Orthopedic With Answer Trauma Review | Dr Hutaif Trauma -...

Lateral subtalar dislocations, which are less common than medial subtalar dislocations, are high-energy injuries that are frequently associated with small osteochondral fractures. It is generally recommended that large fragments be internally fixed, and small fragments entrapped within the joint be excised. Although arthrosis frequently occurs after this injury and is the most common long-term complication, primary subtalar arthrodesis is not indicated. A talar neck fracture is not evident on the radiographs, and lateral subtalar dislocation usually does not lead to instability.
REFERENCE: Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.
3/. Figure 2 shows the lateral radiograph of an 8-year-old boy who sustained an acute injury to the elbow after falling down the stairs. Management should consist of
1- closed reduction, followed by a long arm cast in 120 degrees of flexion.
2- closed reduction, followed by percutaneous cross pin fixation.
3- open reduction and internal fixation using an oblique screw combined with an absorbable suture as a tension band.
4- a large intramedullary screw.
5- a long arm cast in full extension.
PREFERRED RESPONSE: 3
DISCUSSION: The patient has a flexion-type olecranon fracture, and the integrity of the extensor mechanism is disrupted. With this degree of displacement, closed reduction and extension casting would not be adequate. The strongest construct is an oblique screw across the fracture site, with a tension band. Healing is rapid in this age group; therefore one of the heavy absorbable sutures can be used as the tension band. Two parallel pins with the stainless steel tension band wire (AO technique) can be used but requires wire dissection for removal. Once the fracture is healed, the single screw can be removed easily with only a small incision. The presence of the screw, across the apophysis, has not been shown to produce any significant growth disturbance. Use of a large intramedullary screw would not be advisable because of the small size of the proximal fragment.
REFERENCES: Murphy DF, Greene WB, Gilbert JA, Dameron TB Jr: Displaced olecranon fractures in adults: Biomechanical analysis of fixation methods. Clin Orthop 1987;224:210-214.
Chambers HG, Wilkins KE: Part IV: Fractures of the proximal radius and ulna, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 629-630.
4/. A 28-year-old man sustains the closed injury shown in Figures 3a through 3c after falling 8 feet while rock climbing. Management should consist of
1- open reduction and internal fixation via an anteromedial arthrotomy.
2- talectomy.
3- primary tibiotalocalcaneal arthrodesis.
4- open reduction and internal fixation via a medial malleolar osteotomy and limited anterior lateral arthrotomy.
5- closed reduction and a non-weight-bearing cast.
PREFERRED RESPONSE: 4
DISCUSSION: The radiographs show a comminuted talar body fracture. The goal of treatment is to minimize the risks of posttraumatic arthrosis of the ankle and subtalar joint and to maintain vascularity. Open reduction and internal fixation with an attempt at anatomic reduction will lead to improved outcomes. Attempting to repair this fracture via an arthrotomy only is extremely difficult, and the addition of a medial malleolar osteotomy is warranted. A limited anterior lateral arthrotomy with minimal soft-tissue stripping may assist with fixation of anterior-lateral and lateral fragments and allow better assessment of reduction of the major fracture line. Nonsurgical care would lead to inadequate reduction and increased risk of both ankle and hindfoot arthrosis. Talectomy and primary ankle and hindfoot arthrodesis should not be performed as primary surgical reconstructive options in this closed injury pattern.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp
1465-1518.
Grob D, Simpson LA, Weber BG, Bray T: Operative treatment of displaced talus fractures. Clin Orthop 1985;199:88-96.
5/. Which of the following types of displaced posterior pelvic disruptions must undergo anatomic reduction and internal fixation to ensure the best clinical outcome?
1- Sacral fracture through the foramen
2- Sacral fracture through the ala
3- Sacroiliac joint dislocation
4- Reverse fracture-dislocation of the sacroiliac joint through the ilium
5- Iliac wing fracture
PREFERRED RESPONSE: 3
DISCUSSION: Although all of the above displaced injuries require reduction, the sacroiliac joint dislocation is a ligamentous injury. Without fixation, healing is unlikely and the result will be a painful dislocation. Both Holdsworth and Tile showed that the sacroiliac joint must be reduced anatomically and stabilized. The injuries through bone will unite fairly rapidly and, if reduced and stabilized with traction or external fixation, will generally result in an acceptable outcome unless modified by other associated problems such as neurologic injury.
REFERENCES: Tile M: Fractures of the Pelvis and the Acetabulum. Baltimore, MD, Williams and Wilkins, 1995.
Holdsworth F W: Dislocation and fracture dislocation of the pelvis. J Bone Joint Surg Br 1948;30:461-465.
Henderson RC: The long-term results of nonoperatively treated major pelvic disruptions. J Orthop Trauma 1989;3:41-47.
6/. A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals that the knee is held in 45 degrees of flexion, and any attempt to actively or passively extend the knee produces pain and muscle spasms. A lateral radiograph is shown in Figure 4. What is the most likely diagnosis?
1- Patellar sleeve fracture
2- Avulsion of the tibial tubercle
3- Avulsion of the anterior tibial spine
4- Osteochondral fracture of the femoral condyle
5- Osteochondral fracture of the patella
PREFERRED RESPONSE: 1
DISCUSSION: This is a typical patellar sleeve fracture. The patellar tendon avulses a portion of the distal bony patella, along with the retinaculum and articular cartilage from the inferior pole of the patella. It is common in children between ages 8 and 10 years. Anatomic reduction and repair of the extensor mechanism are mandatory to reestablish full knee extension.
REFERENCES: Houghton GR, Ackroyd CE: Sleeve fractures of the patella in children: A report of three cases. J Bone Joint Surg Br 1979;61:165-168.
Wu CD, Huang SC, Liu TK: Sleeve fracture of the patella in children: A report of five cases. Am J Sports Med 1991;19:525-528.
7/. A 12-year-old girl sustains an acute injury to the right elbow in a fall. An AP radiograph is shown in Figure 5. Nonsurgical management will most likely result in
1- a painful nonunion.
2- asymptomatic nonunion.
3- chronic elbow instability.
4- tardy ulnar nerve palsy.
5- cubitus varus.
PREFERRED RESPONSE: 2
DISCUSSION: The patient has a significantly displaced medial epicondyle fracture. The only absolute indication for surgical treatment is irreducible incarceration in the joint. Nonsurgical management usually results in a painless nonunion with good elbow function and little elbow instability. Prolonged immobilization should be avoided to prevent stiffness. Tardy ulnar nerve palsy and cubitus varus are not complications of medial epicondyle fractures.
REFERENCES: Chamber HG, Wilkins KE: Part IV: Apophyseal injuries of the distal humerus, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 801-812.
Farsetti P, Potenza V, Caterini R, Ippolito E: Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am 2001;83:1299-1305.
8/. Which of the following factors is considered most important when assessing an ankle fracture for surgical treatment?
1- Level of the fibular fracture
2- Displacement of the fibular fracture
3- Size of the posterior malleolus
4- Position of the talus in the mortise
5- Rupture of the deltoid ligament
PREFERRED RESPONSE: 4
DISCUSSION: Although all of these factors may influence the decision to perform surgery, the most important is the position of the talus in the mortise. The goal of treatment of ankle fractures is to maintain the talus centered in the mortise. If it is in this position, the other factors do not enter into the decision to intervene surgically.
REFERENCES: Stover MD, Kellam JF: Articular fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 105-119.
Hahn DM, Colton CL: Malleolar fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 559-581.
Tile M: Fractures of the ankle, in Schatzker J, Tile M (eds): Rationale of Operative Fracture Care, ed 2. Berlin, Springer-Verlag, 1998, pp 523-561.
9/. A 35-year-old woman who underwent open reduction and internal fixation of a calcaneal fracture 14 months ago reports pain that has failed to respond to nonsurgical management. Examination reveals limited painful subtalar motion but no hindfoot deformity. A lateral radiograph is shown in Figure 6. Surgical reconstruction is best accomplished with
1- calcaneal osteotomy.
2- subtalar joint arthrodesis.
3- triple arthrodesis.
4- pantalar arthrodesis.
5- distraction bone block arthrodesis.
PREFERRED RESPONSE: 2
DISCUSSION: The patient has posttraumatic subtalar joint arthrosis that developed following a calcaneal fracture. Because there is no hindfoot deformity, in situ subtalar joint arthrodesis is the treatment of choice. Calcaneal osteotomy or distraction bone block arthrodesis is beneficial in patients with severe talar dorsiflexion or malunion of the calcaneal body. Triple arthrodesis is not warranted without changes at the transverse tarsal joint, and typically even with injury into the calcaneocuboid joint, this joint is often asymptomatic. Pantalar arthrodesis is not indicated as the pathology is occurring at the subtalar joint and not in the ankle joint.
REFERENCES: Sanders R: Fractures and fracture-dislocations of the calcaneus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999,
pp 1422-1464.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
Chandler JT, Bonar SK, Anderson RB, Davis WH: Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures. Foot Ankle Int 1999;20:18-24.
10/. Which of following side effects is most commonly seen in a pediatric patient undergoing ketamine anesthesia?
1- Respiratory depression
2- Increased salivary secretion
3- Hypertension
4- Emergence phenomena
5- Cerebral vasoconstriction
PREFERRED RESPONSE: 2
DISCUSSION: The most common deleterious side effect of ketamine is increased salivation and tracheobronchial secretions. For this reason, an antisialagogue agent should be given. While lack of sufficient respiratory depression is one of the major advantages of using ketamine, apnea can occur if the drug is given too rapidly intravenously. Emergence phenomena is common in adults but relatively rare in children.
REFERENCES: Furman JR: Sedation and analgesia in the child with a fracture, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 62-63.
White PF, Way WL, Trevor AJ: Ketamine: Its pharmacology and therapeutic uses. Anesthesiology 1982;56:119-136.
McCarty EC, Mencio GA, Walker LA, Green NE: Ketamine sedation for the reduction of children’s fractures in the emergency department. J Bone Joint Surg Am 2000;82:912-918.
11/. Figures 7a and 7b show the radiographs of a 51-year-old woman who injured her left leg after falling off a stepladder. Surgical reconstruction is performed with a compression screw and side plate; the postoperative radiograph is shown in Figure 7c. Following gradual progression of weight bearing, she reports that she slipped again and placed full weight on the extremity. She now notes a new onset of increased pain in her left thigh and hip region. Follow-up radiographs are shown in Figures 7d and 7e. Reconstruction should consist of
1- conversion to a longer side plate with the same compression screw and tube angle.
2- in situ bone grafting.
3- hardware removal and reconstruction with an intramedullary device that provides fixation into the femoral head and neck.
4- hardware removal and retrograde femoral nailing.
5- revision reconstruction with cerclage wiring.
PREFERRED RESPONSE: 3
DISCUSSION: The initial fracture was an unstable reverse oblique intertrochanteric fracture with subtrochanteric extension. Initial fixation with a high-angled screw and side plate construct may not provide stability as well as a 95 degree fixed-angle device or a intramedullary hip screw device. The follow-up radiographs show loss of fixation and further propagation of the fracture distally. Reconstruction would best be accomplished with hardware removal and conversion to a long intramedullary nail with femoral head fixation or a 95 degree angled plate and screw device. Conversion to a longer plate does not improve the biomechanical situation at the primary fracture site. In situ bone grafting would not provide any additional stability and would not correct the deformity. The proximal femoral fracture is not amenable to retrograde nailing. Cerclage wiring will not sufficiently enhance stability and is not indicated.
REFERENCES: Bridle SH, Patel AD, Bircher M, Calvert PT: Fixation of intertrochanteric fractures of the femur: A randomized prospective comparison of a gamma nail and dynamic hip screw. J Bone Joint Surg Br 1991;73:330-334.
DeLee JC: Fractures and dislocations of the hip, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 1659-1825.
Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.
12/. An intoxicated 68-year-old man fell at home. Examination reveals abrasions on his forehead, 2/5 weakness of his hand intrinsics and finger flexors, and 4/5 strength of the deltoid, biceps, and triceps bilaterally. Lower extremity motor function is 5/5. Sensory examination to pain and temperature is diminished in his hands but intact in his lower extremities. Deep tendon reflexes are depressed in all four extremities, but perianal sensation and rectal tone are intact. Foley catheterization yields 700 mL of urine. Radiographs of the cervical spine reveal multilevel spondylosis without fracture or subluxation. An MRI scan reveals high-intensity signal change within the cord substance at C5. What is the most likely diagnosis?
1- Brown-Sequard syndrome
2- Central cord syndrome
3- Anterior cord syndrome
4- Posterior cord syndrome
5- Bilateral brachial plexus palsy
PREFERRED RESPONSE: 2
DISCUSSION: Central cord syndrome is characterized by greater neurologic involvement of the upper extremities than the lower extremities. This is typically seen in older patients with cervical spondylosis without associated bony injury or joint subluxation. The prognosis for recovery is fair. Patients with Brown-Sequard syndrome have an ipsilateral motor deficit and contralateral loss of pain and temperature. Prognosis for recovery depends on the mechanism of injury, which is often of a penetrating nature. Anterior cord syndrome results from anterior compression such as occurs with a burst or teardrop fracture of the vertebral body; patients have bilateral motor loss, pain, and temperature loss with preservation of proprioception and vibratory sensation (posterior column function). The prognosis for recovery is generally poor. Posterior cord syndrome is rare and is associated with loss of posterior column function (proprioception and vibration).
REFERENCES: Northrup BE: Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 541-549.
Schneider RC, Thompson JM, Rebin J: The syndrome of acute central cervical spinal cord injury. J Neurol Neurosurg Psychiatry 1958;21:216-227.
13/. A 23-year-old woman sustains an injury to her right hand after falling off her snowboard. Examination reveals that she has difficulty moving her fingers. A radiograph and a clinical photograph are shown in Figures 8a and Figure 8b. Management should consist of
1- closed reduction and buddy taping.
2- in situ pinning.
3- open reduction and internal fixation.
4- casting for 6 weeks.
5- dynamic extension splinting.
PREFERRED RESPONSE: 3
DISCUSSION: The radiograph reveals oblique fractures of the third and fourth metacarpals. The rotational component of the fracture displacement is well visualized on the clinical photograph, which shows scissoring of the middle finger over the ring finger. The fracture obliquity results in rotational deformity that cannot be adequately maintained and held by closed treatment. The treatment of choice is open reduction and internal fixation.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999, pp 711-771.
Freeland AE, Benoist LA, Melancon KP: Parallel miniature screw fixation of spiral and long oblique hand phalangeal fractures. Orthopedics 1994;17:199-200.
Freeland AE, Geissler WB: Plate fixation of metacarpal shaft fractures, in Blair WF (ed): Techniques in Hand Surgery. Baltimore, MD, Williams and Wilkins, 1996, pp 255-264.
