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OITE Review

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Title: OITE Review


1
OITE Review
  • Selected by
  • Waleed Awwad, MD, FRCSC

2
1997
3
  • Year1997 Question 7
  • Figure 2 shows the lateral radiograph of the left
    hindfoot and ankle of a patient who fell 10 feet
    and landed on his left foot. The most predictable
    advantage of open reduction and internal fixation
    compared with closed management without reduction
    is
  • a. an earlier return to function.
  • b. decreased subtalar range arthrosis.
  • c. increased ankle dorsiflexion.
  • d. increased subtalar range of motion.
  • e. restoration of height and width of the heel.

4
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5
  • Correct Answer e
  • Explanation Remember, when the calcaneus
    fractures it loses height, widens, shortens, and
    falls into varus. None of the first four answers
    are very "predictable" and thats what they ask
    for. In butress plating, you can restore much of
    the height and width

6
  • Year1997 Question 10
  • What is the most appropriate biomechanical
    fixation method/device for a reverse oblique
    intertrochanteric fracture?
  • a. Ender pins
  • b. Sliding hip screw
  • c. 95-degree fixed angle device
  • d. Cerclage wire with interfragmentary fixation
  • e. Medial displacement osteotomy with sliding hip
    screw

7
  • Correct Answer c
  • Too proximal for Enders. The fracture line would
    be parallel to a DHS screw so that would be bad
    AO fundamentals. Cerlage wiring and interfrags is
    a pretty weak construct. Medial
    displacementosteotomies (Fig.18-31 attached) are
    done mainly for intertrochs where the Gr. Troch
    is fractured off or where there is no
    posteromedial bone (calcar) continuity. There is,
    however, a "notching" that can be done to make a
    reverse intertroch more stable. (Fig. 18-25
    attached)

8
  • Year1997 Question
  • Figure 5a shows the radiograph of a 22-year-old
    man 3 years after undergoing reduction and
    fixation for a fracture of the radius and ulna
    with two plates secured with 4.5 mm screws. A
    postoperative radiograph after the plate removal
    is shown in Figure 5b. Which of the following
    factors increases the risk of re-fracture?
  • a. Young age
  • b. Incomplete healing
  • c. Use of a large plate
  • d. Bony overgrowth around the plate
  • e. Insufficient amount of time between fracture
    and plate removal

9
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10
  • Correct Answer c
  • Young age would decrease the risk (not 1).
    Theres no evidence of incomplete healing (npt
    2). They used 4.5 mm screws where a 3.5 mm would
    have been adequate. Bony overgrowth is evident
    and could potentially be a stress riser, but not
    nearly as much as those empty 4.5 mm screw holes
    (not 4). 3 years is plenty of time before plate
    removal can be done (not 5).

11
  • Year1997 Question 28
  • Figures 7a and 7b show the wound and radiograph
    of a 44-year-old man who underwent plating for a
    closed fracture of his tibia 7 months ago. The
    wound has been draining for 4 months, and
    cultures are positive for Staphylococcus aureus.
    In addition to antibiotics, metal removed, and
    debridement, treatment should include
  • a. electrical stimulation and casting.
  • b. soft-tissue coverage and re-plating with a
    bone graft.
  • c. bone grafting, soft-tissue coverage, and
    application of a cast.
  • d. external fixation, staged soft-tissue
    coverage, and bone grafting.
  • e. intramedullary rodding, staged soft-tissue
    coverage, and bone grafting.

12
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13
  • Correct Answer d
  • Osteomyelitis, or inflammation of the bone, can
    result from hematogenous seeding, from direct
    inoculation (ie, following open fractures or
    following open reduction and internal fixation of
    fractures), or from the contiguous spread of
    bacteria from infected structures. Early
    diagnosis and effective surgical and antibiotic
    management can control the infection suppression
    of its activity may last a lifetime. Basic
    treatment should include thorough debridement,
    irrigation, wound management (external fixation,
    staged soft-tissue coverage), and bone grafting.

14
  • Year1997 Question 32
  • Figures 10a and 10b show radiographs of a 27
    year-old woman who sustained an injury to her
    left, nondominant forearm as a result of a motor
    vehicle accident. Under anesthesia, it is noted
    that the distal radioulnar joint is unstable but
    reducible in supination. Treatment should include
  • a. closed reduction, followed by splint
    immobilization with the limb in supination.
  • b. closed reduction and external fixation of the
    radius, followed by splint immobilization with
    the limb in supination.
  • c. open reduction and external fixation of the
    radius, with fixation of the radioulnar joint.
  • d. open reduction and internal plate fixation of
    the radius, with fixation of the distal
    radioulnar joint.
  • e. open reduction and internal plate fixation of
    the radius, with immobilization of the distal
    radioulnar joint in supination.

15
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16
  • Correct Answer e
  • The Galeazzi eponym, originally defined as
    fracture of the distal third of the radial shaft
    with an associated dislocation of the distal
    radioulnar joint (DRUJ), has been applied when
    referring to a fracture anywhere along the radial
    shaft as well as to fractures to both radius and
    ulna that occur in conjunction with a DRUJ
    injury. Monteggia and Galeazzi lesions require
    anatomic reduction of the diaphyseal fracture
    component in order to restore the normal axial
    interrelationship of the forearm bones and allow
    reduction of the dislocation. Fracture fixation
    is accompanied best by plating. Residual
    instability of a reduced DRUJ after anatomic
    plating of the radius can usually be addressed by
    immobilizing the limb in supination for 6 weeks
    postoperatively. Temporary pin fixation of the
    DRUJ is rarely required. Cast immobilization
    after surgical treatment of closed, unstable
    single bone forearm injuries has not been shown
    to have any detrimental effect on functional
    outcome.

17
  • Year1997 Question 37
  • The incidence of vascular injury after an
    anterior knee dislocation is
  • a. less than 5.
  • b. 10 to 25.
  • c. 30 to 50.
  • d. 60 to 80
  • e. greater than 95.

18
  • Correct Answer c
  • Knee dislocation are classified relative to the
    position of the tibia, and there are five types.
    Anterior knee dislocation occur most frequently
    (40), followed by posterior (33), lateral
    (18), and other (5). The incidence of vascular
    injury after an anterior or posterior knee
    dislocation has been reported to be 20 - 35.
    (Most studies quote 30). Neurologic injuries
    most frequently involve the common peroneal nerve
    nerve because of its tethered proximity to the
    fibular head. Lateral and posterolateral
    dislocations are the most frequent causes of
    common peroneal nerve injury. Overall, incidence
    of neurologic injuries varies between 16 and
    40. Less than 50 of patients will have partial
    or complete recovery from a peroneal nerve.

