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2. Trauma MCQs

Practice Set 272 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 5421

Topic: 2. Trauma

A 67-year-old man who underwent humeral head arthroplasty for a four-part fracture 6 months ago reports that he is still unable to actively elevate his arm. Rehabilitation after surgery consisted of a sling with passive range-of-motion exercises for 2 weeks and then progressed to active-assisted and strengthening exercises at 3 weeks. Radiographs are shown in Figures 28a and 28b. What is the primary cause of his inability to elevate the arm?

. Rotator cuff tear
. inadequate strengthening exercises
. Instability
. Tuberosity nonunion
. Prosthetic loosening

Correct Answer & Explanation

. Tuberosity nonunion

Explanation

The radiographs show nonunion of both the greater and lesser tuberosities. Tuberosity pull-off and nonunion remain among the most common causes of failed humeral head arthroplasty for fracture. Strict attention to securing the tuberosities to each other and to the shaft, and autogenous bone grafting from the excised humeral head will decrease the incidence of pull-off and improve healing rates. Active-assisted range-of-motion and strengthening exercises should be delayed until tuberosity healing is noted radiographically, usually at 6 to 8 weeks postoperatively. Hartsock LA, Estes WJ, Murray CA, et al: Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am 1998;29:467-475. Hughes M, Neer CS: Glenohumeral joint replacement and postoperative rehabilitation. Phys Ther 1975;55:850-858.

Question 5422

Topic: 2. Trauma

A 52-year-old woman who is right hand-dominant sustains an injury to her elbow in a fall. A radiograph is shown in Figure 60. The preferred treatment of this injury pattern should include

Trauma Board Review 2009: High-Yield MCQs (Set 4) - Figure 23

. lateral plating of the proximal ulna and fixation of the radial head.
. Kirschner wire/tension band fixation of the proximal ulna alone.
. closed reduction and casting.
. dorsal plating of the proximal ulna and radial head replacement.
. total elbow arthroplasty.

Correct Answer & Explanation

. dorsal plating of the proximal ulna and radial head replacement.

Explanation

The patient has a Bado type 2 variant Monteggia fracture with a radial head fracture. The type 2 variant is associated with a higher nonunion rate and poorer outcomes compared to other Bado-type Monteggia fractures. While it is potentially acceptable to repair the radial head, factors such as higher degrees of comminution and older age lead toward replacement as the treatment of choice. Plate and screw fixation is favored over Kirschner wire/tension band fixation because this is not a simple olecranon fracture. Plate placement in a type 2 fracture is dorsal to counteract very high tensile forces associated with fixation failure. Egol KA, Tejwani NC, Bazzi J, et al: Does a Monteggia variant lesion result in a poor functional outcome? A retrospective study. Clin Orthop Relat Res 2005;438:233-238. Jupiter JB, Leibovic SJ, Ribbans W, et al: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.

Question 5423

Topic: 2. Trauma

Figure 63 shows the radiographs of a 23-year-old man who sustained a twisting injury at work. Swelling, tenderness, and ecchymosis are noted about the entire midfoot. What associated injury is most likely to be problematic?

Trauma Board Review 2009: High-Yield MCQs (Set 4) - Figure 26

. Peroneal tendon tear
. Lateral process talus fracture
. Talar neck fracture
. Lisfranc injury
. Deltoid ligament tear

Correct Answer & Explanation

. Lisfranc injury

Explanation

This cuboid compression fracture ("nutcracker" injury) is associated with subtle injury to the Lisfranc complex. This diagnosis must be made to ensure proper treatment.

Question 5424

Topic: 2. Trauma

A 32-year-old man sustained a fracture of his upper arm in a motor vehicle accident. Radiographs are shown in Figure 32. Because of other associated injuries, surgical stabilization is chosen. What technique will result in the least complications and the best outcome?