14/. A 32-year-old man sustained an L1 burst fracture with 90% canal compromise, intact posterior elements, and kyphosis of 25% at the L1 level. He has an incomplete neurologic injury. Definitive management should consist of
1- bed rest for 8 weeks, followed by mobilization in a total contact thoracolumbosacral orthosis.
2- immediate laminectomy only.
3- anterior decompression, vertebral body reconstruction, and stabilization.
4- in situ posterior fusion.
5- short segment posterior fixation and fusion.
PREFERRED RESPONSE: 3
DISCUSSION: With an incomplete injury, the best chance for recovery occurs when the canal is cleared and the neural structures are decompressed. Anterior decompression, vertebral body reconstruction, and anterior stabilization have been shown to be highly effective in the treatment of burst-type injuries. Laminectomy alone is contraindicated because it increases the instability. Short segment posterior fixation has a high rate of failure in this type of injury at this level.
REFERENCES: Kaneda K, Abumi K: Burst fractures with neurologic deficits of the thoracolumbar spine. J Bone Joint Surg Am 1997;79:69-83.
McGuire R Jr: The role of anterior surgery in the treatment of thoracolumbar fractures. Orthopedics 1997;20:959-962.
15/. The management of a complex multifragmentary diaphyseal fracture of either the tibia or femur has changed during the last decade. Which of the following principles of treatment is now considered less important?
1- Anatomic alignment
2- Indirect reduction
3- Anatomic reduction of the fragments
4- Relatively stable fixation
5- Functional aftercare
PREFERRED RESPONSE: 3
DISCUSSION: Although the original concept of internal fixation was one of anatomic reduction and stable fixation, over the past 10 to 15 years there has been a change based on the advent of intramedullary nailing and bridge plating. It is now appreciated that in a multifragmentary diaphyseal fracture, particularly of the lower extremity, the achievement of axis alignment (mechanical and anatomic axis) is all that is required. Healing will occur by callus. Relatively stable fixation is achieved through intramedullary nailing or bridge plating, providing adequate pain relief for functional aftercare.
REFERENCES: Perren SM, Claes L: Biology and mechanics of fracture management, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000,
pp 7-32.
deBoer P: Diaphyseal fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 93-104.
Mast J, Jakob R, Ganz R: Planning and Reduction Techniques in Fracture Surgery. Berlin, Springer-Verlag, 1989.
16/. A 68-year-old woman who sustained a closed distal tibia fracture 2 years ago was initially treated with an external fixator across the ankle for 12 weeks, followed by intramedullary nailing of the fibula and lag screw fixation of the tibia. She continued to report persistent pain so she was treated with a brace and a bone stimulator. She now reports pain in her ankle. Examination reveals ankle range of motion of 8 degrees of dorsiflexion to 25 degrees of plantar flexion. She is neurovascularly intact. Current radiographs are shown in Figures 9a through 9c. What is the next most appropriate step in management?
1- A cast and weight bearing as tolerated
2- A brace and an ultrasound bone stimulator
3- Intramedullary nailing
4- Open reduction and plate fixation with bone grafting
5- Fibular osteotomy
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a nonunion of the distal fifth of the tibia. The nonunion appears to be oligotrophic, somewhere between atrophic and hypertrophic. Management requires stabilization and stimulation of the local biology, which can be accomplished with open reduction and internal fixation with bone grafting. Bracing or casting does not provide enough stability. Ultrasound bone stimulation has been shown to speed fresh fracture repair but is not indicated in nonunions. The distal segment is too short for intramedullary nailing. A fibular osteotomy alone would increase instability and, even with prolonged casting, would be unlikely to lead to successful repair.
REFERENCES: Carpenter CA, Jupiter JB: Blade plate reconstruction of metaphyseal nonunion of the tibia. Clin Orthop 1996;332:23-28.
Lonner JH, Siliski JM, Jupiter JB, Lhowe DW: Posttraumatic nonunion of the proximal tibial metaphysis. Am J Orthop 1999;28:523-528.
Stevenson S: Enhancement of fracture healing with autogenous and allogeneic bone grafts. Clin Orthop 1998;355:S239-S246.
Wiss DA, Johnson DL, Miao M: Compression plating for non-union after failed external fixation of open tibial fractures. J Bone Joint Surg Am 1992;74:1279-1285.
17/. A patient has a displaced midshaft transverse fracture of the humerus and is neurologically intact. Following closed reduction and application of a coaptation splint, the patient cannot dorsiflex the wrist or the fingers at the metacarpophalangeal joints of the hand. What is the next most appropriate step in management?
1- Observation with a high expectation for recovery
2- Observation for 1 week, followed by exploration if recovery is not evident
3- Immediate exploration of the radial nerve and fracture fixation
4- Immediate exploration of the radial nerve without fracture fixation
5- Removal of the coaptation splint and repeat reduction
PREFERRED RESPONSE: 1
DISCUSSION: The answer to this question is controversial. All of the standard textbooks state that development of a radial nerve palsy during initial fracture management may represent a laceration or injury of the nerve by bone fragments at the time of manipulation; therefore, surgery should be considered. However, it appears that there is no scientific basis for this decision. A review of the available literature shows that the results were the same for patients who were observed as for those who underwent radial nerve exploration. The indications for surgical exploration include palsies associated with open fractures, irreducible closed fractures, and vascular injuries. The only other relative indication for surgical exploration is following manipulation of a Holstein-Lewis fracture (a distal third fracture of the humerus with a lateral spike). In this type of fracture, exploration may be necessary if a closed reduction leads to radial nerve palsy because the spike may lacerate or compress the nerve. Observation for return of nerve function may be appropriate for 3 months or longer prior to considering late exploration.
REFERENCES: Bostman O, Bakalim G, Vainionpaa S, Wilppula E, Patiala H, Rokkanen P: Radial palsy in shaft fracture of the humerus. Acta Orthop Scand 1986;57:316-319.
Shaz JJ, Bhatti NA: Radial nerve paralysis associated with the fractures of the humerus: A review of 62 cases. Clin Orthop 1983;172:171-176.
Holstein A, Lewis GB: Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg Am 1963;458:1382-1388.
18/. A 24-year-old woman has a spleen laceration and hypotension. Radiographs reveal a pulmonary contusion and a displaced mid-diaphyseal fracture of the femur. The trauma surgeon clears her for stabilization of the femoral fracture. What technique will offer the least potential for initial complications?
1- External fixation
2- Plate fixation
3- Unreamed unlocked intramedullary nailing
4- Reamed statically locked intramedullary nailing
5- Reamed unlocked nailing
PREFERRED RESPONSE: 1
DISCUSSION: A concern in the multiply injured patient who has a pulmonary contusion is the potential for further pulmonary compromise because of embolization of marrow, blood clot, or fat during manipulation of the medullary canal. Recent evidence has shown that the presence of a lung injury is the most important determining factor in future deterioration. However, despite the lung injury and its potential consequences, this patient’s femur fracture needs stabilization. Because damage control in the multiply injured patient requires a technique that can be performed rapidly and consistently, the treatment of choice is application of an external fixator. By placing two pins above and below the fracture and with longitudinal traction, the fracture is quickly realigned and stabilized. This allows the patient to be resuscitated and treated at a later date when definitive management of the fracture can be carried out. There is little difference between plate fixation and intramedullary nailing.
REFERENCES: Bosse MJ, MacKenzie EJ, Riemer BL, et al: Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated with either intramedullary nailing with reaming or with a plate: A comparative study. J Bone Joint Surg Am 1997;79:799-809.
Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN: External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics. J Trauma 2000;48:613-623.
Pape HC, Auf’m’Kolk M, Puffrath T, et al: Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion: A cause of posttraumatic ARDS? J Trauma 1993;34:540-548.
19/. Figure 10 shows the radiograph of a 9-year-old girl who injured her left lower leg after being thrown from a horse. Examination reveals no other injuries. Which of the following forms of management will provide the lowest rate of complications and the earliest return to function?
1- Distal femoral pin and 90-90 traction for 3 weeks, followed by a spica cast
2- Closed reduction and stabilization with an external fixator
3- Closed reduction and stabilization with an interlocking nail
4- Closed reduction and stabilization with multiple flexible intramedullary nails
5- Open reduction and stabilization with a plate and screws
PREFERRED RESPONSE: 4
DISCUSSION: Because the patient has a transverse midshaft fracture with no evidence of comminution, the treatment of choice is closed reduction and stabilization with flexible intramedullary nails. Transverse fractures treated with an external fixator heal with poor callus and have a high refracture rate. In addition, the pin tracks produce undesirable and excessive scarring. Femoral pin traction is safe and effective but results in considerable muscle wasting and a slow return to function. Interlocking nails run the risk of greater trochanteric growth disturbance and/or osteonecrosis of the femoral head in this age group. Plate fixation, while effective, requires considerable tissue dissection with large scar formation. It also requires a rather extensive dissection for later plate removal.
REFERENCES: Ligier JN, Metaizeau JP, Prevot J, Lascombes P: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.
Heinrich SD, Drvaric D, Darr K, MacEwen GD: Stabilization of pediatric diaphyseal femoral fractures with flexible intramedullary nails (a technique paper). J Orthop Trauma 1992;6:452-459.
20/. A 25-year-old woman has had continuous pain after falling on her outstretched wrist 12 weeks ago. A current radiograph is shown in Figure 11. Management should consist of
1- open reduction and internal fixation with bone grafting.
2- closed reduction and percutaneous pin fixation.
3- aspiration and steroid injection.
4- closed manipulation and a long arm cast.
5- in situ open bone grafting.
PREFERRED RESPONSE: 1
DISCUSSION: The patient has a scaphoid fracture with cystic resorption of the distal aspect of the midthird of the scaphoid. This fracture is unlikely to heal without intervention. Percutaneous pinning, closed manipulation, and bone grafting will not restore alignment. Treatment requires restoration of scaphoid length, bone grafting, and internal fixation to obtain healing with normal alignment.
REFERENCES: Cooney WP, Linscheid RL, Dobyns JH, Wood MB: Scaphoid nonunion: Role of anterior interpositional bone grafts. J Hand Surg Am 1988;13:635-650.
Fernandez DL: A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg Am 1984;9:733-737.
Stark HH, Rickard TA, Zemel NP, Ashworth CR: Treatment of ununited fractures of the scaphoid by illiac bone grafts and Kirschner-wire fixation. J Bone Joint Surg Am
1988;70:982-991.
Feldman MD, Manske PR, Welch RL, Szerzinski JM: Evaluation of Herbert screw fixation for the treatment of displaced scaphoid nonunions. Orthopedics 1997;20:325-328.
21/. A 7-year-old boy sustains an acute injury to the distal radial metaphysis, along with a completely displaced Salter-Harris type I fracture of the ulnar physis, as shown by the arrows in Figure 12. After satisfactory reduction of both injuries, what is the major concern?
1- Loss of reduction of the ulnar physis
2- Loss of reduction of the radial metaphysis
3- Physeal arrest of the distal radius
4- Physeal arrest of the distal ulna
5- Osteonecrosis of the ulnar epiphysis
PREFERRED RESPONSE: 4
DISCUSSION: While injury of the distal radial metaphysis is a rather common occurrence, the incidence of physeal arrest is only about 4% to 5% of patients. While injury of the distal physis of the ulna is rare, the incidence of physeal arrest is greater than 50% in fractures of this structure. These patients need to be followed closely both clinically and radiographically to look for the signs of distal ulnar/physeal arrest such as loss of the prominence of the ulna and ulnar deviation of the hand. Radiographically, progressive shortening of the ulna is observed.
REFERENCES: Nelson OA, Buchanan JR, Harrison CS: Distal ulnar growth arrest. J Hand Surg Am 1984;9:164-170.
Ogden JA: Skeletal Injury in the Child. New York, NY, Springer-Verlag, 2000, pp 632-635.
22/. A 28-year-old man sustained a fracture-dislocation of T8 in a motor vehicle accident 1 week ago. The injury resulted in complete paraplegia. Management should consist of
1- mobilization in a kinetic therapy bed for 8 weeks.
2- initiation of a steroid protocol.
3- immediate laminectomy of T7, T8, and T9.
4- application of a total contact orthosis.
5- open reduction and posterior segmental stabilization and grafting.
PREFERRED RESPONSE: 5
DISCUSSION: With a complete injury in the thoracic spinal cord, the likelihood of neurologic recovery is small. If possible, treatment should be planned to allow rapid mobilization and rehabilitation without the use of braces and their associated skin problems. The use of long segment fixation provides for rapid mobilization without having to use braces postoperatively. The use of steroid protocol is controversial and should be considered only if it can be started within 8 hours of the injury. Laminectomy is contraindicated because it will increase instability.
REFERENCE: Tasdemiroglu E, Tibbs PA: Long-term follow-up results of thoracolumbar fractures after posterior instrumentation. Spine 1995;20:1704-1708.
23/. A 30-year-old woman sustained a nondisplaced unilateral facet fracture of C5 in a motor vehicle accident. She is neurologically intact and has no other injuries. Management should consist of
1- skeletal tong traction for 6 weeks.
2- halo application.
3- immobilization in a rigid collar for 6 weeks.
4- open reduction posteriorly with interspinous wiring and bone grafting.
5- open reduction anteriorly with diskectomy, interbody grafting, and plating.
PREFERRED RESPONSE: 3
DISCUSSION: The patient has a stable bony fracture that will heal with immobilization in a rigid collar. Flexion-extension radiographs may be obtained at 6 weeks to verify that there is no instability; mobilization may then be begun.
REFERENCE: Clarke CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 457-464.
24/. A 26-year-old man is brought to the emergency department unresponsive and intubated after being found lying on the side of the road. He has a Glasgow Coma Scale score of 6. A chest tube has been inserted on the right side of the chest for a pneumothorax. An abdominal CT scan reveals a small liver laceration and minimal intraperitoneal hematoma. A pneumatic antishock garment (PASG) is on but not inflated. He has bilateral tibia fractures. A pelvic CT scan shows an anterior minimally displaced left sacral ala fracture and left superior and inferior rami fractures. He has received 2 L of saline solution and 4 units of blood but remains hemodynamically unstable. What is the next most appropriate step in management?
1- Inflation of the abdominal portion of the PASG
2- Application of a pelvic clamp
3- Application of a pelvic external fixator
4- Rapid infusion of 4 more units of blood
5- Angiography and embolization
PREFERRED RESPONSE: 5
DISCUSSION: There is no identifiable thoracic, abdominal, or long bone source of ongoing bleeding. The patient has a lateral compression Burgess-Young type I pelvic ring injury. This injury does not increase the pelvic volume because it is not unstable in external rotation. Application of a PASG, a pelvic clamp, or an external fixator may be helpful if the patient has a pelvic injury that is unstable in external rotation or translation but would be of little use in this injury pattern. Persistent hemodynamic instability after administration of 4 units of blood is the decision point where most authors would recommend angiography and embolization. If the pelvis is unstable in external rotation or translation, inflation of the PASG trousers or application of an external fixator is recommended before angiography. Attributing the hemodynamic instability to the head injury before ruling out the pelvis as a source is not indicated.