19
  • Year1997 Question 40
  • A 45-year-old man sustains an injury to his
    pelvic ring as a result of a motor vehicle
    accident. Radiographs are shown in Figures 11a
    through 11c, and a CT scan is shown in Figure
    11d. Examination reveals that he is
    hemodynamically stable and has no associated
    injuries. Management should include
  • a. anterior sacroiliac plate fixation.
  • b. anterior fixation of the pubic symphysis.
  • c. posterior fixation of the left sacroiliac
    joint.
  • d. early mobilization and weight bearing without
    internal fixation.
  • e. combined anterior fixation to the pubic
    symphysis and posterior fixation of the left
    sacroiliac joint.

20
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21
  • Correct Answer b
  • Disruptions of the symphysis pubis are variable.
    The symphyseal ligaments, the pubic meniscus, and
    the arcuate ligament may be disrupted. For
    isolated disruptions of the symphysis pubis, most
    authors advocate closed, nonsurgical management,
    especially when the symphysis diastasis is less
    than 2.5 cm. In cases where the diastasis exceeds
    this limit, stabilization should be pursued.

22
  • Year1997 Question 41
  • Radiographs of a 24-year-old man who sustained an
    open tibial frature 11 months ago are shown in
    Figures 12a and 12b. Examination shows an
    anteromedial draining wound over the midtibia.
    Which of the following methods will most
    accurately identify the pathologic
    microorganisms?
  • a. Swab culture of the sinus tract
  • b. Operative sampling of the sinus tract
  • c. Operative sampling of the posterolateral
    sequestrum
  • d. Operative sampling of deep specimens from
    multiple foci
  • e. Needle aspiration of the distal tibial
    metaphyseal abscess

23
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24
  • Correct Answer d
  • In a recent study, pathogens that were identified
    on cultures of material obtained by swabbing of
    the superficial aspect of a wound and needle
    biopsy were compared with those that were
    isolated from material that was obtained at
    debridement. The cultures of material that was
    obtained by superficial swabbing of the wound and
    needle biopsy were inadequate for prediction of
    the presence of aerobic organisms. Moreover, the
    failure to isolate anaerobies from the material
    obtained by needle biopsy did not rule out the
    presence of anerobic organisms, nor does it rule
    out the possibility that osteomyelitis may be
    reactivated after intramedullary nailing with
    reaming. Therfore, tissue for culture of aerobic
    and anerobic organisms must be obtained during
    operative debridement in order to identify all
    pathogenic organisms. Other studies have shown
    that cultures must be taken from multiple sites
    in chronic osteomyelitis of long bones in order
    to properly treat all varieties of bacteria
    present.

25
  • Year1997 Question
  • A 37-year-old man who sustained a type IIIB open
    fracture of the middle third of the tibia after a
    severe crush injury has significant contusions
    and some necrosis of the posterior muscles.
    Treatment consists of debridement and external
    fixation. Which of the following muscle flaps
    should be used for soft-tissue coverage of the
    exposed anteromedial tibia?
  • a. Soleus
  • b. Fasciocutaneous
  • c. Medial gastrocnemius
  • d. Lateral gastrocnemius
  • e. Free vascularized muscle

26
  • Correct Answer e
  • Grade IIIB indicates initial soft-tissue loss and
    extensive areas of denuded bone that make later
    flap coverage necessary. All grade IIIB and many
    grade IIIC wounds require flap coverage. For the
    proximal third of the leg, such coverage is best
    achieved with a gastrocnemius flap a soleus flap
    will cover soft-tissue defects extending towards
    the mid-aspect of the tibia, but a free flap is
    required for more distal defects. If the solius
    or gastrocnemius muscles have been damaged, they
    are unsuitable for local coverage and a free flap
    must be substituted.

27
  • Year1997 Question 44
  • A previously active 36-year-old woman who
    fractured her right ankle 10 years ago and was
    treated with 6 weeks of cast immobilization now
    has had pain and swelling for the past year and
    is no longer able to play tennis or jog.
    Examination shows swelling and a 10-degree loss
    of dorsiflexion when compared with the normal,
    contralateral ankle. Radiographs show shortening
    of the fibula, widening of the ankle mortise,
    lateral tilt of the talus, and slight narrowing
    of the tibiotalar joint space. Treatment should
    include
  • a. ankle fusion.
  • b. osteotomy of the fibula.
  • c. deltoid ligament reconstruction.
  • d. a custom-made plastic shoe insert.
  • e. nonsteroidal anti-inflammatory drug therapy

28
  • Correct Answer b
  • Patients who had reconstructive surgery for a
    malunion of a displaced fracture of the fibula
    were evaluated. In these patients who had pain,
    swelling of the ankle, and stiffness at an
    average of six years after the injury, the
    malunions were classified radiographically as
    either occult or overt. An occult malunion was
    one in which the talus remained in its normal
    position, but the lateral malleolus showed
    residual displacement, characterized byexternal
    rotation and shortening. In an overt malunion,
    there were similar changes in the lateral
    malleolus to correct the external rotation and
    shortening, to reduce the lateral subluxation or
    the anterior aspect of the tibiofibular joint,
    and to restore the stability of the talus.

29
  • Year1997 Question 61
  • A 38-year-old woman who sustained multiple blunt
    injuries, including a unilateral lateral
    compression injury to the pelvic ring as a result
    of a motor vehicle accident, is awake, alert, and
    normotensive however, she has a decreased pulse
    pressure, a pulse of 110/min and a urine output
    of 20 mL/hr. She responds to an initial fluid
    bolus however, after the fluids are slowed,
    perfusion begins to deteriorate. An increase in
    fluids and blood administration is instituted. To
    evaluate the abdomen as a potential bleeding
    source, management should include
  • a. obtaining a CT scan of the abdomen.
  • b. obtaining lateral decubitus radiographs of the
    abdomen.
  • c. obtaining a crosstable lateral radiograph of
    the abdomen.
  • d. performing an exploratory laporatomy.
  • e. performing a supraumbilical diagnostic
    peritoneal lavage.

30
  • Correct Answer e
  • This question is for the initial evaluation of
    hemodynamic instability in a multitrauma patient
    with pelvic fractures. This question specifically
    asks for the test to evaluate the abdomen as a
    source of bleeding. While a CT scan can help us
    identify the pelvic fracture, a DPL is the
    quickest way to identify intra-abdominal
    bleeding, and the trauma surgeons can tell pretty
    quickly whether a patient needs to go to OR based
    on the outflow color from the DPL.

