Menu

2. Trauma MCQs

Practice Set 267 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 5321

Topic: 2. Trauma

An active 72-year-old woman sustained a mid-diaphyseal right humerus fracture 16 months ago. History reveals that she was first treated with a brace for 7 months. Additional treatment consisted of intramedullary nailing 9 months ago. Recently the rod was removed, and the patient now reports pain and gross motion at the fracture site. Current radiographs are shown in Figures 37a and 37b. What is the next most appropriate step in management?

. Electrical stimulation with an implanted coil
. Ultrasound stimulation for 30 minutes per day
. Locked intramedullary nailing with bone graft
. Ilizarov external fixation with intermittent distraction and compression
. Plate and screw fixation with bone graft

Correct Answer & Explanation

. Plate and screw fixation with bone graft

Explanation

The patient has a well-established nonunion in a very porotic bone. Electrical stimulation has been found effective in treating tibial nonunions, but there is very little data on humeral nonunions, especially chronic well-established ones. Ultrasound stimulation is effective in accelerating fracture healing, but there is little data concerning the treatment of nonunions. Intramedullary nailing with bone graft is an option, but it maybe difficult to obtain a rigid construct in a very porotic bone. An Ilizarov-type external fixator would be an alternative, but there is little clinical data for the humerus and it may be poorly tolerated. A plate and screw construct with bone graft combines rigidity with the biologic advantage of the bone graft. A recent series reported on the use of a plate combined with onlay allograft for recalitrant nonunions. Cement augmentation for screw fixation either in the canal or added to the screw holes may be helpful in select cases. Hornicek FJ, Zych GA, Hutson JJ, Malinin TI: Salvage of humeral nonunions with onlay bone plate allograft augmentation. Clin Orthop 2001;386:203-209.

Question 5322

Topic: 2. Trauma

An adult with a distal humeral fracture underwent open reduction and internal fixation. What is the most common postoperative complication?

. Loss of elbow range of motion
. Nonunion
. Malunion
. Infection
. Ulnar nerve dysfunction

Correct Answer & Explanation

. Loss of elbow range of motion

Explanation

Most patients lose elbow range of motion after open reduction and internal fixation of a distal humeral fracture. Ulnar nerve dysfunction, nonunion, and infection all occur less commonly. Webb LX: Distal humerus fractures in adults. J Am Acad Orthop Surg 1996;4:336-344.

Question 5323

Topic: 2. Trauma

Figure 31 shows the radiograph of an 8-year-old boy who has a swollen forearm after falling out of a tree. Examination reveals that all three nerves are functionally intact, and there is no evidence of circulatory embarrassment. Management should consist of

Trauma 2000 Practice Questions: Set 3 (Solved) - Figure 12

. open reduction of both the radius and ulna with plate and screw fixation.
. closed reduction and a long arm cast, with the elbow in 90 degrees of flexion and the forearm in neutral rotation.
. closed reduction and a long arm cast, with the elbow in 120 degrees of flexion and the forearm in full supination.
. closed reduction and a long arm cast, with the elbow extended and the forearm pronated.
. closed reduction and intramedullary pin fixation of both the radius and ulna.

Correct Answer & Explanation

. closed reduction and intramedullary pin fixation of both the radius and ulna.

Explanation

The patient has a Bado type IV Monteggia lesion. It involves dislocation of the radial head and fractures of both the radial and ulnar shafts. These fractures are very difficult to manage by closed reduction alone. The radial and ulnar shafts first have to be stabilized surgically to give a lever arm to reduce the radial head. In this age group, intramedullary pins are easy to insert percutaneously and cause less tissue trauma than plates and screws. In these types of injuries, the focus is often on the forearm fracture; the radial head dislocation may not be appreciated as was the case with this patient. Gibson WK, Timperlake RW: Operative treatment of a type IV Monteggia fracture-dislocation in a child. J Bone Joint Surg Br 1992;74:780-781.

