OITE Trauma Review

OITE Trauma Review H. Pakzad Wed Sept 12, 2007

2006 – Question 1 Which of the following arteries provides the single dominant proximal blood supply to the medial head of the gastrocnemius muscle? 1- Anterior tibial 2- Posterior tibial 3- Peroneal 4- Genicular 5- Sural

Each muscle has one dominant pedicle consisting of the sural artery and vein given off by the popliteal artery at the level of the knee joint. The sural arteries run distally with the tibial nerve branches for several centimeters before entering the muscle bellies on their anterior surfaces.

2006 – Question 8 Two years following open reduction and internal fixation of a pilon fracture, which of the following parameters correlates most closely with a poor clinical outcome and inability to return to work? 1 - Metaphyseal comminution 2- Quality of reduction 3- Time to surgery 4- Lower level of education 5- Open fracture

2006 – Question 13 During placement of an iliosacral screw into the body of S1, what pelvic radiographic view should be obtained to help avoid entering the S1 neuroforamen? 1- AP 2- Lateral 3- Inlet 4- Outlet 5- Obturator oblique

2006 – Question 16 A 22-year-old woman has wrist pain after falling on her outstretched hand 2 weeks ago. Examination reveals tenderness in the anatomic snuffbox. A radiograph is shown. Treatment should consist of 1- open reduction and internal fixation using the Russe bone graft technique via a volar approach. 2- open reduction and internal fixation with a compression screw via a volar approach. 3- open reduction and internal fixation with vascularized bone graft via a volar approach. 4- open reduction and internal fixation with vascularized bone graft via a dorsal approach. 5- a cast brace for 6 weeks

2006 – Question 22 Following imaging show the injury a 17-year-old boy sustained in a recreational vehicle accident 3 weeks ago. Examination reveals mild asymmetry and regional discomfort referable to the right sternoclavicular joint. The remainder of the physical examination findings are unremarkable. Management should consist of 1 - closed reduction. 2- open reduction and pin fixation. 3- sternoclavicular ligamentous reconstruction. 4- nonsurgical treatment with resumption of unrestricted activity in 3 months. 5- nonsurgical treatment with cessation of contact sports indefinitely.

2006 – Question 27 What type of nonunion is most likely to unite by increasing biomechanical stability? 1- Atrophic 2- Oligotrophic 3- Hypertrophic 4- Infected 5- Synovial pseudarthrosis

2006 – Question 28 On an AP ankle radiograph, the measurement of the tibial clear space (the syndesmotic space) should be less than 5 mm if there is no syndesmotic widening. The tibial clear space is defined as the 1- distance between the medial border of the fibula and the incisura fiibularis. 2- distance from the incisura fibularis to the lateral tibial border. 3- distance from the medial malleolus to the talus. 4- overlap of the anterior portion of the lateral tibia on the fibula. 5- overlap of the posterior portion of the lateral tibia on the fibula.

2006 – Question 33 A greater trochanteric entry site for femoral intramedullary nailing, compared to a piriformis fossa starting point, is associated with: 1- more disruption of the gluteus medius tendon. 2- more disruption of the short external rotator tendons. 3- more disruption of the medial femoral circumflex artery. 4- greater hoop stresses with an anterior starting point. 5- greater colinearity with a long axis of the femoral shaft.

2006 – Question 39 In patients with ipsilateral femoral neck and shaft fractures, what percent of femoral neck fractures are significantly displaced? 1 - 5% 2- 20% 3- 40% 4- 70% 5- 90%

2006 – Question 41 When comparing antegrade nailing of femoral shaft fractures treated with a fracture table versus manual traction, the manual traction group had significantly less 1- fluoroscopy time. 2- shortening of the femur. 3- assistants per case. 4- exchange nailings. 5- internal rotational deformities.

2006 – Question 51 To minimize the risk of iatrogenic traction injury to the sciatic nerve during open reduction and internal fixation of the acetabulum through the Kocher-Langenbeck exposure, the leg should be in what position? 1- Extended at the hip and extended at the knee 2- Extended at the hip and flexed at the knee 3- Flexed at the hip and extended at the knee 4- Flexed at the hip and flexed at the knee 5- Abducted at the hip and extended at the knee

2006 – Question 57 A lower discharge Glasgow Coma Scale score in a patient with a femoral fracture and a head injury has been associated with 1- surgery within 24 hours after injury. 2- hypotension and hypoxia. 3- prolonged length of stay in the ICU. 4- major non-orthopaedic surgeries. 5- the presence of pneumonia.

