fracture. When performed in the post-operative period, the timed up and go (TUG) test may be used to predict which patient outcome?

. Stair climbing ability
. Need for a walking aid
. Implant failure
. Balance impairment
. Independent performance of activities of daily living (ADL)

Correct Answer & Explanation

. Stair climbing ability

Explanation

The timed up and go (TUG) test may be used as a clinical indicator of function and the need for a walking aid in patients treated with hip hemiarthroplasty for femoral neck fracture at 2-year follow-up.Hip fractures are a cause of significant functional decline for elderly patients. Many outcome tests have been developed to prediction function after hip fracture to manage patient expectations and to assist in rehabilitation planning. The TUG test objectively measures functional mobility and dynamic balance. The test is performed by timing the amount of seconds it requires for a patient to stand up from a chair, walk 10ft (3.05m), return to the chair, and sit.Laflamme et al performed a prospective study evaluating the utility of the TUG test to predict functional outcomes in patients undergoing hip hemiarthroplasty for femoral neck fracture. The TUG scores were significantly higher at 4-days and 3-weeks postoperatively in patients requiring a walking aid compared with patients walking independently at two-years. Patients who performed the test in >58s at 4-days postoperatively had an eightfold greater risk of requiring an assistive device.Springer et al prospectively analyzed the unipedal stance test (UPST) with eyes open and closed in healthy subjects to establish normative values for the test across age and gender groups. Performance on the test was found to be age-specific and not related to gender. The UPST is a method of quantifying static balance ability.Kristensen et al studied the relative and absolute inter tester reliability of TUG in patients with hip fractures. The authors found that the TUG has a high interobserver reliability and an improvement by 6.2 seconds for a patient with a baseline of 20s indicates a change in functional mobility.Video A shows the timed up and go test.Incorrect Answers:

Question 3647

Topic: Pelvic & Acetabular Trauma

Anterior penetration of an iliosacral screw through the sacral ala would most likely lead to weakness of which of the following movements?

. Hip flexion
. Hip adduction
. Knee extension
. Ankle plantarflexion
. Great toe dorsiflexion

Correct Answer & Explanation

. Great toe dorsiflexion

Explanation

DISCUSSION: Penetration of an iliosacral screw through the sacral ala would injure the ipsilateral L5 nerve root (great toe dorsiflexion). This can be avoided with proper understanding of the sacral anatomy as well as iliosacral screw starting points. The three required views for placement of this screw are: lateral sacral, pelvic inlet, and pelvic outlet. The referenced study by Ziran et al is an excellent review of fluoroscopic evaluation of screw placement. They reported that the anterior border of the S1 body is best seen with overlap of the S1 and S2 anterior cortex while the superior aspect of the S1 foramen is best seen with overlap of the S2 foramen on the superior pubic ramus.The referenced study by Routt et al reviewed 177 patients with pelvic ring injuries treated with these screws and found that quality triplanar imaging decreased intraoperative and postoperative complications. They also recommend supplemental fixation of iliosacral screws with posterior plating in noncompliant patients.

Question 3648

Topic: 2. Trauma
  • Which of the following injuries is most commonly associated with a fracture of the scapular body?
. Vascular injury
. Tear of the rotator cuff
. Injury to the brachial plexus
. Fracture of the upper thoracic rib
. Fracture of the proximal humerus

Correct Answer & Explanation

. Fracture of the upper thoracic rib

Explanation

Ada and Miller reviewed 148 fractures in 113 scapulae. Ninety-six percent had associated injuries, the most common being fracture of an upper thoracic rib. Other associated injuries included lung trauma, head injury, cervical spine injury, clavicle fractures and brachial plexus injury.

Question 3649

Topic: 2. Trauma

-
A clinical trial is being conducted on a new orthopaedic device that is different from existing devices that are moderately successful, but have frequent complications when used to treat fractures in the elderly. To comply with international standards for clinical trials, the investigator must include in the study design

. reassurance that Medicare will pay for the treatment.
. consent forms that patients or their guardians are able to understand.
. a detailed description of the device, omitting the fact that it is part of a study.
. a provision that the patient’s care will be discontinued if he or she does not enroll in the study.
. a provision that the study will be carried out to completion, whether or not the device is as effective as those currently in existence.

Correct Answer & Explanation

. consent forms that patients or their guardians are able to understand.

