Menu

Pediatric Upper Extremity & Spine MCQs

Practice Set 8 of 33

This practice set contains high-yield board review questions covering key concepts in Pediatric Upper Extremity & Spine. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 141

Topic: Pediatric Upper Extremity & Spine

A junior resident, eager to proceed with surgery, bypasses a thorough radiographic analysis and detailed preoperative planning for a patient with a tibial deformity, relying instead on intraoperative fluoroscopy for guidance. Based on Paley's principles, what is the most likely consequence of this approach?

. A. Faster surgical time and reduced patient exposure to radiation.
. B. A higher chance of achieving perfect alignment due to real-time adjustments.
. C. Increased risk of iatrogenic deformities and potential surgical failure.
. D. Improved patient satisfaction due to quicker recovery.
. E. Elimination of the need for external fixators.

Correct Answer & Explanation

. C. Increased risk of iatrogenic deformities and potential surgical failure.

Explanation

Correct Answer: CThe text emphasizes the critical importance of preoperative planning: "Before a single incision is made or a pin is driven, the deformity must be precisely defined. Rushing this diagnostic step is akin to setting sail without a map—the final destination will be left entirely to chance, and the patient will bear the consequences." Ignoring meticulous planning significantly increases the risk of surgical errors, leading to iatrogenic deformities and ultimately surgical failure.Option Ais incorrect; while surgical time might seem faster initially, complications from inadequate planning can prolong overall treatment and recovery. Relying solely on intraoperative fluoroscopy might also increase radiation exposure compared to well-planned, efficient surgery.Option Bis incorrect; real-time adjustments without a clear geometric plan are prone to error and are unlikely to achieve perfect alignment, especially in complex deformities.Option Dis incorrect; surgical failure and iatrogenic deformities would lead to worse patient outcomes and prolonged recovery, not improved satisfaction.Option Eis incorrect; preoperative planning is independent of the choice of fixation method (external vs. internal) and does not eliminate the need for an external fixator if it is indicated for the correction.

Question 142

Topic: Pediatric Upper Extremity & Spine

A full-length standing radiograph of a patient, similar to , reveals that the mechanical axis passes 20 mm medial to the center of the knee joint. According to Paley's principles, what type of overall limb deformity does this finding represent?

. A. Neutral alignment.
. B. Valgus deformity.
. C. Varus deformity.
. D. Recurvatum deformity.
. E. Antecurvatum deformity.

Correct Answer & Explanation

. C. Varus deformity.

Explanation

Correct Answer: CThe text clearly defines: "A lateral deviation of the axis from the knee center indicates a valgus deformity... while a medial deviation indicates a varus deformity." A deviation of 20 mm medial to the knee center is a significant medial deviation, characteristic of a varus deformity (bow-legged).Option Ais incorrect; neutral alignment is typically 8-10mm medial to the tibial spine, not 20mm medial.Option Bis incorrect; a valgus deformity would be indicated by a lateral deviation of the mechanical axis.Options D and Eare incorrect; recurvatum and antecurvatum refer to sagittal plane deformities (hyperextension or flexion), whereas mechanical axis deviation describes coronal plane alignment.

Question 143

Topic: Pediatric Upper Extremity & Spine

A surgeon is performing a closing wedge osteotomy to correct a 25-degree distal femoral recurvatum deformity. Intraoperative fluoroscopy, as shown, demonstrates the closure of the posterior wedge while preserving the anterior cortex. This technique is a direct application of Paley's Osteotomy Rule One. What is the primary biomechanical advantage of preserving the anterior cortex as an intact hinge in this specific scenario?

. A. It facilitates easier bone graft placement in the posterior gap.
. B. It allows for controlled limb lengthening during correction.
. C. It provides immense intrinsic stability, dictates the sagittal plane of correction, and prevents unwanted translation.
. D. It minimizes blood loss by preserving the anterior vascular supply to the femur.
. E. It enables the use of an external fixator without the need for internal fixation.