REFERENCES: Burgess AR, Eastridge BJ, Young JW, et al: Pelvic ring disruptions: Effective classification system and treatment protocols. J Trauma 1990;30:848-856.
Evers BM, Cryer HM, Miller FB: Pelvic fracture hemorrhage: Priorities in management. Arch Surg 1989;124:422-424.
Flint L, Babikian G, Anders M, Rodriguez J, Steinberg S: Definitive control of mortality from severe pelvic fracture. Ann Surg 1990;211:703-707.
25/. A patient has a displaced complex intra-articular distal humeral fracture. What factor is considered most important when deciding on what surgical approach to use?
1- Visualization of the articular surface
2- Avoidance of an olecranon osteotomy
3- A muscle-sparing approach
4- The likelihood a total elbow arthroplasty will be performed
5- The likelihood that reconstruction of the anterior elbow joint will be performed
PREFERRED RESPONSE: 1
DISCUSSION: When managing a complex intra-articular fracture, it is imperative that there is adequate visualization of the joint; this usually means an extensile approach. At the elbow, this is usually through a transolecranon osteotomy. The recent addition of a muscle-sparing approach as described by Bryan and Morrey has gained popularity, but it is difficult to maintain soft-tissue viability and it may put the ulnar nerve at risk. A triceps-splitting approach, which can be used for simple single articular splits into the joint where extra-articular reduction is available, is possible and good results have been reported. To date, there is minimal data on these alternative approaches for comminuted intra-articular distal humeral fractures.
REFERENCES: McKee MD, Mehne DK, Jupiter JP: Fractures of the distal humerus: Part II, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1483-1522
McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR: Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82:1701-1707.
Patterson SD, Bain GI, Mehta JA: Surgical approaches to the elbow. Clin Orthop
2000;370:19-33.
Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: A triceps-sparing approach. Clin Orthop 1982;166:188-192.
26/. The use of nasotracheal intubation for airway management is contraindicated in the acute multiply injured patient when the patient has
1- suspected cervical spine trauma.
2- head injuries and spontaneous respirations.
3- respiratory arrest.
4- a need for prolonged ventilatory support.
5- a hemopneumothorax.
PREFERRED RESPONSE: 3
DISCUSSION: The use of nasotracheal intubation is less desirable in patients with respiratory arrest because placement of the tube is most reliable when the patient is breathing. Nasotracheal intubation is advantageous in patients with suspected cervical spine trauma because it does not require hyperextension of the neck. A nasotracheal tube may be more comfortable than an orally placed tube because it is fixed at several points and moves less freely within the larynx, subglottic area, and trachea. The presence of a hemothorax or pneumothorax does not affect the choice of airway control but does require placement of a chest tube.
REFERENCES: Colice GL: Prolonged intubation versus tracheostomy in the adult. J Intern Care Med 1987;2:85.
Shackford S: Spine injury in the polytrauma patient: General surgical and orthopaedic considerations, in Levine AM, Eismont FJ, Garfin S, Zigler JE (eds): Spine Trauma. Philadelphia, PA, WB Saunders, 1998, pp 9-15.
27/. A 65-year man has right hip pain after a fall. Radiographs reveal a reverse oblique intertrochanteric femoral fracture. Treatment consists of reduction and internal fixation. Which of the following implants is most commonly associated with nonunion and hardware failure?
1- Sliding hip screw
2- Dynamic condylar screw
3- 95 blade plate
4- Cephalomedullary nail
5- Intramedullary hip screw
PREFERRED RESPONSE: 1
DISCUSSION: Reverse oblique intertrochanteric femoral fractures account for 5% of all intertrochanteric or subtrochanteric fractures. They are uncommon but not rare and will be encountered in practice. The sliding hip screw is associated with the most problems because of its design. When reverse oblique fractures are fixed with a sliding hip screw, the action of the construct causes medial displacement of the distal fragment rather than compression of the proximal and distal fragments. All of the other implants prevent medial displacement of the distal segment. It should not be assumed that simply using one of the other implants is reason for success. There is a significant failure rate for each of these implants with reverse oblique fractures. The implant must be ideally placed and the fracture must be reduced.
REFERENCES: Haidukewych GJ, Israel TA, Berry DB: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.
Baumgaertner MR, Chrostowski JH, Levy RN: Intertrochanteric hip fracture, in Browner BD, Jupiter JP, Levine AM, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1833-1881.
28/. Figure 13a shows the radiograph of a 9-year-old girl who sustained complete transverse fractures of the radial and ulnar shafts while in-line skating. A manipulative closed reduction is performed, and the result is seen in Figure 13b. What is the next most appropriate step in management?
1- Wedge the cast to correct angulation.
2- Accept the present alignment and continue follow-up.
3- Perform open reduction and internal fixation of both the radius and ulna with plates and screws.
4- Perform open reduction and internal fixation of both the radius and ulna with intramedullary rods.
5- Remanipulate both the radius and ulna and stabilize with an external fixator.
PREFERRED RESPONSE: 2
DISCUSSION: Bayonet apposition of the radius and ulnar shafts is quite acceptable, as long as the angulation is less than 10 degrees. The rotation must be acceptable as well. This patient went on to full healing, with full supination and pronation of the forearm and no cosmetic deformity.
REFERENCES: Price CT, Scott DS, Kurzner ME, Flynn JC: Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-712.
Vittas D, Larsen E, Torp-Pedersen S: Angular remodeling of midshaft forearm fractures in children. Clin Orthop 1991;265:261-264.
29/. In Figure 14, the primary fracture line in a calcaneal fracture is best depicted by which of the following schematics?
1- A
2- B
3- C
4- D
5- E
PREFERRED RESPONSE: 1
DISCUSSION: The schematic labeled A best depicts the primary fracture line in a calcaneal fracture. The primary fracture line in an axial-loading fracture of the calcaneus occurs from superior-lateral to inferior-medial. This fracture line separates the calcaneus into sustentacular and tuberosity fragments and typically enters the subtalar joint through the posterior facet. Although additional fracture lines typically occur, the primary fracture line is almost always present. If surgical reduction is planned, reducing the primary fracture is always a key step.
REFERENCES: Macey LR, Benirschke SK, Sangeorzan BJ, Hansen ST: Acute calcaneal fractures: Treatment option and results. J Am Acad Orthop Surg 1994;2:36-43.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
30/. A 45-year-old man who sustains a medial subtalar dislocation while playing basketball undergoes immediate closed reduction. No fractures or osteochondral defects are noted on postreduction radiographs. The next most appropriate step in management should consist of
1- a long leg cast for 6 weeks.
2- an ankle support and return to activities.
3- a short leg cast for 4 weeks.
4- open repair of ligaments and active range of motion.
5- open repair of ligaments and casting for 6 weeks.
PREFERRED RESPONSE: 3
DISCUSSION: Most subtalar dislocations can be easily reduced by closed methods. If no fractures or defects are seen on the postreduction radiographs, then the success rate with cast immobilization is good. Medial dislocations have a better prognosis than lateral dislocations. Late instability is rare; therefore, the duration of immobilization should not be excessive. Most subtalar dislocations result in some stiffening of the hindfoot, and painful degenerative arthrosis is the most common serious complication.
REFERENCE: Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.
31/. A 21-year-old woman sustained a minimally displaced traumatic spondylolisthesis of C2 (Hangman’s fracture) after striking the windshield with her forehead during a motor vehicle accident. Management should consist of
1- skeletal tong traction for 6 weeks.
2- anterior C2-3 diskectomy, grafting, and plate fixation.
3- halo application for 8 weeks.
4- a rigid collar for 4 to 6 weeks, followed by mobilization.
5- posterior stabilization with C2 pedicle screws.
PREFERRED RESPONSE: 4
DISCUSSION: According to the classification of Levine and Edwards, a type I Hangman’s fracture is minimally displaced without angulation and represents a stable injury. Good clinical success has been achieved with nonsurgical management consisting of use of a rigid collar until the patient reports pain relief, followed by quick mobilization.
REFERENCE: Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985;67:217-226.
32/. A 25-year-old patient who sustained multiple bilateral rib fractures, a pulmonary contusion, a left nondisplaced transtectal acetabular fracture, and a closed humerus fracture in a motor vehicle accident 2 weeks ago is transferred from another hospital. The humerus fracture has been surgically treated. There are no signs of infection, and the trauma surgeon wants to mobilize the patient as soon as possible. Radiographs are shown in Figures 15a and 15b. Management of the humerus fracture should consist of
1- open reduction and plate fixation.
2- a humeral fracture brace.
3- a locking intramedullary nail.
4- insertion of at least two additional pins.
5- removal of the pins and a long arm hanging cast.
PREFERRED RESPONSE: 1
DISCUSSION: The radiographs show a distal third humerus fracture that is angulated, rotated, and not rigidly fixed. Rigid fixation is needed because mobilization is highly desirable to improve pulmonary function. The acetabular fracture is through the weight-bearing dome but is nondisplaced. Nonsurgical management of the acetabular fracture requires at least 6 weeks of touchdown weight bearing to minimize the forces across the hip joint. Open reduction and plate fixation would achieve anatomic reduction and immediate mobilization. A single posterolateral 4.5-mm plate or two 3.5-mm plates at 90 degrees are possible alternatives. Immediate weight bearing on a plated humerus fracture with the use of crutches or a walker has been shown to be safe and would allow touchdown weight bearing, protecting the hip. None of the other options would achieve this goal for this distal fracture.
REFERENCE: Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD: Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma 2000;49:278-280.
33/. Figure 16 shows the radiograph of a 23-year-old man who has severe right shoulder pain after his motorcyle hit a bridge guardrail. He is neurologically intact. Nonsurgical management will most likely result in
1- nonunion of the clavicle or glenoid.
2- thoracic outlet syndrome.
3- less than 50% range of motion compared with the contralateral shoulder.
4- less than 50% strength compared with the contralateral shoulder.
5- high patient satisfaction and good shoulder function.
PREFERRED RESPONSE: 5
DISCUSSION: Internal fixation of the clavicle, glenoid, or both has been recommended for fractures of the clavicle and glenoid neck (floating shoulders). Recently, the inherent instability of these dual fractures has been questioned in a biomechanical model without further disruption of the coracoclavicular or acromioclavicular ligamentous structures. Nonsurgical management of the majority of combined scapular/glenoid fractures in patients with less than 10 mm of displacement has resulted in excellent shoulder function and will most likely achieve an excellent result in this patient.
REFERENCES: Egol KA, Connor PM, Karunakar MA, Sims SH, Bosse MJ, Kellam JF: The floating shoulder: Clinical and functional results. J Bone Joint Surg Am 2001;83:1188-1194.
Williams GR Jr, Naranja J, Klimkiewicz J, et al: The floating shoulder: A biomechanical basis for classification and management. J Bone Joint Surg Am 2001;83:1182-1187.
Edwards SG, Whittle AP, Wood GW: Nonoperative treatment of ipsilateral fractures of the scapular and clavicle. J Bone Joint Surg Am 2000;82:774-779.
34/. An 18-year old man has a simple oblique fracture of the humeral shaft that requires surgical stabilization to maintain reduction and facilitate mobilization. Which of the following methods will provide the best outcome?
1- Unreamed intramedullary nail
2- Reamed statically locked intramedullary nail
3- External fixation
4- Plate fixation and interfragmentary compression
5- Bridge plate stabilization
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a simple fracture pattern that can be reduced anatomically and stabilized with absolute stability by interfragmental compression and protection plating. This will guarantee a 95% to 98% union rate with no radial nerve palsy. Intramedullary nailing does not equal these results in a simple fracture pattern in the humerus. Bridge plating is indicated for multifragmented fracture patterns when anatomic reduction and absolute stability cannot be achieved. External fixation is reserved for severe open fractures.
REFERENCES: Chapman JR, Henley MP, Agel J, Benca PJ: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166.
Farragos AF, Schemitsch EH, McKee MD: Complications of intramedullary nailing for fractures of the humeral shaft: A review. J Orthop Trauma 1999;13:258-267.
Modabber M, Jupiter JB: Operative management of diaphyseal fractures of the humerus: Plate versus nail. Clin Orthop 1998;347:93-104.
35/. A 28-year-old painter has had increasing pain in his hand and forearm after sustaining a paint injection wound to the tip of his left index finger 24 hours ago. Management should consist of
1- hospital admission and IV antibiotics.
2- emergent surgical debridement.
3- oral antibiotics, splinting, and elevation.
4- nonsteroidal anti-inflammatory drugs and splinting.
5- oral antibiotics and a tetanus shot.
PREFERRED RESPONSE: 2
DISCUSSION: The clinical presentation soon after injury may be surprisingly innocuous, but all high-pressure injection injuries of various materials are best treated by emergent surgical debridement of all foreign material from the flexor tendon sheath as well as the subcutaneous tissues. Subsequent hospital admission, IV antibiotics, and possible repeat debridements usually are necessary. The use of antibiotics alone is inadequate treatment of this severe injury.
REFERENCES: Pinto MR, Turkula-Pinto LE, Cooney WP, Wood MB, Dobyns JH: High-pressure injection injuries of the hand: Review of 25 patients managed by open wound technique. J Hand Surg Am 1993;18:125-130.
Urbaniak JR, Evans JP, Bright DS: Microvascular management of ring avulsion injuries. J Hand Surg Am 1981;6:25-30.
Tsai TM, Manstein C, DuBou R, Wolff T, Kutz JE, Kleinert HE: Primary microsurgical repair of ring avulsion amputation injuries. J Hand Surg Am 1984;9:68-72.
Kay S, Werntz J, Wolff T: Ring avulsion injuries: Classification and prognosis. J Hand Surg Am 1989;14:204-213.
Schnall SB, Mirzayan R: High-pressure injection injuries to the hand, in Kozin SH (ed): Hand Clinics: Upper Extremity Trauma. Philadelphia, PA, 1999, pp 245-248.
36/. A 21-year-old basketball player inverts his foot during practice. Examination reveals obvious deformity of the hindfoot with a prominence of the talar head dorsolaterally and medial displacement of the forefoot. A radiograph is shown in Figure 17. What is the most likely obstacle to closed reduction?
