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 5381
Topic: 2. Trauma
A 54-year-old man sustained a small superficial abrasion over the left acromioclavicular joint after falling from his bicycle. Examination reveals no other physical findings. Radiographs show a displaced fracture of the lateral end of the clavicle distal to a line drawn vertically to the coracoid process. Management should consist of
Correct Answer & Explanation
. a sling for comfort, followed by physical therapy when pain-free.
Explanation
Displaced clavicular fractures lateral to the coracoid process (Neer type II and III) are best managed nonsurgically with sling immobilization and physical therapy, starting with pendulum exercises and progressing to active-assisted exercises when comfortable. Supervised therapy should be performed for 3 months or until full painless motion is achieved. In one study by Robinson and Cairns, this form of treatment provided patients with an 86% chance of avoiding a secondary reconstructive procedure.
Question 5382
Topic: 2. Trauma
A 6-year-old child sustained a closed nondisplaced proximal tibial metaphyseal fracture 1 year ago. She was treated with a long leg cast with a varus mold, and the fracture healed uneventfully. She now has a 15-degree valgus deformity. What is the next step in management?
Correct Answer & Explanation
. Continued observation
Explanation
The tibia has grown into valgus secondary to the proximal fracture. This occurs in about one half of these injuries, and maximal deformity occurs at 18 months postinjury. The deformity gradually improves over several years, with minimal residual deformity. Therefore, treatment at this age is unnecessary as there is a high rate of recurrence and complications regardless of technique. The valgus deformity is not a result of physeal injury or growth arrest. Medial proximal tibial hemiepiphysiodesis is an excellent method of correcting the residual deformity but is best reserved until close to the end of growth. Brougham DI, Nicol RO: Valgus deformity after proximal tibial fractures in children. J Bone Joint Surg Br 1987;69:482. McCarthy JJ, Kim DH, Eilert RE: Posttraumatic genu valgum: Operative versus nonoperative treatment. J Pediatr Orthop 1998;18:518-521.
Question 5383
Topic: 2. Trauma
A 17-year-old high school football player reports wrist pain after being tackled. Radiographs are shown in Figures 22a through 22c. What is the recommended intervention?
Correct Answer & Explanation
. Open reduction and differential pitch screw placement via a dorsal approach
Explanation
The patient has an acute fracture of the proximal pole. A 100% healing rate has been reported for open reduction and internal fixation of proximal pole fractures via a dorsal approach. This allows for direct viewing of the fracture line, facilitates reduction, and bone grafting can be done through the same incision if necessary. A vascularized or corticocancellous graft is reserved for nonunions. Proximal fractures are very slow to heal with a cast, if they heal at all. As a small fragment, percutaneous fixation is very difficult and has been reported for waist fractures. Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.
Question 5384
Topic: 2. Trauma
A 25-year-old student sustains the injury shown in Figures 13a through 13c after falling off a curb. Initial management should consist of
Correct Answer & Explanation
. non-weight-bearing in a short leg cast.
Explanation
The radiographs reveal a fracture entering the 4-5 intermetatarsal articulation, consistent with a zone 2 injury. This classically is also referred to as a Jones fracture. The history and radiographic findings indicate this is an acute fracture, which guides management. A zone 1 fracture enters the fifth tarsometatarsal joint, and a zone 3 fracture is a proximal diaphyseal fracture distal to the 4-5 articulation. Initial management is usually nonsurgical and consists of non-weight-bearing in a short leg cast. This method has been shown to result in a better healing rate compared to weight bearing as tolerated. Rosenberg GA, Sterra JJ: Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg 2000;8:332-338.
Question 5385
Topic: 2. Trauma
A 12-year-old boy sustains open comminuted midshaft tibial and fibular fractures while playing indoor soccer. The wound is grossly clean and measures 7 cm with some periosteal stripping. Antibiotics and tetanus toxoid are administered immediately in the emergency department. Following irrigation and debridement of the wound in the operating room, treatment should include
Correct Answer & Explanation
. an external fixator.