Trauma 2006 Practice Questions: Set 3 (Solved) - Figure 10

. Retrograde locked intramedullary nail
. Antegrade reamed locked intramedullary nail
. Flexible nails
. Open reduction and plate fixation
. External fixation

Correct Answer & Explanation

. Open reduction and plate fixation

Explanation

Most humeral fractures will heal with nonsurgical functional brace management. When the initial pain has subsided in a coaptation splint, the patient is converted to a functional brace and allowed to use the arm for activities. The fracture should heal within 6 weeks to 12 weeks with acceptable results. Surgery is indicated if there is vascular injury, open injury, floating elbow, chest injury, bilateral humeral fractures, or if a reduction cannot be obtained or maintained. The surgical treatment of choice is either antegrade reamed locked intramedullary nailing or plate osteosynthesis. Plate osteosynthesis appears to offer better results with respect to union, function, and risk of complications. Schemitsch EH, Bhandari M: Fractures of the humeral shaft, in Browner BD: Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1481-1511.

Question 5425

Topic: 2. Trauma

A 23-year-old man who was the restrained driver in a car involved in a high-speed motor vehicle accident sustained the closed injury shown in Figures 32a through 32c. Which of the following factors has the greatest impact on the risk of osteonecrosis?

. Surgical stabilization within 6 to 8 hours of injury
. Extent of initial fracture displacement
. Nicotine use
. Posterior-to-anterior screw fixation
. Anatomic fracture reduction

Correct Answer & Explanation

. Extent of initial fracture displacement

Explanation

The incidence of osteonecrosis following displaced talar neck fractures is most related to the extent of initial fracture displacement. With increasing fracture displacement, the tenuous vascular supply to the talar body is more at risk for damage, thereby increasing the risk of osteonecrosis. Although displaced talar neck fractures have historically been considered a surgical emergency, recent studies have shown that the timing of surgical intervention bears no impact on the development of osteonecrosis. While nicotine use has an influence on fracture healing, it has never been shown to be a factor in osteonecrosis, nor has posterior-to-anterior screw fixation or the quality of fracture reduction. Lindvall E, Haidukewych G, Dipasquale T, et al: Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 2004;86:2229-2234.

Question 5426

Topic: 2. Trauma

A 28-year-old man underwent open reduction and internal fixation of a closed, displaced, intra-articular calcaneal fracture 8 weeks ago. Examination now reveals that the lateral wound is red and draining purulent material. Cultures obtained from the wound grow out Staphylococcus aureus. Radiographs show early healing of the fracture. What is the next most appropriate step in management?

Foot & Ankle Board Review 2006: High-Yield MCQs (Set 2) - Figure 23

. Intravenous antibiotics
. Debridement of the wound without hardware removal
. Debridement of the wound with hardware removal
. Vacuum-assisted closure (VAC) and negative pressure therapy
. Total calcanectomy

Correct Answer & Explanation

. Debridement of the wound with hardware removal

Explanation

Intravenous antibiotics alone will not adequately treat this infection. At 8 weeks after surgery, the hardware must be removed because Staphylococcus aureus is a virulent microbe. VAC therapy alone is not adequate without debridement and hardware removal, but it may play a role in postoperative wound care. Calcanectomy is a salvage procedure for calcaneal osteomyelitis or recalcitrant heel ulceration. Benirschke SK, Kramer PA: Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma 2004;18:1-6. Lim EV, Leung JP: Complications of intra-articular calcaneal fractures. Clin Orthop 2001;391:7-16.

Question 5427

Topic: 2. Trauma

A 20-year-old man sustained a closed tibial fracture and is treated with a reamed intramedullary nail. What is the most common complication associated with this treatment?

Trauma 2006 Practice Questions: Set 1 (Solved) - Figure 9

. Nonunion
. Malunion
. Infection
. Knee pain
. Compartment syndrome

Correct Answer & Explanation

. Knee pain

Explanation

The most common complication is anterior knee pain (57%). The knee pain is activity related (92%) and exacerbated by kneeling (83%). Although knee pain is the most common complication, most patients rate it as mild to moderate and only 10% are unable to return to previous employment. Some authors report less knee pain with a peritendinous approach when compared to a tendon-splitting approach. In one study, nail removal resolved pain in 27%, improved it in 70%, and made it worse in 3%. The incidence of the other complications was: infection 0% to 3%, nonunion 0% to 6%, and malunion 2% to 13%. Compartment syndrome is rare after nailing. Court-Brown CM: Reamed intramedullary tibial nailing: An overview and analysis of 1106 cases. J Orthop Trauma 2004;18:96-101. McQueen MM, Gaston P, Court-Brown CM: Acute compartment syndrome: Who is at risk? J Bone Joint Surg Br 2000;82:200-203.