Question 5324

Topic: 2. Trauma

A 25-year-old left hand-dominant man has severe left shoulder pain after being involved in a high-speed motor vehicle accident. Examination reveals that he is unable to move the left shoulder. His neurovascular status is intact in the entire left upper extremity. A radiograph is shown in Figure 19. What is the most appropriate surgical management of this injury?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 2) - Figure 20

. Arthroscopic reduction and fixation
. Percutaneous pinning
. Open reduction and internal fixation
. Hemiarthroplasty with tuberosity reconstruction
. Reverse shoulder arthroplasty

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

In this young patient, every attempt must be made to retain the native proximal humerus; therefore, open reduction and internal fixation should be attempted of both the articular segment and tuberosities to the humeral shaft. This is best accomplished through an open approach. Shoulder arthroplasty should be reserved for the elderly and for failed internal fixation. Ko JY, Yamamoto R: Surgical treatment of complex fractures of the proximal humerus. Clin Orthop Relat Res 1996;327:225-237.

Question 5325

Topic: 2. Trauma

Figures 5a and 5b show the radiographs of an 11-year-old boy who felt a pop and immediate pain in his right knee as he was driving off his right leg to jam a basketball. Examination reveals that the knee is flexed, and the patient is unable to actively extend it or bear weight on that side. There is also a large effusion. Management should include

. ice and elevation, followed by graduated range-of-motion exercises.
. a long leg cast.
. excision of the fragment.
. open reduction and internal fixation.
. observation until maturity, followed by anterior cruciate ligament repair.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

Fractures through the cartilage on the inferior pole of the patella, the so-called sleeve fracture, are often difficult to diagnose because of the paucity of ossified bone visible on the radiographs. If the fracture is missed and the fragments are widely displaced, the patella may heal in an elongated configuration that may result in compromise of the extensor mechanism function. The treatment of choice is open reduction and internal fixation using a tension band wire technique to achieve close approximation of the fragments and restore full active knee extension. Heckman JD, Alkire CC: Distal patellar pole fractures: A proposed common mechanism of injury. Am J Sports Med 1984;12:424-428.

Question 5326

Topic: 2. Trauma

Figure 19 shows the radiograph of a 45-year-old woman who has a painful nonunion. Treatment should consist of

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 16

. revision internal fixation with a longer side plate and bone grafting.
. open reduction and internal fixation with a 95-degree fixed angle device and bone grafting.
. hardware removal and retrograde intramedullary nailing.
. placement of an implantable bone stimulator.
. proximal femoral resection and total hip arthroplasty.

Correct Answer & Explanation

. open reduction and internal fixation with a 95-degree fixed angle device and bone grafting.

Explanation

The radiograph reveals a reverse obliquely subtrochanteric/intertrochanteric fracture. Open reduction and internal fixation should be accomplished with a 95-degree fixed angle device. An intramedullary nail with screw fixation into the head is another possible technique. Either method should correct the varus deformity. Exchange of a high-angled screw and plate device to a longer side plate and bone grafting does not afford any improvement in the mechanical stability. Hardware removal and retrograde intramedullary nailing is not indicated for this level of a proximal femoral injury. Placement of an implantable bone stimulator may change local biologic factors but would not enhance mechanical stability. The patient's femoral head is intact without signs of collapse; therefore, hardware removal, proximal femoral resection, and total hip arthroplasty are not warranted. Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.

Question 5327

Topic: 2. Trauma

A 17-year-old boy underwent open reduction and internal fixation of a navicular fracture 5 days ago. A follow-up examination now reveals a tensely swollen foot with erythema and multiple skin bullae. The patient is febrile and has marked pain with palpation of the entire forefoot and hindfoot. What is the next step in management?

. Application of a compressive dressing and boot brace and monitoring of compartment pressures
. Administration of IV antibiotics and strict elevation
. Oral antibiotics, elevation, and close follow-up
. Debridement of the bullae and application of a new cast
. Urgent surgical debridement and IV antibiotics

Correct Answer & Explanation

. Urgent surgical debridement and IV antibiotics

Explanation

Necrotizing fasciitis is a rapidly progressive soft-tissue infection with the potential to threaten both life and limb. Patients who are immunocompromised (HIV infection, diabetes mellitus, alcohol abuse) are at increased risk. However, any patient in the immediate postoperative phase is susceptible to wound infection. Early detection is the key. Necrotizing fasciitis is primarily a surgical problem that requires urgent debridement and broad-spectrum IV antibiotics. Rapid diagnosis and prompt treatment help to reduce mortality, which may approach 30%. Debridement of the bullae and observation are not indicated. Although elevation and close follow-up may be warranted early on, in this patient, surgical debridement is the next step. Ault MJ, Geiderman J, Sokolov R: Rapid identification of group A streptococcus as the cause of necrotizing fasciitis. Ann Emerg Med 1996;28:227-230.