Explanation

In any research on human beings, each potential subject must be adequately informed of the aims. methods, anticipated benefits and potential hazards of the study and the discomfort it may entail. He or she should be informed that he or she is at liberty to abstain from participation in the study and that he or she is free to withdraw his or her consent to participation at any time. The physician should then obtain the subject’s freely-given informed consent. preferably in writing.

Question 3650

Topic: 2. Trauma

Figure 1 shows a patient with an open tibia fracture who presents to the emergency department after a propeller injury in brackish water (river water and sea water). What is the most appropriate antibiotic coverage for this patient?

. Gentamicin and penicillin
. Cefazolin and penicillin
. Doxycycline and ceftazidime
. Vancomycin and sulfamethoxazole-trimethoprim

Correct Answer & Explanation

. Doxycycline and ceftazidime

Explanation

Discussion: The clinical photo shows significant soft tissue wounds with associated tibia fracture. With the amount of soft tissue damage and periosteal stripping this would be classified as a Gustilo Type IIIB injury. The brackish water environment where this particular injury occurred influences the antibiotic choice secondary to the particular organisms found in this setting. Brackish water is made up of both fresh and salt water with common organisms that include Vibrio species, Aeromonas hydrophila, Pseudomonas species, Erysipelothrix rhusiopathiae, and Mycobacterium marinum. The combination of both Doxycycline (tetracycline) and Ceftazidime (third-generation cephalosporin) cover these particular pathogens. Standard antibiotic coverage for Gustilo Type I and II injures is 1st generation cephalosporin (cefazolin), with Type III being 1st generation cephalosporin and aminoglycoside (cefazolin and gentamicin) or a fluoroquinolone. In Type III injuries, Penicillin is commonly added in barnyard injuries for extended coverage ofsoil-borne pathogens (clostridial species). Vancomycin is not indicated for coverage in marine environments, rather it is more commonly used for populations with a high prevalence of nosocomial infections. Sulfamethoxazole-trimethoprim is not used for open fracture coverage.

Question 3651

Topic: 2. Trauma

Which of the following is true regarding intimate partner violence (IPV)?

. Most patients do not have a fear of domestic retaliation upon reporting
. Victims of IPV rarely have a history of injury during the previous 12 months
. Interdisciplinary collaboration yields positive outcomes
. Emotional abuse is easily identifiable in patients suffering from IPV
. Victims of IPV feel comfortable discussing their issues to male physcians

Correct Answer & Explanation

. Interdisciplinary collaboration yields positive outcomes

Explanation

DISCUSSION: Identification of IPV is essential in the orthopedic ambulatory setting. Discerning physical abuse is more straightforward as patients can have frequent visits with multiple, unexplained fractures. Emotional abuse is more difficult to discern. Communication and awareness is advocated. Most barriers to reporting include a lack of awareness of IPV, downplaying of the situation, fear of partner retaliation, concern for custody conflicts, shame, embarrassment and a reluctance to talk to male physicians.Interdisciplinary collaboration among healthcare workers was a predictor of positive treatment outcomes. Included were more accurate assessments of past history, more descriptive emotional symptoms as displayed by victims and written documentation of recommendations concerning intervention and linkage to community resources.Bhandari et al performed a cross-sectional study of 282 women who presented to fracture clinic at two Level-I trauma centers in Canada. The prevalence of abuse was found to be 32% while 8.5% were found to have a history of previous abuse in the past 12 months. Ethnicity, socioeconomic status, and injury patterns were not associated with abuse.Shields et al reviewed 153 cases of domestic violence victims who presented to two Emergency departments. They determined that positive treatment outcomes were correlated to the degree of interdisciplinary collaboration among treating health care providers.

Question 3652

Topic: 2. Trauma

What is the most common clinically significant preventable complication secondary to the treatment of a displaced talar neck fracture?

