Multiple Choice Questions

Trauma

Please use the comments section at the bottom of the page if you have any query or feedback about any of the questions.

 

39. Which of the following structures is disrupted in patients with an acute medial subtalar dislocation:

A) Lisfranc ligament
B) Long plantar ligament 
E) Anterior talofibular ligament
C) Talocalcaneal ligament
D) Calcaneonavicular ligament

Correct Answer: C

As the foot and the subtalar joint move medially, the subtalar ligaments and the ligaments on the lateral aspect of the ankle are disrupted. The talocalcaneal, or interosseous, ligament is the only ligament that is vulnerable in an acute medial subtalar dislocation

Author: Rajesh Bahadur Lakhey

 

38. A 22-year-old collegiate basketball player presents for treatment of a stress fracture of the base of the fifth metatarsal at the junction of the metaphysis and diaphysis. The fracture was treated operatively, and the patient returned to playing basketball. Three months later, it was apparent that a repeat fracture was present. The fracture was treated with screw removal and a repeat screw fixation. Four months later, after a successful basketball season, he sustained a repeat stress fracture of the metatarsal. On examination, he has a mild cavovarus foot configuration with normal ankle range of motion. Inversion is 15° and eversion is 5°. The base of the fifth metatarsal is prominent. 

The most likely cause for the repeat fracture is:

A) Abnormal ankle biomechanics
B) Chronic unrecognized ankle instability 
C) A varus heel 
D) Bone sclerosis of the fifth metatarsal base
E) Chronic avascularity of the fifth metatarsal base 

Correct Answer: C

The most common cause of recurrent injury to the fifth metatarsal is unrecognized varus heel deformity. Surgeons must also check for ankle instability, which may be present in this patient. 

A varus heel, ankle instability, and injury to the fifth metatarsal are associated with recurrent deformity.

Author: Rajesh Bahadur Lakhey

 

37. A 23-year-old man sustains an injury to his foot when falling off a ladder. The foot is grossly twisted inward, and the talonavicular joint is dislocated with the talar head penetrating through the extensor brevis muscle. The dislocation is reduced. 

The likelihood of this resulting in avascular necrosis of the talus is:

A) Rare
B) 20% 
C) 40%
D) 70% 
E) 100%

Correct Answer: A

Medial peritalar dislocation does not result in avascular necrosis of the talus. The development of subtalar arthritis is more likely

Author: Rajesh Bahadur Lakhey

36. 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.

Author: Rajesh Bahadur Lakhey

 

35. A patient presents for treatment in your emergency department following an injury that he sustained 4 hours earlier. His foot was run over by a piece of heavy industrial equipment. On examination, he has pain in the foot, a displaced fracture of the second metatarsal, a 3-cm area of severe contusion over the forefoot, and numbness of the dorsal surface of the foot. 

The next examination that you recommend is:

A) Measurement of compartment pressures in the foot
B) Magnetic resonance imaging of the tarsometatarsal joint
C) Computerized axial tomography of the midfoot
D) Doppler evaluation of the foot pulses
E) Laser Doppler flowmetry 

Correct Answer: A

Because of his history, this patient may have a compartment syndrome of the foot. Although other studies may be relevant as part of his evaluation, a compartment syndrome mandates emergency treatment. Vascular evaluation, including laser Doppler flowmetry is unreliable in diagnosing compartment syndrome. Imaging studies may be performed as part of the surgical work-up, but they are not indicated at this time.

Author: Rajesh Bahadur Lakhey

34. A 12-year-old boy presents to the emergency department after being struck by a car. His only complaint at the time of presentation is right ankle pain. After obtaining an excellent reduction and casting the leg, the risks of a future growth disturbance through the involved physis must be discussed with the family. 

What are the chances of a significant growth disturbance of his leg:

A) < 1%
B) 2% to 3%
C) 10% to 15%
D) 45% to 55%
E) 80% to 90%

Correct Answer: C

This is a Salter-Harris type II fracture of the distal tibia. The distal tibia is at moderate risk for growth arrest after physeal injury. The average incidence of growth disturbance is 15% for all physeal injuries in this area. The marked displacement and mechanism of injury in this patient increase the risk of permanent physeal damage. The patient’s age and remaining growth also increase the likelihood of a growth arrest causing a significant deformity or leg length discrepancy

Author: Fouad Chaudery


33. A glenoid profile radiograph of a 21-year-old male rugby player with multiple traumatic anterior shoulder dislocations is presented:

Which of the following is the preferred treatment:

A) Sling for a period of 6 weeks
B) Physiotherapy emphasizing strengthening of dynamic shoulder stabilizers
C) Capsular shift
D) Bankart reconstruction
E) Coracoid transfer procedure

Correct Answer: E

The radiograph demonstrates anterior glenoid rim insufficiency, which is a risk factor for failure of soft tissue reconstructions especially in contact athletes. 

The arrows on the figure represent the anterior border of the glenoid rim. A coracoid transfer procedure to reconstruct the anterior bony deficiency maximizes the possibility for successful restoration of shoulder stability.

Author: Fouad Chaudhry

 

32. All of the following factors have been used to explain why exertional compartment syndrome is more common in the lower leg when compared to the upper arm except:

A) Muscle straining that occurs in the lower leg seldom occurs in the upper arm.
B) Muscle compartments of the upper arm blend anatomically with the shoulder girdle making it less likely that bleeding would be confined to the compartment of the upper extremity.
C) The brachialis fascia is less taut than the crural fascia.
D) The brachialis fascia yields more to increased intracompartmental pressure as compared to the crural fascia.
E) The pulse pressure of the lower extremity is greater than that of the upper extremity.

Correct Answer: A

Medial meniscal tears account for approximately 45% of acute tears and 70% of chronic tears in patients with ACL insufficiency. 