31
  • Year1997 Question 64
  • An 18-year-old woman has a closed femoral shaft
    fracture and facial trauma. Cervical spine
    radiographs are normal. Because of moderate
    facial edema, internal fixation of the femur is
    delayed. Two days later, the patient is noted to
    have mental confusion and dyspnea. The lungs are
    clear to auscultation with normal breath sounds.
    Vital signs are pulse, 100/min respiration,
    35/min blood pressure, 140/95 mm Hg. Arterial
    blood gases are pO2, 70 pCO2, 45. The pH was
    7.35. The most likely diagnosis is
  • a. occult head injury.
  • b. pulmonary embolism.
  • c. spontaneous pneumothorax.
  • d. fat embolism.
  • e. upper airway obstruction

32
  • Correct Answer d
  • This scenario is pointing to fat embolism from
    the beginning. This is a young patient with a
    long bone fracture, two days out. The abg
    suggests acute hyppoxemia, without a compensated
    metabolic situation. While the confusion can be
    associated with a head injury, the abg is not.
    Confusion from hypoxemia is probably causal, and
    dyspnea too, is associated with fat embolism. The
    three most worrisome problems are listed, being
    PE, pneumothorax, and acute upper airway
    obstruction. The breath sounds woulkd all be
    affected in these however.

33
  • Year1997 Question 74
  • A 25-year-old woman who has multiple injuries,
    including closed femoral and tibial shaft
    fractures, is initially awake and alert, but
    during resusitation she becomes somnolent. A
    chest radiograph shows three rib fractures on the
    right side, and an AP view of the pelvis shows a
    3-cm pubic diastasis. She has a systolic blood
    pressure of 220 mm Hg and a pulse rate of 38/min.
    Treatment should include
  • a. pelvic angiography.
  • b. diagnostic peritoneal lavage.
  • c. emergency CT scan of the head and a
    neurosurgical consultation.
  • d. administration of 2 L of crystalloid and blood
    type and crossmatching.
  • e. insertion of a chest tube in the midclavicular
    line of the second intercostal space.

34
  • Correct Answer c
  • Although hypotension could be the cause of her
    somnolence, her SBP is quite high indicating that
    this is not likely, also she is not tachycardic
    which is a hallmark of hypovolemic shock. Cardiac
    Tamponade or tension ptx is another thought but
    this is not mentioned on the CXR. The only other
    source for somnolence to consider is neurogenic.
    Choices 1,2,4 all pertain to diagnosis of a
    hypovolemic origin. Choice 3 is best as it
    directly deals with a neurogenic origin as is
    likely in this case scenario.

35
  • Year1997 Question 88
  • Initial radiographs of a 56-year-old man who
    sustained a closed fractue of the distal tibia in
    a motor vehicle accident are shown in Figures 24a
    and 24b. Figure 24c shows a clinical photograph
    of the injured foot and ankle in the operating
    room 8 days later. The chances of surgical wound
    complications are most likely to be minimized by
  • a. avoiding plate fixation of the distal tibia.
  • b. keeping the incisions spread by more than 7
    cm.
  • c. using low-profile malleable plates.
  • d. using a "pilon" fracture incision and a
    femoral distractor.
  • e. using a topical antibiotic cream and delaying
    surgery for 3 to 5 more days

36
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37
  • Correct Answer a
  • Several studies over the last several years have
    concluded that limited internal fixation (usually
    lateral) combined with external fixation reduce
    the risk of soft tissuue insult in pilon fxs.
    Choice 2, keeping the incisions 7 cm apart is
    correct but it is even better to not make 2
    incisions at all. Choice 3, using low profile
    plates is also a good idea, but again, no plate
    is even better. Choice 4, using a pilon fracture
    incision and a femoral distractor indicates the
    intent for ORIF, which would be best avoided.
    Choice 5, using a topical antibiotic cream and
    delaying surgery for 3 to 5 more days is only
    partially true. Abx cream is not recommende nor
    helpful. Most authors do recommend delaying any
    open surgery until 10-14 days after the trauma to
    allow the soft tissue swelling to subside.
    JAAOS 1994 Nov./Dec. 297-305ReferencesKeyword
    s Question 16 of 145

38
  • Year1997 Question 120
  • An 18-year-old active duty soldier sustains a
    6-cm segmental loss to the tibial diaphysis from
    an antipersonnel mine. Treatment consists of a
    fine wire circular external fixator with bone
    transport, and the immediate postopertive course
    is uneventful. The patient is given instructions
    in advancing the frame during a convalescent
    leave. A radiograph taken 5 weeks postoperatively
    shows a gain of 4.5 cm and a radiolucent linear
    area transversely through the middle of the
    regenerate bone. This finding is most likely the
    result of
  • a. a fracture.
  • b. a pin tract infection.
  • c. advancing the frame too fast.
  • d. advancing the frame to slowly.
  • e. infection within the regenerate

39
  • Correct Answer c
  • The Ilizarov method of distraction osteosynthesis
    typically calls for lengthening/distracting at a
    rate of 1mm/day. At 7 weeks out, the radiographs
    show 4.5cm of distraction. This is 1cm longer
    than it should be distracted and accounts for the
    radiolucency in the regenerate bone. There is no
    history which is consistent with refracture or
    infection.

40
  • Year1997 Question
  • A patient undergoes anatomic reduction and stable
    fixation of a spiral distal fibula fracture that
    is 4.5 cm above the joint. With which of the
    following concomitant injuries is the patient
    most likely to benefit from placement of a
    syndesmosis screw?
  • a. Deltoid ligament rupture
  • b. Wagstaffes avulsion fracture
  • c. Rupture of the anterior inferior tibiofibular
    ligament
  • d. Oblique medial malleolus fracture that has
    been reduced and stabilized
  • e. Transverse medial malleolus fracture that has
    been reduced and stabilized

41
  • Correct Answer a
  • In 1991, J Soleri, et al performed a
    biomechanical cadaveric study to investigate the
    need for syndesmotic screws in a Weber C ankle
    fracture. Their results supported earlier studies
    which showed that the medial complex (medial
    malleolus and deltoid ligament) is the primary
    stabilizer of the talus in the ankle mortise. As
    a result, they recommended the placement of a
    syndesmotic screw in Weber C ankle fractures with
    deltoid ligament insufficiency.

42
  • Year1997 Question
  • A 25-year-old man sustains multiple injuries,
    including a pelvic ring disruption, in a motor
    vehicle accident. He is hemodynamically stable.
    Attempts to pass a urinary catheter are
    unsuccessful. What diagnostic test should be
    obtained next?
  • a. CT scan
  • b. Cystogram
  • c. Urinalysis
  • d. Excretory urogram
  • e. Retrograde urethrogram

43
  • Correct Answer e
  • In pelvic trauma, inability to pass a urinary
    catheter may be a sign of urethral trauma. A
    retrograde urethrogram is sthe diagnositic study
    of choice.