. Osteonecrosis
. Nonunion
. Malunion
. Infection
. Osteoarthritis of the ankle joint

Correct Answer & Explanation

. Malunion

Explanation

DISCUSSION: The most important consequence of a displaced talar neck fracture after closed or open treatment is malunion.  Because displacement of the talar neck is associated with displacement of the subtalar joint, any malunion leads to intra-articular incongruity or malalignment of the subtalar joint.  Varus malunion is common when there is comminution of the medial talar neck.  This results in pain, osteoarthritis, and hindfoot deformity that requires further treatment.  Because of these complications, it is imperative that all displaced talar neck fractures are reduced anatomically; fragmented fractures may require bone grafting to maintain the length and rotation of the neck.REFERENCES: Tile M: Fractures of the talus, in Schatzker J, Tile M (eds): Rationale of Operative Fracture Care, ed 2.  Berlin, Springer-Verlag, 1996, pp 563-588.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.Raaymakers EL: Complications of talar fractures, in Tscherne H, Schatzker J (eds): Major Fractures of the Pilon, the Talus, and Calcaneus: Current Concepts of Treatment.  Berlin, Springer-Verlag, 1993, pp 137-142.

Question 3653

Topic: 2. Trauma


74 A

B
year-old with the injury seen in Figures 74a and 74b

. - Retrograde intramedullary (IM) nailing
. - Open reduction and internal fixation (ORIF) with screws alone
. - Locking condylar plate
. - Circular external fixation
. - Lateral and medial plates

Correct Answer & Explanation

. - Open reduction and internal fixation (ORIF) with screws alone

Explanation

DISCUSSIONFigures 71a through 71d reveal a severe intra-articular distal femur fracture that is best treated with ORIF with a locking condylar plate. A retrograde IM nail is not an ideal option for this application. Lateral and medial nonlocking plates have gone by the wayside in favor of locked plating and fixed-angle devices. External fixation will not allow for articular reconstruction and is best reserved for temporary stabilization of these fractures. Screws alone will not address this injuryFigures 72a and 72b reveal an extra-articular distal femur fracture that is best treated with an IM nail, which would also allow for earlier weight bearing. Screw fixation alone is inappropriate, and this does not necessitate medial and lateral plate fixation. Although a locking condylar plate could be used, blood loss in a polytrauma patient may be problematic. ?Figures 73a and 73b show a comminuted supracondylar femur fracture with complex intra-articular involvement. This would be treated using the same application as seen in Figures 71a through 71d.Figures 74a and 74b reveal a coronal plane fracture of the medial femoral condyle, which can be treated with screws alone.RECOMMENDED READINGSGwathmey FW Jr, Jones-Quaidoo SM, Kahler D, Hurwitz S, Cui Q. Distal femoral fractures: current concepts. J Am Acad Orthop Surg. 2010 Oct;18(10):597-607. Review. PubMed PMID: 20889949.View Abstract at PubMedMarkmiller M, Konrad G, Südkamp N. Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications? Clin Orthop Relat Res. 2004 Sep;(426):252-7. PubMed PMID: 15346082.View Abstract at PubMedNork SE, Segina DN, Aflatoon K, Barei DP, Henley MB, Holt S, Benirschke SK. The association between supracondylar-intercondylar distal femoral fractures and coronal plane fractures. J Bone Joint Surg Am. 2005 Mar;87(3):564-9. PubMed PMID: 15741623.View Abstract atPubMed

Question 3654

Topic: 2. Trauma

-Where is the physis with the highest growth rate (in mm per year) located?

. Proximal humerus
. Distal femur
. Distal tibia
. Distal radius

Correct Answer & Explanation

. Proximal humerus

Explanation

Question 3655

Topic: 2. Trauma

An 11-year-old girl sustained an injury to her right foot when a 500-lb headstone fell on it. The headstone was removed after 3 minutes. Radiographs show multiple midfoot fractures. Examination reveals severe pain that is worse with passive toe motion. Clinical photographs are shown in Figure 28. Management should consist of

. a short leg cast and elevation of the foot.
. fasciotomies of the foot.
. MRI.
. CT.
. stress radiographs.

Correct Answer & Explanation

. fasciotomies of the foot.

Explanation

DISCUSSION: The patient has a classic history and examination for an acute compartment syndrome of the foot.  CT, MRI, or stress radiographs are not necessary prior to emergent fasciotomies of the foot.  These studies can be performed after the initial fasciotomies to determine the best long-term management of the fractures.  There are nine compartments in the foot.  These are decompressed through three incisions (two on the dorsal foot and one medially).  A short leg cast does not address the compartment syndrome and could be limb threatening with excessive swelling in a circumferential cast.  It is preferable to splint severe crush injuries rather than apply a cast.REFERENCES: Fulkerson E, Razi A, Tejwani N: Review: Acute compartment syndrome of the foot.  Foot Ankle Int 2003;24:180-187.Weber TG, Manoli A II: Compartment syndromes of the foot.  Foot Ankle Clin 1999;4:473-486.