Explanation
Open fractures in children have similar rates of short-term complications such as compartment syndrome, vascular injury, and nerve injury when compared to adult fractures. Primary wound closure should be used for Gustillo and Anderson type 1 or uncomplicated type 2 fractures after surgical debridement. Skeletal stabilization may consist of external fixation, flexible nails, or casting with or without supplementary pin fixation. For an open comminuted midshaft fracture, external fixation is the treatment of choice. Reamed intramedullary nailing is contraindicated in children with an open physis. Plate fixation has a high complication rate in severe open fractures.
Question 5386
Topic: 2. Trauma
Figures 32a and 32b show the radiographs of a 13-year-old boy who sustained a fracture while playing football 1 week ago. Management at the time of injury included application of a cast and the use of crutches. A follow-up office visit reveals a normal neurologic examination, and the patient reports no discomfort with the cast and crutches. Management should now include
Correct Answer & Explanation
. cast wedging in the outpatient clinic.
Explanation
Stable fractures and minimally displaced fractures in children can and should be treated by closed methods. Because loss of reduction is common, alignment of tibia fractures must be monitored closely for the first 3 weeks after cast application. This is most easily handled in a cooperative patient by cast wedging. Some children require application of a second cast under general anesthesia 2 to 3 weeks after injury, particularly if the subsidence of swelling has caused the cast to loosen. Surgical indications include the presence of soft-tissue injuries, unstable fracture patterns, fractures associated with compartment syndrome, and the child with multiple injuries. Surgical options in children include percutaneous pins, external fixation, plates and screws, and intramedullary nails. Heinrich SD: Fractures of the shaft of the tibia and fibula, in Rockwood CA, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 1340-1346.
Question 5387
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
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. 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.
Question 5388
Topic: 2. Trauma
A 22-year-old man sustained a stable pelvic fracture, bilateral femur fractures, and a left closed humeral shaft fracture in a motor vehicle accident. Examination 24 hours after injury reveals that the patient is confused and has shortness of breath. A clinical photograph of his conjunctiva is shown in Figure 44. He has a temperature of 101 degrees F (38.3 degrees C) and a pulse rate of 120/min. Laboratory studies show a hemoglobin level of 8 g/dL, a platelet count of 50,000/mm3, and a PaO2 of 57 mm Hg on 2L of oxygen. What is the most likely diagnosis?
Correct Answer & Explanation
. Fat embolism syndrome
Explanation
The major criteria for the diagnosis of fat embolism syndrome include hypoxemia (PaO2 of less than 60 mm Hg), central nervous system depression, and a petechial rash that is most often located in the axillae, conjunctivae, and palate. The rash is often transient. Tachycardia, pyrexia, anemia, thrombocytopenia, and the presence of fat in the urine are all considered minor criteria. To establish the diagnosis of fat embolism syndrome, one major and four minor signs should be present. Pulmonary embolism, which is the major differential diagnosis, usually is not associated with conjunctival petechia or thrombocytopenia.
Question 5389
Topic: 2. Trauma
A 30-year-old elite marathon runner reports chronic pain over the lateral aspect of the distal right leg and dysesthesia over the dorsum of the foot with active plantar flexion and inversion of the foot. Examination reveals a tender soft-tissue fullness approximately 10 cm proximal to the lateral malleolus. The pain is exacerbated by passive plantar flexion and inversion of the ankle. There is also a positive Tinel's sign over the site of maximal tenderness. There is no motor weakness, and deep tendon reflexes are normal. Radiographs and MRI of the leg are normal. What is the next most appropriate step in management?