44
  • Year1997 Question
  • A 35-year-old man sustains a closed Galeazzi
    fracture-dislocation and a fracture of the ulnar
    styloid process as a result of a high-speed motor
    vehicle accident. The radius fracture is
    anatomically fixed with a plate however, the
    ulnar head remains dislocated. What structure is
    most likely responsible for preventing reduction?
  • a. Radioulnar capsule
  • b. Pronator Quadratus
  • c. Flexor carpi ulnaris
  • d. Extensor carpi ulnaris
  • e. Triangular fibrocartilage complex

45
  • Correct Answer d
  • Difficulty with reduction of the ulnar head may
    be caused by interposition of the ECU. Due to its
    firm attachment to the triangular fibrocartilage
    complex by its fibro-osseous sheath, it is
    usually the structure that prevents reduction

46
  • Year1997 Question
  • Examination of a construction worker who received
    an accidental electric shock while on the job
    reveals that he is awake, alert, and holding his
    arm tightly against the chest and holding his
    forearm tightly to the front of the trunk.
    External rotation and abduction are severely
    limited and painful. Which of the following
    injuries best accounts for these findings?
  • a. Luxatio erecta
  • b. Anterior dislocation of the glenhumeral joint
  • c. Superior dislocation of the glenhumeral joint
  • d. Posterior dislocation of the glenhumeral joint
  • e. Greater tuberosity fracture of the proximal
    humerus

47
  • Correct Answer d
  • Common causes of failure to externally rotate
    shoulder are DJD, adhesive capsulitis, and
    posterior dislocation. Seizures are the most
    common cause of posterior dislocations.

48
  • Year1997 Question
  • A 30-year-old soccor player has pain and swelling
    4 hours after being kicked in the anterior
    compartment of the leg. Which of the following
    physical findings best indicates increased
    compartment pressure?
  • a. Anterior compartment tenderness
  • b. Pain with active ankle dorsiflexion
  • c. Pain with passive flexion of the toes
  • d. Pain with passive extension of the toes
  • e. Decreased sensation on the dorsum of the foot

49
  • Correct Answer c
  • Severe pain, out of proportion to the injury,
    with passive stretching of a muscle is indicative
    of increased compartment pressures. Toe flexion
    would stretch the EHL and EDC muscles which
    reside in the anterior compartment. This
    compartment as well as the deep post. compartment
    are the most commonly involved. Generally
    speaking, compartment syndrome usually occurs in
    less than 24 hours. Ischemic injury starts when
    the pressures reach 10 - 20 mmHg below DBP.
    Paralysis and sensory changes can occur within
    one hour of the ischemia. Within the first 4
    hours of ischemia only noepraxic injury occurs,
    but after 8 hours there is axonotmesis which is
    irreversible. Also, the area of highest pressure
    is not always palpable but is generally at the
    level of the fracture.

50
  • Year1997 Question
  • A 31-year-old woman has had instability of the
    right ankle for the past 10 years. Stress
    radiographs show asymmetrical anterior drawer
    translation, excess lateral opening, and a
    unilateral os subfibulare on the affected side.
    In this patient, the os subfibulare represents
  • a. a supernumary bone.
  • b. an unfused accessory ossification center.
  • c. a nonunion of an avulsion fracture of the
    talus.
  • d. a nonunion of an avulsion fracture of the
    fibula.
  • e. a nonunion of an avulsion fracture of the
    calcis.

51
  • Correct Answer d
  • This patient has signs c/w a torn anterior
    talofibular ligament (the most commonly ruptured
    ligament in the human body). It is thought that
    an os subfibulare represents an avulsion fracture
    of the anterior talofibular ligament and is not a
    normal variant. Anatomic studies have shown that
    there is no secondary ossification center at this
    site and when examined at the time of surgery it
    was noted that these all represented an avulsion
    fracture. An os subtibiale was noted in 20 of
    normal x-rays and found to be bilateral 50 of
    the time.

52
  • Year1997 Question
  • A 20-year-old man who sustains closed femoral and
    tibial shaft fractures has mild distension of the
    abdomen, a systolic blood pressure of 75 mm Hg,
    and a pulse rate of 135/min. His neurovascular
    examination is normal. Lateral cervical spine,
    chest, and AP pelvis radiographs are normal.
    After administration of 2 L of crystalloid, he
    has a systolic blood pressure of 95 mm Hg and a
    pulse rate of 120/min. Management should now
    include
  • a. diagnostic peritoneal lavage.
  • b. immediate femoral nailing and splinting of the
    tibia.
  • c. immediate stabilization of both the femur and
    the tibia.
  • d. splinting the tibia and placing the femur in
    skeletal traction.
  • e. simultaneous retrograde femoral nailing and an
    exploratory laparotomy

53
  • Correct Answer a
  • Shock can be classified as hypovolemic,
    cardogenic, neurogenic, and septic.
  • Class I....... blood volume loss up to
    15.....HR lt 100.......SBP NI...........Pulse
    pressure NI
  • Class II...... blood volume loss
    15-30.........HR gt 100.......SBP
    NI...........Pulse pressure decreased
  • Class III..... blood volume loss
    30-40.........HR gt 120.......SBP
    lt90..........Pulse pressure decreased
  • Class IV..... blood volume loss
    gt40...........HR gt 140.......SBP lt90..........
  • Pulse pressure decreased In a study of 100
    patients with femur fractures (62 w/isolated fx
    and 38 w/additional fxs) no patient had greater
    than class II shock. In a patient with a closed
    femur fx and hypotension further work up is
    required to determine the cause of the
    hypotension (ie DPL). Treatment of the fracture
    immediately is indicated to decrease the risk of
    ARDS, and fat emboli syndrome

54
  • Year1997 Question 244
  • A 29-year-old man who has an isolated knee injury
    following a motor vehicle accident is
    neurovascularly intact, Plain radiographs are
    shown in Figures 68a and 68b, and two cuts of an
    axial CT scan are shown in Figures 68a and 68d.
    Reduction and fixation would be best accomplished
    by
  • a. percutaneous reduction and hybrid external
    fixation.
  • b. arthroscopically assisted reduction and
    percutaneous screw fixation from anterolateral to
    posterolateral.
  • c. open reduction and plating through an
    anterolateral approach with meniscal elevation.
  • d. open reduction with screw fixation through a
    midline anterior approach with tibial tubercle
    elevation.
  • e. open reduction and plating through an approach
    between the medial head of the gastrocnemius and
    the semitenedinosus.

55
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56
  • Correct Answer e
  • Lateral plateau fractured 70-80 and medial
    plateau only 10-20. This is due to medial
    plateau being stronger, and when fractured is
    usually a more violent injury w/more soft tissue
    injuries (meniscal tear 50, ligamentatous injury
    30, peroneal neuropraxia, popliteal vessel
    injury, and compartment syndrome. Schatzker
    Classification Type I Split fx of lateral
    plateau. Type II Split depression fx of lateral
    plateau. Type III Depression fx of lateral
    plateau. Type IV Fracture of medial plateau.
    Type V Bicondylar fx. Type VI Plateau fx
    w/separation of metaphysis from diaphysis. RX of
    Types I - IV lateral L plates, Types V, and VI
    ring or hybrid fixator. Rx of Type IV fx cannot
    be performed by anterior approach and must be
    exposed directly from posteromedial or
    posterolateral incisions.