2006 – Question 64 Following figures show the radiographs of a 45-year-old man who sustained a distal one third tibial fracture 3 months ago. The patient should be told that he is at greatest risk for the development of which of the following conditions? 1- Medial knee arthritis 2- Contralateral medial knee arthritis 3- Ankle pain and stiffness 4- Low back pain 5- Ipsilateral hip pain

Long-term effects of tibial angular malunion on the knee and ankle joints. • Puno RM, Vaughan JJ, Stetten ML, Johnson JR. • Department of Orthopaedic Surgery, University of Louisville, Kentucky 40292. Twenty-seven patients with 28 tibial fractures were evaluated for an average of 8.2 years (range 6.0-12.3 years) following their injuries. There were 16 closed and 12 open fractures, all of which healed uneventfully. Overall, 50% of the ankles and 75% of the knees were rated good to excellent. The patients' knee and ankle joint malalignments were extrapolated using a method previously published. This was made possible by knowing both the degree and site of angular deformity. Correlation between joint malalignments and clinical outcome were performed. Analysis showed that greater degrees of ankle malalignment produce poorer clinical results (p = 0.001).Conversely, the patients with lesser degrees of ankle joint malalignment had a higher percentage of good to excellent results (p = 0.006, p = 0.003, p = 0.03). The knee results did not correlate with the degree of joint malalignment (p = 0.82). The findings in this study show that there is merit in reducing tibial fractures as close to anatomical configuration as possible to lessen the chance of early degenerative arthritis. • PMID: 1941305 [PubMed - indexed for MEDLINE]

2006 – Question 70 A 25-year-old man has right knee pain after being involved in a motor vehicle accident. Radiographs reveal a distal femoral fracture with metaphyseal comminution. What is the most common missed injury diagnosed by CT? 1- Coronal fracture of the medial femoral condyle 2- Coronal fracture of the lateral femoral condyle 3- Sagittal fracture of the medial femoral condyle 4- Sagittal fracture of the lateral femoral condyle 5- Anterior cruciate ligament tear

2006 – Question 77 Femoral nailing through the piriformis fossa is contraindicated in adolescents with open physes because of the risk of? 1- osteonecrosis 2- rotational malalignment 3- shortening 4- coxa vara 5- increased intramedullary pressure

2006 – Question 81 A terrible triad elbow injury that includes a comminuted non-reconstructable radial head fracture and a type III coronoid fracture associated with an elbow dislocation is best treated with acute radial head 1- resection and lateral collateral ligament repair 2- resection, coronoid open reduction and internal fixation, and medial collateral ligament repair 3- arthroplasty alone 4- arthroplasty and coronoid open reduction and internal fixation 5- arthroplasty, coronoid open reduction and internal fixation, and lateral collateral ligament repair

2006 – Question 85 A patient sustained a distal fibular fracture that was treated nonsurgically. Current radiographs reveal an increased talocrural angle. What is the most likely long-term abnormality related to this malunion? 1- Lateral talar tilt 2- Medial talar tilt 3- Anterior talar subluxation 4- Posterior talar subluxation 5- Medial ostcochondral defect

A prospective, randomized study of the management of severe ankle fractures J Bone Joint Surg Am. 1985;67:67-78. WA Phillips, HS Schwartz, CS Keller, HR Woodward, WS Rudd The difference in the talocrural angle between the injured and normal sides was the only statistically significant radiographic indicator of a good prognosis. 78.4 degrees (range 74 to 83) The talocrural angle is the superior and medial angle formed by the intersection of a line joining the tips of both malleoli and of a line perpendicular to the distal tibial articular surface.