1- Posterior tibial tendon
2- Impaction fracture of the head of the talus
3- Posterior tibial neurovascular bundle
4- Achilles tendon
5- Calcaneus fracture
PREFERRED RESPONSE: 2
DISCUSSION: The patient has a medial subtalar dislocation. These injuries should be reduced as soon as possible to minimize risk to the skin. Most often, this can be done easily, and further radiographic evaluation then can be performed as necessary. On rare occasions, closed reduction is not possible because of fractures of the articular surface of the talus, navicular, interposed extensor digitorum brevis, or transverse fibers of the cruciate crural ligament. The posterior tibial tendon is the most common obstruction to closed reduction in lateral subtalar dislocations, which are less common than medial dislocations. The majority of both injuries can be managed by closed reduction and immobilization.
REFERENCES: Mulroy RD: The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation. J Bone Joint Surg Am 1953;37:859-863.
Heckman JD: Fractures and dislocations of the foot, in Rockwood CA, Green DP, Bucholz RW (eds): Fractures in Adults. Philadelphia, PA, JB Lippincott, 1991, pp 2093-2100.
Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.
37/. A 27-year-old woman sustained a bilateral C5-6 facet subluxation in a motor vehicle accident. Neurologic evaluation reveals normal motor, sensory, and reflex functions. She is awake, alert, and cooperative. Initial management should consist of
1- halo application.
2- skeletal traction and attempted closed reduction.
3- a soft cervical collar.
4- immediate transfer to the operating room for closed reduction.
5- immediate transfer to the operating room for open reduction and
stabilization posteriorly.
PREFERRED RESPONSE: 2
DISCUSSION: As long as the patient is alert and cooperative, an attempt can be made to reduce the dislocation. This should not be attempted in a patient who is obtunded, comatose, or uncooperative. If any neurologic changes are noted during the reduction maneuver, the attempt should be stopped, appropriate radiographic studies obtained, and open reduction and stabilization planned in the operating room.
REFERENCE: Eismont FJ, Arena MJ, Green BA: Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets: Case reports. J Bone Joint Surg Am 1991;73:1555-1560.
38/. A 22-year-old patient sustained a jamming injury to the right little finger. The lateral radiograph shown in Figure 18 reveals comminution of the base of the middle phalanx, with palmar and dorsal metaphyseal cortical involvement. The articular surface also is disrupted. Management should consist of
1- indirect fracture reduction via traction and early mobilization.
2- volar plate arthroplasty.
3- open reduction and internal fixation.
4- closed reduction and percutaneous pin fixation.
5- cast immobilization.
PREFERRED RESPONSE: 1
DISCUSSION: This fracture, known as a pilon fracture, represents comminution of the base of the middle phalanx with both palmar and dorsal cortical disruption. The treatment method that allows the best function and fewest complications is indirect reduction achieved through specific dynamic splinting or the use of specifically designed proximal interphalangeal joint external fixators. Early mobilization can be achieved by either of these techniques. Volar plate arthroplasty is indicated for a simple fracture-dislocation of the proximal interphalangeal joint with comminution of the volar fracture fragment and dorsal dislocation of the remaining articular surface. Open reduction and internal fixation or percutaneous pinning adds surgical risks and scarring and typically will not provide added stability. Cast immobilization will not achieve the goal of early range of motion.
REFERENCES: Stern PJ, Roman RJ, Kiefhaber TR, McDonough JJ: Pilon fractures of the proximal interphalangeal joint. J Hand Surg Am 1991;16:844-850.
Krakauer JD, Stern PJ: Hinged device for fractures involving the proximal interphalangeal joint. Clin Orthop 1996;327:29-37.
39/. Figure 19 shows the radiograph of a 12-year-old boy who sustained an injury to his hand when another child fell on him. Management should consist of
1- early motion and muscle strengthening.
2- immobilization in a thumb spica cast with the thumb abducted.
3- open reduction and internal fixation through a volar approach.
4- open reduction and internal fixation through a dorsal approach.
5- closed reduction and percutaneous pin fixation.
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a Salter-Harris type III fracture of the proximal phalanx of the thumb. It is usually caused by an abduction injury where the ulnar collateral ligament avulses a fragment away from the proximal epiphysis and is the most common childhood gamekeeper’s injury. If there is greater than 1 mm of separation or a significant articular step-off, an open reduction, performed through an extensor aponeurosis-splitting approach, is required to reestablish joint congruity and stability. Percutaneous or closed methods of reduction are usually ineffective. The dorsal approach avoids the volar neurovascular structures. Since the ulnar collateral ligament is still attached, this area does not need to be visualized. The major goal is to reestablish joint congruity and bony stability. This can be easily performed via the dorsal approach.
REFERENCES: Carey TP: Fracture and dislocations of the phalanges, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994, pp 435-436.
Ogden JA: Skeletal Injury in the Child. New York, NY, Springer-Verlag, 2000, p 668.
40/. Figures 20a through 20c show the radiographs of a 69-year-old woman who has severe pain in her dominant right arm after falling on the ice. History includes arthritis, hypertension, and heart disease. She is neurovascularly intact. Management should consist of
1- a long arm cast.
2- immediate functional bracing.
3- closed reduction and percutaneous pin fixation.
4- percutaneous olecranon pin traction.
5- total elbow arthroplasty.
PREFERRED RESPONSE: 5
DISCUSSION: The radiographs reveal a severely comminuted distal humerus fracture. A long arm cast, functional bracing, and closed reduction and percutaneous pin fixation all have a poor outcome and could result in a nonunion that will be very difficult to treat. Open reduction and internal fixation is indicated in most supracondylar humerus fractures, but total elbow arthroplasty is a good alternative in elderly patients who have multiple medical problems and when the fracture pattern may preclude stable enough internal fixation to allow postoperative motion.
REFERENCES: Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997;79:826-832.
Morrey BF: Fractures of the distal humerus: Role of elbow replacement. Orthop Clin North Am 2001;31:145-155.
41/. An 18-year-old man has acute respiratory distress after sustaining injuries in a motorcycle accident. He has a blood pressure of 80/60 mm Hg and a pulse rate of 110/min. Examination reveals chest tympany to percussion, distended neck veins, and deviation of the trachea away from his right hemithorax where the breath sounds are diminished. Heart sounds are regular and normal on auscultation. Initial management should consist of
1- administration of 2 L of saline solution.
2- subxiphoid pericardial aspiration.
3- rapid infusion of 500 mL of colloid solution.
4- insertion of a large-bore needle in the right third or fourth intercostal space.
5- intubation followed by mechanical ventilation.
PREFERRED RESPONSE: 4
DISCUSSION: Tension pneumothorax occurs when air trapped in the pleural space between the lung and chest wall achieves sufficient pressure to compress the lungs and shift the mediastinum. Urgent needle decompression of the pleural space air followed by definitive chest tube placement is the treatment of choice.
REFERENCE: Mattox KL, Feliciano DV, Moore EE (eds): Management of Shock, ed 4. New York, NY, McGraw Hill, 2000, p 215.
42/. A 27-year-old man has neck pain after being involved in a motor vehicle accident. A lateral cervical radiograph is shown in Figure 21. What would be the most common neurologic finding?
1- Cruciate paralysis
2- Quadraplegia
3- Normal function
4- Absent bulbocavernosus reflex
5- Greater occipital nerve dysesthesia
PREFERRED RESPONSE: 3
DISCUSSION: The radiographic findings are consistent with a type II Hangman’s fracture or traumatic spondylolisthesis of C2. This occurs with more than 3 mm of displacement according to the classification of Levine and Edwards. Even though the radiograph reveals significant displacement, the overall space available for the neural elements is increased, therefore minimizing the risk of neural compromise. Neurologic injury is most frequently encountered in type III injuries that are associated with bilateral facet dislocations of C2 on C3 but is infrequent in type I (less than 3 mm displacement) and type II traumatic spondylolisthesis. When neurologic deficits are associated with type II injuries, it is usually the result of an associated head injury. Cruciate paralysis occurs as a result of the crossover of the motor and sensory tracts at different levels of the cord at the C1-C2 junction. This results in normal sensation but complete loss of motor function.
REFERENCES: Levine AM: Traumatic spondylolisthesis of the axis (Hangman’s fracture), in Levine AM, Eismont FJ, Garfin S, Zigler JE (eds): Spine Trauma. Philadelphia, PA, WB Saunders, 1998, pp 287-288.
Francis WR, Fielding JW, Hawkins RJ, Pepin J, Hensinger R: Traumatic spondylolisthesis of the axis. J Bone Joint Surg Br 1981;63:313-318.
43/. After stabilizing a bimalleolar ankle fracture with a plate and lag screws for the fibula and two interfragmental compression screws for the medial malleolus, a syndesmosis screw is indicated in which of the following situations?
1- In all suprasyndesmotic fibular fractures
2- In all transsyndesmotic fibular fractures
3- When there is increased medial clear space with external rotation stress
4- If the deltoid ligament is ruptured
5- If the posterior malleolus is fractured
PREFERRED RESPONSE: 3
DISCUSSION: It is imperative to recognize the need for a position screw (syndesmosis screw) to hold the syndesmosis in proper alignment when surgically stabilizing an ankle fracture. Although many different fracture patterns are suspicious for a disrupted syndesmosis, the only sure way to assess the syndesmosis is to stress it with abduction and external rotation of the talus and attempt to displace the fibula from the incisura fibularis. Under fluoroscopy, the talus will move laterally and displace the fibula, show a valgus talar tilt, or show an increase in the medial clear space. If any or all of these signs occur, a syndesmosis screw is inserted after making sure that the fibula is reduced into the incisura fibularis. This screw may traverse three or four cortices but must not act as a lag screw. It usually is inserted with the ankle in maximal dorsiflexion, although this is probably not necessary because it is almost impossible to overcompress the syndesmosis. The diameter of the screw does not make any difference. It may or may not be removed but not before 3 months.
REFERENCES: Tornetta P III, Spoo JE, Reynolds FA, Lee C: Overtightening of the ankle syndesmosis: Is it really possible? J Bone Joint Surg Am 2001;83:489-492.
Stover MD, Kellam JF: Articular fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 105-119.
Hahn DM, Colton CL: Malleolar fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 559-581.
Tile M: Fractures of the ankle, in Schatzker J, Tile M (eds): Rationale of Operative Fracture Care, ed 2. Berlin, Springer-Verlag, 1998, pp 523-561.
44/. A 32-year-old man sustains multiple injuries in a motorcycle accident including ipsilateral open right femur and comminuted tibia fractures. He has acute abdominal distention and tenderness to palpation. The pelvis is stable to examination. He has a blood pressure of 70/40 mm Hg despite appropriate fluid resuscitation and a pulse rate of 120/min; the pulse is thready. Which of the following procedures is considered the highest priority in the management of this patient?
1- Emergent CT of the abdomen and pelvis
2- Insertion of a Swan-Ganz catheter to monitor the cardiac index
3- Administration of albumin solution
4- Emergent laparotomy in the operating room
5- Application of a pneumatic antishock garment
PREFERRED RESPONSE: 4
DISCUSSION: The patient is in hemorrhagic shock, and timely hemostasis in the operating room should be the highest priority. Further imaging and insertion of central lines carry the risk of further delays in arresting the source of the patient’s bleeding. Albumin (colloid) solutions have questionable indications, are expensive, and have been associated with increased mortality. Crystalloid solutions such as normal saline or lactated Ringer’s solution are the initial resuscitative fluid of choice until blood becomes available. Pneumatic antishock garments have been associated with higher mortality rates, particularly in patients with cardiac and thoracic vascular injuries.
REFERENCES: Krettek C, Simon RG, Tscherne H: Management priorities in patients with polytrauma. Langenbecks Arch Surg 1998;383:220-227.
Weigelt JA: Resuscitation and initial management. Crit Care Clin 1993;9:657-671.
45/. A 35-year-old man sustained an injury to his lower extremity after falling 10 feet from a ladder; initial management was nonsurgical. He now reports chronic hindfoot and anterior ankle pain. Radiographs are shown in Figures 22a and 22b. Surgical reconstruction of this painful process should consist of
1- talectomy and tibiocalcaneal arthrodesis.
2- in situ subtalar joint arthrodesis.
3- distraction bone block subtalar joint arthrodesis.
4- lateral wall exostectomy of the calcaneus.
5- tibiotalar joint arthrodesis.
PREFERRED RESPONSE: 3
DISCUSSION: The radiographs reveal a hindfoot deformity that developed following a severe, comminuted, intra-articular fracture of the calcaneus. There is deformity of the calcaneal body and collapse of the talus into the calcaneus, leading to dorsiflexion of the talus and anterior ankle joint impingement. Distraction bone block subtalar joint arthrodesis will assist with correction of the calcaneal height and will allow for an improved talar declination angle. With this procedure, care must be taken to avoid placing the hindfoot into further varus. A similar reconstruction option not listed would be a calcaneal osteotomy and arthrodesis as described by Romash. Talectomy and tibiocalcaneal arthrodesis are not warranted because the primary structure of the talus and ankle joint is well preserved. In situ subtalar joint arthrodesis will not correct the deformity, and symptoms about the ankle and hindfoot would most likely persist. Lateral wall calcaneal exostectomy may decrease pain from subfibular impingement but will not deal directly with subtalar joint arthrosis and deformity.
REFERENCES: Carr JB, Hansen ST , Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
Romash MM: Reconstructive osteotomy of the calcaneus with subtalar arthrodesis for malunited calcaneal fractures. Clin Orthop 1993;290:157-167.
46/. An 8-year-old boy falls and injures his thumb. A radiograph is shown in Figure 23. Initial management should consist of
1- closed reduction.
2- closed reduction and percutaneous pinning.
3- open reduction through a volar approach.
4- open reduction through a dorsal approach.
5- splinting for comfort.
PREFERRED RESPONSE: 1
DISCUSSION: The radiograph shows a complete simple dislocation of the metacarpophalangeal joint. The clue to this injury is the perpendicular alignment of the proximal phalanx to the metacarpal on the lateral radiograph. This must be differentiated from the complete complex dislocation pattern that is irreducible because of the interposed volar plate. In lateral radiographs of these injuries, the long axes of the proximal phalanx and the metacarpal are parallel. Simple dislocations are amenable to closed reduction and casting. Some authors have recommended ulnar collateral ligament repair if instability is detected on examination after reduction.
REFERENCES: O’Brien ET: Part IV: Dislocations of hand and carpus, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 429-431.
Bohart PC, Gelberman RH, Vardell RF, Solomon PB: Complex dislocations of the MCP joint. J Bone Joint Surg Am 1974;56:1459-1463.
47/. A 28-year-old anesthesia resident has aching pain in his dominant right forearm after injuring it while playing basketball 1 week ago. He reports that he is unable to perform regional anesthesia that requires manipulation of a needle. Examination reveals that he is unable to flex the interphalangeal joint of the thumb, and flexion of the distal interphalangeal joint of the index finger is weak. Management should consist of
1- stretching of the forearm in pronation, wrist flexion, and splinting.
2- primary tendon repair of the flexor pollicis longus and flexor digitorum profundus to the index finger, followed by immobilization.