57
  • Year1997 Question 253
  • A 35-year-old man sustained a comminuted type II
    open fracture of the humeral shaft associated
    with a complete radial nerve palsy as a result of
    a motor vehicle accident. Along with
    administration of antibiotics and debridement,
    treatment should include
  • a. skeletal traction, an electromyogram, and
    nerve conduction studies.
  • b. immediate nerve exploration and application of
    a hanging arm cast.
  • c. surgical fracture fixation and immediate nerve
    exploration.
  • d. surgical fracture fixation and nerve
    exploration if no recovery is apparant after 4
    months.
  • e. functional humeral bracing and nerve
    exploration in four months if no recovery is
    apparant after 4 months.

58
  • Correct Answer c
  • 10-18 incidence. 90 neuropraxia w/95 of these
    recovering spontaneously within 3-4 months. If no
    return evident clinically EMG/NCS studies are
    indicated w/possible delayed exploration. Injury
    to nerve that occurs during initial fracture
    management may indicate laceration by bone
    fragments and should be explored immediately.
    Other indications for primary exploration are
    open fx, penetrating injuries, and spiral fx of
    mid distal 1/3 (Holstein-Lewis Fx).

59
  • Year1997 Question 270
  • Radiographs of a fracture after a rotational
    injury are shown in Figure 78. A mortise view
    shows no widening of the ankle mortise. There is
    no swelling or tenderness over the medial ankle.
    Which of the following treatment options will
    most rapidly and effectively restore ankle
    function?
  • a. Removable fracture brace, and early
    mobilization
  • b. Closed reduction and nonweightbearing cast
    immobilization
  • c. Open reduction and plate fixation of the
    lateral malleolus
  • d. Open reduction of the lateral malleolus and
    repair of the torn anterior tibiofibular ligament
  • e. Open reduction of the lateral malleolus,
    repair of the torn anterior tibiofibular
    ligament, and repair of the deltoid ligament

60
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61
  • Year1997 Question 272
  • Figures 79a and 79b show a fracture of the tibia
    in a 53-year-old woman who fell down stairs.
    Management consists of closed reduction, casting,
    and bracing. Which of the following factors is
    most likely to compromise the outcome?
  • a. Early weightbearing
  • b. Age of the patient
  • c. The intact fibula
  • d. The initial angulation
  • e. Location of the fracture

62
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63
1998
64
  • Year1998 Question 5
  • A 17-year-old boy who sustained a closed clavicle
    fracture after he was ejected from an all-terrain
    vehicle was treated with a figure-of-8 brace 1
    year ago. He now reports continuous pain at the
    site of the fracture and is unable to actively
    raise his arm above his head. A radiograph is
    shown in Figure 1. Management should now consist
    of
  • a. an onlay bone graft.
  • b. electrical stimulation.
  • c. resection of the distal clavicle.
  • d. plate fixation and a bone graft.
  • e. smooth wire fixation and a bone graft.

65
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66
  • Correct Answer d
  • The xray here reveals a midshaft non-united
    clavicle fx. The boy is one year out and
    intervention of some sort is indicated at this
    time. The recommended choice at this time is
    plate fixation with bone graft. Bone graft alone
    or Kwires will not yield a stable fixation
    allowing compression and healing.

67
  • Year1998 Question 8
  • What is the treatment of choice for an adult who
    has an isolated fracture of the ulna at the
    junction of the distal and middle thirds, with 5
    degrees apex dorsal angulation and a 25
    displacement?
  • a. Intramedullary rodding
  • b. Functional bracing
  • c. Closed reduction and a long arm cast
  • d. Closed reduction and application of an
    external fixator
  • e. Open reduction and internal fixation with a
    dorsal plate

68
  • Correct Answer b
  • Isolated fractures of the mid/distal ulna
    (nightstick variety) do not always require ORIF
    as do their radial counterparts. Studies have
    shown that functional bracing is as effective as
    ORIF if there is lt10degrees angulation and lt50
    displacement. A long arm cast is not necessary as
    this only leads to elbow stiffness. These pts
    should be followed radiographically for
    progressive displacement which would necessitate
    ORIF. It is important also to look for associated
    injuries about the elbow and wrist.

69
  • Year1998 Question 26
  • Which of the following provides the most stable
    fixation for comminuted fractures of the
    posterior acetabular wall?
  • a. Cable
  • b. Buttress plate
  • c. Methylmethacrylate
  • d. Multiple lag screws
  • e. Multiple Kirschner wires

70
  • Correct Answer b
  • Fractures of posterior wall occur more freq than
    any other type of acetabular fracture. Nearly 33
    of isolated post. Wall fxs are comminuted.
    Failure of fixation is devastating complication
    best prevented by rigid fixation. Often
    comminuted fractures involve fragments close to
    post rim such that attempts to fix these with
    screws or pins would violate the articular
    surface. Study referenced tested screws alone vs
    plate/screws (buttress) under wt-bearing
    conditions and found plate much stronger.

71
  • Year1998 Question 28
  • What posterior pelvic ring injury is most
    commonly associated with neurologic compromise?
  • a. Sacral fracture lateral to the foramina
  • b. Sacral fracture medial to the foramina
  • c. Sacroiliac fracture-dislocation
  • d. Sacroiliac dislocation
  • e. Iliac wing fracture

72
  • Correct Answer b
  • Classification of Sacral fractures Based on
    direction, location and level of sacral fractures
    Each type has characteristic clinical
    presentationsClassification of Sacral Fractures
    Zone 1 region of ala Occasionally associated
    with partial damage to L5 nerve root MOI-lateral
    compression Zone 2 region of sacral foramina
    Frequently assoc. with sciatica Zone 3 region of
    central canal Frequently assoc. with saddle
    anesthesia and loss of sphincter function High
    incidence (25) seen in falls (Jumpers fx)
    Routine pelvic x-rays are useless Require
    Ferguson views, tomograms or CT scans

73
  • Year1998 Question 29
  • A patient has a noncomminuted displaced fracture
    of the radial head with a distal radioulnar
    dissociation. What is the most appropriate
    treatment for the radial head?
  • a. Allograft replacement
  • b. Radioulnar synostosis
  • c. Excision of the radial head
  • d. Open reduction and internal fixation
  • e. Silicone radial head replacement

74
  • Correct Answer d
  • Radial head fractures account for 33 elbow
    fractures MOI-axial load on pronated forearm
    Mason classification Type I non-displaced or
    minimally displaced ( articular surface lt 2mm)
    Type II displaced gt 2 mm Type III comminuted,
    not reconstructable Type IV fracture plus elbow
    dislocation Essex-Lopresti fracture of radial
    head with DRUJ dissociation. disruption of
    interosseous membrane Problem with silicone
    implants-much less stiff than intact interosseous
    membrane allowing for radial shortening over
    time. Problem with excision---same, radial
    shortening with loss of wrist motion In bad Type
    III fxs, may require excision of head with
    implant, then if proximal migration of radius
    occurs pt will require radioulnar synostosis in
    future but not acutely.