Question 5428

Topic: Upper Extremity Trauma

A 52-year-old man who was a former high school pitcher now reports loss of elbow flexion and extension with pain at the extremes of motion. Nonsurgical management has failed to provide relief. Examination reveals movement from 50 degrees to 110 degrees and is painful only at the limits of motion. A radiograph is shown in Figure 12. Treatment should consist of

Shoulder 2002 Practice Questions: Set 1 (Solved) - Figure 29

. excision of the osteophytes and loose bodies and anterior and posterior capsular releases.
. removal of the loose bodies.
. anterior capsular release.
. anterior and posterior capsular releases.
. interposition arthroplasty.

Correct Answer & Explanation

. excision of the osteophytes and loose bodies and anterior and posterior capsular releases.

Explanation

Based on the history, examination, and radiograph, the patient has typical degenerative arthritis of the elbow. This condition is found almost exclusively in men, and there is almost universally a history of repetitive heavy use or overuse of the elbow. Patients report pain at terminal extension and usually have a flexion contracture. Radiographs reveal osteophytes on the coronoid and olecranon and in the coronoid and olecranon fossae. The osteophytes are often associated with loose bodies that sometimes are attached to the soft tissues. Treatment should consist of removal of all loose bodies and impinging osteophytes using open technique or by arthroscopy. The capsular contractures should be released at the same time. Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294. Morrey BF: Primary degenerative arthritis of the elbow: Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br 1992;74:409-413. Redden JF, Stanley D: Arthroscopic fenestration of the olecranon fossa in the treatment of osteoarthritis of the elbow. Arthroscopy 1993;9:14-16.

Question 5429

Topic: 2. Trauma

A patient has a displaced midshaft transverse fracture of the humerus and is neurologically intact. Following closed reduction and application of a coaptation splint, the patient cannot dorsiflex the wrist or the fingers at the metacarpophalangeal joints of the hand. What is the next most appropriate step in management?

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 27

. Observation with a high expectation for recovery
. Observation for 1 week, followed by exploration if recovery is not evident
. Immediate exploration of the radial nerve and fracture fixation
. Immediate exploration of the radial nerve without fracture fixation
. Removal of the coaptation splint and repeat reduction

Correct Answer & Explanation

. Observation with a high expectation for recovery

Explanation

The answer to this question is controversial. All of the standard textbooks state that development of a radial nerve palsy during initial fracture management may represent a laceration or injury of the nerve by bone fragments at the time of manipulation; therefore, surgery should be considered. However, it appears that there is no scientific basis for this decision. A review of the available literature shows that the results were the same for patients who were observed as for those who underwent radial nerve exploration. The indications for surgical exploration include palsies associated with open fractures, irreducible closed fractures, and vascular injuries. The only other relative indication for surgical exploration is following manipulation of a Holstein-Lewis fracture (a distal third fracture of the humerus with a lateral spike). In this type of fracture, exploration may be necessary if a closed reduction leads to radial nerve palsy because the spike may lacerate or compress the nerve. Observation for return of nerve function may be appropriate for 3 months or longer prior to considering late exploration. Bostman O, Bakalim G, Vainionpaa S, Wilppula E, Patiala H, Rokkanen P: Radial palsy in shaft fracture of the humerus. Acta Orthop Scand 1986;57:316-319. Shaz JJ, Bhatti NA: Radial nerve paralysis associated with the fractures of the humerus: A review of 62 cases. Clin Orthop 1983;172:171-176.

Question 5430

Topic: 2. Trauma

Figure 16a shows the radiograph of a 34-year-old woman who sustained a basicervical fracture of the femoral neck. The fracture was treated with a compression screw and side plate. Seven months postoperatively, she continues to have significant hip pain and cannot bear full weight on her hip. A recent radiograph is shown in Figure 16b. Management should now consist of

. continued non-weight-bearing and a bone stimulator.
. removal of the hardware, bone grafting of the femoral neck, and refixation.
. removal of the hardware and hemiarthroplasty.
. removal of the hardware and total hip arthroplasty.
. removal of the hardware and a valgus osteotomy.

Correct Answer & Explanation

. removal of the hardware and a valgus osteotomy.