3- electrodiagnostic examination, followed by decompression of the anterior interosseous nerve within the next 2 to 3 weeks.
4- splinting followed by observation; surgical decompression of the median nerve may be required if no improvement in seen in 3 months.
5- splinting followed by observation; surgical decompression of the anterior interosseous nerve may be required if no improvement is seen in 6 months.
PREFERRED RESPONSE: 5
DISCUSSION: The patient has anterior interosseous nerve palsy. Initial management should consist of splinting followed by observation; surgical decompression may be required if there is no improvement in the functional deficit in 6 months. Anterior interosseous nerve palsy is classically described as an inability to flex the interphalangeal joint of the thumb because of flexor pollicis longus paralysis and a weakness or inability to flex the distal interphalangeal joint of the index finger because of weakness and/or paralysis of the flexor digitorum profundus to the index finger. There has been some controversy in the literature as to whether this represents a true peripheral compression neuropathy or neuritis. Recent recommendations have been to extend the period of observation from 3 to 6 months before surgical decompression, as most cases will resolve within 6 months.
REFERENCES: Miller-Breslow A, Terrono A, Millender LH: Nonoperative treatment of anterior interosseous nerve paralysis. J Hand Surg Am 1990;15:493-496.
Stern PJ, Fassler PR: Anterior interosseous nerve compression syndrome, in Gelberman RH (ed): Operative Nerve Repair and Reconstruction. Philadelphia, PA, 1991, vol 2, pp 983-1002.
48/. A 5-year-old girl sustains an isolated injury to the right shoulder area after falling off the monkey bars. Examination reveals intact neurovascular function in the extremity distally, but she is quite uncomfortable. An AP radiograph of the proximal humerus is shown in Figure 24. Her parents state that she is a very talented gymnast. Considering her age and potential athletic career, management should consist of
1- a shoulder spica cast with the upper extremity in the salute position.
2- a sling and swathe for 3 weeks, followed by gradual motion and strengthening.
3- closed reduction and antegrade intramedullary pinning.
4- closed reduction and retrograde intramedullary nailing.
5- open reduction and internal fixation with small plates and screws.
PREFERRED RESPONSE: 2
DISCUSSION: In this age group, bayonet apposition can produce very good results. Healing occurs rapidly, and remodeling usually is complete in less than 1 year. All of the other methods have significant risks of complications and are unnecessary for this fracture.
REFERENCES: Martin RF: Fractures of the proximal humerus and humeral shaft, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994,
pp 144-148.
Sanders JO, Rockwood CA Jr, Curtis RJ: Fractures and dislocation of the humeral shaft and shoulder, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 937-939.
49/. The cortical injury to the posterolateral distal fibula shown in Figure 25 indicates involvement of which of the following structures?
1- Deltoid ligament
2- Anterior talofibular ligament
3- Calcaneal fibular ligament
4- Superior peroneal retinaculum
5- Syndesmosis
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a rim avulsion fracture that is the result of a forceful twisting injury as the superior peroneal retinaculum is avulsed from its fibular attachment along with a small rim of bone. Injuries to the anterior talofibular ligament or calcaneal fibular ligament would show cortical avulsions more anteriorly or distally at the fibular tip. Deltoid ligament injuries would reveal medial radiographic changes. In a true injury to the syndesmosis, if osseous structures do show avulsion, it would be more directly posterior or anterior on the distal fibula or would occur on the tibial surface.
REFERENCES: Murr S: Dislocation of the peroneal tendons with marginal fracture of the lateral malleolus. J Bone Joint Surg Br 1961;43:563-565.
Clanton TO: Athletic injuries to the soft tissues of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1090-1209.
50/. A 52-year-old woman underwent open reduction and internal fixation for radial and ulnar shaft fractures 2 months ago. In a second fall she refractured her forearm and required revision surgery with bone grafting. One month after the second operation she notes erythema, swelling, and drainage from the volar radial incision. In addition to antibiotic treatment, management should consist of
1- observation and splinting.
2- local wound drainage under local anesthesia.
3- incision and drainage, deep wound cultures, removal of the plates and screws, and cast application.
4- incision and drainage, deep wound cultures, and removal of the fixation only if it is loose.
5- incision and drainage, deep wound cultures, and bone grafting.
PREFERRED RESPONSE: 4
DISCUSSION: Deep infections after plating of closed fractures of the forearm are unusual. However, the risk increases with repeat surgeries. Debridement of all infected, nonviable tissue is the initial step in management. The fixation may be retained if it is stable, but if the plate and screws are loose, they should be removed and revision performed after removal of nonviable bone. Either external fixation or repeat plating may be performed. Late infections after fracture union may be treated with plate and screw removal, debridement, and IV antibiotics.
REFERENCES: Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 53-63.
Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr: Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am 1986;68:1008-1017.
Chapman MW, Gordon JE, Zissimos AG: Compression-plate fixation of acute fractures of the diaphysis of the radius and ulna. J Bone Joint Surg Am 1989;71:159-169.
51/. A left-handed 23-year-old man who fell 5 feet from a ladder onto his left elbow sustained the closed injury shown in Figure 26. Management should consist of
1- percutaneous pin fixation.
2- a percutaneous 6.5-mm screw.
3- long arm casting in flexion.
4- open reduction and internal fixation with a tension band plate.
5- closed reduction and long arm casting in extension.
PREFERRED RESPONSE: 4
DISCUSSION: The radiographs reveal a displaced olecranon fracture. To maximize joint congruity of this intra-articular injury, open reduction and internal fixation is the treatment of choice. A tension band plate will assist with maintenance of the reduction and may aid in early range of motion because injuries to the elbow are prone to stiffness. The oblique fracture line is particularly well suited to plate fixation. Percutaneous pin fixation is unlikely to achieve anatomic joint reduction that can be obtained with open means. External immobilization will not accomplish joint reduction and will most likely lead to a nonunion.
REFERENCES: Hotchkiss RN: Fractures and dislocations of the elbow, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 929-1024.
Murphy DF, Greene WB, Gilbert JA, Dameron TB Jr: Displaced olecranon fractures in adults: Biomechanical analysis of fixation methods. Clin Orthop 1987;224:210-214.
Hume MC, Wiss DA: Olecranon fractures: A clinical and radiographic comparison of tension band wiring and plate fixation. Clin Orthop 1992;285:229-235.
52/. Which of the following is a long-term complication of ankle arthrodesis for posttraumatic arthritis?
1- Progressive limb-length discrepancy
2- Contralateral ankle arthritis
3- Ipsilateral hindfoot and midfoot arthritis
4- Ipsilateral knee arthritis
5- Talar osteonecrosis
PREFERRED RESPONSE: 3
DISCUSSION: Ankle arthrodesis for posttraumatic ankle arthrosis provides reliable pain relief. However, the long-term sequela of joint arthrodesis is the development of arthrosis in the surrounding joints. Over time, following ankle arthrodesis, the ipsilateral hindfoot and midfoot joints show signs of joint space wear, and this may be symptomatic. With a stable ankle arthrodesis, progressive limb-length discrepancy or talar osteonecrosis is not expected. Ankle arthrodesis has not been definitively linked to ipsilateral knee arthritis or contralateral ankle arthritis.
REFERENCES: Coester LM, Saltzman CL, Leupold J, Pontarelli W: Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 2001;83:219-228.
Mazur JM, Schwartz E, Simon SR: Ankle arthrodesis: Long-term follow-up with gait analysis. J Bone Joint Surg Am 1979;61:964-975.
53/. A 19-year-old female long-distance runner has an incomplete tension-side femoral neck stress fracture. Management should consist of
1- limited weight bearing for 6 weeks, followed by a progressive return to activity.
2- no weight bearing for 6 weeks, followed by no running for 6 months.
3- no weight bearing for 2 weeks, followed by internal fixation if symptoms persist.
4- internal fixation at the time of diagnosis.
5- cessation of running for 6 weeks.
PREFERRED RESPONSE: 4
DISCUSSION: Unlike compression-side stress fractures, tension-side stress fractures on the superior side of the femoral neck are at a very high risk of displacement, even if the patient is not bearing weight. It is highly recommended to treat these fractures like acute fractures and to proceed with internal fixation emergently. Once the fracture has displaced, the prognosis is poor in terms of returning to sports, even when reduced and internally fixed. Nonsurgical management, such as limited weight bearing and low-impact activities, works very well for other lower extremity stress fractures. A training program evaluation (shoes, tracks, schedule) is always indicated for all patients with stress fractures.
REFERENCE: Boden BP, Osbahr DC: High-risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.
54/. A 7-year-old girl who sustained a type III posteromedial extension supracondylar fracture underwent a closed reduction at the time of injury. Figure 27a shows the position of the fracture fragments prior to percutaneous medial and lateral pin fixation. Following surgery, healing was uneventful and the patient regained a full painless range of motion. Fifteen months after the injury, she now reports loss of elbow motion and moderate pain with activity. A current AP radiograph is shown in Figure 27b. What is the most likely cause of her symptoms?
1- Latent osteomyelitis from the percutaneous pins
2- Muscle weakness because of a lack of postinjury rehabilitation
3- Tardy ulnar nerve paralysis from injury by the medial pin
4- Osteonecrosis of the trochlea, producing joint incongruity
5- A new acute process
PREFERRED RESPONSE: 4
DISCUSSION: The patient sustained a very distal supracondylar fracture of the humerus. Fractures in this area can disrupt the blood vessels supplying the lateral ossification center of the trochlea. With disturbance of the blood supply in this area, local osteonecrosis occurs and disrupts the support for the overlying articular surface, producing joint incongruity and localized degenerative arthritis.
REFERENCES: Haraldsson S: The interosseous vasculature of the distal end of the humerus with special reference to the capitellum. Acta Orthop Scand 1957;27:81-93.
Morrissy RT, Wilkins KE: Deformities following distal humeral fracture in childhood. J Bone Joint Surg Am 1984;66:557-562.
55/. A 55-year-old man sustained an isolated closed fracture of the humerus. Initial neurologic examination reveals no active wrist or finger extension. Radiographs are shown in Figures 28a and 28b. Management should consist of
1- closed treatment and observation for return of nerve function.
2- closed treatment and immediate tendon transfer.
3- open nerve exploration without internal fixation of the fracture.
4- open nerve exploration with plating of the fracture.
5- open nerve exploration with intramedullary rodding of the fracture.
PREFERRED RESPONSE: 1
DISCUSSION: The patient has an isolated closed injury involving the humeral diaphysis. The lack of wrist and finger extension indicates injury to the radial nerve. Based on these findings, ongoing observation of the nerve is warranted with delayed exploration after 3 to 4 months if there are no signs of progressive return of nerve function. Treatment of the fracture should include external immobilization and fracture bracing. An indication for nerve exploration and surgical stabilization would be an open fracture.
REFERENCES: Zuckerman JD, Kovil KJ: Fractures of the shaft of the humerus, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 1025-1053.
Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.
56/. Examination of a 41-year-old man who was thrown from a motorcycle reveals that both legs appear externally rotated and there is bruising in the perineal area. He has a blood pressure of 80/40 mm Hg, a pulse rate of 140/min, a respiratory rate of 25/min, and he appears confused. Following administration of 4 L of saline solution and 2 units of packed red blood cells, he has a blood pressure of 80/40 mm Hg, a pulse rate of 160/min, and a respiratory rate of 25/min. The abdominal assessment for intraperitoneal blood is negative. An AP radiograph shows an anteroposterior compression injury with 7 cm of symphysis diastasis but no posterior displacement in the sacroiliac joints. What is the next most appropriate step in management?
1- Stabilization of the pelvis through noninvasive methods
2- Additional crystalloid solution replacement
3- External fixation in the operating room
4- Angiographic embolization
5- Continuing observation of vital signs
PREFERRED RESPONSE: 1
DISCUSSION: Because the patient has sustained a major high-energy injury to the pelvic ring, it can be assumed that there is serious bleeding or hemodynamic instability related to a pelvic vascular injury. The goal of intervention at this time is to assist in the resuscitative effort and to stop the bleeding. All attempts at providing fluid and blood are important, but without cessation of the bleeding continued loss occurs and significant problems can ensue such as coagulopathy and multiple organ failure. Noninvasive methods of stabilizating the pelvic ring should be used to stop the bleeding. These methods include wrapping a sheet around the pelvis or using commercially available belts, vacuum beanbags, or pneumatic shock garments. This will provide time to prepare for arteriography and/or external fixation. The next step is debatable but in view of negative findings for intra-abdominal blood, arteriography performed with the pelvis reduced using noninvasive methods would be ideal.
REFERENCES: Bassam D, Cephas GA, Ferguson KA, Beard LN, Young JS: A protocol for the initial management for unstable pelvic fractures. Am Surg 1998;64:862-867.
Levine AM (ed): Orthopaedic Knowledge Update: Trauma. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 217-226.
Mucha P Jr, Welch TJ: Hemorrhage in major pelvic fractures. Surg Clin North Am 1988;68:757-773.
57/. A 32-year-old man sustained a closed injury after falling 25 feet from a roof. His ankle and foot are severely swollen. Radiographs and CT scans are shown in Figures 29a through 29d. Initial management should consist of
1- closed reduction and application of a long leg cast.
2- open reduction and internal fixation with plate and screw fixation.
3- percutaneous plate fixation.
4- spanning external fixation with delayed limited open reduction and internal fixation.
5- primary ankle arthrodesis.
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a severe high-energy injury from axial loading to the left ankle and distal tibia. This is a closed injury, but the soft tissues are injured and severely swollen. Initial treatment should focus on skeletal stabilization, and incisions directly over the fracture area should be avoided until soft-tissue stabilization has occurred. Immediate spanning external fixation with plans for a delayed reconstruction as needed for the joint surface is the treatment of choice. Closed reduction and application of a constrictive long leg cast may lead to increased risk of tissue necrosis. Immediate open procedures to internally fix the fracture add the risks of soft-tissue necrosis and are to be avoided. Percutaneous plating may be one of the delayed fixation options but should not be used immediately. Primary ankle arthrodesis is not indicated.
REFERENCES: Thordarson DB: Complications after treatment of tibial pilon fractures: Prevention and management strategies. J Am Acad Orthop Surg 2000;8:253-265.
Marsh JL, Bonar S, Nepola JV, DeCoster TA, Hurwitz SR: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509.
Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am 1996;78:1646-1657.
58/. Which of the following parameters is considered most important when assessing an acetabular fracture for surgical indications?
1- Age of the patient
2- Failure to maintain reduction of the head under the dome without traction
3- Presence of a femoral head impaction lesion
4- Direction of the femoral head displacement
5- Fragmentation of the fracture
PREFERRED RESPONSE: 2
DISCUSSION: The most important aspect in the decision for surgery in an acetabular fracture is the ability of the femoral head to remain concentrically reduced under the dome in AP and Judet oblique views of the pelvis. If this parameter is present, then the need for surgery is determined by other aspects such as fragmentation, age, incongruity, and displacement. If the head remains stable under the dome without traction, there is sufficient acetabular dome to provide stability, and nonsurgical treatment may be appropriate.
