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 3861
Topic: 2. Trauma
A 27-year-old man sustains a displaced femoral neck fracture and undergoes urgent open reduction internal fixation. What is the most prevalent complication after this injury?
Correct Answer & Explanation
. Osteonecrosis
Explanation
Femoral neck fractures in young patients are difficult to treat, and AVN is a significant concern. Despite advances in both imaging and implants, this injury often leads to functional impairment. Haidukewych et al followed treatment of femoral neck fractures in young patients. They found almost 10% of displaced fractures were associated with the development of nonunion, whereas 27% were associated with the development of osteonecrosis. Their results were influenced by fracture displacement and the quality of reduction.
Question 3862
Topic: 2. Trauma
Figures 38a and 38b show the AP and lateral radiographs of a 12-year-old baseball pitcher who has pain in his right dominant elbow. Management should consist of
Correct Answer & Explanation
. elimination of offending activities and cross-training.
Explanation
The patient has a stress fracture of the olecranon; therefore, the most appropriate management is modification of activities below the threshold of symptoms to allow for healing. Ultrasound provides no benefit, and immobilization is not necessary. MRI is not necessary because there is no associated ligamentous injury. Arthroscopy is not indicated.
Question 3863
Topic: 2. Trauma
A 78-year-old woman reports a 1-week history of severe low back pain. She denies any trauma or recent falls. She is neurologically intact, and is able to ambulate, although she does require the use of a walker. Radiographs of the lumbar spine show a T11 compression fracture with a 20% loss of anterior column height. What is the most appropriate management at this time? Review Topic
Correct Answer & Explanation
. Bed rest until symptoms resolve
Explanation
The patient has sustained a thoracic compression fracture, which is very common in elderly patients, and can occur with minimal to no trauma. There is approximately a 20% loss of anterior vertebral body height. The patient is neurologically stable, and is able to ambulate with an assistive device. Initial treatment should consist of progressive mobilization with analgesics as needed. Fractures treated in this manner have a high rate of success, and surgical treatment is often not necessary. In the absence of neurologic impairment or impending structural instability, surgical decompression and fusion is not indicated. Bed rest is contraindicated. Cement augmentation is a reasonable treatment option when a patient fails nonsurgical management, although recent studies have called into question its efficacy when compared with placebo.
Question 3864
Topic: 2. Trauma
-A 45-year-old woman sustained a fall from height and has the injury shown in Figures 135a and 135b.A 3-dimensional reconstruction CT scan is shown in Figure 135c. Joint-spanning external fixation is applied on the day of injury. Ten days later, her skin is acceptable for definitive fixation. What is the most appropriate type of fixation for her fracture?
Correct Answer & Explanation
. Percutaneous screws and cast
Explanation
Question 3865
Topic: 2. Trauma
A 24-year-old man has right forearm pain after sliding head first into home plate. Examination reveals that the arm is swollen, but there are no neurovascular deficits or skin lacerations. Radiographs reveal a both-bone forearm fracture. The ulna has an oblique fracture with a 30% butterfly fragment, and the radius is comminuted over 75% of its circumference. In addition to reduction and plate fixation of both bones, management should consist of:
Correct Answer & Explanation
. no additional grafting.
Explanation
The patient has a both-bone fracture with a comminuted radial shaft. Open reduction and internal fixation of both bones is the treatment of choice. In the past, Chapman and associates recommended bone grafting radial shaft fractures with more than 30% comminution of the circumference. This has remained the recommendation in most textbooks. More recent studies, where modern biologic plating techniques were used, found that the addition of bone graft to comminuted fractures was not necessary because the union rate did not differ from that of nongrafted comminuted fractures.