Correct Answer & Explanation

. C. It provides immense intrinsic stability, dictates the sagittal plane of correction, and prevents unwanted translation.

Explanation

Correct Answer: CThe case explicitly highlights the critical technical pearl of preserving the anterior cortex as an 'intact cortical hinge' during a closing wedge osteotomy for distal femoral recurvatum. This maneuver is crucial because it effectively places the Axis of Correction of Angulation (ACA) directly at the anterior cortex. Since the CORA for this deformity is also located at the anterior cortex, this perfectly satisfies Paley's Osteotomy Rule One. The biomechanical advantage is immense: the intact hinge provides intrinsic stability, dictates the precise sagittal plane of correction, and actively prevents unwanted translation, rotation, or excessive shortening during the closure of the wedge. This ensures a pure angular correction without iatrogenic translation.Option Ais incorrect. While bone graft might be used in some osteotomies, the primary purpose of the cortical hinge is not to facilitate graft placement, and closing wedges typically don't require grafting in the same way opening wedges do.Option Bis incorrect. Closing wedge osteotomies inherently cause some limb shortening, not lengthening. Lengthening is associated with opening wedge osteotomies or distraction osteogenesis.Option Dis incorrect. While preserving soft tissues is generally good for vascularity, the primary biomechanical role of the cortical hinge is mechanical stability and controlled correction, not solely blood loss reduction.Option Eis incorrect. The cortical hinge provides stability to the osteotomy itself, but it does not negate the need for appropriate internal or external fixation to maintain the correction and allow for healing.

Question 144

Topic: Pediatric Upper Extremity & Spine

A 40-year-old patient with a history of distal femoral trauma presents with a gait abnormality. A weight-bearing lateral radiograph is obtained. The sagittal mechanical axis, represented by a plumb line from the center of the femoral head, passes significantly posterior to the center of the knee joint. Based on the case description, what does this finding indicate?

. A. Normal sagittal alignment, as the mechanical axis should pass posterior to the knee.
. B. Proximal femoral procurvatum, causing the knee to shift anteriorly.
. C. Distal femoral recurvatum, where the knee joint is positioned posterior to the mechanical plumb line.
. D. Tibial procurvatum, causing the knee to shift posteriorly.
. E. A compensatory ankle equinus deformity, unrelated to femoral alignment.

Correct Answer & Explanation

. C. Distal femoral recurvatum, where the knee joint is positioned posterior to the mechanical plumb line.

Explanation

Correct Answer: CThe case explicitly defines the sagittal mechanical axis: 'In a normally aligned lower limb, this mechanical plumb line passes directly through the center of the knee joint and falls slightly anterior to the ankle joint center.' It then states, 'When the distal femur is deformed into recurvatum, the knee joint is positioned posterior to this plumb line.' Therefore, a sagittal mechanical axis passing significantly posterior to the center of the knee joint is a direct indication of distal femoral recurvatum.Option Ais incorrect, as normal alignment requires the mechanical axis to passthroughthe center of the knee, not posterior to it.Option Bis incorrect. Proximal femoral procurvatum would typically cause the knee to shift anteriorly relative to the mechanical axis, or lead to a flexion deformity.Option Dis incorrect. Tibial procurvatum would cause an apex anterior deformity of the tibia, which would tend to position the knee anteriorly relative to the mechanical axis, or cause a fixed flexion deformity.Option Eis incorrect. While compensatory ankle deformities can occur, the primary finding described (knee posterior to the mechanical axis) directly points to a femoral sagittal plane deformity.

Question 145

Topic: Pediatric Upper Extremity & Spine

A 30-year-old patient with a 25-degree distal femoral recurvatum deformity is scheduled for a closing wedge osteotomy. The CORA has been identified at the anterior cortex. To achieve a pure angular correction without translation, what is the correct geometric design for the resected bone wedge?