REFERENCES: Tile M: Assessment and management of acetabular fractures, in Tile M (ed): Pelvic and Acetabular Fractures, ed 2. Baltimore, MD, Williams and Wilkins, 1995, pp 305-354.
Letournel E: Acetabular fractures: Classification and management. Clin Orthop 1980;151:81-106.
Letournel E, Judet R: Fractures of the Acetabular, ed 2. Berlin, Springer-Verlag, 1993, pp 29-49.
59/. A 57-year-old man has had right ankle pain for the past 10 months following an injury that went untreated. Radiographs are shown in Figures 30a through 30c. Management should consist of
1- ankle arthrodesis.
2- modified Brostrom ligament reconstruction.
3- restoration of fibular length, alignment, and rotation.
4- cast immobilization.
5- tibial shortening osteotomy.
PREFERRED RESPONSE: 3
DISCUSSION: The radiographs reveal a malunited distal fibular fracture with shortening. Because there appears to be an adequate cartilage space within the ankle joint, the role of reconstruction would be to prevent arthrosis and the need for ankle arthrodesis, as well as to decrease symptoms. The treatment of choice is restoration of fibular length, alignment, and rotation with osteotomy plating, and bone grafting as needed. There is no indication for ligament reconstruction of a mechanically stable ankle, and tibial shortening osteotomy will not assist in correcting the deformity. Cast immobilization may assist with improvement of symptoms but will not correct the overall process. Determination of fibular length is best done by comparing the talocrural angle of the injured side with the uninjured side. The goal is to perfectly reduce the talus in the ankle mortise.
REFERENCES: Marti RK, Raaymakers EL, Nolte PA: Malunited ankle fractures: The late results of reconstruction. J Bone Joint Surg Br 1990;72:709-713.
Geissler W, Tsao A, Hughes J: Fractures and injuries of the ankle, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 2201-2206.
Yablon IG, Leach RE: Reconstruction of malunited fractures of the lateral malleolus. J Bone Joint Surg Am 1989;71:521-527.
60/. A 32-year-old man sustains a forceful inversion injury while playing soccer. Examination reveals tenderness in the lateral hindfoot and midfoot region with associated ecchymosis and swelling. Radiographs show proximal migration of the os peroneum. Active eversion is still present. These findings indicate disruption of the
1- extensor digitorum brevis.
2- plantar fascia.
3- peroneus brevis.
4- peroneus longus.
5- syndesmosis.
PREFERRED RESPONSE: 4
DISCUSSION: The os peroneum is an accessory ossicle located within the peroneus longus tendon. It is typically located at the level of the cuboid groove in the lateral hindfoot and midfoot region. Proximal migration of the os peroneum indicates disruption of the peroneus longus tendon and is an important clue to diagnosis. This unusual condition can cause chronic lateral ankle pain, and surgical repair may be indicated. Active eversion indicates that the peroneus brevis is clinically intact. Disruption of the extensor digitorum brevis, plantar fascia, or syndesmosis would have no effect on the position of the os peroneum.
REFERENCES: Thompson FM, Patterson AH: Rupture of the peroneus longus tendon: Report of three cases. J Bone Joint Surg Am 1989;71:293-295.
Clanton TO: Athletic injuries to the soft tissues of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1090-1209.
61/. A 24-year-old man sustained a grade IIIb open tibial fracture and an ipsilateral grade IIIa femoral fracture in a motorcycle accident. He is unresponsive, intubated, and has a Glasgow Coma Scale score of 8. He is resuscitated and taken to the operating room for definitive orthopaedic care. Which of the following intraoperative problems will most likely adversely affect his long-term outcome?
1- Blood loss during debridement
2- Prolonged tourniquet time
3- Failure to stabilize both fractures with intramedullary nails
4- Episodic hypotension
5- Loss of dorsalis pedis pulse
PREFERRED RESPONSE: 4
DISCUSSION: Traumatic brain injury is considered to be either primary or secondary. Primary injury is direct or impact damage to the brain, and secondary injury can have intracranial or systemic causes. While treatment has little impact on primary brain injury, secondary brain injury can be avoided. There are also many causes of intracranial secondary brain injury, including intracranial hypertension or cerebral edema. There are many causes of systemic secondary brain injury, but none has a greater impact on outcome than hypotension or hypoxia. In fact, the occurrence of hypotension postinjury causes a 10- to 15-fold increase in mortality. In a series by Pietropaoli and associates, the mortality rate for head-injured patients that were normotensive during surgery was 25%, but if they were hypotensive the mortality rate was 82%. In the same series, the number of patients with a Glasgow Coma Scale score of either 4 or 5 dropped from 58% in those patients that were normotensive during surgery to 6% in those patients that became hypotensive during surgery. Efforts to avoid hypotension postinjury and especially during surgery should be of primary importance.
REFERENCES: Chesnut RM, Marshall LF, Klauber MR, et al: The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216-222.
Pietropaoli JA, Rogers FB, Shackford SR, Wald SL, Schmoker JD, Zhuang J: The deleterious effects of intraoperative hypotension on outcome in patients with severe head injury. J Trauma 1992;33:403-407.
Schmeling GJ, Schwab JP: Polytrauma care: The effect of head injuries and timing of skeletal fixation. Clin Orthop 1995;318:106-116.
Townsend RN, Lheureau T, Protech J, Reimer B, Simon D: Timing fracture repair in patients with severe brain injury (Glascow Coma Scale score
J: Fracture of the forearm, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 323-337.
Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.
72/. A 15-year-old baseball pitcher who reports increasing pain in his right shoulder over the past 3 weeks states that the pain increases the more he pitches. Radiographs of both shoulders are shown in Figures 35a and 35b. What is the next most appropriate step in management?
1
Increased pitching activity in conjunction with aggressive physical therapy

2
Biopsy of the lesion in the proximal humerus

3
Complete rest with no activity

4
Immobilization in a shoulder spica cast in the salute position

5
Cessation of pitching and a vigorous program of muscle strengthening

The patient has a rotational stress fracture of the proximal humeral physis (Little Leaguer’s shoulder). The symptoms of increasing pain with activity and relief with rest are typical of a stress injury. Treatment should consist of cessation of throwing activity but rehabilitation of the shoulder girdle muscles. The pitching technique should be evaluated as well.
REFERENCES: Barnett LS: Little League shoulder syndrome: Proximal humeral epiphyseolysis in the adolescent baseball pitchers: A case report. J Bone Joint Surg Am 1985;67:495-496.
Cahill BR, Tullos HS, Fain RH: Little league shoulder: Lesions of the proximal humeral epiphyseal plate. J Sports Med 1974;2:150-152.
73/. A 36-year-old man sustains a traumatic spondylolisthesis of L5 on S1. Surgical stabilization requires pedicular fixation into the sacrum. If the screw is placed in a medial to lateral direction and penetrates the sacral ala, what nerve root is at risk?
1- L2
2- L3
3- L4
4- L5
5- S1
PREFERRED RESPONSE: 4
DISCUSSION: The L5 nerve root lies directly over the superior and anterior alae. If the screw is directed approximately 20 degrees laterally and bicortical purchase is achieved, there is the risk of injuring the L5 nerve root. If the screw is directed medially into the body of S1, there is little risk of injury. The same root is at risk during placement of an iliosacral screw.
REFERENCES: Ebraheim NA, et al: Lumbosacral nerve and dorsal screw placement. Orthopedics 2000;23:245-247.
Ebraheim NA, Mermer M, Xu R, Yeasting RA: Radiological evaluation of S1 dorsal screw placement. J Spinal Disord 1996;9:527-535.
Routt ML Jr, Nork SE, Mills WJ: Percutaneous fixation of pelvic ring disruptions. Clin Orthop 2000;375:15-29.
74/. A 25-year-old woman who fell on her outstretched hand reports chronic pain over the hypothenar eminence region and some dorsal ulnar wrist pain. She also notes difficulty playing golf and tennis. Plain radiographs of the hand and wrist are unremarkable. A CT scan is shown in Figure 36. What is the next most appropriate step in management?
1- Ultrasound therapy
2- MRI for further soft-tissue evaluation
3- Open reduction and internal fixation of the hook of the hamate
4- Excision of the hook of the hamate
5- Electrodiagnostic evaluation
PREFERRED RESPONSE: 4
DISCUSSION: The CT scan reveals a hook of the hamate nonunion with irregular resorption at the fracture site, which is at the base of the hamate. Symptomatic relief of the pain and discomfort has been well documented after excision of the hook of the hamate. Ultrasound therapy will not provide long-term symptomatic relief or induce nonunion healing. MRI for further soft-tissue evaluation is inappropriate because this is a bony problem; the bony architecture of the wrist is best visualized by CT. Open reduction and internal fixation of the hook of the hamate does not provide the symptomatic relief that is found with excision of the hook of the hamate. In addition, the technical difficulties and relative risk of persistent nonunion after open reduction and internal fixation are not merited when hamate excision can be effected easily and causes no long-term untoward effects. Electrodiagnostic evaluation is inappropriate because there is no history of the persistent numbness and tingling that is found in peripheral compression neuropathies.
REFERENCES: Stark HH, Chao EK, Zemel NP, Rickard TA, Ashworth CR: Fracture of the hook of the hamate. J Bone Joint Surg Am 1989;71:1206-1207.
Failla JM: Hook of hamate vascularity: Vulnerability to osteonecrosis and nonunion. J Hand Surg Am 1993;18:1075-1079.
Carter PR, Easton RG, Littler JW: Ununited fracture of the hook of the hamate. J Bone Joint Surg Am 1977;59:583-588.
Egawa M, Asai T: Fracture of the hook of the hamate: Report of six cases and the suitability of computerized tomography. J Hand Surg Am 1983;8:393-398.
75/. An active 72-year-old woman sustained a mid-diaphyseal right humerus fracture 16 months ago. History reveals that she was first treated with a brace for 7 months. Additional treatment consisted of intramedullary nailing 9 months ago. Recently the rod was removed, and the patient now reports pain and gross motion at the fracture site. Current radiographs are shown in Figures 37a and 37b. What is the next most appropriate step in management?
1- Electrical stimulation with an implanted coil
2- Ultrasound stimulation for 30 minutes per day
3- Locked intramedullary nailing with bone graft
4- Ilizarov external fixation with intermittent distraction and compression
5- Plate and screw fixation with bone graft
PREFERRED RESPONSE: 5
DISCUSSION: The patient has a well-established nonunion in a very porotic bone. Electrical stimulation has been found effective in treating tibial nonunions, but there is very little data on humeral nonunions, especially chronic well-established ones. Ultrasound stimulation is effective in accelerating fracture healing, but there is little data concerning the treatment of nonunions. Intramedullary nailing with bone graft is an option, but it maybe difficult to obtain a rigid construct in a very porotic bone. An Ilizarov-type external fixator would be an alternative, but there is little clinical data for the humerus and it may be poorly tolerated. A plate and screw construct with bone graft combines rigidity with the biologic advantage of the bone graft. A recent series reported on the use of a plate combined with onlay allograft for recalitrant nonunions. Cement augmentation for screw fixation either in the canal or added to the screw holes may be helpful in select cases.
REFERENCES: Hornicek FJ, Zych GA, Hutson JJ, Malinin TI: Salvage of humeral nonunions with onlay bone plate allograft augmentation. Clin Orthop 2001;386:203-209.
Jupiter JB: The treatment of complex non-unions of the humeral shaft with a combination of surgical techniques. J Bone Joint Surg Am 1990;72:701-707.
76/. A 47-year-old man ruptured his left patellar tendon and twisted his right ankle in a fall. Initial radiographs of the ankle are unremarkable. One week following repair of the left patellar tendon, he reports increased pain with weight bearing in his right ankle. A follow-up radiograph is shown in Figure 38. Management of the ankle injury should consist of
1- functional rehabilitation with range of motion and strengthening.
2- reduction and screw fixation of the syndesmosis.
3- closed reduction and a long leg cast.
4- repair of the talofibular ligaments.
5- fibular osteotomy and plate fixation.
PREFERRED RESPONSE: 2
DISCUSSION: The radiograph reveals disruption of the syndesmosis with lateral displacement of the talus and widening of the medial ankle clear space. No fibular fracture is noted, although radiographs of the entire tibia and fibula are necessary to rule out a more proximal fibula fracture. There is clear instability of the syndesmosis, and surgical stabilization is needed, either by direct repair of the ligaments or more commonly with surgical stabilization of the fibula to the tibia with screws. Functional rehabilitation and early range of motion are indicated with anterior-lateral ankle sprains but not with true instability of the syndesmosis. In anterior syndesmotic injuries in which there are no signs of instability on plain radiographs or with stressing, cast immobilization and protected weight bearing until tenderness subsides is warranted. Long leg cast immobilization is unlikely to be adequate in maintaining reduction of the syndesmosis. Repair of the talofibular ligaments or fibular osteotomy does not address the pathology at the syndesmosis. Chronic syndesmotic disruption is likely to lead to chronic ankle pain and early arthrosis.
REFERENCES: Wuest TK: Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg 1997;5:172-181.
Edwards GS Jr, DeLee JC: Ankle diastasis without fracture. Foot Ankle 1984;4:305-312.
77/. A 45-year-old man reports severe discomfort following a twisting injury to his right ankle and foot. Plain radiographs are negative; however, the CT scans shown in Figures 39a and 39b reveal a fracture. Management should consist of
1- open reduction and internal fixation.
2- percutaneous pin fixation.
3- excision of the fracture fragment.
4- primary calcaneocuboid joint arthrodesis.
5- a walking cast or removable cast boot.
PREFERRED RESPONSE: 5
DISCUSSION: The CT scans show a fracture of the anterior process of the calcaneus that involves less than 25% of the joint surface with minimal to no displacement. The preferred treatment is external immobilization in either a walking cast or, more typically, a removable cast boot. For larger fractures that involve more than 25% of the articular surface with joint incongruity, open reduction and internal fixation may be indicated. Primary calcaneocuboid joint arthrodesis is not warranted because symptoms are rare in most patients. Delayed excision of the fragment is a late reconstructive option if painful nonunion develops. Percutaneous pin fixation is not indicated beceause there tends to be inherent stability in this fracture.
REFERENCES: Heckman JD: Fractures and dislocations in the foot, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 2267-2405.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
78/. Which of the following complications occurs more commonly after antegrade femoral nail insertion when compared with retrograde insertion?
