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 3801
Topic: 2. Trauma
A 66-year-old male sustains an open crush injury to his right lower leg with significant skin loss. His history is significant for COPD, diabetes controlled with an insulin pump, and testicular cancer treated with bleomycin twenty years ago. A radiograph of the chest shows a pneumothorax which is treated with a thoracostomy tube. Which of the following is not a contraindication to hyperbaric oxygen treatment for this patient?
Correct Answer & Explanation
. Presence of an acute open fracture and crush injury
Explanation
The presence of a crush injury to an extremity is an indication for hyperbaric oxygen (HBO) therapy. The remainder of the options listed are contraindications to hyperbaric oxygen treatment. Hyperbaric oxygen therapy potentially can provide enhanced oxygen delivery to peripheral tissues affected by vascular disruption, cytogenic and vasogenic edema, and cellular hypoxia caused by extremity trauma.
Question 3802
Topic: 2. Trauma
In a polytraumatized patient with a high lactate level, large base deficit, and pulmonary injury, what is the best initial treatment for a femoral shaft fracture?
Correct Answer & Explanation
. Unreamed femoral nail
Explanation
To prevent the "secondary hit" phenomenon in the polytraumatized patient, the use of Damage Control Orthopaedics has been accepted as the best initial treatment option until the patient has been successfully resuscitated. The use of reamed or unreamedintramedullary nails in the acute setting is to be avoided because of the possibility of increasing the patient's morbidity. Plating is time consuming and leads to blood loss which should be avoided in the severely injured patient. Skeletal traction and supine positioning are detrimental in the trauma patient. Expedient external fixation, resuscitation, and later definitive treatment with an intramedullary nail is considered to be the best choice for the polytraumatized patient with a femoral shaft fracture.
Question 3803
Topic: 2. Trauma
Which statement is true with respect to acetabular fracture surgery as the time between injury and surgery increases?
Correct Answer & Explanation
. Decreased chance of anatomic fracture reduction
Explanation
Madhu et al showed time to surgery was a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum. Both anatomic reduction and functional outcome significantly worsened as time to surgery increased. It was found anatomic reduction was more likely when surgery was within 15 days for elementary fracture and 5 days for associated. Heterotopic ossification showed a trend towards increased odds with increased time to surgery but did not reach significance. Neurologic injury is more associated with the initial injury. Non-union is more frequent in non-anatomic reductions. Multi-organ failure was not commented on, but infection showed a trend towards being more likely with longer time to surgery.
Question 3804
Topic: 2. Trauma
All of the following are true statements regarding compartment syndrome in the pediatric patient EXCEPT:
Correct Answer & Explanation
. Mechanism of injury is the best predictor of compartment syndrome development
Explanation
DISCUSSION: Compartment syndrome can often be difficult to diagnose in the pediatric patient. Mechanism of injury is not the best predictor of compartment syndrome development or diagnosis in pediatric patients. It is important to note that functional outcome following compartment syndrome in patients is inversely related to the duration of elevated tissue pressures before surgical fasciotomy. Level 4 evidence by Bae et al reviewed 33 children with compartment syndrome. They found that all 10 compartment syndrome patients that had access to nurse or patient-controlled analgesia (PCAs), during their initial evaluation, demonstrated an increasing requirement for pain medication. Matsen et al reviewed 24 children with compartment syndrome with the most common causes being fracture, vascular injury, and tibial osteotomy. The study concluded that it is imperative that a compartment syndrome be identified and treated as promptly as possible.
Question 3805
Topic: Upper Extremity Trauma
A 58-year-old man has a painful, warm, erythematous, and fluctuant area over his left olecranon. An aspiration would be most likely to reveal:
Correct Answer & Explanation
. Staphylococcus aureus.
Explanation
DISCUSSION: Staphylococcus aureus is the most common causative organism in septic bursitis, making up 80% or more of cases of culture-proven septic bursitis. Staphylococcus aureus was the most frequent pathogen (217 out of 256 or 85%), followed by Streptococcus pyogenes (16), other streptococci (15), Enterococcus faecalis (4), and coagulase-negative staphylococci (2).
Question 3806
Topic: 2. Trauma
A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?