Question 5328

Topic: 2. Trauma

A 68-year-old woman who sustained a closed distal tibia fracture 2 years ago was initially treated with an external fixator across the ankle for 12 weeks, followed by intramedullary nailing of the fibula and lag screw fixation of the tibia. She continued to report persistent pain so she was treated with a brace and a bone stimulator. She now reports pain in her ankle. Examination reveals ankle range of motion of 8 degrees of dorsiflexion to 25 degrees of plantar flexion. She is neurovascularly intact. Current radiographs are shown in Figures 9a through 9c. What is the next most appropriate step in management?

. A cast and weight bearing as tolerated
. A brace and an ultrasound bone stimulator
. Intramedullary nailing
. Open reduction and plate fixation with bone grafting
. Fibular osteotomy

Correct Answer & Explanation

. Open reduction and plate fixation with bone grafting

Explanation

The patient has a nonunion of the distal fifth of the tibia. The nonunion appears to be oligotrophic, somewhere between atrophic and hypertrophic. Management requires stabilization and stimulation of the local biology, which can be accomplished with open reduction and internal fixation with bone grafting. Bracing or casting does not provide enough stability. Ultrasound bone stimulation has been shown to speed fresh fracture repair but is not indicated in nonunions. The distal segment is too short for intramedullary nailing. A fibular osteotomy alone would increase instability and, even with prolonged casting, would be unlikely to lead to successful repair. Carpenter CA, Jupiter JB: Blade plate reconstruction of metaphyseal nonunion of the tibia. Clin Orthop 1996;332:23-28. Lonner JH, Siliski JM, Jupiter JB, Lhowe DW: Posttraumatic nonunion of the proximal tibial metaphysis. Am J Orthop 1999;28:523-528. Stevenson S: Enhancement of fracture healing with autogenous and allogeneic bone grafts. Clin Orthop 1998;355:S239-S246.

Question 5329

Topic: 2. Trauma

Figure 21 shows the radiograph of an 18-year-old man who was brought to the emergency department with shoulder pain following a rollover accident on an all-terrain vehicle. Examination reveals a fracture with massive swelling; however, the skin is intact and not tented over the fracture. Based on these findings, initial management should consist of

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 26

. closed reduction of the displaced clavicular fracture.
. a figure-of-8 clavicular brace to stabilize the clavicular fracture.
. arteriography to evaluate for vascular injury.
. electromyography to evaluate for a brachial plexus injury.
. CT to evaluate for a scapular fracture.

Correct Answer & Explanation

. arteriography to evaluate for vascular injury.

Explanation

The radiographic and clinical findings suggest a scapulothoracic dissociation with a widely displaced clavicular fracture and a laterally displaced scapula. These injuries have a high association with neurovascular injuries to the brachial plexus and subclavian artery. Emergent vascular evaluation with arteriography and possible vascular repair are indicated. This repair can be combined with open reduction and internal fixation of the clavicle to improve stability. Delay in treatment of these vascular injuries can be devastating. Iannotti JP, Williams GR (eds): Disorders of the Shoulder. Philadelphia, PA, Lippincott, 1999, pp 632-635.

Question 5330

Topic: 2. Trauma

A 35-year-old man sustains a closed Monteggia fracture. Examination reveals that sensation, vascular status, and finger flexion are normal. When he extends his wrist, it deviates radially, and he is unable to extend his fingers or thumb. After reduction of the fracture, what is the next step in treatment for the extensor deficits of the thumb and fingers?

. Exploration of the radial nerve
. Exploration of the median nerve
. Nerve conduction velocity studies
. Tendon transfers after the fracture is stabilized
. Observation

Correct Answer & Explanation

. Observation

Explanation

The posterior interosseous nerve is located adjacent to the radial neck, placing it at risk for a traction injury with a dislocation of the proximal radius. The typical neurapraxia that results can be expected to resolve with observation within the first 6 to 12 weeks. If recovery is not clinically evident by 3 months, neurophysiologic studies are indicated. Jessing P: Monteggia lesions and their complicating nerve damage. Acta Orthop Scand 1975;46:601-609.