1- Increased blood loss
2- Decreased range of motion of the knee
3- Infection
4- Hip pain
5- Muscle weakness
PREFERRED RESPONSE: 4
DISCUSSION: There is no difference between the rates of union, malunion, range of motion of the hip or knee, muscle weakness, or infection for the two types of femoral nail insertion. The only difference is the location of the morbidity, which is around the insertion point of the rod. The antegrade technique has more morbidity about the hip, and the retrograde insertion technique has more morbidity about the knee.
REFERENCES: Morgan E, Ostrum RF, DiCicco J, McElroy J, Poka A: Effects of retrograde femoral intramedullary nailing on the patellofemoral articulation. J Orthop Trauma 1999;13:13-16.
Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R: Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma 2001;15:161-169.
Ostrum RF, Agarwal A, Lakatos R, Poka A: Prospective comparison of retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma 2000;14:496-501.
Tornetta P III, Tiburzi D: Antegrade or retrograde reamed femoral nailing: A prospective, randomized trial. J Bone Joint Surg Br 2000;82:652-654.
79/. A 24-year-old man has right forearm pain after sliding head first into home plate. Examination reveals that the arm is swollen, but there are no neurovascular deficits or skin lacerations. Radiographs reveal a both-bone forearm fracture. The ulna has an oblique fracture with a 30% butterfly fragment, and the radius is comminuted over 75% of its circumference. In addition to reduction and plate fixation of both bones, management should consist of
1- bone grafting the radius only.
2- bone grafting both the radius and ulna.
3- bone graft substitute for both the radius and ulna.
4- no additional grafting.
5- no additional grafting but postoperative electrical stimulation.
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a both-bone fracture with a comminuted radial shaft. Open reduction and internal fixation of both bones is the treatment of choice. In the past, Chapman and associates recommended bone grafting radial shaft fractures with more than 30% comminution of the circumference. This has remained the recommendation in most textbooks. More recent studies, where modern biologic plating techniques were used, found that the addition of bone graft to comminuted fractures was not necessary because the union rate did not differ from that of nongrafted comminuted fractures.
REFERENCES: Anderson LD, Sisk TD, Tooms RE, Park WI III: Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am 1975;57:287-297.
Chapman MW, Gordon JE, Zissimos AG: Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am 1989;71:159-169.
Wright RR, Schmeling GJ, Schwab JP: The necessity of acute bone grafting in diaphyseal forearm fractures: A retrospective review. J Orthop Trauma 1997;11:288-294.
Wei SY, Born CT, Abene A, Ong A, Hayda R, Delong WG Jr: Diaphyseal forearm fractures treated with and without bone graft. J Trauma 1999;46:1045-1048.
80/. A 32-year-old woman has an isolated left posterior wall acetabular fracture in which about 25% of the wall surface is involved. Which of the following criteria would indicate the need for surgical reduction and fixation?
1- Fracture comminution
2- Displacement of 1 mm at the fracture site
3- Involvement of the ischial facet
4- Femoral head subluxation during fluoroscopic examination
5- Presence of a bilateral pneumothorax
PREFERRED RESPONSE: 4
DISCUSSION: Fractures with a posterior wall fragment that makes up less than one third of the surface generally are stable. Conversely, fractures with a fragment making up more than 50% of the surface are unstable. Patients with an intermediate fracture fragment should undergo a fluoroscopic examination under sedation or anesthesia to determine if the fragment is truly stable. If so, the patient can be treated nonoperatively and safely mobilized.
REFERENCES: Tornetta P III: Non-operative management of acetabular fractures: The use of dynamic stress views. J Bone Joint Surg Br 1999;81:67-70.
Keith JE Jr, Brashear HR Jr, Guilford WB: Stability of posterior fracture-dislocations of the hip: Quantitative assessment using computed tomography. J Bone Joint Surg Am 1988;70:711-714.
81/. A 25-year-old man reports wrist pain following a motorcycle accident. Examination reveals minimal swelling, slightly limited active range of motion, and point tenderness in the snuff box region. AP and oblique radiographs are shown in Figures 40a and 40b. Management should consist of
1- closed reduction and a short arm cast for 10 weeks.
2- closed reduction and a long arm cast for 10 weeks.
3- open reduction and internal fixation.
4- limited intercarpal fusion.
5- proximal row carpectomy.
PREFERRED RESPONSE: 3
DISCUSSION: The radiographs reveal a scaphoid fracture with displacement and comminution and an unstable fracture pattern. Treatment should consist of open reduction and internal fixation. In displaced scaphoid fractures and fractures with unstable fracture patterns, closed reduction is ineffective and is likely to lead to nonunion. Limited intercarpal fusion and proximal row carpectomy are used to correct a variety of traumatic and posttraumatic problems of the wrist.
REFERENCES: Amadio PC, Taleisnik J: Fractures of the carpal bone, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 809-823.
Rettig ME, Kozin SH, Cooney WP: Open reduction and internal fixation of acute displaced scaphoid waist fractures. J Hand Surg Am 2001;26:271-276.
Cooney WP, Dobyns JH, Linscheid RL: Fractures of the scaphoid: A rational approach to management. Clin Orthop 1980;149:90-97.
Szabo RM, Manske D: Displaced fractures of the scaphoid. Clin Orthop 1988;230:30-38.
82/. A 42-year-old woman reports that she has low back pain and had a transient loss of consciousness after falling off a horse. She denies having neck pain but notes that she was involved in a motor vehicle accident 2 years ago and had neck pain at that time. Examination reveals full range of motion of the neck and no localized tenderness. The neurologic examination is normal. A lateral radiograph of the cervical spine is obtained. Figures 41a and 41b show CT and MRI scans. What is the most likely diagnosis?
1- Cervical sprain
2- Atlas fracture
3- Acute displaced odontoid fracture
4- Odontoid nonunion
5- Hangman’s fracture
PREFERRED RESPONSE: 4
DISCUSSION: The examination findings do not correlate with an acute injury (full range of cervical motion and the absence of pain). Radiographically, the fracture appears old based on the smooth contour of the fracture fragments and the absence of soft-tissue swelling. Flexion-extension radiographs can be obtained to determine potential instability; if present, stabilization and fusion should be considered.
REFERENCES: Schatzker J, Rorabeck CH, Waddell JP: Non-union of the odontoid process: An experimental investigation. Clin Orthop 1975;108:127-137.
Clark CR, White AA III: Fractures of the dens: A multicenter study. J Bone Joint Surg Am 1985;67:1340-1348.
83/. What neurologic structure is most at risk when performing intramedullary screw fixation of a fifth metatarsal base fracture?
1- Saphenous nerve
2- First branch of the lateral plantar nerve
3- Superficial peroneal nerve
4- Sural nerve
5- Deep peroneal nerve
PREFERRED RESPONSE: 4
DISCUSSION: The sural nerve and its terminal branches course through the lateral hindfoot and midfoot area and are directly at risk in surgeries involving the peroneal tendon complex and the fifth metatarsal. The first branch of the lateral plantar nerve originates in the tarsal tunnel region and courses across the plantar heel area to innervate the abductor digiti minimi; it is not at direct risk with fifth metatarsal surgery. The saphenous, superficial peroneal, and deep peroneal nerves are not at risk anatomically with a lateral midfoot incision.
REFERENCES: Donley BG, McCollum MJ, Murphy GA, Richardson EG: Risk of sural nerve injury with intramedullary screw fixation of fifth metatarsal fractures: A cadaver study. Foot Ankle Int 1999;20:182-184.
Lawrence SJ, Botte MJ: The sural nerve in the foot and ankle: An anatomic study with clinical and surgical implications. Foot Ankle Int 1994;15:490-494.
84/. A 25-year-old man sustained an L1 compression fracture in a fall from his roof. He is neurologically intact and has no other injuries. Radiographs reveal a 25% loss of height anteriorly and 5 degrees of kyphosis at the fracture site. A CT scan reveals no compromise of the posterior column. Management should consist of
1- bed rest only for 6 weeks.
2- mobilization in a kinetic therapy bed for 6 weeks, followed by a hyperextension brace.
3- a total contact thoracolumbosacral orthosis and rapid mobilization.
4- anterior decompression, vertebral reconstruction, and stabilization.
5- posterior reduction, stabilization, and grafting.
PREFERRED RESPONSE: 3
DISCUSSION: The patient has a stable fracture that can be initially treated with bed rest, followed by bracing and quick mobilization. The outcome is good and surgery is not required. These fractures can be treated nonsurgically if there is less than 50% compression, 15 degrees of angulation, and intact posterior structures.
REFERENCES: Cantor JB, Lebwohl NH, Garvey T, Eismont FJ: Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine 1993;18:971-976.
Rechtine GR II, Cahill D, Chrin AM: Treatment of thoracolumbar trauma: Comparison of complications of operative versus nonoperative treatment. J Spinal Disord 1999;12:406-409.
85/. A 35-year-old man sustained a 10% compression fracture of the C5 vertebra in a diving accident. Radiographs show good alignment, and examination reveals no neurologic compromise. An MRI scan reveals no significant soft-tissue disruption posteriorly. Management should consist of
1- observation.
2- a rigid collar for 6 weeks.
3- halo vest application.
4- open reduction and posterior stabilization.
5- open reduction, diskectomy, grafting, and anterior plate stabilization.
PREFERRED RESPONSE: 2
DISCUSSION: The patient has a stable flexion-compression injury of the cervical spine. The fracture occurs as a result of compression failure of the vertebral body. If the force continues, a tension failure of the posterior structures occurs, leading to potential dislocation. Immobilization in a rigid cervical orthosis will allow this fracture to heal.
REFERENCES: Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 457-464.
Allen GL, Ferguson RL, Lehmann TR, O’Brien RP: A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine 1982;7:1-27.
86/. Figures 42a and 42b shows the radiographs of a 20-year-old man who sustained a hyperextension injury to his little finger. Multiple attempts at closed reduction have been unsuccessful. Management should now consist of
1- external traction.
2- open reduction and internal stabilization.
3- repeat closed reduction under general anesthesia.
4- open reduction.
5- percutaneous pin fixation in the current position.
PREFERRED RESPONSE: 4
DISCUSSION: The radiographs show a complex dislocation of the little finger metacarpophalangeal joint. This is characterized by obvious dislocation on the AP and lateral views and a type of bayonet apposition best visualized on the lateral view. Irreducibility of this injury is caused by displacement of the volar plate that has been traumatically avulsed from its origin on the metacarpal, with subsequent displacement into the metacarpophalangeal joint. This abnormal position of the volar plate causes irreducibility that can be corrected only by open reduction. This can be effected either by dorsal or palmar approaches.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 711-771.
Becton JL, Christian JD Jr, Goodwin HN, Jackson JG III: A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg Am 1975;57:698-700.
Green DP, Terry GC: Complex dislocation of the metacarpophalangeal joint: Correlative pathological anatomy. J Bone Joint Surg Am 1973;55:1480-1486.
87/. A 34-year-old man sustains an extra-articular fracture of the proximal phalanx of his right index finger in a fall. Examination reveals that the fracture is closed and oblique in orientation. Closed reduction and splinting fail to maintain the reduction. Management should now consist of
1- repeat closed reduction and buddy taping.
2- closed reduction and percutaneous pin fixation, followed by casting.
3- open reduction and plate fixation, followed by casting.
4- open reduction and screw fixation, followed by splinting and early motion.
5- open reduction and intramedullary fixation with absorbable implants.
PREFERRED RESPONSE: 2
DISCUSSION: The patient has an unstable oblique fracture of the proximal phalanx that is easily reducible but unstable; therefore, the treatment of choice is closed reduction and percutaneous pin fixation, followed by casting. Closed reduction and percutaneous pin fixation offers a better functional result than open reduction and plate fixation. Repeat closed reduction and buddy taping is inadequate because of the inherently unstable fracture pattern. Buddy taping will allow the dislocation to recur. The other options represent more aggressive surgical techniques than are necessary to treat this fracture.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 711-771.
Green DP, Anderson JR: Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am 1973;55:1651-1653.
88/. Figures 43a and 43b show the AP and lateral radiographs of the radius and ulna of a 9-year-old patient. The fracture is manipulated and placed in a long arm cast with the elbow flexed to 90 degrees and the forearm to neutral rotation. Figures 43c and 43d show the alignment of the fracture after the manipulation. What is the next most appropriate step in management?
1- Stabilize the present reduction internally with intramedullary pins.
2- Accept the present reduction and obtain follow-up radiographs in 1 week.
3- Remanipulate the fracture and place the forearm in pronation.
4- Remanipulate the fracture and place the forearm in supination.
5- Stabilize the present reduction with plates and screws.
PREFERRED RESPONSE: 4
DISCUSSION: By placing the forearm at neutral rotation, as shown in Figures 43c and 43d, the distal fragment has become malrotated by 90 degrees. This is evident by the fact that the bicipital tuberosity is rotated 90 degrees to the radial styloid. Normally, it should be directly opposite (180 degrees) to the radial styloid. The correct alignment was present in the original radiographs shown in Figures 43a and 43b. Another clue to the malrotation in the postreduction radiographs is the difference in the diameters of the opposing radial shafts. To correct this rotational malalignment, the distal fragment needs to be remanipulated into supination so that it is correctly aligned with the supinated proximal radius.
REFERENCES: Evans EM: Fractures of the radius and ulna. J Bone Joint Surg Br 1951;33:548-561.
Milch H: Roentgenographic differentiation between torsion and rotational fractures of the forearm. Bull Hosp Jt Dis 1949;10:216-225.
89/. Which of the following findings is an indication for adjunctive use of high-dose steroids?
1- C6 level injury secondary to a unilateral facet fracture-dislocation with weakness of wrist extension
2- C6 burst fracture with no neurologic deficit
3- L3 burst fracture with cauda equina syndrome
4- Incomplete spinal cord injury in a patient 24 hours after injury
5- Complete C6 level deficit in patient with spinal shock and a fracture-dislocation at C5 on C6 5 hours after injury
PREFERRED RESPONSE: 5
DISCUSSION: According to NASCIS III, the high-dose steroid protocol involves infusion of 30 mg/kg methylprednisolone followed by 5.4 mg/kg/h for 24 hours if the patient has sustained a spinal cord injury within the last 3 hours. The drip is continued for 48 hours if administration is started between 3 and 8 hours of the onset of neurologic deficit. No benefit has been conclusively demonstrated with steroids administered beginning 8 hours or longer after injury. Steroid use is not indicated for nerve root deficits, brachial plexus deficits, or gunshot wounds.
REFERENCES: Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 319-328.
Bracken MB, Shepard MJ, Holford TR, et al: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: Results of the Third National Acute Spinal Cord Injury randomized controlled trial. National Acute Spinal Cord Injury Study. JAMA 1997;277:1597-1604.