Correct Answer & Explanation
. Adversely affected general health status and posttraumatic arthritis
Explanation
DISCUSSION: Two recent studies by Pollak and associates and Marsh and associates have focused on function after high-energy tibial plafond fractures. Findings are unfavorable even when anatomic reduction is performed in the best centers and patients are provided excellent rehabilitation. Function improves up to 2 years after injury, but even basic walking skills remain adversely affected. Virtually all patients have long-term adverse general health effects compared to their gender and age-matched peers. Posttraumatic degenerative arthritis is present in most ankles. Patients should be told early about the long-term prognosis, and early vocational/psychological counseling should be given. Despite these adverse outcomes, only a minority of patients require fusion or arthroplasty.
Question 3807
Topic: 2. Trauma
A 5-year-old boy reports intermittent left elbow pain. History reveals that he injured his elbow 4 months ago, but had no treatment. He is now using his arm normally but reports pain almost daily. Examination reveals tenderness over the lateral epicondyle and a prominence is evident. Range of motion is from -5 degrees to 120 degrees. Radiographs are shown in Figure 67. Management should include:
Correct Answer & Explanation
. open reduction and internal fixation.
Explanation
DISCUSSION: The patient has a nonunion of the lateral condyle of the left humerus. Observation or cast treatment at this stage is not likely to lead to healing of the fracture. MRI will not add any additional information. Open reduction, with minimal posterior soft-tissue stripping, is recommended to establish union of the fracture. Local or other bone graft may also be required. There are no studies that indicate that the displaced fracture will heal with late percutaneous fixation. REFERENCES: Wattenbarger JM, Gerardi J, Johnson CE: Late open reduction internal fixation of lateral condyle fractures. J Pediatr Orthop 2002;22:394-398. Flynn JC: Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-696.
Question 3808
Topic: 2. Trauma
In a locking plate screw construct, axial forces are borne by which of the following?
Correct Answer & Explanation
. Plate
Explanation
In a traditional plate system, fracture security depends on the friction between the plate and the underlying bone. Bicortical fixation will decrease the toggle and improve stability. Locking plates absorb axial forces transmitted from the screws. Such plates do not require plate compression against the bone, thus preserving periosteal blood supply.
Question 3809
Topic: 2. Trauma
A 40-year-old man sustains a fall while mountain biking and presents with a posterior elbow fracture-dislocation. The elbow is reduced in the ER and noted to be grossly unstable with varus and valgus stress. Imaging demonstrates a two-part radial head fracture involving 40% of the articular surface and a fracture involving less than 10% of the coronoid tip. He is taken to the OR for surgical reconstruction. After fixation of the radial head and repair of the LCL complex, the elbow is fluoroscopically examined and noted to be unstable with valgus stress. The elbow is ranged and dislocates at less than 45 degrees of flexion with the forearm in full supination. What is the next best step in management?
Correct Answer & Explanation
. Repair of the medial collateral ligament
Explanation
This patient has persistent elbow instability likely secondary to medial collateral ligament (MCL) rupture and therefore should undergo repair of the MCL, followed by repeat fluoroscopic examination. Small coronoid fractures involving less than or equal to 10% of the coronoid tip do not confer major elbow instability and do not necessitate repair. In a cadaveric study of a simulated terrible triad injury, when residual instability was present after radial head repair or arthroplasty and lateral ulnar collateral ligament (LUCL) repair, repair of the MCL was more effective than fixation of small coronoid fractures in restoring elbow stability.
Question 3810
Topic: 2. Trauma
What is the most frequent complication of both lateral closing wedge high tibial osteotomy and medial opening wedge osteotomy?
Correct Answer & Explanation
. Patella baja
Explanation
Scuderi and associates reported on patellar height after a high tibial osteotomy. Eighty-nine percent of the patellae, as measured by the Insall-Salvati index, and 76.3 percent, as measured by the Blackburne-Peel index, were observed to be lowered. More recently, Wright and associates reported a 64% incidence of patella baja in patients undergoing a medial opening wedge osteotomy. This is the most common complication compared to the others listed.
Question 3811
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
Correct Answer & Explanation
. reassurance that Medicare will pay for the treatment.
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 subjectโs freely-given informed consent. preferably in writing.
Question 3812
Topic: 2. Trauma
Figure 46 shows the AP radiograph of a patient with right shoulder pain. What is the most likely diagnosis?