Question 5331

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
. bone grafting the radius only.
. bone grafting both the radius and ulna.
. bone graft substitute for both the radius and ulna.
. no additional grafting.
. no additional grafting but postoperative electrical stimulation.

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. Anderson LD, Sisk TD, Tooms RE, Park WI III: Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am 1975;57:287-297. Chapman MW, Gordon JE, Zissimos AG: Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am 1989;71:159-169. Wright RR, Schmeling GJ, Schwab JP: The necessity of acute bone grafting in diaphyseal forearm fractures: A retrospective review. J Orthop Trauma 1997;11:288-294.

Question 5332

Topic: 2. Trauma

The mother of a 5-year-old child reports that he has had a fever of 103 degrees F (39.4 degrees C), leg swelling, and has been unwilling to bear weight on his right lower leg for the past 7 days. Examination reveals point tenderness at the distal femur. Aspiration at the metaphysis yields 10 mL of purulent fluid, and a Gram stain reveals gram-positive cocci. In addition to hospital admission, management should include

. IV antibiotics.
. IV antibiotics and immobilization of the lower extremity.
. IV antibiotics, surgical incision and drainage of the abscess, and immobilization of the lower extremity.
. IV antibiotics and repeated aspirations of the metaphyseal region.
. oral antibiotics with careful monitoring of blood levels.

Correct Answer & Explanation

. IV antibiotics, surgical incision and drainage of the abscess, and immobilization of the lower extremity.

Explanation

The patient has a subperiosteal abscess. Because aspiration revealed 10 mL of purulent fluid, the treatment of choice is surgical incision and drainage of the abscess, followed by immobilization to reduce the risk of pathologic fracture. With an adequate response to IV antibiotics and a susceptible bacteria, the patient may then be switched to oral antibiotics.

Question 5333

Topic: 2. Trauma
Figures 48a and 48b show the elbow radiographs of a 5-year-old boy who fell from a tree after dinner. Examination reveals that he is unable to extend his wrist. Management should consist of immediate
. closed reduction and pinning of the fracture in the operating room.
. closed reduction, pinning of the fracture, and radial nerve exploration in the operating room.
. closed reduction and splinting in the emergency department.
. splinting of the arm and observation of neurovascular function, followed by closed reduction and pinning in the operating room the following morning.
. olecranon skeletal traction for reduction, followed by casting when the reduction has been stabilized by callus.

Correct Answer & Explanation

. splinting of the arm and observation of neurovascular function, followed by closed reduction and pinning in the operating room the following morning.

Explanation

In the absence of vascular compromise, there has been no proven value to proceeding immediately to surgery, especially when the patient has a full stomach and runs a significant risk of perioperative aspiration. It would be more prudent to wait until the next morning with a surgical plan of closed reduction and pinning. Open reduction should be reserved for the unusual case where closed treatment has not been successful. The implication that there may be a radial nerve injury associated with this fracture does not alter the treatment plan, and with a high level of certainty would be expected to resolve. Attempting closed reduction in the emergency department creates the opportunity for uncertain results and is not tolerated well by most patients. Skeletal traction, with its associated lengthy hospitalization and the technical difficulties associated with both the traction and radiographic evaluations, has fallen into disfavor for typical clinical situations. Iyengar SR, Hoffinger SA, Townsend DR: Early versus delayed reduction and pinning of type III displaced supracondylar fractures of the humerus in children: A comparative study. J Orthop Trauma 1999;13:51-55.

Question 5334

Topic: 2. Trauma

A 55-year-old woman fell and sustained an elbow dislocation with a coronoid fracture and a radial head fracture. The elbow is reduced and splinted. What is the most common early complication?

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 23

. Brachial artery intimal tear
. Recurrent dislocation
. Forearm compartment syndrome
. Posterior interosseous nerve injury
. Ulnar nerve palsy

Correct Answer & Explanation

. Recurrent dislocation

Explanation

The patient has a dislocation of the elbow with displaced coronoid process and radial head fractures. The elbow is extremely unstable after this injury, and recurrent dislocation in a splint is the most common early complication. Skeletal stabilization of the fractures is required to restore stability of the joint. Characteristics of the fractures will determine the techniques required to restore stability. Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551.

