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.

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• 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

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• 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)

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• 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

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• 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).

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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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

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• 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.

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• 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

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• 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.

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• 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

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• 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.

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• 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.

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• 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

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• 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.

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• 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.

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• 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.

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• 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

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• 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

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• 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

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• 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.

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• 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.

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• 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.

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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.

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• 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.

87
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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