. A. A 25-degree wedge with its base anterior and apex posterior, located at the CORA.
. B. A 25-degree wedge with its base posterior and apex anterior, terminating precisely at the CORA on the anterior cortex.
. C. A 25-degree wedge with equal anterior and posterior resection, centered at the CORA.
. D. A 25-degree wedge with its base medial and apex lateral, to correct the sagittal plane deformity.
. E. A 25-degree wedge with its base lateral and apex medial, to correct the sagittal plane deformity.

Correct Answer & Explanation

. B. A 25-degree wedge with its base posterior and apex anterior, terminating precisely at the CORA on the anterior cortex.

Explanation

Correct Answer: BThe case describes the biomechanics of a closing wedge osteotomy for distal femoral recurvatum. Recurvatum is an apex posterior deformity, meaning the distal segment is tilted anteriorly. To correct this, the osteotomy must 'close' posteriorly. Therefore, the geometry of the wedge is dictated as follows: 'The base of the resected wedge is posterior. The apex of the resected wedge is anterior, terminating precisely at the CORA on the anterior cortex.' This design allows for the posterior gap to close, correcting the hyperextension, while the anterior cortex acts as the hinge, fulfilling Paley's Rule One for pure angular correction.Option Ais incorrect. A wedge with its base anterior and apex posterior would correct a procurvatum (flexion) deformity, not recurvatum.Option Cis incorrect. Equal anterior and posterior resection would not create a wedge for angular correction; it would primarily shorten the bone.Options D and Eare incorrect. Medial/lateral wedge resections are for frontal plane deformities (varus/valgus), not sagittal plane recurvatum.

Question 146

Topic: Pediatric Upper Extremity & Spine

A 22-year-old patient presents with a distal femoral valgus deformity and an associated external rotation of the distal segment. The surgeon plans a supracondylar femoral osteotomy. Considering the unique biomechanics of distal femoral deformities compared to proximal femoral deformities, which statement accurately describes the surgical approach to simultaneous angulation and rotation correction in this specific scenario?

. Simultaneous correction is highly complex and generally avoided due to significant bone end translation.
. The mechanical axis lies far medial to the bone, necessitating compensatory angular cuts for rotation.
. The mechanical and anatomic axes converge distally, making simultaneous correction geometrically simpler with less translation.
. Rotation must always be corrected first, followed by angular correction, regardless of the femoral segment.
. The illusion of femoral neck length changes is a major confounding factor in distal femoral osteotomies.

Correct Answer & Explanation

. The mechanical and anatomic axes converge distally, making simultaneous correction geometrically simpler with less translation.

Explanation

Correct Answer: CThe case states under 'The Simplicity of Distal Femoral Osteotomies': 'In stark contrast to the proximal femur, distal femoral osteotomies are far more forgiving. As the mechanical axis travels distally down the leg, it naturally converges with the anatomic axis, eventually meeting at the exact center of the knee joint. A supracondylar femoral osteotomy is therefore performed at a level where the mechanical and anatomic axes are very close together or entirely coincident. Because the mechanical axis passes directly through or very near the distal osteotomy site, acute derotation around the mechanical axis does not cause significant translation or gapping of the bone ends. This anatomic reality makes the simultaneous correction of angulation and rotation in the distal femur a much simpler geometric and surgical endeavor compared to the proximal femur.'Option A is incorrectbecause the text explicitly states it is 'much simpler' and 'far more forgiving' in the distal femur due to axis convergence.Option B is incorrectbecause the mechanical axis converges with the anatomic axis distally, unlike the proximal femur where it lies far medial.Option D is incorrectbecause while angulation first, then rotation is a general principle, the distal femur's unique biomechanics allow for simpler simultaneous correction, as described.Option E is incorrectbecause the illusion of femoral neck length changes is specific to the proximal femur and its neck, not relevant for distal femoral osteotomies.