Question 5335

Topic: 2. Trauma
A 13-year-old boy hyperextends his knee while playing basketball and reports a pop that is followed by a rapid effusion. A lateral radiograph is shown in Figure 4. Initial management consists of attempted reduction with extension, with no change in position of the fragment. What is the next most appropriate step in management?
. A long leg cast in 90 degrees of knee flexion for 6 weeks
. Open reduction and internal fixation with a transphyseal 6.5-mm screw and washer
. Arthroscopic anterior cruciate ligament reconstruction with hamstring tendons
. Arthroscopic debridement and staged anterior cruciate ligament reconstruction when skeletally mature
. Open reduction and internal fixation with suture or intra-epiphyseal screw placement

Correct Answer & Explanation

. Open reduction and internal fixation with suture or intra-epiphyseal screw placement

Explanation

Avulsion fractures of the tibial spine are rare injuries that result from rapid deceleration or hyperextension of the knee in skeletally immature individuals. This injury is the equivalent of ruptures of the anterior cruciate ligament in adults. These fractures are classified as types 1 through 3. Type 1 is a minimally displaced fracture, type 2 fractures have an intact posterior hinge, and type 3 fractures have complete separation. The radiograph demonstrates a completely displaced, or type III, tibial spine avulsion. Surgical reduction is indicated in type 2 fractures that fail to reduce with knee extension and in all type 3 fractures. Reduction may be arthroscopic or open, with fixation of the bony fragment using a method that maintains physeal integrity and prevents later growth arrest. Preferred techniques would be with suture or an intra-epiphyseal screw. Wiley JJ, Baxter MP: Tibial spine fractures in children. Clin Orthop 1990;255:54-60. Mulhall KJ, Dowdall J, Grannell M, et al: Tibial spine fractures: An analysis of outcome in surgically treated type III injuries. Injury 1999;30:289-292. Owens BD, Crane GK, Plante T, et al: Treatment of type III tibial intercondylar eminence fractures in skeletally immature athletes. Am J Orthop 2003;32:103-105.

Question 5336

Topic: 2. Trauma

A 25-year-old woman who fell on her outstretched hand reports chronic pain over the hypothenar eminence region and some dorsal ulnar wrist pain. She also notes difficulty playing golf and tennis. Plain radiographs of the hand and wrist are unremarkable. A CT scan is shown in Figure 36. What is the next most appropriate step in management?

Trauma 2000 Practice Questions: Set 3 (Solved) - Figure 21

. Ultrasound therapy
. MRI for further soft-tissue evaluation
. Open reduction and internal fixation of the hook of the hamate
. Excision of the hook of the hamate
. Electrodiagnostic evaluation

Correct Answer & Explanation

. Excision of the hook of the hamate

Explanation

The CT scan reveals a hook of the hamate nonunion with irregular resorption at the fracture site, which is at the base of the hamate. Symptomatic relief of the pain and discomfort has been well documented after excision of the hook of the hamate. Ultrasound therapy will not provide long-term symptomatic relief or induce nonunion healing. MRI for further soft-tissue evaluation is inappropriate because this is a bony problem; the bony architecture of the wrist is best visualized by CT. Open reduction and internal fixation of the hook of the hamate does not provide the symptomatic relief that is found with excision of the hook of the hamate. In addition, the technical difficulties and relative risk of persistent nonunion after open reduction and internal fixation are not merited when hamate excision can be effected easily and causes no long-term untoward effects. Electrodiagnostic evaluation is inappropriate because there is no history of the persistent numbness and tingling that is found in peripheral compression neuropathies. Stark HH, Chao EK, Zemel NP, Rickard TA, Ashworth CR: Fracture of the hook of the hamate. J Bone Joint Surg Am 1989;71:1206-1207. Failla JM: Hook of hamate vascularity: Vulnerability to osteonecrosis and nonunion. J Hand Surg Am 1993;18:1075-1079. Carter PR, Easton RG, Littler JW: Ununited fracture of the hook of the hamate. J Bone Joint Surg Am 1977;59:583-588.