Correct Answer & Explanation
. Traumatic osteolysis
Explanation
Posttraumatic osteolysis of the distal portion of the clavicle is a condition that can be a complication of acute or repetitive trauma. The distal end of the clavicle is frayed and resorbed. Resorption may occur after weeks or months. The end of the clavicle may reconstitute over a period of months, or the acromioclavicular joint may remain widened. The differential diagnosis for distal clavicular erosion also includes rheumatoid arthritis, hyperparathyroidism, neoplastic destruction, cleidocranial dysplasia, and pyknodysostosis. Acutely, a type 2 acromioclavicular joint injury does not result in erosion or resorption of the clavicle. Periosteal sleeve injuries radiographically mimic acromioclavicular joint dislocation. Rickets occurs only in childhood.
Question 3813
Topic: Pelvic & Acetabular Trauma
In patients with Crowe types III and IV developmental dysplasia of the hip with high hip centers, acetabular reconstruction often requires lowering the acetabular component into the native acetabulum. In doing so, considerable risk for limb lengthening beyond 4 cm exists, making the hip difficult to reduce and raising the risk for nerve injury. Which technique is used to overcome this problem?
Correct Answer & Explanation
. Subtrochanteric osteotomy with femoral shortening
Explanation
DISCUSSION: When substantial lengthening of a dysplastic hip will occur because a high dislocation is relocated into a considerably lower acetabulum, a femoral shortening may be necessary to reduce the hip and avoid a stretch injury to the sciatic nerve. No other choice specifically addresses the need for femoral shortening, and high offset stems and lateralized liners may exacerbate the problem if used alone and without femoral shortening.
Question 3814
Topic: 2. Trauma
Which of the following factors has been shown to increase the risk of peroneal tendon pathology in patients who have undergone posterior plating of lateral malleolar fractures?
Correct Answer & Explanation
. Use of cut or trimmed plates
Explanation
Low plate positioning with a prominent screw head in the most distal hole of the plate was shown to be correlated with peroneal tendon lesions. Distal plate placement in the absence of prominent screws was not associated with tendon lesions. Trimmed plates, locked plates, and uncontoured plates have not been shown to increase the risk of peroneal tendon pathology.
Question 3815
Topic: 2. Trauma
Figures 36a and 36b show the radiographs of a 48-year-old woman who smokes cigarettes and sustained a segmental femoral shaft fracture in a motor vehicle accident 9 months ago. Initial management consisted of stabilization with a reamed statically locked intramedullary nail. She now reports lower leg pain that increases with activity. In addition to advising the patient to quit smoking, management should include
Correct Answer & Explanation
. exchange reamed nailing with bone graft.
Explanation
DISCUSSION: The patient has an oligotrophic nonunion of the distal femoral fracture. Although the proximal fracture appears incompletely united, it was stable at exchange nailing. The treatment of choice is exchange reamed nailing to at least 2 mm above the nail in place. Bone grafting is debatable. Recent studies have shown a 70% to 75% success rate with exchange nailing only, so in nonhypertrophic nonunions, bone grafting can be considered. Nonsurgical management consisting of observation or external stimulation runs the risk of implant failure. Plate fixation is acceptable but is considered a second choice because of the need to consider stabilization of the proximal fracture until union is achieved. Also, plate fixation definitely requires bone grafting. REFERENCES: Webb LX, Winquist RA, Hansen ST: Intramedullary nailing and reaming for delayed union or nonunion of the femoral shaft: A report of 105 consecutive cases. Clin Orthop 1986;212:133-141. Weresh MJ, Hakanson R, Stover MD, et al: Failure of exchange reamed intramedullary nailing for ununited femoral shaft fractures. J Orthop Trauma 2000;14:335-338. Hak DG, Lee SS, Goulet JA: Success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. J Orthop Trauma 2000;14:178-182.
Question 3816
Topic: 2. Trauma
Examination of a 32-year old woman who has pain in her shoulder as a result of a head-on motor vehicle accident reveals tenderness directly over the scapula and painful motion of the shoulder. Radiographs show a displaced extra-articular fracture of the scapula. Which of the following studies would best detect commonly associated injuries?
Correct Answer & Explanation
. Echocardiogram
Explanation
Ninety-six percent of patients with scapular fractures has associated injuries, with rib fractures in the upper thorax being the most common. Pulmonary injuries were second in frequency (37%) with hemopneumothorax (29%) and pulmonary contusion (8%). Head injury was third (34%) and there were nine skull fractures. Clavicle fractures on the ipsilateral side occurred in 25%. The most frequent level of spinal cord injury was cervical (12%). Four patients suffered a permanent cord injury: two quadriplegics, one paraplegic, and one Brown-Sequard Syndrome. There were four brachial plexus injuries. Three recovered and the one with a persistent deficit also had a reflex sympathetic dystrophy. His injury was caused by a self-inflicted shotgun blast. Radiograph of the chest would provide the best overall survey for evaluation. The remaining studies would only evaluate isolated areas.