Question 147

Topic: Pediatric Upper Extremity & Spine

A surgeon is evaluating a post-traumatic supracondylar femoral malunion. The Lateral Distal Femoral Angle (mLDFA) is measured using the mechanical axis of the femur. If the surgeon decides to use the anatomic axis of the femur instead to calculate the distal femoral joint orientation, what is the corresponding normal anatomic angle (aLDFA)?

. 87 degrees
. 81 degrees
. 93 degrees
. 99 degrees
. 75 degrees

Correct Answer & Explanation

. 87 degrees

Explanation

The normal mechanical LDFA (mLDFA) is approximately 87 degrees. Because the anatomic axis of the femur is in about 7 degrees of valgus relative to the mechanical axis, the normal anatomic LDFA (aLDFA) is approximately 81 degrees (87 - 6 to 7 degrees).

Question 148

Topic: Pediatric Upper Extremity & Spine

A surgeon is planning a complex femoral osteotomy to correct a valgus deformity. When drawing the axes to identify the CORA, which of the following statements accurately reflects the Paley principles regarding the choice of axes for the femur compared to the tibia?

. For both the femur and tibia, the anatomic and mechanical axes are essentially parallel and can be used interchangeably.
. For the femur, the anatomic axis and mechanical axis diverge significantly, and consistency (e.g., using mechanical axes throughout) is paramount.
. For the tibia, the anatomic axis and mechanical axis diverge significantly, requiring careful selection.
. The mechanical axis is only used for the tibia, while the anatomic axis is always used for the femur.
. The choice of axis (anatomic vs. mechanical) is irrelevant for planning femoral osteotomies.

Correct Answer & Explanation

. For the femur, the anatomic axis and mechanical axis diverge significantly, and consistency (e.g., using mechanical axes throughout) is paramount.

Explanation

Correct Answer: BThe text clearly states: 'Femur: The anatomic axis and mechanical axis of the femur diverge significantly (typically by about 7 degrees). The anatomic axis is the mid-diaphyseal line, while the mechanical axis runs from the center of the femoral head to the center of the knee. Consistency is paramount: if you start your planning with mechanical axes, you must finish with mechanical axes. Mixing the two will lead to catastrophic planning errors.'Option Ais incorrect because it misrepresents the relationship between femoral anatomic and mechanical axes.Option Cis incorrect because it misrepresents the relationship for the tibia; for the tibia, the anatomic and mechanical axes are essentially parallel.Option Dis incorrect as both axes can be used for both bones, but with specific considerations for the femur.Option Eis incorrect; the choice of axis is highly relevant and critical for accurate planning, especially in the femur.

Question 149

Topic: Pediatric Upper Extremity & Spine

A resident, while planning an osteotomy, mistakenly places the physical hinge (ACA) along the Longitudinal Bisector Line (lBL) but not at the CORA, as illustrated in the diagram. What will be the biomechanical consequence of performing the osteotomy and rotating the bone fragments around this incorrectly placed hinge?

. Perfect collinear realignment of the bone axes without any translation.
. Pure translation of the bone's axes without any change in length.
. Significant lengthening of the bone with associated translation.
. Significant shortening of the bone with associated translation.
. An unpredictable combination of angulation, translation, and rotation.

Correct Answer & Explanation

. Pure translation of the bone's axes without any change in length.

Explanation

Correct Answer: BThe text explicitly states regarding the Longitudinal Bisector Line (lBL): 'If a hinge is placed anywhere on the lBL (and off the CORA), rotating the bone fragments will result in pure translation—the axes will become parallel but will never become collinear.Movement of the ACA along the lBL leads to translation of the bone's axes without change in length.' This is typically an error to be avoided in frontal plane angular realignment.Option Ais incorrect; this outcome is achieved when the hinge is placed on the tBL, ideally at the CORA.Options C and Dare incorrect; while length changes can occur with hinge placement off the CORA along the tBL, hinging on the lBL primarily causes translation without length change.Option Eis too general; the specific consequence of hinging on the lBL is pure translation.