2006 – Question 87 The inhibitory effect of quinolone-class antimicrobials on early fracture healing is most directly linked to toxic effects on which of the following structures? 1- Vascular endothelial cells 2- Osteoblasts 3- Ostcoclasts 4- Chondrocytes 5- Macrophages

2006 – Question 91 Following X-rays show AP & Lateral Wrist of a 23-year-old man who sustained a gunshot wound to the left wrist from a handgun. The muzzle velocity is approximately 1.500 ft/sec. Dorsal and volar wounds measuring 3 mrn in diameter are visible on the wrist but are not actively bleeding. The patient's vascular examination is normal, and he has normal motor function and sensation in the median, ulnar, and radial nerve distributions. Treatment should consist of 1- I&D in the OR, and IV Ab for 7 days 2- I&D in the OR, and IV Ab for 7 days, followed by oral Ab for 7 days 3- I&D, Ext fixation in the OR and IV Ab for 3 days 4- local wound care in the ER and IV Ab for 7 days 5- local wound care in the ER and oral Ab for 3 days

2006 – Question 100 A 35-year-old woman has foot pain after tripping down a flight of stairs 2 weeks ago. The midfoot is swollen and tender, and she walks with a limp. Non-weight-bearing and weight-bearing radiographs are shown in next slide. Treatment should consist of; 1- closed reduction and a short leg- cast. 2- closed reduction and percutaneous pinning 3- open reduction and internal fixation. 4- weight bearing- as tolerated in a postoperative shoe. 5- external fixation.

Sport Question 2 time Grand Slam Champion (Wimbledon 2004 & US Open 2006) • Birth date: April 19,1987 • Birthplace: Siberia, Russia • Ht./Wt.: 6'2/130 lbs. • Plays Right-handed • Sustained shoulder injury recently

Maria Sharapova

2006 – Question 110 Which of the following is considered the most common problem that limits active overhead shoulder motion after hemiarthroplasty performed for a four-part proximal humeral fracture? 1- Retroversion of the prosthesis 2- Varus alignment of the prosthesis 3- Acromioclavicular arthritis 4- Greater tuberosity nonunion 5- Use of a cemented stem

2006 – Question 115 Which of the following is considered the most common disadvantage of using posterior anti-glide plating in the treatment of lateral malleolar fractures compared to lateral neutralization plating? 1- Intra-articular penetration of the distal screws 2- Inability to stabilize the syndesmosis 3- Peroneal irritation if the plate is placed too distally 4- Poor distal fixation 5- A biomechanically weaker construct

2006 – Question 129 When using hyperbaric oxygen treatment for a crush injury to the extremity, which of the following mechanisms of action is present? 1- Increased hydrostatic pressures 2- Increased tissue edema 3- Increased gradient for diffusion 4- Decreased leukocyte function 5- Decreased arteriolar vasoconstriction

2006 – Question 132 A 66-year-old woman reports persistent pain after falling and being diagnosed with a foot sprain 1 year ago. She also notes that she is becoming "flatfooted" on that side. Radiographs are shown in the following slides. Surgical management should consist of 1- medial displacement calcaneal osteotomy. 2- lateral column lengthening, through the calcaneocuboid joint. 3- lateral column lengthening through the calcaneus. 4- tarsometatarsal arthrodesis. 5- subtalar fusion

2006 – Question 140 According to the Lauge-Hansen classification. what is the mechanism of injury for the fracture shown in next slide? 1- Supination external rotation 2- Supination adduction 3- Pronation abduction 4- Pronation external rotation 5- Pronation dorsiflexion

2006 – Question 140 Hallmark: 1- Supination External Rotation: - Spiral fracture of the fibula AT the level of the syndesmosis 2- Supination adduction: - Transverse fracture of the fibula below the syndesmosis- Vertically, oriented medial malleolar fracture 3- Pronation abduction: - Short, oblique fracture of the fibula AT or ABOVE the level of the syndesmosis 4- Pronation external rotation - Spiral fracture of the fibula ABOVE the syndesmosis

Supination-Adduction Supination External Rotation Pronation-Abduction Pronation External Rotation

2006 – Question 143 What subset of patients is expected to have a poorer outcome following open reduction and internal fixation of a displaced intra-articular calcaneal fracture? 1- Younger men 2- Women 3- Patients with a lower post-fracture Bohler angle 4- Patients not receiving workers' compensation 5- Patients with a lighter workload

OITE Trauma Review