Correct Answer & Explanation
. Fascial release and neurolysis of the superficial peroneal nerve
Explanation
The patient has entrapment of the superficial peroneal nerve against its fascial opening in the distal leg. It is typically exacerbated by passive or active plantar flexion and inversion of the foot, which leads to traction of the nerve as it exits this opening. Treatment involves release of the fascial opening to reduce this traction phenomenon. Closure of the defect will only aggravate the condition and potentially result in an exertional compartment syndrome. A four-compartment fasciotomy is only indicated for an established compartment syndrome of the leg. Styf J: Diagnosis of exercise-induced pain in the anterior aspect of the lower leg. Am J Sports Med 1988;16:165-169. Sridhara CR, Izzo KL: Terminal sensory branches of the superficial peroneal nerve: An entrapment syndrome. Arch Phys Med Rehabil 1985;66:789-791.
Question 5390
Topic: 2. Trauma
A 25-year-old man is involved in a motor vehicle accident and brought to the emergency department at 4 am on Sunday morning. He has a closed distal third femoral shaft fracture. His leg is initially pulseless but after applying inline traction, a distal pulse can be palpated and the limb appears to be viable. The pulse in the injured limb "feels" different than the pulse in the uninjured limb. What is the next step in assessing the vascular status of this limb?
Correct Answer & Explanation
. Ankle-brachial index (ABI)
Explanation
The patient initially has a distal third femoral fracture and a pulseless limb. The first step is to reduce the fracture and reassess the vascular status. Although the pulse returns, it feels different than the quality of the pulse in the contralateral uninjured extremity. There is a risk of a vascular injury with this fracture pattern due to tethering of the femoral vessels at the adductor hiatus; therefore, the vascular status needs further assessment since the pulses are not symmetrical. A physical examination is not very accurate in assessing whether a vascular injury is present; therefore, serial examinations are not appropriate. Angiography is very sensitive and specific but is time consuming and can cause complications secondary to the dye and the arterial puncture required to perform it. Duplex ultrasound is effective but is very operator-dependent and may not be available 24 hours a day. The ABI is easily performed and has been shown to be sensitive and specific. If the value is greater than 0.9, the negative predictive value is 99% and when the value is less than 0.9, it is 95% sensitive and 97% specific for a major arterial injury. It has been shown to be useful for blunt lower extremity injuries as well as knee dislocations. Levy BA, Zlowodzki MP, Graves M, et al: Screening for extremity arterial injury with the arterial pressure index. Am J Emerg Med 2005;23:689-695. Abou-Sayed H, Berger DL: Blunt lower-extremity trauma and politeal artery injuries: Revisiting the case for selective arteriography. Arch Surg 2002;137:585-589.
Question 5391
Topic: 2. Trauma
A 57-year-old woman with diabetes mellitus has purulent drainage from a lateral incision after undergoing open reduction and internal fixation of a displaced ankle fracture 10 days ago. Examination reveals moderate erythema and a foul odor coming from the wound. Cultures are obtained. What is the next most appropriate step in management?
Correct Answer & Explanation
. Debridement of the wound and maintenance of the hardware
Explanation
Early postoperative wound infections after open reduction and internal fixation should be treated with aggressive debridement and maintenance of stability of the fracture. If infection persists following healing of the fracture, the hardware should be removed. Carragee EJ, Csongradi JJ, Bleck EE: Early complications in the operative treatment of ankle fractures: Influence of delay before operation. J Bone Joint Surg Br 1991;73:79-82.
Question 5392
Topic: 2. Trauma
A 16-year-old high school football player sustains an injury to the left hip. The avulsed fragment identified by the arrow in Figure 34 represents the origin of which of the following structures?
Correct Answer & Explanation
. Rectus femoris
Explanation
The avulsed fragment represents the origin of the rectus femoris from the anterior inferior iliac spine and the brim of the acetabulum. Avulsion of the anterior inferior iliac spine is much less common than avulsion of the anterior superior iliac spine with its origin of the sartorius. The origin of the gluteus minimus is from the outer cortex of the iliac wing and has not been reported as a source of bony avulsion. The hip capsule is composed of the ischiofemoral and pubofemoral ligaments, in addition to the iliofemoral ligament. The pelvic attachment of the ischiofemoral ligament is from the ischial part of the acetabulum posteriorly, while the pubofemoral ligament attaches to the pubic portion inferiorly. Technically, ligaments do not have origins and insertions as muscle tendon groups do, but have attachment sites. Metzmaker JN, Pappas AM: Avulsion fractures of the pelvis. Am J Sports Med 1985;13:349-358.