75
  • Year1998 Question 31
  • Examination of a 45-year-old construction worker
    who was crushed by falling dirt and buried to
    midchest level reveals hemodynamic instability
    however, radiographs of the chest are normal, and
    results of a diagnostic peritoneal lavage are
    negative. Despite the administration of a fluid
    bolus and packed red blood cells, hemodynamic
    instability persist. A radiograph of the pelvis
    is shown on Figure 4. The next step in the
    management should be
  • a. application of a pelvic external fixator.
  • b. a pelvic sling.
  • c. angiography of the pelvis.
  • d. open reduction and internal fixation.
  • e. open packing of the pelvic hematoma.

76
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77
  • Correct Answer a
  • Pelvic ring injuries treatment requirements are
    related to degree of osseous-ligamentous injury,
    displacement and treatment requirements are
    related to degree of osseous-ligamentous injury,
    displacement and presence of associated
    pelvic/abd/thoracic/ or head injuries 20 have
    associated hemodynamic instability 15 mortality
    rate Algorhythm

78
  • Year1998 Question 53
  • Which of the following conditions associated with
    a closed fracture of the clavicle indicates the
    need for open reduction and internal fixation?
  • a. Injury to the subclavian artery
  • b. Injury to the brachial plexus
  • c. Segmented fracture
  • d. 100 displacement
  • e. Associated displaced surgical neck fracture of
    the humerus

79
  • Correct Answer a
  • Indications for open reduction/internal fixation
    of acute clavicle fractures include Open
    fracture Skin tenting that fails to respond to
    closed reduction "Floating shoulder" -
    Ipsilateral clavicle and unstable scapula
    fracture Neurovascular injury that is progressive
    or fails to respond to closed reduction Brachial
    plexus injuries do not necessitate ORIF as they
    are most likely due to stretching of the plexus
    and unlikely to improve with exploration. If
    subclavian artery or vein injury is suspected, an
    anteriogram should be performed. Exploration is
    mandatory in the event of a torn large vessel.
    Some type II distal clavicle fractures

80
  • Year1998 Question 56
  • 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
  • a. adding the scores in all five body systems.
  • b. adding the squares of the scores in the three
    most severely injured systems.
  • c. doubling the cumulative scores for head and
    chest systems.
  • d. combining the scores from the most and least
    injured systems.
  • e. correcting the score in the most severely
    injured system for age.

81
  • Correct Answer b
  • The Injury Severity Score (ISS) was developed in
    1974 to help predict morbidity and mortality of
    the multiply injured patient and also for
    purposes of evaluating and directing emergency
    and subsequent care. Injury scores until that
    time had failed to take into account the
    importance of concomitant injuries to different
    major body systems and their affect on mortality.
    Poor correlation existed between injury score and
    mortality. The Injury Severity score was
    developed as a modification of the Abbreviated
    Injury Score (AIS) which assesses the severity of
    injury to each of five different systems (head or
    neck, face, chest, abdominal or pelvic contents,
    extremities or pelvic girdle and general). Scores
    for each system ranged from 0-5. Researchers
    found that if, instead of taking the cumulative
    score (as in AIS) the squares of the scores in
    the three most severely injured systems were
    added, mortality and morbidity were closely
    predicted. Highest score possible 75.

82
  • Year1998 Question 74
  • A patient sustained a joint depression-type
    fracture of the calcaneus that healed despite
    lack of treatment. The loss of dorsiflexion the
    patient is now experiencing is most likely the
    result of
  • a. widening and shortening of the heal.
  • b. weakness of the gastrocnemius-soleus complex.
  • c. anterior impingement from a horizontal talus.
  • d. unrecognized compartment syndrome of the foot.
  • e. degenerative arthritis of the tibiotalar joint.

83
  • Correct Answer c
  • In a joint depression fracture, the calcaneus is
    driven upward against the talus by the impact. A
    fracture line is created that begins in the sinus
    tarsi near the lateral wall and propagates
    obliquely across the posterior facet to the
    medial wall. This fracture line is known as the
    primary fracture line. Because the posterior
    facet is no longer under the talus, the talus
    settles into a position parallel to the ground.
    Even though the foot is in a neutral position,
    any attempt to dorsiflex the foot will cause the
    talar neck to impinge on the anterior aspect of
    the tibia.

84
  • Year1998 Question 78
  • Which of the following injuries is most commonly
    associated with a fracture of the scapular body?
  • a. Vascular injury
  • b. Tear of the rotator cuff
  • c. Injury to the brachial plexus
  • d. Fracture of an upper thoracic rib
  • e. Fracture of the proximal humerus

85
  • Correct Answer d
  • 96 of patients had associated injuries, with
    upper thoracic rib fractures being most common.
    Most scapular fractures occur as a result of
    direct impact over the scapular region. Other
    associated injuries hemopneumothorax 29,
    pulmonary contusion 8, head injury 34,
    ipsilateral clavicle fracture 25, cervical spine
    injury 12. Surgical indications - scapular neck
    fractures with more than 40 degrees of angulation
    in either the transverse or coronal plane, or
    with 1 cm or more of displacement - greater than
    3 to 5 mm step-off of glenoid joint surface -
    scapular spine fractures at the base of the
    acromion and those with more than 5 mm
    displacement may be at risk for the development
    of a nonunion

86
  • Year1998 Question 80
  • Figure 16 shows the AP radiograph of a
    32-year-old man with a fracture cephalad to the
    fovea of the femoral heat. A CT scan shows a
    single head fragment. After closed reduction of
    the hip, there is 5 mm of residual articular
    incongruity. Management should now include
  • a. hybrid total hip arthroplasty.
  • b. noncemented hemiarthroplasty of the hip.
  • c. closed reduction and percutaneous pin
    fixation.
  • d. open reduction through an anterior approach to
    the hip.
  • e. excision of the head fragment.

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88
  • Correct Answer d
  • Pipkin classification of femoral head fractures
    - Type I occurs below the fovea - Type II
    occurs above the fovea, consequently the blood
    supply through the foveal artery may be intact -
    Type III associated with femoral neck fracture -
    Type IV associated with an acetabular fracture -
    With fractures involving the fovea or involving
    the superior weightbearing dome, anatomic
    reduction is mandatory. If this is not achieved
    through a closed reduction and confirmed by CT,
    open reduction is carried out through a
    Smith-Petersen anterior approach to the hip.
    Stabilization of the fracture through
    interfragmental screw compression techniques is
    required.