Question 150

Topic: Pediatric Upper Extremity & Spine

A surgeon is performing a corrective osteotomy for a complex lower extremity deformity. The ultimate goal is to achieve perfect, collinear realignment of the bone's mechanical axis. According to the Paley principles, which of the following scenarios, as depicted in the diagram, represents the ideal spatial relationship between the planned correction and its execution?

. The Axis of Correction of Angulation (ACA) is placed parallel to the CORA.
. The osteotomy cut is made at the CORA, and the ACA is placed distal to it.
. The ACA passes directly through the CORA.
. The CORA is located on the Transverse Bisector Line (tBL), and the ACA is placed on the Longitudinal Bisector Line (lBL).
. The ACA is placed on the convex side of the deformity, regardless of the CORA location.

Correct Answer & Explanation

. The ACA passes directly through the CORA.

Explanation

Correct Answer: CThe text states: 'The ideal surgical scenario, as meticulously depicted above, occurs when theACA passes directly through the CORA. When this geometric condition is met, the correction will result in perfect, collinear realignment of the bone's mechanical or anatomic axes. This specific, optimized point, where the planned axis and actual axis of correction meet, is termed theACA-CORA.'Option Ais incorrect; parallel placement would result in translation.Option Bis incorrect; the ACA is the hinge, not necessarily the cut, and its relationship to the CORA is key.Option Dis incorrect; placing the ACA on the lBL would result in translation, not collinear realignment.Option Eis incorrect; while ACA placement on the convex side can achieve an opening wedge, the ideal relationship for perfect collinear realignment without translation is when the ACA passes through the CORA.

Question 151

Topic: Pediatric Upper Extremity & Spine

A 16-year-old undergoes a supracondylar femoral osteotomy for a valgus deformity. The surgeon places the hinge (axis of rotation) at the medial cortex of the distal femur, which is NOT located at the CORA. What is the expected outcome of this correction according to Paley's Rule 3?

. Perfect colinear alignment of the mechanical axis
. Angulation correction with a resulting translation deformity
. Pure translation correction without angulation
. Complete correction of the joint line convergence angle
. Overcorrection into severe varus

Correct Answer & Explanation

. Angulation correction with a resulting translation deformity

Explanation

According to Paley's Osteotomy Rule 3, if both the axis of rotation (hinge) and the osteotomy are placed away from the CORA, angulation will occur, but a secondary translation deformity will be introduced. The mechanical axes will end up parallel rather than colinear.

Question 152

Topic: Pediatric Upper Extremity & Spine

A 7-year-old male presents to the emergency department after falling from monkey bars onto an outstretched right hand. Clinical examination reveals marked diffuse swelling over the right elbow, predominantly on the lateral aspect, with significant tenderness over the lateral epicondyle. Active and passive range of motion are severely restricted and painful. Initial standard AP and lateral radiographs are equivocal for the extent of displacement and articular involvement of a suspected lateral condyle fracture. Given the high clinical suspicion, an additional radiograph is obtained, as shown below:

Which of the following statements best describes the utility of this specific radiographic view in this clinical scenario?

. It is primarily used to assess for supracondylar humerus fractures and associated neurovascular compromise.
. It provides a clearer view of the olecranon fossa, aiding in the diagnosis of olecranon fractures.
. It places the lateral condyle in profile, removing superimposition of the radial head and ulna, and is highly sensitive for detecting subtle displacement.
. It is the preferred view for evaluating medial epicondyle avulsion fractures and assessing ulnar nerve entrapment.
. It is most useful for identifying subtle radial head subluxation or dislocation in pediatric patients.

Correct Answer & Explanation

. It places the lateral condyle in profile, removing superimposition of the radial head and ulna, and is highly sensitive for detecting subtle displacement.