Question 3866
Topic: 2. Trauma
An orthopaedic surgeon in his first year of practice is negotiating with a private for-profit hospital to be their employed trauma specialist. The state of employment is known to have a high rate of malpractice claims because of a favorable plaintiff legal environment. During the course of negotiations, malpractice insurance is being discussed. The surgeon should ask the hospital to provide which type of malpractice insurance policy? Review Topic
Correct Answer & Explanation
. Claims made with "nose" coverage
Explanation
An occurrence policy provides coverage for all claims made during employment irrespective of when it is filed (during or postemployment) and therefore is the best option. Claims made policy only covers suits for the time employed. A prepurchased "tail" is needed to provide coverage for cases that occurred during employment but filed postemployment. Nose coverage is applicable if the surgeon was previously employed and did not have tail coverage from previous employment, but this surgeon just emerged from training where it is not applicable. Claims made without tail coverage is unwise because the surgeon would be unprotected or have to purchase his own policy postemployment. Only in certain situations does sovereign immunity exist, and generally not in a for-profit system. Occurrence coverage with nose coverage is incorrect because it does not apply to this surgeon with no previous employment or claims policy lacking tail coverage.
Question 3867
Topic: Lower Extremity Trauma
A 19-year-old woman sustained a displaced talar neck fracture while cliff jumping. The fracture is managed with open reduction and internal fixation. Which of the following best describes the findings in the 2-months postoperative radiographs shown in Figures 67a and 67b, and subsequent treatment plan? Review Topic
Correct Answer & Explanation
. There is a positive Hawkins sign, indicating the patient is unlikely to develop osteonecrosis.
Explanation
The radiographs reveal a positive Hawkins sign, a subchondral lucency in the talar dome best seen on a mortise radiograph indicating viability of the talar body. Once a Hawkins sign appears, it is unlikely that that the patient will develop osteonecrosis.Osteonecrosis is best diagnosed with radiographs. Although MRI can be helpful in assessing the extent of osteonecrosis, it is unnecessary for purely diagnostic purposes. A Hawkins sign typically will appear at 6 to 8 weeks after fracture; however, the absence of a Hawkins sign at that time does not necessarily indicate osteonecrosis. Most authors agree that even in the absence of a Hawkins sign, weight bearing can commence at 10 to 12 weeks after surgery.
Question 3868
Topic: 2. Trauma
Figure 21 shows the AP radiograph of a 41-year-old patient who sustained a closed bicolumnar fracture of the distal humerus that resulted in a painful nonunion. What is the best initial construct for rigid stabilization of this fracture pattern?
Correct Answer & Explanation
. Dual 3.5-mm reconstruction plate fixation
Explanation
The dual plate fixation construct is significantly stronger than single plate or βYβ plate fixation. Two-plate constructs at right angles, the ulnar plate medially and the lateral plate posteriorly, would appear to be biomechanically optimal. This approach usually is feasible at the time of surgery. Clinically, dual 3.5-mm reconstruction or dynamic compression plates are superior to one-third tubular plate fixation. Supplementary external fixation is not considered a better treatment option. Failure of fixation and nonunion are often the result of inadequate fixation and osteoporosis.
Question 3869
Topic: 2. Trauma
A patient who underwent open reduction and internal fixation of an olecranon fracture 2 months ago now reports painless limitation of motion. Examination reveals a well-healed incision and a flexion-extension arc from 40 degrees to 80 degrees. The patient has been performing home exercises. Radiographs are shown in Figures 26a and 26b. What is the most appropriate treatment?
Correct Answer & Explanation
. Formal physical therapy and static progressive splinting
Explanation
The radiographs do not show an articular malunion. Treatment is directed at the soft-tissue contracture and should begin with formal physical therapy and static progressive splinting. Radiation therapy is effective in the perioperative period and is indicated when ectopic bone formation is a concern.
Question 3870
Topic: 2. Trauma
What is the most appropriate treatment for a 17-year-old boy who sustained a gunshot wound to his forearm from a handgun with a muzzle-velocity of 1000 feet/second if he is neurovascularly intact and radiographs reveal no fracture?
Correct Answer & Explanation
. Irrigation and local wound care in the emergency department followed by 3 days of oral antibiotics
Explanation
The question refers to appropriate management of a gunshot wound to the forearm. Low-velocity wounds are less severe, are more common in the civilian population, and are typically attributed to bullets with muzzle velocities below 1,000 to 2,000 feet per second. Low-velocity injuries with stable, non-operative fractures can be treated with local wound care and oral antibiotics. Studies have shown that patients with low-velocity gunshot-induced fractures can be managed without the use of short-term intravenous antibiotics with no increased risk of infection. Local irrigation and debridement, tetanus prophylaxis, and oral antibiotics for 2-3 days is adequate for low-velocity gunshot wounds.