89
  • Year1998 Question 81
  • Figure 17a shows the postoperative AP hip
    radiograph of a 35-year-old woman who sustained
    an isolated fracture of the femoral neck while
    skiing 7 months ago. Treatment consisted of open
    reduction and screw fixation. She now reports
    continuous pain in the groin and an inability to
    bear weight. AP and lateral radiographs shown in
    Figures 17b and 17c reveal no evidence of healing
    of the fracture. Management at this time should
    consist of
  • a. a quadratus femoris pedicle bone graft.
  • b. a proximal femoral allograft.
  • c. intertrochanteric osteotomy.
  • d. total hip arthroplasty.
  • e. hip hemiarthroplasty

90
  • Correct Answer c
  • An abduction osteotomy at the intertrochanteric
    level, converts shearing forces into compressive
    forces. The compression promotes healing of the
    fracture

91
  • Year1998 Question 84
  • Which of the following surgical approaches to the
    hip is associated with the highes incidence of
    heterotopic ossification?
  • a. Ilioinguinal
  • b. Extended iliofemoral
  • c. Combined ilioinguinal and Kocher-Langenbeck
    (posterior)
  • d. Kocher-Langenbeck (posterior)
  • e. Kocher-Langenbeck (posterior) with
    trochanteric osteotomy

92
  • Correct Answer b
  • Heterotopic ossification after an acetabular
    fracture has been shown to be related to the
    surgical exposure, male sex, associated head
    injury, and the fracture type. The incidence of
    Brooker III and IV heterotopic ossification in
    the Kocher-Langenbeck exposure was 10.5 for the
    ilioinguinal exposure, 2 extended iliofemoral,
    35 combined Kocher-Langenbeck/ilioinguinal
    exposures, 27.

93
  • Year1998 Question 108
  • Which of the following radiographic views best
    shows the size and displacement of a posterior
    wall fracture of the acetabulum?
  • a. Inlet view of the pelvis
  • b. Outlet view of the pelvis
  • c. AP view of the hip
  • d. Iliac oblique view (external oblique) of the
    hip
  • e. Obturator oblique view (internal oblique) of
    the hip

94
  • Correct Answer e
  • Obturator Oblique (internal oblique) inlet view
    best shows A/P displacement of the pelvis (not
    acetabulum) outlet view shows superior
    displacement posteriorly and both superior or
    inferior displacement anteriorly (PELVIS) AP of
    hip-shows 1. Pelvic brimCanterior border of
    anterior column 2. Ileoischial line- border of
    posterior column 3. Roof of acetabulum 4. Medial
    wall of acetabulum 5. Posterior border of
    acetabulum Iliac oblique (external oblique)-45
    degree external rotation with beam centered on
    hip. Shows posterior column, anterior border of
    acetabulum and iliac wing Obturator oblique
    (internal oblique)-elevate affected hip up 45
    degrees. Shows obturator foramen, anterior
    column, posterior lip

95
  • Year1998 Question 113
  • Figure 25a shows the initial postoperative AP
    radiograph, and FIgures 25b and 25c show the
    current AP and lateral radiographs of a
    46-year-old woman who underwent open reduction
    and internal fixation of a distal fibula fracture
    and placement of a syndesmosis screw 15 months
    ago. She has full function, but the ankle swells
    with activity. Th radiographs reveal that
  • a. fixation of the syndesmosis has failed.
  • b. widening of the ankle mortise has led to
    failure of fixation.
  • c. infection around the syndesmosis screw has led
    to osteomyelitis.
  • d. the syndesmosis screw is broken.
  • e. motion between the tibia and fibula has caused
    loosening of the syndesmosis screw

96
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97
  • Correct Answer e
  • 1. fixation failure is incorrect because the
    mortise is not wide 2. mortise is not widened 3.
    osteomyelitis would not have the uniform
    sclerotic margin 4. the screw isnt broken 5.
    only three cortices are crossed and this allows
    motion at the syndesmosis which causes the
    lucency References

98
  • Year1998 Question 127
  • A healed fracture of the tibia that demonstrates
    25 degrees apex posterior angulation and 28
    degrees varus angulation on AP and lateral
    radiographs is most accurately described as a
  • a. complex deformity with angulation in two
    planes.
  • b. single deformity less than 20 degrees, apex
    posterolateral.
  • c. single deformity greater than 30 degrees, apex
    posterolateral.
  • d. single deformity less than 20 degrees, apex
    posterolmedial
  • e. single deformity greater than 30 degrees, apex
    posteromedial

99
  • Correct Answer c
  • Single deformity greater than 30deg, apex
    posterolateral. To accurately describe
    post-traumatic long bone deformities (fractures,
    malunions or nonunions) with regards to
    angulation and/or translation it is important to
    realize that the actual deformity is rarely in a
    pure apex anterior, posterior, valgus of varus
    direction. Instead the true plane of the apex is
    tangential to the points of reference given by
    the radiographs. This plane, described as the
    apex of the deformity, can be precisely
    calculated using trigonometric formulae or
    crudely assessed by extrapolating from two films
    at 90deg to each other (AP lat). For example, a
    tibial angulation that appears apex posterior on
    the lateral view and in varus on the AP is
    actually a single deformity with a
    posterolaterally directed apex. Similarly, an
    apex that is anterior and valgus is not two
    separate deformities but rather a single
    deformity with an apex that is directed
    anteromedially. The true angle of this deformity
    is always greater than that seen on either the AP
    or lateral views there are mathematical tables
    available for determining this, or you can
    estimate. Finally, angulation and translation
    should be regarded and described separately since
    they are often in different planes.

100
  • Year1998 Question 134
  • Which of the following methods of treatment of a
    displaced Lisfranc fracture-dislocation will most
    reliably lead to good functional results?
  • a. Weightbearing short leg cast
  • b. Nonweightbearing short leg cast
  • c. Removable splint and early motion
  • d. Open reduction and internal fixation
  • e. Elastic compression bandage with full
    weightbearing

101
  • Correct Answer d
  • lisfranc injuries occur at the midfoot with
    damage to the articulation between the
    metatarsals and cuneiforms. The Lisfanc ligament
    courses obliquely between the second metatarsal
    and medial cuneiform. As many as 95 of patients
    with Lisfanc joint dislocations have been shown
    to have associated metatarsal fractures.
    Fractures of the midtarsal bones (cuneiforms,
    cuboid and navicular) have been seen in up to 39
    of these patients. Diagnosis requires adequate
    radiographs (AP, lateral and oblique films) with
    close attention to anatomic relationships. The
    medial border of the second metatarsal should
    line up with the medial border of the middle
    cuneiform on the AP film while the medial border
    of the fourth metatarsal should be aligned with
    the medial border of the cuboid on the oblique
    film. Nondisplaced fractures without ligament
    instability (stress radiographs) can be treated
    in non-weightbearing cast for six weeks. In
    displaced or unstable injuries, open anatomic
    reduction and fixation is indicated. With severe
    comminution, the tarsometatarsal joints within
    the medial column can be fused acutely.