Explanation

The patient sustained a high-angle femoral neck fracture. The follow-up clinical findings and radiograph show that she now has a nonunion with failed internal fixation. The joint appears preserved. In a healthy, young patient, arthroplasty of the femoral head, although possible, is not ideal. Excellent healing and function can be obtained in 70% to 80% of patients with femoral neck nonunion with a valgus intertrochanteric osteotomy. Marti RK, Schuller HM, Raaymakers EL: Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br 1989;71:782-787.

Question 5431

Topic: 2. Trauma
A 43-year-old former professional hockey player reports severe pain in his chest after being checked from the side in a pick-up hockey game. An MRI scan and plain radiographs are shown in Figures 25a through 25c. What is the most likely diagnosis?
. Anterior sternoclavicular joint dislocation
. Posteroinferior sternoclavicular joint dislocation
. Anterior acromioclavicular joint dislocation
. Posterior acromioclavicular joint dislocation
. Acromial fracture

Correct Answer & Explanation

. Anterior sternoclavicular joint dislocation

Explanation

Anterior dislocation is the most common type of sternoclavicular dislocation. The medial end of the clavicle is displaced anterior or anterosuperior to the anterior margin of the sternum. The serendipity view can show this dislocation, as will CT of the chest. An anterior sternoclavicular joint dislocation will appear superiorly displaced, while a posterior sternoclavicular joint dislocation is inferiorly displaced on the serendipity view.

Question 5432

Topic: 2. Trauma

A 100-lb 9-year-old boy has a closed midshaft transverse femoral fracture. The oblique fracture is shortened by 3 cm with a 10-degree varus angulation. Surgical management consists of intramedullary, retrograde flexible titanium nailing. To optimize fracture stability, the surgeon should

. insert the largest diameter nails possible.
. place asymmetric nails, with the smaller nail placed medially.
. impact the distal ends of the nail into the medullary canal.
. open the fracture to permit anatomic alignment.
. apply a hinged knee orthosis.

Correct Answer & Explanation

. insert the largest diameter nails possible.

Explanation

The technique of intramedullary nailing with titanium elastic nails is based on the concept of balanced forces across the fracture site with two equally sized nails. Implantation of the largest sized nails possible, with two equally sized nails, maximizes the stiffness at the fracture site, thereby optimizing fracture alignment and stability. Impacting the nails into the medullary canal can impact the fixation by minimizing distal purchase of the nail at the cortical insertion site. Closed reduction commonly permits bony reduction and passage of the nails; open reduction is reserved for inability to align the fracture. Luhmann SJ, Schootman M, Schoenecker PL, et al: Complications of titanium elastic nails for pediatric femur fractures. J Pediatr Orthop 2003;23:443-447. Lascombes P, Haumont T, Journeau P: Use and abuse of flexible intramedullary nailing in children and adolescents. J Pediatr Orthop 2006;26:827-834.

Question 5433

Topic: Upper Extremity Trauma

A 27-year-old professional baseball pitcher who underwent arthroscopic olecranon debridement continues to have medial-sided elbow pain during late cocking. Physical examination reveals laxity and pain with valgus stress testing. What is the most likely cause of his pain?

. Ulnar neuritis
. Excessive olecranon resection
. Osteochondritis dissecans of the capitellum
. Olecranon stress fracture
. Valgus extension overload

Correct Answer & Explanation

. Excessive olecranon resection

Explanation

Both the medial collateral ligament and the olecranon contribute to valgus stability of the elbow. Excessive olecranon resection increases the demand placed on the medial collateral ligament in resisting valgus forces during throwing. Bone removal from the olecranon should be limited to osteophytes. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 101-111.

Question 5434

Topic: 2. Trauma

A 24-year-old woman who has hypotension, a head injury, and who experienced a poor response to resuscitation has been taken to the operating room for a splenectomy. Following abdominal surgery she remains unstable with increasing pulmonary respiratory pressures and decreasing oxygen saturation. She has a transverse mid-diaphyseal fracture of the tibia with a 4-cm laceration and soil-contaminated muscle in the wound. Based on these findings, management should consist of

. debridement and locked intermedullary nailing.
. debridement and plate fixation.
. debridement and external fixation.
. debridement and traction.
. skeletal traction.

Correct Answer & Explanation

. debridement and external fixation.