Question 5393
Topic: 2. Trauma
A 10-year-old girl was thrown over the handlebars of her bicycle and landed directly on her left shoulder. She was treated with a figure-of-8 strap and analgesics. Follow-up examination 2 weeks later reveals that the lateral end of the clavicle is superiorly dislocated relative to the acromion. A radiograph of the shoulder shows calcification lateral to the coracoid process at the level of the acromion, and the clavicle is superiorly displaced. Management should consist of
Correct Answer & Explanation
. supportive immobilization until the patient is pain-free.
Explanation
In adults, a direct blow on the acromion usually results in an acromioclavicular dislocation. In children, however, the usual injury from this mechanism is a physeal fracture of the lateral clavicle. The clavicular shaft fragment, analogous to the metaphyseal portion of a physeal fracture, herniates through the periosteum, leaving the distal periosteal sleeve in contact with the lateral (distal) physeal fragment. The treatment of choice is immobilization until the patient is pain-free. Falstie-Jensen S, Mikkelsen P: Pseudodislocation of the acromioclavicular joint. J Bone Joint Surg Br 1982;64:368-369.
Question 5394
Topic: 2. Trauma
A 36-year-old woman sustained a tarsometatarsal joint fracture-dislocation in a motor vehicle accident. The patient is treated with open reduction and internal fixation. What is the most common complication?
Correct Answer & Explanation
. Posttraumatic arthritis
Explanation
The most common complication associated with tarsometatarsal joint injury is posttraumatic arthritis. In one series, symptomatic arthritis developed in 25% of the patients and half of those went on to fusion. In another series, 26% had painful arthritis. Initial treatment should consist of shoe modification, inserts, and anti-inflammatory drugs. Fusion is reserved for failure of nonsurgical management. Hardware failure may occur, but it is clinically unimportant. Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618. Arntz CT, Veith RG, Hansen ST Jr: Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am 1988;70:173-181.
Question 5395
Topic: 2. Trauma
Figure 18a shows the clinical photograph of a 2-year old boy who has a deformity of the right leg. Examination reveals eight cutaneous markings similar to those shown in Figure 18b. Radiographs are shown in Figure 18c. Management should consist of
Correct Answer & Explanation
. a clamshell orthosis.
Explanation
The diagnosis of neurofibromatosis may be based on the presence of at least six cafe-au-lait spots larger than 5 mm in diameter and the osseous lesion shown in Figure 18c. Neurofibromatosis occurs in 50% of patients who have an anterolateral bowing deformity of the tibia, and this bowing may be the first clinical manifestation of this disorder. The patient has anterolateral bowing of the tibia and fibula that warrants concern for a possible fracture and pseudarthrosis; therefore, the limb should be protected in a total contact orthosis to prevent fracture. In contradistinction to posteromedial bowing of the tibia and fibula, spontaneous remodeling of an anterolateral bowing deformity is not expected. Intramedullary nailing or the use of a vascularized fibula is reserved for the treatment of a congenital pseudarthrosis of the tibia. Crawford AH Jr, Bagamery N: Osseous manifestations of neurofibromatosis in childhood. J Pediatr Orthop 1986;6:72-88.
Question 5396
Topic: 2. Trauma
A 51-year-old man sustained an open fracture of his tibia in Korea 42 years ago. An infection developed and it was resolved with surgical treatment. For the past 6 months, an ulcer with mild drainage has developed over the medial tibia. The ulcer is small and there is minimal erythema at the ulcer site. A radiograph and MRI scan are shown in Figures 43a and Figure 43b. Initial cultures show Staphylococcus aureus susceptible to the most appropriate antibiotics. Laboratory studies show an erythrocyte sedimentation rate of 70 mm/h. What is the most appropriate surgical treatment at this time?