Explanation

Correct Answer: CThe image provided is an internal oblique radiograph of the elbow. As detailed in the teaching case, this view is crucial in pediatric elbow trauma, particularly for assessing lateral condyle fractures. It is obtained by internally rotating the arm 45 degrees, which places the lateral condyle in profile and removes the superimposition of the ulna and radial head. This specific projection is highly sensitive for detecting gap formation at the posterior aspect of the lateral metaphysis, often the first sign of displacement, and unequivocally demonstrates the true extent of the fracture line and any subtle displacement or rotation that might be missed on standard AP and lateral projections.Option A is incorrect:While supracondylar fractures are common, this view is not primarily for their assessment or neurovascular compromise, which is a clinical finding.Option B is incorrect:The internal oblique view is not specifically designed to visualize the olecranon fossa or diagnose olecranon fractures.Option D is incorrect:Medial epicondyle fractures are best assessed on standard AP and lateral views, sometimes with an external oblique view, but not typically the internal oblique. Ulnar nerve entrapment is a clinical diagnosis.Option E is incorrect:Radial head subluxation (nursemaid's elbow) is a clinical diagnosis, and while radial head dislocations can be seen on standard views, the internal oblique is not the primary view for this assessment.

Question 153

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from a trampoline and sustains a Gartland Type III supracondylar humerus fracture. On initial examination, the hand is pink and warm, but the radial pulse is not palpable. What is the most appropriate next step in management?
. Immediate open vascular exploration
. Emergent CT angiography
. Closed reduction and percutaneous pinning, followed by reassessment of the pulse
. Fasciotomy of the forearm
. Administration of systemic thrombolytics

Correct Answer & Explanation

. Closed reduction and percutaneous pinning, followed by reassessment of the pulse

Explanation

In a patient with a 'pulseless but pink' (well-perfused) hand following a supracondylar fracture, the first step is urgent closed reduction and percutaneous pinning. The pulse often returns after fracture reduction relieves kinking or compression of the brachial artery.

Question 154

Topic: Pediatric Upper Extremity & Spine
A 4-year-old girl is evaluated for elbow pain after a fall. Radiographs demonstrate a supracondylar humerus fracture. The anterior humeral line passes anterior to the capitellum, but the posterior humeral cortex remains intact. According to the Gartland classification, what type of fracture is this?
. Type I
. Type II
. Type III
. Type IV
. Flexion Type

Correct Answer & Explanation

. Type II

Explanation

A Gartland Type II supracondylar humerus fracture is defined as an extended and displaced fracture with an intact posterior cortical hinge. The anterior humeral line characteristically passes anterior to the middle third of the capitellum.

Question 155

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from the monkey bars and sustains an extension-type Gartland Type III supracondylar humerus fracture. Upon physical examination, which of the following nerve injuries is most likely to be identified?
. Ulnar nerve
. Radial nerve
. Anterior interosseous nerve
. Musculocutaneous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. It is a motor branch of the median nerve, and injury typically presents as an inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (the 'OK' sign).

Question 156

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents to the emergency department after falling from a trampoline. Radiographs reveal a Gartland Type III supracondylar humerus fracture. The distal fragment is displaced posterolaterally. Based on this specific displacement pattern, which of the following nerve deficits is most likely to be present on examination?
. Inability to extend the metacarpophalangeal joints of the fingers
. Decreased sensation over the dorsal first web space
. Inability to cross the index and middle fingers
. Inability to flex the interphalangeal joint of the thumb
. Inability to flex the distal interphalangeal joint of the small finger

Correct Answer & Explanation

. Inability to flex the interphalangeal joint of the thumb

Explanation

In a posterolaterally displaced extension-type supracondylar humerus fracture, the proximal fragment is driven anteromedially, placing the anterior interosseous nerve (AIN) and median nerve at highest risk. AIN palsy presents as the inability to flex the IP joint of the thumb and the DIP joint of the index finger (positive OK sign).