Question 5337

Topic: Upper Extremity Trauma

A patient with an acromioclavicular dislocation has a very prominent distal clavicle. Examination reveals that the deformity increases rather than reduces with an isometric shoulder shrug. Which of the following structures is most likely intact?

Anatomy 2002 Practice Questions: Set 1 (Solved) - Figure 8

. Trapezoid ligament
. Conoid ligament
. Acromioclavicular ligament
. Deltoid muscle origin
. Trapezius muscle insertion

Correct Answer & Explanation

. Deltoid muscle origin

Explanation

Severely displaced acromioclavicular injuries disrupt the deltotrapezial fascia and muscular origin in addition to the ligaments (acromioclavicular and coracoclavicular or trapezoid and conoid). When the deltoid is still attached to the clavicle, an isometric shoulder shrug will tend to reduce the displacement. When the deltoid is detached but the trapezius is attached, this manuever will increase the deformity and surgery may be indicated.

Question 5338

Topic: 2. Trauma

Figure 8 shows the AP radiograph of a 33-year-old woman who sustained a midshaft clavicle fracture from a motorcycle accident 15 months ago. She continues to have significant pain with activities of daily living. Management should consist of

Shoulder 2002 Practice Questions: Set 1 (Solved) - Figure 18

. use of an electrical bone stimulation unit.
. open reduction and internal fixation with a dynamic compression plate placed superiorly and autogenous bone grafting.
. open reduction and internal fixation with a dynamic compression plate placed inferiorly and autogenous bone grafting.
. intramedullary screw fixation.
. partial claviculectomy.

Correct Answer & Explanation

. open reduction and internal fixation with a dynamic compression plate placed superiorly and autogenous bone grafting.

Explanation

The patient has a symptomatic painful atrophic midclavicular nonunion, and the treatment of choice is rigid internal fixation with a dynamic compression plate and autogenous bone grafting. A tension band effect is desired and achieved by placing the plate superiorly. Excellent success rates of 90% to 100% have been reported using this technique. Intramedullary screw fixation without bone grafting has a decreased success rate. Partial claviculectomy is not a preferred option. Jupiter JB, Leffert RD: Non-union of the clavicle: Associated complications and surgical management. J Bone Joint Surg Am 1987;69:753-760.

Question 5339

Topic: Upper Extremity Trauma

Figure 7 shows the radiograph of an 18-year-old hockey player who sustained a shoulder injury during a fall into the side boards. Examination reveals a significant prominence at the acromioclavicular joint. Management should consist of

Sports Medicine 2001 Practice Questions: Set 1 (Solved) - Figure 22

. a figure-of-8 clavicle strap.
. a sling for comfort, followed by early range-of-motion and strengthening exercises.
. open reduction and stabilization.
. immobilization in a spica cast.
. resection of the distal clavicle.

Correct Answer & Explanation

. open reduction and stabilization.

Explanation

The radiograph shows a type V acromioclavicular separation with greater than 100% superior elevation of the clavicle. This finding implies detachment of the deltoid and trapezius from the distal clavicle. Because of severe compromise of function and potential compromise to the overlying skin, surgery is the treatment of choice for type V acromioclavicular separations. During reduction and repair, meticulous repair of the deltotrapezial fascia will also aid in securing the repair. Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.

Question 5340

Topic: 2. Trauma

A 19-year-old female long-distance runner has an incomplete tension-side femoral neck stress fracture. Management should consist of

. limited weight bearing for 6 weeks, followed by a progressive return to activity.
. no weight bearing for 6 weeks, followed by no running for 6 months.
. no weight bearing for 2 weeks, followed by internal fixation if symptoms persist.
. internal fixation at the time of diagnosis.
. cessation of running for 6 weeks.

Correct Answer & Explanation

. internal fixation at the time of diagnosis.

Explanation

Unlike compression-side stress fractures, tension-side stress fractures on the superior side of the femoral neck are at a very high risk of displacement, even if the patient is not bearing weight. It is highly recommended to treat these fractures like acute fractures and to proceed with internal fixation emergently. Once the fracture has displaced, the prognosis is poor in terms of returning to sports, even when reduced and internally fixed. Nonsurgical management, such as limited weight bearing and low-impact activities, works very well for other lower extremity stress fractures. A training program evaluation (shoes, tracks, schedule) is always indicated for all patients with stress fractures.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page