Question 3817
Topic: 2. Trauma
Figure 57 is the radiograph of a 58-year-old woman who is right-hand dominant and has fallen on her flexed right elbow and is seen in the emergency department reporting isolated episodes of right elbow pain. Examination reveals that the skin is contused but intact, and her distal neurovascular examination is normal. What is the most appropriate treatment? Review Topic
Correct Answer & Explanation
. Percutaneous pinning
Explanation
The patient has sustained an isolated, closed fracture of the olecranon without associated instability. The bone is radiographically osteopenic and the fracture is displaced, comminuted, and includes articular marginal impaction. Plate fixation is preferred in the presence of comminution or associated transolecranon or radiocapitellar instability. Displaced fractures are generally treated surgically in an effort to restore articular congruity, restore extensor function, and to allow for early mobilization in an effort to maximize functional outcomes. A tension band wireconstruct is a commonly used technique but is reserved for simple fracture patterns without comminution. Excision and triceps advancement can be considered in elderly, low-demand patients that have small unreconstructable fracture patterns without associated elbow instability.
Question 3818
Topic: Pelvic & Acetabular Trauma
Which of the following descriptions is true regarding APC-II (anterior-posterior compression) pelvic injuries as classified by Young and Burgess?
DISCUSSION: APC II injuries are unstable injuries and occur as a result of high-energy trauma. Anatomic structures which are injured or torn include the pubic symphysis, anterior iliosacral ligaments, and the sacrotuberous ligaments. The posterior sacroiliac ligaments are spared in APC-II injuries, and differentiate an APC-II injury from an APC-III injury, in which the posterior ligaments are also torn.Burgess et al review the classifications of pelvic ring disruptions and their association with mortality. They concluded that APC injuries required more blood replacement and were related to death more often than lateral compression, vertical shear, or combined mechanism pelvic injuries.Tile studied the anatomy of anterior to posterior pelvic ring injuries. Although the anterior structures, the symphysis pubis and the pubic rami, contribute to 40% to the stiffness of the pelvis, clinical and biomechanical studies have shown that the posterior sacroiliac complex is more important to pelvic-ring stability. The posterior sacroiliac ligamentous complex is more important to pelvic-ring stability than the anterior structures and therefore, the classification of pelvic fractures is based on the stability of the posterior lesion.
Question 3819
Topic: 2. Trauma
An 86-year-old woman sustained a fracture of the humerus and underwent surgical fixation 8 weeks ago. There was no radial nerve function below the elbow after surgery. Radiographs are shown in Figures 51a and 51b. What is the most appropriate management at this time?
Correct Answer & Explanation
. Observation for another 2 months
Explanation
DISCUSSION: Most radial nerve palsies associated with closed fractures of the humerus resolve spontaneously, including Holstein-Lewis lesions (radial nerve palsy associated with oblique distal third fractures of the humerus). Initial sign of recovery at the brachioradialis may not occur for 4 months. There has been no evidence of deleterious effects occurring during this observation period. There are advocates of early exploration of the nerve. Exploration in the intermediate period between 1 and 4 months is not supported. As overall alignment of the fracture is acceptable, there is no need for hardware exchange until nonunion is clearly identified. REFERENCES: Shao YC, Harwood P, Grotz MR, et al: Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br 2005;87:1647-1652. Green DP: Radial nerve palsy, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Greenโs Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 112.
Question 3820
Topic: 2. Trauma
Among the options listed below, what is the best treatment for the complication shown in Figure 10c?
Correct Answer & Explanation
. Removal of hardware and revision using a second-generation femoral nail
Explanation
Discussion: Proximal femur fractures can be treated using a variety of implants including intramedullary nails, blade plates, and locking plates. The comminution and lack of medial cortical support may predispose these fractures to nonunion. The recent popularity of locking plates for proximal femur treatment has increased their use for this fracture; however, a disproportionately high rate of failure of these plates, including early implant failure with plate and screw breakage, cut out with varus collapse, and nonunion have been reported. Once failure occurs, the best fixation method among the options detailed is an intramedullary nail (second generation with screws into the femoral head) and restoration of alignment.
Test Yourself
Switch to an interactive, timed exam simulation to truly master this topic.