102
  • Year1998 Question 144
  • A patient is in respiratory distress as a result
    of a high-speed motor vehicle accident. After
    emergency intubationm the arterial blood is
    poorly oxygenated, and examination shows
    left-sided trachael deviation, absence of breath
    sounds on the right sidem and tympany on
    percussion over the right side of the chest.
    Management should include
  • a. positive-pressure ventilation.
  • b. an immediate radiograph of the chest.
  • c. adjustment of the position of the endotrachael
    tube.
  • d. insertion of a large-bore needle into the
    pericardial space.
  • e. insertion of a large-bore needle in the right
    second intercostal space, midclavicular line

103
  • Correct Answer e
  • These are classic signs of a tension
    pneumothorax. A tension PTX results when there is
    damage to the lung parenchyma allowing inspired
    air to escape into the pleural space. This leads
    to an increase in intrapleural pressure and a
    shift in the mediastinum to the contralateral
    side, resulting in narrowing or occlusion of the
    vena cava at the diaphragm. Immediate thoracic
    decompression is mandatory to prevent death. This
    is performed by placing a large-bore needle into
    the second intercostal space in the midlavicular
    line . This should be followed immediately by
    tube thoracostomy

104
  • Year1998 Question 145
  • The axial stability of a 4-pin uniplanar external
    fixator used to treat a patient who has a
    transverse midthird fracture of the tibia with a
    5-mm fracture gap can be most greatly increased
    by
  • a. allowing the ends of the fracture to touch.
  • b. adding a second connecting bar.
  • c. adding one pin to each fracture fragment.
  • d. increasing the pin diameter from4 mm to 6 mm.
  • e. decreasing the connecting bar-to-bone distance
    from 6 cm to 4 cm.

105
  • Correct Answer a
  • Bone contact allows load sharing between bone and
    fixator for compressive, torsional, and certain
    bending loads. Without bone contact, the external
    fixator must support full load, and this can have
    a significant effect on fracture healing. With
    transverse fxs, application of compression
    across the fracture site can greatly increase the
    stiffness of the frame-bone system.

106
  • Year1998 Question 157
  • Figure 35 shows the postoperative radiograph of a
    femur fracture proximal to a total knee
    prosthesis that was treated by open reduction and
    plate fixation 9 months ago. What is the most
    likely reason the previously well-seated screw
    has backed out of the central portion of the
    plates?
  • Infection
  • Nonunion
  • Improper screw length
  • Osteonecrosis of the distal fragment
  • Use of a cortical screw instead of a cancellous
    screw

107

108
  • Correct Answer b
  • Failure of fx healing is the most common clinical
    complication of fxs. The factors that influence
    fx healing differ from case to case. Morphologic
    studies of ununited fxs have described 2
    different types of nonunions (1) those with
    unmineralized fibrous and fibrocartilaginous
    tissue bridging the fx gap, and (2) those with a
    cleft or gap between the ends of the fxd bone,
    which are usually covered with similar fibrous
    tissue or fibrocartilage. The former situation,
    which is clinically the more common one, is
    called a nonunion the latter is called
    pseudarthrosis. An analysis of 95 human tissue
    specimens of nonunions and pseudarthroses
    demonstrated that in extraarticular fxs, all
    cases of delayed healing are first nonunions.
    Subsequently, microscopic clefts may appear
    within the tissues that compose the nonunion,
    and, in time and only in certain cases, a
    dominant cleft may propagate to form a
    practically complete separation of the fx ends,
    ie., pseudarthrosis. See attached article

109
  • Year1998 Question 192
  • To prevent injury to the posterior interosseous
    nerve during the approach for reduction and
    fixation of a fracture of the radial head,
    anterior retraction should be performed with the
    forearm
  • maximally pronated and the elbow extended.
  • b. maximally pronated and the elbow flexed.
  • c. maximally supinated and the elbow flexed.
  • d. maximally supinated and the elbow extended.
  • e. in neutral rotation, with the elbow extended.

110
  • Correct Answer b
  • The posterior interosseous nerve is vulnerable to
    injury during the posterolateral approach to the
    radial head as it winds around the neck of the
    radius within the substance of the supinator
    muscle. Maximal pronation and flexion at the
    elbow moves the nerve medially out of the
    operative field so that the supinator and the
    underlying joint capsule can be incised without
    danger.

111
  • Year1998 Question 213
  • In patients older than age 50 years who
    experience shoulder dislocation or proximal
    humerus fracture, the incidence of associated
    neurologic abnormality documented by
    electromyogram is as high as
  • 10
  • b. 20
  • c. 50
  • d. 70
  • e. 90

112
  • Correct Answer C
  • Several complications can occur with glenohumeral
    dislocations and humeral neck fractures including
    rotator cuff tear, vascular injuries,
    osteonecrosis, and nerve injuries. When diagnosed
    by EMG the incidence of axillary and other types
    of nerve lesions is 20-30 for all age groups.
    Blom and Dahlback found that patients over 50 are
    considerably more affected. In this age range the
    incidence of nerve injury documented by EMG may
    be as high as 50 (23 of 53 patients).

113
  • Year1998Question 241
  • A 37-year-old laborer sustained a fracture of the
    posterior acetabular wall. Two years following
    operative management, the patient reports
    severely limited hip motion, and back pain.
    Radiographs reveal extensive mature heterotopic
    ossification with preservation of the hip joint
    space. Management should now consist of
  • resection arthroplasty and local radiation.
  • b. in situ fusion of the hip.
  • c. excision of heterotopic bone, total hip
    arthroplasty, and oral indomethacin.
  • d. excision of heterotopic bone, and local
    radiation.
  • e. excision of heterotopic bone,
    hemiarthroplasty, and oral indomethacin.

114
  • Correct Answer d
  • The use of various prophylactic measures to
    decrease the incidence of ectopic bone formation
    has been reported in the literature. One
    suggested approach is to minimize surgical
    osteotomies and the amount of subperiosteal
    stripping and pericapsular trauma during
    operation. Many surgeons seek to maximize the use
    of the ilioinguinal and Kocher-Langenbeck
    approaches. these approaches, however, remain
    inadequate for certain T shaped and both column
    fractures, as well as old fractures that require
    the extended iliofemoral approach for reduction.
    Another approach to prophylactic therapy is low
    dose radiation immediately after hip surgery
    several authors have reported success in reducing
    the incidence and severity of HO. Prophylactic
    use of diphosphonate to reduce the amount of
    ectopic bone formation after total hip
    arthroplasty has been shown to be ineffective.
    Diphosphonate compounds prevent mineralization of
    the osteoid matrix, but not the production of the
    matrix. Moreover, diphosphonate must be
    administered systemically, and mineralization of
    the osteoid can proceed once it is d
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