Question 3871
Topic: 2. Trauma
Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0Β° to 90Β° and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted. What is the underlying cause of the pathology noted in the figures?
Correct Answer & Explanation
. Genetic mutation
Explanation
The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatmentof a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.
Question 3872
Topic: 2. Trauma
Presence of diabetes-induced peripheral neuropathy has been shown to be an independent risk factor for postoperative complications of which of the following injuries?
Correct Answer & Explanation
. Ankle fractures
Explanation
DISCUSSION: Presence of peripheral neuropathy has important implications in treating ankle fractures in diabetic patients. Increased immobilization periods, attention to tight glucose control, and adjunct/alternative operative techniques may be necessary for an optimal outcome. The first referenced article by Chaudry et al is an excellent review of diabetic ankle fractures. The second reference by Costigan et al noted that peripheral neuropathy is the most significant risk factor for postoperative complications, followed closely by lack of pedal pulses preoperatively. The last referenced article by Jones et al noted a significantly higher complication rate in diabetics with operative ankle fractures, and reported that neuroarthropathy is a significant risk factor for postoperative complications.
Question 3873
Topic: 2. Trauma
An 85-year-old right hand dominant male sustains a fall onto his elbow while trying to get out of the car. His past medical history is significant for diabetes, congestive heart failure, and COPD. He lives in a nursing home, and is able to ambulate at baseline without and assistive devices. What would be the ideal definitive surgical treatment options in this patient? Review Topic
Correct Answer & Explanation
. ORIF through an olecranon osteotomy with 90-90 plating
Explanation
This elderly low-demand patient would most benefit from a total elbow arthroplasty (TEA) done through a direct posterior tricep sparing approach.TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients appear to accommodate to objective limitations in function with time, and suffer less complications with TEA than ORIF in select cases.Sorensen et al evaluated short- to medium term outcome of total elbow arthroplasty (TEA) in complex fractures of the distal humerus by evaluating 24 consecutive cases. Twenty of the patients were followed for almost 2 years, and their MEPS were 15 excellent, 4 good and 1 fair result. They concluded that TEA in complex fractures of the distal humerus in elderly patients can result in acceptable short- to medium term outcome.Mckee et al conducted a prospective, randomized, controlled trial to comparefunctional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary total elbow arthroplasty (TEA). They randomized 42 patients and found that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF, based on the MEPS.Illustration A shows radiographs of a TEA. Incorrect Answers:
Question 3874
Topic: 2. Trauma
Figure A is the radiograph of an 11-year-old boy who fell directly on his left shoulder while riding a bicycle. He complained of pain in his left shoulder. An MRI scan of the injury is likely to reveal what findings? Review Topic
Correct Answer & Explanation
. Disruption of the coracoclavicular ligaments
Explanation
In children, fractures of the distal clavicle are almost always through the distal physis and adjacent metaphysis, and, consequently, the acromioclavicular joint is rarely dislocated. The coracoclavicular ligaments usually remain attached to the thick periosteum on the undersurface of the clavicle and are rarely damaged. Because of the thick periosteum and intact ligaments, these fractures are inherently stable and heal well with conservative treatment. In contrast, similar injuries in adults pose a higher risk for surgical intervention.
Question 3875
Topic: 2. Trauma
Bridge plating of the olecranon is MOST appropriate in which of the following clinical scenarios?
Correct Answer & Explanation
. Comminuted olecranon fracture in 45-year-old male
Explanation
DISCUSSION: Bridge plating is most appropriately used for fixation of comminuted fractures which are not able to be fixed anatomically. Of the choices listed above, this would be most appropriate in a comminuted fracture in a 45-year-old male. In contrast, literature shows that severely comminuted, osteoporotic low-demand elderly are best treated with olecranon fracture excision and triceps advancement when possible.