Question 3656

Topic: 2. Trauma

An 18-year-old female Marine Corps recruit enters basic training. Her enlistment history and physical examination showed that she was an elite high school cross country runner. What is her most significant risk factor for a femoral or pelvic stress fracture during basic training?

. Running mileage during the 2 months prior to basic training
. Self-rated fitness
. Running frequency during the 2 months prior to basic training
. No menstrual bleeding during the year prior to basic training
. Race/ethnicity

Correct Answer & Explanation

. Running mileage during the 2 months prior to basic training

Explanation

DISCUSSION: Approximately 5% of female recruits incur a stress fracture during the 13 weeks of Marine Corps basic training. Approximately 40% of these were femoral or pelvic stress fractures that were more severe than in civilian athletes or male military recruits. Only women who reported no menses during the previous year had a greater likelihood of femoral or pelvic stress fractures than did women who reported 10 to12 menses. The referenced study did not find a statistically significant increase in risk of stress fracture in those recruits who had lesser menstrual irregularities in the year prior to recruit training, but there was a trend toward increased risk of stress fracture.REFERENCES: Shaffer RA, Rauh MJ, Brodine SK, et al: Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med 2006;34:108-115.Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy ofOrthopaedic Surgeons, 2004, pp 273-283.

Question 3657

Topic: 2. Trauma

The major benefit of irrigation with a castile soap solution over irrigation with bacitracin solution for the treatment of the open fracture shown in Figure 42 can be seen in which of the following outcomes?

. Decreased rate of postoperative infection
. Decreased rate of nonunion
. Decreased rate of primary wound healing problems
. Decreased rate of reoperation
. Increased rate of bone healing

Correct Answer & Explanation

. Decreased rate of primary wound healing problems

Explanation

DISCUSSION: The mainstay of early treatment of open fractures includes irrigation and debridement.  Prior to the development of antibiotics, this was traditionally accomplished with some form of detergent irrigation.  Antibiotic irrigation has been in favor more recently but has mixed scientific results related to its use.  Results of at least one major study show the use of a nonsterile liquid soap additive (castile soap) is at least as effective as the use of bacitracin with regards to the rate of postoperative infection and fracture healing, and shows a significant decrease in problems with soft-tissue healing.REFERENCE: Anglen JO: Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds: A prospective, randomized study.  J Bone Joint Surg Am 2005;87:1415-1422.

Question 3658

Topic: 2. Trauma

Figures 1a through 1c are the radiographs of a 40-year-old woman who sustained a minor injury to her left ring finger. Prior to this injury, she was asymptomatic, but she now notes pain and swelling. What is the best course of treatment?


. Observation only
. Fluoroscopic-guided intralesional steroid injection followed by serial radiographs.
. Immediate curettage without bone grafting
. Splint immobilization with curettage and possible grafting after the fracture has healed

Correct Answer & Explanation

. Splint immobilization with curettage and possible grafting after the fracture has healed

Explanation

DISCUSSIONThis patient has a fracture of the middle phalanx attributable to the presence of an enchondroma. Enchondromas are the most common benign bone tumor affecting the hand. This particular enchondroma has thinned the cortices extensively so that even minor trauma can cause a pathologic fracture. Observation is not the best treatment because a fracture is present, and, at a minimum, the digit should be immobilized. Intralesional steroid injections have a role in the treatment of simple bone cysts; however, this treatment is not recommended for enchondromas. Immediate curettage alone is not the best treatment because it does not include bone graft (either autograft or allograft) or bone graft substitute. Also, it would be best to allow the fracture to heal prior to curettage to prevent fracture displacement. An enchondroma this size necessitates a graft because of high risk for refracture if curettage alone is performed. Many surgeons believe it is best if a fracture heals prior to curettage and grafting because this allows better graft containment and eliminates concern about fracture displacement. Recent data suggest early surgery using injectable calcium sulfate cement in the fracture setting can achieve satisfactory results. Splintimmobilization would allow fracture healing, and then curettage with bone graft can be performed after healing occurs.RECOMMENDED READINGSJacobson ME, Ruff ME. Solitary enchondroma of the phalanx. J Hand Surg Am. 2011 Nov;36(11):1845-7. doi: 10.1016/j.jhsa.2011.05.002. Epub 2011 Jun 11. Review. PubMed PMID: 21658859.Sassoon AA, Fitz-Gibbon PD, Harmsen WS, Moran SL. Enchondromas of the hand: factors affecting recurrence, healing, motion, and malignant transformation. J Hand Surg Am. 2012 Jun;37(6):1229-34. doi: 10.1016/j.jhsa.2012.03.019. Epub 2012 Apr 27. PubMed PMID: 22542061.CLINICAL SITUATION FOR QUESTIONS 2 THROUGH 5A 45-year-old man injured his arm when it was forcibly extended while he was flexing his elbow. He notes swelling in the antecubital fossa and arm weakness. The physician suspects a distal biceps rupture.