Question 157

Topic: Pediatric Upper Extremity & Spine
A 4-year-old girl falls from monkey bars. Radiographs of the elbow reveal a fracture of the distal humerus. The anterior humeral line passes completely anterior to the capitellum, indicating posterior displacement of the distal fragment, but the posterior cortex remains intact, functioning as a hinge. What is the correct Gartland classification for this fracture?
. Gartland Type I
. Gartland Type II
. Gartland Type III
. Gartland Type IV
. Milch Type II

Correct Answer & Explanation

. Gartland Type II

Explanation

The Gartland classification describes pediatric extension-type supracondylar humerus fractures. A Type II fracture is displaced (evidenced by the anterior humeral line passing anterior to the capitellum) but maintains an intact posterior cortical hinge.

Question 158

Topic: Pediatric Upper Extremity & Spine
During intraoperative fluoroscopic evaluation of a reduced Gartland Type III supracondylar humerus fracture, the surgeon measures Baumann's angle on the anteroposterior (AP) view. What post-traumatic deformity is this measurement primarily designed to assess and prevent?
. Cubitus valgus
. Cubitus varus
. Recurvatum deformity
. Flexion contracture
. Pronation deformity

Correct Answer & Explanation

. Cubitus varus

Explanation

Baumann's angle (the angle between the longitudinal axis of the humerus and the physeal line of the capitellum) is critical for assessing coronal plane alignment. Failure to restore an appropriate Baumann's angle frequently results in a cubitus varus (gunstock) deformity.

Question 159

Topic: Pediatric Upper Extremity & Spine
A 7-year-old boy presents to the ED with visible right elbow deformity after a fall on the playground. His injury films are shown in figures A and B. The injury is closed, and there is a palpable radial pulse with a well-perfused hand. He undergoes multiple attempts at closed reduction and percutaneous pinning with 3 lateral pins in the operating room. Final radiographs show some gapping at the fracture site. At the end of the case, the radial pulse is no longer palpable and the hand appears pale. What is the next best step in management?
. Place a medial pin to further stabilize the fracture
. Remove all of the pins and displace the fracture
. Obtain an emergent CT angiogram to assess arterial flow
. Explore the artery
. Splint the arm in extension as the fracture is now stabilized

Correct Answer & Explanation

. Remove all of the pins and displace the fracture

Explanation

The patient has a type III supracondylar humerus fracture that lost a palpable radial pulse after closed reduction. Due to continued gapping at the fracture site, the next best step is to remove the pins, displace the fracture, and reassess perfusion as the brachial artery was likely interposed in the fracture site during the reduction maneuver. The management of supracondylar humerus fractures is dictated significantly by the neurovascular examination. Loss of pulse and a pale, cool hand warrants emergent closed reduction and percutaneous pinning. If the vascular status does not change, open exploration is warranted. When a hand becomes pulseless and cool after reduction, it is typically due to the brachial artery being interposed in the fracture site. Undoing the reduction can often help. If there is still evidence of vascular compromise, open exploration is warranted.

Question 160

Topic: Pediatric Upper Extremity & Spine
  • The Injury Severity Score (ISS), using point scores from five different body systems, is a method that aids in predicting the chances of mortality in a patient with multiple injuries by
. adding the scores, in all five body systems
. adding the squares of the scores in the three most severely injured systems
. doubling the cumulative score for head and chest injuries
. combining the scores from the most and least injured systems
. correcting the score in the most severely injured system for age

Correct Answer & Explanation

. adding the scores, in all five body systems

Explanation

The Abbreviated Injury Scale (AIS) is made up of scores from 5 body systems (head/neck, face, chest, abdomen, extremity/pelvis) graded from 1 minor to 5 critical. The ISS is the sum of the squares of the highest AIS grade in each of the three most severely injured areas. The AIS pertains to individual injuries. The ISS is used for multiple injuries. Using the ISS dramatically increased the correlation between severity of injury and mortality.

Test Yourself

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

On this Page