Question 3876
Topic: 2. Trauma
Figure 81 is the radiograph of a healthy 72-year-old man who has a 3-month history of medial knee pain. He denies any specific trauma. Until 3 months ago when the pain began, he had been an avid runner for many years. Initial treatment should be oral anti-inflammatory medication
Correct Answer & Explanation
. alone.
Explanation
This patient has bone-on-bone end-stage arthritis that was asymptomatic until 3 months ago. Patients older than age 65 are at increased risk for adverse gastrointestinal effects when placed on nonsteroidal anti-inflammatory drugs, and they should be placed on a proton pump inhibitor prophylaxis at the same time. Use of glucosamine is controversial. Glucosamine hydrochloride has been shown in prospective studies to have no beneficial effect. However, glucosamine sulfate has been shown to have a positive effect on pain, but no effect on function.
Question 3877
Topic: 2. Trauma
A 29-year-old woman was injured in a high-speed motor vehicle accident 3 hours ago. Radiographs are shown in Figures 7a through 7e. Her right foot injury is open and contaminated. Her associated injuries include a closed head injury and a ruptured spleen requiring resection. She has had 6 units of packed red blood cells and the trauma surgeon has turned her care over to you. Her current base deficit is 10 and her urinary output has averaged 0.4 mL/kg for the last 2 hours. What is the best treatment at this time?
Correct Answer & Explanation
. Irrigation and debridement, external fixation of the ankle, foot, and femur, splinting of the forearm
Explanation
The patient appears to be a borderline or unstable surgical patient following her initial trauma and splenectomy (high base deficit and low urine output). She needs continued resuscitation and minimal additional blood loss. This is best accomplished with irrigation and debridement of the ankle, external fixation of the ankle, foot, and femur, and splinting of the forearm. A traction pin for the femoral fracture will not control bleeding as well as an external fixator. Intramedullary nailing of the femur and open reduction and internal fixation of the forearm would be appropriate in patients that are euvolemic and stable.
Question 3878
Topic: 2. Trauma
An 8-year-old boy weighing 70 lb sustains a displaced diaphyseal femur fracture and is treated with two flexible retrograde intramedullary rods. What is the most common complication following treatment with this technique? Review Topic
Correct Answer & Explanation
. Limb-length discrepancy
Explanation
Flexible retrograde intramedullary nailing is now the preferred treatment for most length-stable diaphyseal femur fractures in school-aged children. The most commonly described complication is irritation about the knee at the rod insertion sites that resolves with rod removal. Limb-length discrepancy and weakness have also been described at lower rates. Malunion or rod bending is usually related to placement of the rods in an unstable fracture pattern or in a larger patient.
Question 3879
Topic: 2. Trauma
A farmer is seen in the emergency department after falling out of a hay loft onto the barn floor below. He is unable to bear weight. Exploration of a 0.5 cm laceration over the anterior tibia reveals bone. Radiographs reveal oblique displaced midshaft tibial and fibular fractures. Based on these findings, what is the most appropriate antibiotic prophylaxis?
Correct Answer & Explanation
. Cephalosporin, aminoglycoside, and penicillin
Explanation
A farm injury is automatically considered a grade III (Gustilo classification) injury regardless of size, energy, or additional soft-tissue injury due to the likelihood of substantial contamination. Antibiotic recommendations for grade III injuries include a first- or second-generation cephalosporin with an aminoglycoside or fluoroquinolone within 3 hours of injury, with penicillin added for farm injuries.
Question 3880
Topic: 2. Trauma
A subtrochanteric femur fracture in which the lesser trochanter is intact is associated with what deformity?
Correct Answer & Explanation
. Adduction and extension of the proximal fragment
Explanation
The most commonly seen deformity in subtrochanteric femur fractures is abduction and flexion of the proximal fragment. Subtrochanteric fractures can pose challenges in reduction because of the muscle attachments proximal and distal to the fragment. The gluteus medius and gluteus minimus attach to the greater trochanter and abduct the proximal fragment. The iliopsoas attaches to the lesser trochanter, flexing and externally rotating the proximal fragment. The short external rotators (piriformis, superior and inferior gamellus) and the obturator internus also cause external rotation of the proximal fragment.
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