Correct Answer & Explanation
. Curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics
Explanation
The patient has chronic tibial osteomyelitis that is due to low virulent bacteria. The history and studies do not suggest the need for an amputation or a free-flap procedure. This is a localized tibial infection that is in a healed bone; there is no need to resect the entire area of the tibia bone around the infection. The most appropriate treatment is curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics. Studies have shown that in cases of localized osteomyelitis that are of low virulence, as little as 1 week of IV antibiotics followed by 6 weeks of oral antibiotics is successful. Patzakis MJ, Zalavras CG: Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: Current management concepts. J Am Acad Orthop Surg 2005;13:417-427.
Question 5397
Topic: Upper Extremity Trauma
A 46-year-old woman fell from her bicycle and sustained the injury shown in Figure 24. Which of the following ligaments has been disrupted?
Correct Answer & Explanation
. Acromioclavicular and coracoclavicular
Explanation
The radiograph shows a type V acromioclavicular joint injury. Type V injuries involve disruption of the acromioclavicular and coracoclavicular ligaments. Type I injuries involve a sprain of the acromioclavicular joint ligaments. Type II injuries involve disruption of the acromioclavicular joint ligaments; the coracoclavicular ligaments are partially injured. Sternoclavicular ligaments stabilize the medial clavicle and the sternum; they are not damaged with acromioclavicular joint dislocations. Fukuda K, Craig EV, An KN, et al: Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Joint Surg Am 1986;68:434-439.
Question 5398
Topic: 2. Trauma
An 8-year-old boy sustains nondisplaced midshaft fractures of the tibia and fibula after being struck by a car while he was riding his bicycle. No other injuries are noted, but the patient reports pain with passive motion of his toes. His neurovascular examination is otherwise normal. What is the best course of action?
Correct Answer & Explanation
. Compartment pressure measurements and inpatient treatment as indicated
Explanation
Pain with passive motion of the toes is a recognized early sign of increased compartment pressures. At a minimum, a baseline evaluation of the leg compartment pressures should be obtained. While it is normal for the patient to have pain related to the associated muscle contusions, any significant concerns should be addressed immediately in light of the severe consequences likely when a compartment syndrome occurs. Mubarak SJ, Owen CA, Hargens AR, et al: Acute compartment syndromes: Diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg Am 1978;60:1091-1095.
Question 5399
Topic: 2. Trauma
A 23-year-old woman falls from a bicycle and sustains a right knee injury. Figures 12a through 12d show radiographs and MRI scans of the knee. What is the most likely diagnosis?
Correct Answer & Explanation
. Anterior cruciate ligament avulsion from the tibia
Explanation
The radiographs and MRI scans both show an avulsion of the anterior cruciate ligament, which has been described by Meyers and McKeever in three different fracture patterns. Type I fractures are nondisplaced or have minimal displacement of the anterior margin. Type II fractures have superior displacement of their anterior aspect with an intact posterior hinge. Type III fractures are completely displaced. Although the injury is visible on the radiographs, it is more subtle in adults than children. Thus, MRI is helpful in clarifying this injury in adults. Open or arthroscopic reduction and internal fixation is recommended for type II and type III fractures that do not respond to closed reduction.
Question 5400
Topic: 2. Trauma
Figures 18a through 18c show the clinical photograph, radiograph, and CT scan of a 21-year-old man who reports persistent pain after injuring his right shoulder 4 months ago. What is the most likely factor associated with this patient's diagnosis?
Correct Answer & Explanation
. Severity of trauma
Explanation
The more severe the trauma, the higher the rate of subsequent clavicular nonunion. Neither duration nor type of immobilization has been clearly demonstrated to be a causative factor in the development of nonunion. Similarly, closed reduction has not been found to alter the healing course in midshaft clavicular fractures. Lazarus MD, Seon C: Fractures of the clavicle, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, vol 2, pp 1241-1242.
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