Explanation

Because the patient is critically ill and requires expeditious care, stabilization of the long bone fracture is required, but definitive care of the fracture should be postponed. The treatment of choice at this time is irrigation with 12 L of saline solution, followed by debridement and nondefinitive stabilization with a simple four-pin external frame to regain axial and rotational alignment. When the patient's condition is more stable, more definitive care can be performed. Bosse MJ, Kellam JF: Orthopaedic management decisions in the multiple trauma patient, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 151-164. Weresh MJ, Stover MD, Bosse MJ, Jeray K, Kellam JF: Pulmonary gas exchange during intramedullary fixation of femoral shaft fractures. J Trauma 1999;46:863-868.

Question 5435

Topic: 2. Trauma

A 45-year-old man who is a smoker has a significant hemothorax and bilateral closed femoral fractures. On insertion of a chest tube, 1,100 mL of blood was returned. He has had 75 mL of chest tube output over the last 2 hours while being resuscitated in the ICU. His base deficit is now 2 and his urine output has been 3 mL/kg over the last hour. What is the next most appropriate step in management?

Trauma 2009 Practice Questions: Set 1 (Solved) - Figure 18

. Continued skin traction
. Skeletal traction of both femurs
. External fixation of both femurs
. Intramedullary nailing of one femur and external fixation and delayed nailing for the other femur
. Intramedullary nailing of both femurs

Correct Answer & Explanation

. Intramedullary nailing of both femurs

Explanation

Although this patient had a hemothorax, the bleeding has stopped and he has been resuscitated to a euvolemic status with a small base deficit and good urine output. External fixation of both femurs is an option but an unnecessary step in the treatment algorithm. Nork SE, Agel J, Russell GV, et al: Mortality after reamed intramedullary nailing of bilateral femur fractures. Clin Orthop Relat Res 2003;415:272-278.

Question 5436

Topic: 2. Trauma

An 18-year-old man sustained closed humeral shaft and forearm fractures of his dominant arm in a motor vehicle accident. Neurovascular examination is intact, and his condition is stable. The best course of action for management of the injuries should be

Shoulder Board Review 2002: High-Yield MCQs (Set 2) - Figure 9

. external fixation of the forearm fracture and functional bracing of the humeral shaft fracture.
. external fixation of both fractures.
. open reduction and internal fixation of both fractures.
. open reduction and the internal fixation of the forearm fracture and functional bracing of the humeral shaft fracture.
. application of a long arm cast.

Correct Answer & Explanation

. open reduction and internal fixation of both fractures.

Explanation

Fractures above and below the elbow constitute floating elbow injuries and are best treated with internal fixation to allow early range of motion and to prevent elbow stiffness. Use of a long arm cast would promote elbow stiffness. External fixation is indicated primarily for open injuries. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Question 5437

Topic: 2. Trauma

A 42-year-old woman with a long-standing history of rheumatoid arthritis undergoes total shoulder arthroplasty for persistent pain that has failed to respond to nonsurgical management. Intraoperative radiographs reveal an oblique, minimally displaced fracture of the greater tuberosity. Based on these findings, what is the best course of action?

Upper Extremity 2005 Practice Questions: Set 3 (Solved) - Figure 1

. Discontinue the procedure and delay completion of the total arthroplasty until the fracture has healed.
. Cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.
. Remove all instrumentation, perform an open reduction and internal fixation of the fracture, and delay completion of the total arthroplasty until the fracture has healed.
. Insert a standard humeral component and apply a humeral orthosis postoperatively.
. Insert a standard humeral prosthesis with suture fixation and autogenous cancellous bone grafting of the greater tuberosity fracture.

Correct Answer & Explanation

. Insert a standard humeral prosthesis with suture fixation and autogenous cancellous bone grafting of the greater tuberosity fracture.

Explanation

The risk of intraoperative fracture in osteoporotic bone in patients with rheumatoid arthritis is significant. Fractures most often occur during humeral head dislocation and positioning for canal reaming. If the fracture occurs at the greater tuberosity, cerclage suture fixation of the tuberosity fracture with autogenous cancellous bone graft from the resected humeral head is the treatment of choice. Wright TW, Cofield RH: Humeral fractures after shoulder arthroplasty. J Bone Joint Surg Am 1995;77:1340-1346. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 215-225.