90/. A 22-year-old man sustained a stable pelvic fracture, bilateral femur fractures, and a left closed humeral shaft fracture in a motor vehicle accident. Examination 24 hours after injury reveals that the patient is confused and has shortness of breath. A clinical photograph of his conjunctiva is shown in Figure 44. He has a temperature of 101 degrees F (38.3 degrees C) and a pulse rate of 120/min. Laboratory studies show a hemoglobin level of 8 g/dL, a platelet count of 50,000/mm3, and a PaO2 of 57 mm Hg on 2L of oxygen. What is the most likely diagnosis?
1- Pulmonary embolism
2- Fat embolism syndrome
3- Sepsis
4- Pneumonia
5- Pneumothorax
PREFERRED RESPONSE: 2
DISCUSSION: The major criteria for the diagnosis of fat embolism syndrome include hypoxemia (PaO2 of less than 60 mm Hg), central nervous system depression, and a petechial rash that is most often located in the axillae, conjunctivae, and palate. The rash is often transient. Tachycardia, pyrexia, anemia, thrombocytopenia, and the presence of fat in the urine are all considered minor criteria. To establish the diagnosis of fat embolism syndrome, one major and four minor signs should be present. Pulmonary embolism, which is the major differential diagnosis, usually is not associated with conjunctival petechia or thrombocytopenia.
REFERENCE: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 308-316.
91/. Figure 45 shows the current radiograph of an 11-year-old girl who sustained a simple nondisplaced fracture of the distal radius 4 weeks ago. Management at the time of injury consisted of application of a short arm cast but no manipulation. What is the major concern at this time?
1- Stiffness of the wrist joint
2- Physeal growth arrest
3- Physeal overgrowth
4- Osteonecrosis of the metaphysis
5- Posttraumatic arthritis
PREFERRED RESPONSE: 2
DISCUSSION: The fracture pattern represents a Peterson type I physeal injury, which is a comminuted metaphyseal fracture in which the fracture lines extend up to the physis. Because there is no displacement of the physis and the fracture lines do not cross the physis, there may be a tendency to dismiss this injury as a simple metaphyseal fracture with no significant sequelae. A small percentage of patients (3% in Peterson’s series) experience growth arrest. In this patient, a disabling ulnar plus deformity, defined as increased ulnar length in relationship to the distal radius, developed.
REFERENCES: Peterson HA: Physeal fractures: Part 2. Two previously unclassified types. J Pediatr Orthop 1994;14:431-438.
Peterson HA: Physeal and apophyseal injuries, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 108-109.
92/. Which of the following is considered the best measure of the adequacy of resuscitation in the first 6 hours after injury?
1- Blood pressure
2- Urine output
3- Central venous pressure
4- Heart rate
5- Base deficit
PREFERRED RESPONSE: 5
DISCUSSION: The end point of resuscitation is adequate tissue perfusion and oxygenation. Blood lactate is the end point of anaerobic metabolism. The level of blood lactate reflects global hypoperfusion and is directly proportional to oxygen debt. Two separate prospective studies have verified a significant difference in mortality when blood lactate was used as a measure of resuscitation when compared to traditional parameters (mean arterial pressure, urine output, central venous pressure, and heart rate). Base deficit is a direct measure of metabolic acidosis and an indirect measure of blood lactate levels. It correlates well with organ dysfunction, mortality, and adequacy of resuscitation. It is easy to measure, can be obtained rapidly, and is an excellent assessment of the adequacy of resuscitation.
REFERENCES: Porter JM, Ivatury RR: In search of the optimal end points of resuscitation in trauma patients: A review. J Trauma 1998;44:908-914.
Elliot DC: An evaluation of the end points of resuscitation. J Am Coll Surg 1998;187:536-547.
93/. A 26-year-old man sustains a displaced bimalleolar fracture by sliding into second base while playing baseball. Following initial closed reduction and splinting of the fracture, moderate swelling is noted. What is the safest time to perform surgery?
1- Immediately
2- When skin wrinkles are present and abrasions are epithelialized
3- Five days after injury
4- Following analysis of laser Doppler skin measurements
5- Following measurement of transcutaneous oxygen tension
PREFERRED RESPONSE: 2
DISCUSSION: Following any closed fracture, the most important determinant for the timing of surgery is the condition of the soft tissues and especially the skin. The best determinant of appropriate soft-tissue condition is the presence of wrinkling of the skin (wrinkle sign) at the site of the incision. A wrinkle sign is present when all the interstitial edema has left the skin; this may take up to 14 to 21 days of elevation. Any abrasion must be epithelialized so that there are no bacteria left at the site. To date, no other method of soft-tissue viability measurement has been shown to be of any clinical benefit.
REFERENCES: Stover MD, Kellam JF: Articular fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 105-119.
Hahn DM, Colton CL, Malleolar fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 559-581.
Tile M: Fractures of the ankle, in Schatzker J, Tile M (eds): Rationale of Operative Fracture Care, ed 2. Berlin, Springer-Verlag, 1998, pp 523-561.
94/. A 28-year-old woman sustained an injury to her dominant right arm after falling off her porch. Examination reveals a deformity at the elbow. She is neurovascularly intact. Figures 46a and 46b show the radiographs obtained before closed reduction, and postreduction radiographs are shown in Figure 46c and 46d. What is the most likely early complication?
1- Radial nerve injury
2- Intra-articular loose body causing a block to motion
3- Lack of active elbow flexion
4- Recurrent dislocation
5- Forearm compartment syndrome
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a complex fracture-dislocation of the elbow. The radial head is fractured, and there is a displaced coronoid fracture. These associated fractures indicate that the elbow is at high risk for recurrent instability after initial treatment. To prevent this complication, surgical treatment will most likely be required and will consist of some or all of the following: radial head open reduction and internal fixation or replacement, coronoid open reduction and internal fixation, medial and lateral ligament repairs, and even articulated external fixation. This patient was treated with open reduction and internal fixation of the radial head, and the elbow redislocated postoperatively.
REFERENCES: Ring D, Jupiter JB: Reconstruction of posttraumatic elbow instability. Clin Orthop 2000;370:44-56.
O’Driscoll SW: Classification and evaluation of recurrent instability of the elbow. Clin Orthop 2000;370:34-43.
O’Driscoll SW, Morrey BF, Korinek S, An KN: Elbow subluxation and dislocation. Clin Orthop 1992;280:186-197.
95/. What is the most likely long-term sequela of the injury shown in Figures 47a and 47b?
1- Peroneal tendon instability
2- Ankle joint instability
3- Subtalar joint arthrosis
4- Ankle joint arthritis
5- Entrapment of the flexor hallucis longus tendon
PREFERRED RESPONSE: 3
DISCUSSION: The imaging studies show a comminuted lateral talar process fracture. This injury is often missed on plain radiographs; therefore, CT provides the best method of diagnostic evaluation. The most likely long-term sequela of this injury is subtalar joint arthrosis. Although this injury involves the fibular gutter region, progression to true ankle arthritis is unlikely. There does not appear to be any association with this injury and chronic mechanical instability of the ankle or disruption of the superior peroneal retinaculum and subsequent peroneal tendon instability. Entrapment of the flexor hallucis longus tendon may occur with fractures of the sustentaculum tali but not with injuries of the lateral talar process. Surgical management includes open reduction and internal fixation versus excision; the goal is preservation of the large articular surface fragments. In this patient, there is significant comminution and early fragment excision may be the best option for acute treatment.
REFERENCES: Tucker DJ, Feder JM, Boylan JP: Fractures of the lateral process of the talus: Two case reports and a comprehensive literature review. Foot Ankle Int 1998;19:641-646.
Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1465-1518.
96/. A 16-year-old high school football player has diffuse pain with attempted digital flexion after injuring the ring finger of the dominant hand 1 week ago. Examination reveals that he is unable to flex the distal interphalangeal joint. Management should consist of
1- surgical exploration and tendon reinsertion of the flexor digitorum profundis.
2- surgical exploration and tendon reinsertion of the flexor digitorum superficialis.
3- steroids and physical therapy.
4- surgical release of the anterior interosseous nerve.
5- surgical release of the median nerve.
PREFERRED RESPONSE: 1
DISCUSSION: The patient has an avulsion of the flexor digitorum profundus. Treatment should include surgical exploration and tendon reinsertion. This is not an avulsion of the flexor digitorum superficialis because the patient’s deficiency is the inability to flex the distal interphalangeal joint, not the proximal interphalangeal joint. Surgical release of the anterior interosseous nerve is not indicated because the flexor digitorum profundus of the ring finger is innervated by the ulnar nerve. A median nerve contusion causes wrist pain and/or numbness and tingling in the median nerve distribution.
REFERENCES: Strickland JW: Flexor tendons: Acute injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 1851-1897.
Leddy JP: Avulsions of the flexor digitorum profundus. Hand Clin 1985;1:77-83.
97/. A 25-year-old construction worker lands on his outstretched hand in a fall. The position of his wrist at the time of impact causes a force that leads to hyperextension, ulnar deviation, and intercarpal supination. Radiographs are shown in Figures 48a and 48b. What type of injury pattern is shown?
1- Scaphoid fracture
2- Radiocarpal dislocation
3- Midcarpal dislocation
4- Transscaphoid dorsal perilunate dislocation
5- Volar lunate dislocation
PREFERRED RESPONSE: 4
DISCUSSION: The patient has a transscaphoid dorsal perilunate dislocation. The radiographs clearly define a dorsal dislocation of the capitolunate joint, and the scaphoid fracture component is easily visible on the AP view. A scaphoid fracture alone is an unlikely diagnosis because of the midcarpal dislocation component. The radiocarpal joint is not dislocated because the lunate is sitting in the lunate fossa of the radius. Isolated radiocarpal dislocations are not associated with a midcarpal disruption. While a midcarpal dislocation is a component of a dorsal perilunate dislocation, this diagnosis does not address the scaphoid fracture. A volar lunate dislocation is not seen because the lunate is reduced in the lunate fossa of the distal radius. Volar lunate dislocations are in the spectrum of injury of perilunate dislocations and fracture-dislocations; however, the radiographs show a transscaphoid dorsal perilunate dislocation.
REFERENCES: Mayfield JK, Johnson RP, Kilcoyne RK: Carpal dislocations: Pathomechanics and progressive perilunar instability. J Hand Surg Am 1980;5:226-241.
Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J: Perilunate dislocations and fracture-dislocations: A multicenter study. J Hand Surg Am 1993;18:768-779.
98/. A 25-year-old construction worker lands on his outstretched hand in a fall. The position of his wrist at the time of impact causes a force that leads to hyperextension, ulnar deviation, and intercarpal supination. Radiographs are shown in Figures 48a and 48b. Management should consist of
1- closed reduction and a long arm cast.
2- closed reduction, percutaneous pin fixation, and a long arm cast.
3- closed reduction and an external fixator.
4- open reduction and internal fixation and soft-tissue repair.
5- proximal row carpectomy.
PREFERRED RESPONSE: 4
DISCUSSION: Open reduction and internal fixation is the treatment of choice for accurate reduction of the disrupted intercarpal ligaments. In addition, the displaced scaphoid fracture will require open reduction and internal fixation and possible bone grafting. Closed reduction and long arm casting will not allow accurate reduction of the dislocated intracarpal intervals, and it is unlikely to allow accurate reduction of the scaphoid. The maneuver required to effect closed reduction of a displaced scaphoid fracture will most likely cause the scaphoid lunate interval to displace. Closed reduction with percutaneous pin fixation or with an external fixator is unable to effect anatomic reduction of the injury. Proximal row carpectomy is used as a salvage procedure for a variety of degenerative and posttraumatic problems of the wrist.
REFERENCES: Kozin SH: Perilunate injuries: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:114-120.
Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J: Perilunate dislocations and fracture-dislocations: A multicenter study. J Hand Surg Am 1993;18:768-779.
Sotereanos DG, Mitsionis GJ, Ginnakopoulos PN, Tomaino MM, Herndon JH: Perilunate dislocation and fracture dislocation: A critical analysis of the volar-dorsal approach. J Hand Surg Am 1997;22:49-56.
99/. A 17-year-old boy who fell on a pitchfork in a barn 1 day ago now has a painful, swollen forearm. Examination reveals erythema, exquisite tenderness, and crepitus to palpation of the forearm. He has a pulse rate of 110/min and a blood pressure of 80/60 mm Hg. Radiographs show subcutaneous air and no fractures. Gram stain of wound drainage reveals a gram-positive bacillus. The next most appropriate step in management should consist of
1- surgical debridement with wound closure and IV antibiotics.
2- surgical debridement with wound closure over suction drains and IV antibiotics.
3- surgical debridement with open wound management and IV antibiotics.
4- IV antibiotics alone.
5- hyperbaric oxygen therapy.
PREFERRED RESPONSE: 3
DISCUSSION: The successful treatment of necrotizing soft-tissue infections such as clostridial myonecrosis depends on prompt recognition and aggressive surgical debridement of all involved muscle, fascia, and soft tissue, resecting to a clearly normal healthy, viable margin. The effective antibiotic regimen for clostridial infection is high-dose penicillin; however, necrotizing infections are frequently polymicrobial so initially broad-spectrum antibiotics are indicated. Hyperbaric oxygen therapy may be used as an adjunct to surgical treatment but is insufficient as a primary therapy. Prolonged application of tourniquets and wound closure should be avoided.
REFERENCES: Pellegrini VD, Evarts CM: Complications, in Rockwood CA Jr, Green DP (eds): Fractures in Adults, ed 3. Philadelphia, PA, JB Lippincott, 1991, pp 365-370.
Gerding DN, Peterson LR: Infections caused by anaerobic bacteria, in Shulman ST, Phair JP, Peterson LR, Warren JR (eds): Infectious Diseases, ed 5. Philadelphia, PA, WB Saunders, 1997, pp 416-417.
Stephens DC: Myositis and fascitis, in Root RK (ed): Clinical Infectious Diseases, ed 1. Oxford, England, Oxford Press University, 1999, pp 769-770.
100. In the management of an open tibia fracture, what factor is considered most important in preventing deep infection?
1- Size of the skin lesion
2- Degree and the completeness of the debridement
3- Amount of contamination
4- Method of fixation
5- Cultures of the wound
PREFERRED RESPONSE: 2
DISCUSSION: The most important aspect of management of any open fracture, and in particular the tibia, is the degree and the completeness of the debridement of the soft tissue and most importantly, the muscle. The ultimate function is determined by the amount of muscle left, as well as the ability to heal. The amount of necrotic muscle left in the wound also determines the predisposition to infection. The method of fixation, the size of the wound, and the amount of contamination are controlled by the surgeon or the injury and have little to do with the long-term outcome. Initial wound cultures have little predictive value.
REFERENCES: Clifford P: Open fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 617-638.
Lee J: Efficacy of cultures in the management of open fractures. Clin Orthop 1997;339:71-75.

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