Question 3659

Topic: 2. Trauma

Which of the following findings is a contraindication to isolated percutaneous pinning of a distal radius fracture?

. Dorsal comminution
. Volar comminution
. Radial comminution
. Intra-articular fracture
. Physeal fracture

Correct Answer & Explanation

. Volar comminution

Explanation

DISCUSSION: Intrafocal pinning allows the Kirschner wires to be placed through a site of comminution and then drilled through intact cortex.  Generally Kapandji intrafocal pinning is done for dorsal comminuted extra-articular dorsal bending fractures, but it also may be used to elevate and buttress radial comminution.  Simple intra-articular fractures can also be treated with pinning alone.  Intrafocal pinning works best as a dorsal or radial buttress to prevent shortening.  When there is volar comminution, the fracture is prone to shortening and supplemental external fixation or plating is recommended.REFERENCES: Trumble TE, Wagner W, Hanel DP, et al: Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation.  J Hand Surg Am 1998;23:381-394.Choi KY, Chan WS, Lam TP, et al: Percutaneous Kirschner-wire pinning for severely displaced distal radial fractures in children: A report of 157 cases.  J Bone Joint Surg Br 1995;77:797-801.Weil WM, Trumble TE: Treatment of distal radius fractures with intrafocal (Kapandji) pinning and supplemental skeletal stabilization.  Hand Clin 2005;21:317-328.

Question 3660

Topic: 2. Trauma

A 29-year-old female has sustained the acute injury shown in Figure A. Which of the following is an indication for open reduction internal fixation in this patient?

. Medial sided tenderness
. Medial sided swelling
. Positive cotton test
. Medial clear space widening with gravity stress radiographs
. Positive squeeze test

Correct Answer & Explanation

. Medial clear space widening with gravity stress radiographs

Explanation

Figure A shows a minimally displaced Weber B ankle fracture. The need for operative treatment would be dependent on fracture stability. A gravity stress test would best demonstrate fracture displacement, syndesmotic injury and medial sided ligamentous integrity.In patients who present with no medial widening on standard ankle radiographs and no clinical symptoms of deltoid ligament injury, the integrity of the deltoid ligament remains unknown. The gravity stress radiograph may be used to help identify a deltoid ligament injury in association with an isolated distal fibular fracture. Stage-IV supination-external rotation fractures, which involve the deltoid ligament, are more likely to be treated operatively as they are often considered unstable ankle fractures.Egol et al. reviewed 101 patients with isolated fibular fracture and an intact mortise. They found that medial tenderness, swelling, and ecchymosis were not sensitive with regard to predicting widening of the medial clear space on stress radiographs. Interestingly, they report that good functional results can be obtained in patients with widening of the medial clear space on a stress radiograph in the absence of medial signs.Gill et al. compared the effectiveness of gravity stress radiograph as compared to manual stress radiograph for the detection of deltoid ligament injury in isolated fibular fracture. A total of twenty-five patients with SER type-II fracture and SER Type IV-equivalent fractures were enrolled. They found the gravity stress radiograph was equivalent to the manual stress radiograph for determining deltoid ligament injury.Figure A shows a mortise radiograph displaying a minimally displaced Weber B ankle fracture. Illustration A shows the positioning for a gravity stress radiograph. The patient is in the lateral decubitus position with the injured leg dependent and off the end of the table, a mortise view is taken in 10° of internal rotation of the tibia.Incorrect Answers:

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