Question 5438

Topic: 2. Trauma

Figure 35 shows the radiograph of a 12-year-old boy who fell off a snowmobile and landed on his left shoulder. He has a closed injury. Management should consist of

Trauma 2006 Practice Questions: Set 3 (Solved) - Figure 15

. a shoulder spica cast.
. closed reduction and percutaneous pinning.
. open reduction to remove the interposed soft tissue.
. a shoulder sling, followed by repeat radiographs to document fracture position.
. open reduction and internal fixation with a 90-degree blade plate.

Correct Answer & Explanation

. a shoulder sling, followed by repeat radiographs to document fracture position.

Explanation

Proximal humeral fractures in children are classified as metaphyseal or Salter-Harris type I or II fractures, and most of these fractures are treated with closed methods. Eighty percent of the growth of the humerus comes from the proximal physis; therefore, tremendous remodeling potential is present. Indications for open reduction include open fractures or severely displaced fractures in adolescents with minimal growth remaining. Acceptable limits of reduction in adolescent proximal humeral fractures include bayonet apposition and angulation of less than 35 degrees. Common blocks to reduction in adolescents include the biceps tendon and periosteum. For this fracture, use of a shoulder sling without reduction will lead to healing and an excellent result as the proximal humerus remodels. Kohler R, Trillaud JM: Fracture and fracture separation of the proximal humerus in children: Report of 136 cases. J Pediatr Orthop 1983;3:326-332. Beaty JH: Fractures of the proximal humerus and shaft in children. Instr Course Lect 1992;41:369-372. Dobbs MB, Luhmann SL, Gordon JE, et al: Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop 2003;23:208-215. Beringer DC, Weiner DS, Noble JS, et al: Severely displaced proximal humeral epiphyseal fractures: A follow-up study. J Pediatr Orthop 1998;18:31-37.

Question 5439

Topic: 2. Trauma

A 28-year-old man was shot in the foot with a .22 caliber handgun approximately 2 hours ago. Examination reveals an entrance wound dorsally and a plantar exit wound. The foot is neurovascularly intact. Radiographs reveal a nondisplaced fracture of the third metatarsal. Soft-tissue management for this injury should consist of

. surface debridement and pulsatile lavage.
. wide debridement and internal fixation.
. extensive prophylactic compartment fasciotomy.
. immediate arteriography.
. observation and IV antibiotics for 7 weeks.

Correct Answer & Explanation

. surface debridement and pulsatile lavage.

Explanation

The patient has sustained a low-velocity, low-caliber gunshot wound to the foot. Because the injury occurred within a period of 8 hours, this is classified as a type I wound. Several studies support the use of surface debridement, cleansing, and sterile dressings as the treatment of choice. More aggressive measures are reserved for high-velocity injuries and shotgun injuries. Brettler D, Sedlin ED, Mendes DG: Conservative treatment of low velocity gunshot wounds. Clin Orthop 1979;140:26-31. Hampton OD: The indications for debridement of gunshot bullet wounds of the extremities in civilian practice. J Trauma 1961;1:368-372.

Question 5440

Topic: 2. Trauma

An 11-year-old boy stepped on a nail and sustained a puncture to the right forefoot 6 days ago. He was wearing tennis shoes at the time of injury. Treatment in the emergency department consisted of local debridement and tetanus prophylaxis; a radiograph was negative for foreign body, chondral defect, or fracture. He was discharged with a 3-day prescription of amoxicillin and clavulanate. The patient now has increasing pain and tenderness at the puncture site. What is the best course of action?

. Change the antibiotic to ciprofloxacin
. Initiate gentamicin
. Resume the prescription for amoxicillin and clavulanate
. Observation and follow-up in 48 hours
. Surgical debridement

Correct Answer & Explanation

. Surgical debridement

Explanation

The initial treatment consisting of oral antibiotics was appropriate but with progressive symptoms, surgical debridement is necessary. Ciprofloxacin is contraindicated in children, and at this stage, oral antibiotics are inadequate. Intravenous antibiotics may be necessary, but surgical debridement is paramount. Failure to respond to the initial management precludes further observation. Riegler HP, Routson T: Complications of deep puncture wounds of the foot. J Trauma 1979;19:18-22.

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