Multiple Choice Questions

Trauma

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 5. A 42-year-old male who works as a professional clown presents with severe ankle pain and gross deformity after tripping and falling over his props at a children’s birthday party. 

His radiograph is shown . 

Following fixation of the medial and lateral malleolar fractures, the syndesmosis is assessed and is found to be persistently unstable. 

All of the following are true regarding posterior malleolar fixation EXCEPT:

A) Fixation of the posterior malleolus obviates the need for syndesmotic fixation in most cases
B) Fixation of the posterior malleolus remains biomechanically inferior to trans-articular syndesmotic fixation
C) Functional and radiographic outcomes following posterior malleolar fixation are equivalent if not superior to those following syndesmotic fixation
D) Non-anatomic fixation of the posterior malleolus will compromise syndesmotic fixation
E) The syndesmosis is often incompletely injured in the setting of a posterior malleolar fracture

Correct Answer : B

Fixation of the posterior malleolus has been shown to be biomechanically superior to single-screw trans-articular syndesmotic fixation. Anatomic reduction and fixation will most often obviate the need for syndesmotic fixation, as the posterior inferior tibiofibular ligament (PITFL) is typically intact and attached to the fragment.

Incorrect Answers:
Answer A: Fixation of the posterior malleolus has been shown to adequately restore syndesmotic stability and obviate the need for additional trans-articular syndesmotic screw fixation in the majority of cases.
Answer C : Studies comparing clinical and functional outcomes following posterior malleolar and syndesmotic fixation have shown equivalent results with improved maintenance of radiographic syndesmotic reduction following posterior malleolar fixation.
Answer D : Non-anatomic fixation of both small and large posterior malleolar fragments has been shown to compromise syndesmotic integrity and anatomic syndesmotic reduction.
Answer E: Radiographic studies evaluating syndesmotic integrity via MRI have shown the PITFL to be completely intact or only partially injured in most cases.

 

4. An 11-year-old boy sustains a fall while jumping on a trampoline. 

He has moderate back pain, an L-5 radiculopathy, and weakness of the right extensor hallucis longus. 

Radiographs and a computerized tomography scan of the lumbar spine demonstrate a slipped vertebral apophysis. 

Posterior ring apophyseal fracture | Radiology Reference Article | Radiopaedia.org

The recommended treatment is:

A) Laminectomy and excision of annulus and vertebral bony margin
B) Bed rest
C) Thoracolumbosacral orthosis
D) Physical therapy
E) Spinal traction

Correct Answer: A

This patient has a slipped vertebral apophysis as a result of trauma. This is analogous to a Salter-Harris type II fracture. 

A portion of the apophysis and annulus slip posteriorly and may impinge on the exiting nerve root. 

These usually do not resolve spontaneously or improve with conservative therapy, and excision is indicated. The disk fragments and retropulsed bone must be removed from the canal with a laminectomy for exposure.

 

3. A 43-year-old construction worker sustained a work-related injury to his foot 7 months ago. 

He was initially treated with cast immobilization and limited weight bearing. He has lateral foot pain and inability to walk comfortably. He has limited walking endurance. 

Upon examination, pain is present laterally along the course of the peroneal tendons, and no motion of the subtalar joint is present.

The recommendation is:

A) Physical therapy followed by job modification 
B) Shoe modification and orthotic support 
C) Nonsteroidal medication, and ankle foot orthoses
D) Injection of the peroneal tendons with cortisone 
E) Subtalar arthrodesis

Correct Answer: E

A worker who sustains a calcaneus fracture must be returned to the work force as soon as possible. Although these alternatives for treatment may be considered in the patient with limited activity and low demands, the longer the time from injury to salvage surgery with arthrodesis, the less likely it is that the injured worker will ever return to gainful employment. Therefore, subtalar arthrodesis should be performed.

 

2. 13y old boy injured his knee playing basketball and is now unable to bear weight. 

Examination reveals tenderness and swelling at the proximal anterior tibia, with a normal neurological examination. 

AP and lateral radiographs are shown .

Management should consist of:

A) MRI
B) a long leg cast
C) fasciotomy of the anterior compartment
D) open reduction and internal fixation
E) patellar advancement

Correct Answer: D

The patient has a displaced intra-articular tibial tuberosity fracture; therefore, the treatment of choice is open reduction and internal fixation. Periosteum is often interposed between the fracture fragments and prevents satisfactory closed reduction. 

Fortunately, most patients with this injury are close to skeletal maturity and therefore, growth arrest and recurvatum are unusual. Non-displaced fractures can be treated with a cast, but displaced fractures are best treated with open reduction and internal fixation. 

Intra-articular fractures can disrupt the joint surface and are sometimes associated with a meniscal tear; therefore, arthroscopy may be needed at the time of open reduction and internal fixation.

 

1. What is the most likely complication following treatment of the humeral shaft fracture shown in the figure attached?


A) Nonunion
B) Shoulder pain
C) Infection
D) Elbow injury
E) Radial nerve injury

Correct Answer: B

The humerus was treated with an intramedullary nail. Findings from two prospective randomized studies of intramedullary nailing or compression plating of acute humeral fractures have shown approximately a 30% incidence of shoulder pain with antegrade humeral nailing. This is the most common complication in both of these series. Nonunions are present in approximately 5% to 10% of humeral fractures treated with an intramedullary nail. 

Infection has an incidence of approximately 1%. 

Elbow injury is unlikely unless the nail is excessively long. 

Rarely, injury to the radial nerve is possible if it is trapped in the intramedullary canal.