Peripheral posterior horn tears of the medial meniscus are the most common type of tear associated with chronic ACL deficiency.

Author: Fouad Chaudhry

 

31. In the setting of chronic anterior cruciate ligament (ACL) deficiency, which of the following meniscal tear patterns is most common:

A) Peripheral posterior horn tears of the medial meniscus
B) Peripheral posterior horn tears of the lateral meniscus
C) Peripheral anterior horn tears of the medial meniscus
D) Peripheral anterior horn tears of the lateral meniscus
E) Central posterior horn tears of the medial meniscus

Correct Answer: E

There are several reasons that have been offered as to why upper arm compartment syndromes are so rare. First, the brachialis fascia is less taut and contains less rigid ligaments than the fascia in the lower leg. Second, the brachialis fascia yields more to increased intracompartmental pressure as compared to the fascia of the lower leg. Third, the muscle compartments of the upper arm blend anatomically with the shoulder girdle making it less likely that bleeding would be confined enough to develop into a compartment syndrome. Finally, muscle stresses that occur in the lower leg during events such as prolonged march seldom occur in the arm.

Author: Fouad Chaudhry

 

30. A 15-year-old female volleyball player twisted her knee while planting her foot. She states she felt her knee give out. She had immediate swelling and was unable to continue participation. She denies hearing a pop. Physical examination reveals a large effusion with a range of motion from full extension to 80° flexion. She has marked tenderness along the medial retinaculum of her knee. She has no joint line tenderness. There is no pathologic laxity involving the collateral or cruciate ligaments. 

The most likely diagnosis is:

A) Partial anterior cruciate ligament tear
B) Posterior cruciate ligament tear
C) Medial collateral ligament sprain
D) Patellar subluxation
E) Peripheral medial meniscal tear

Correct Answer: D

Patellar subluxation is a common injury in athletes. It generally presents with a large effusion. Patients usually have a limited arc of motion but can usually obtain full extension. In addition to medial retinacular tenderness, patients will have apprehension to attempts at lateral displacement of the patella. 

Treatment is initially nonoperative, emphasizing quadriceps strengthening. Operative treatment is reserved for patients with continued instability despite appropriate rehabilitation.

Author: Fouad Chaudhry

 

29. A 16-year-old male high school football player was making a tackle when he felt sudden pain in his right long finger. He has swelling and tenderness along the volar aspect of the injured digit. He is unable to actively flex the distal interphalangeal joint of the injured digit. Radiographs are negative for fracture. 

Recommended treatment should include:

A) Observation
B) Splinting of the distal interphalangeal joint in extension
C) Splinting of the distal interphalangeal joint in flexion
D) Immediate active range of motion exercises
E) Surgical repair

Correct Answer: E

Avulsion of the flexor digitorum profundus, or "jersey finger," is a common injury in football. Appropriate treatment includes surgical repair.

Author: Fouad Chaudhry

 

28. Following tibial eminence fractures in skeletally-immature patients, all of the following sequelae have been described except:

A) Residual anterior cruciate ligament laxity
B) Lengthening of the tibial spine
C) Loss of knee flexion
D) Hypertrophy of the tibial spine
E) Loss of terminal knee extension

Correct Answer: B

The overall results following adequate reduction of the tibial spine are good to excellent. Loss of terminal knee extension is thought to occur due to hyperemia, subsequent hypertrophy or displacement of the tibial spine and resultant bony blockage. Knee stiffness and loss of extension- very common, late anterior instability- upto 60%; possibly secondary to ligamentous stretch; unclear whether clinically significant. Malunion can lead to impingement ( similar to cyclops lesion after anterior cruciate ligament reconstruction)

Author: Fouad Chaudhry

 

27. After landing awkwardly on his flexed knee, a 22-year-old basketball player has immediate onset of pain and difficulty bearing weight. With the knee flexed 30°, examination reveals increased varus, external rotation, and posterior translation which decreases when the knee is flexed to 90°. 

The patient most likely has injured what structures:

A) Posterolateral complex
B) Posterolateral complex and posterior cruciate ligament
C) Posterior cruciate ligament
D) Lateral collateral ligament
E) Posterior cruciate ligament and medial collateral ligament

Correct Answer: A

With an isolated injury to the posterior cruciate ligament (PCL), posterior translation increases at greater degrees of flexion demonstrating the greatest posterior translation at 90°. Injury to the lateral collateral ligament leads to varus laxity in 30° flexion without posterior translation. With an injury to the PCL and posterolateral complex, varus, external rotation, and posterior translation are detectable at 30° and increase as the knee is flexed to 90°. Isolated tears of the posterolateral complex lead to increased varus, external rotation, and posterior translation at 30° that decreases as the knee is flexed to 90° and the PCL tightens.

Author: Fouad Chaudhry

 

26. The most common cause of an indirect injury to the Lisfranc joint occurs through which mechanism:

A) Compression
B) Hyperdorsiflexion
C) Axial load of a plantarflexed foot
D) Supination and external rotation
E) Pronation and adduction

Correct Answer: C

The indirect mechanism of injury involves axial loading of a plantarflexed foot. This type of mechanism is commonly cited in soccer, basketball, and gymnastics. The most frequent pattern in the indirect mechanism is failure of the weaker dorsal tarsometatarsal ligaments in tension with dorsal dislocation of the metatarsals .

Author: Fouad Chaudhry

 

25. Distal one-third clavicle fractures constitute what percentage of all clavicle fractures:

A) 15%
B) 30%
C) 45%
D) 60%
E) 90%

Correct Answer: A

Distal one-third clavicle fractures constitute 15% of all clavicle fractures. 

The most common location for a clavicle fracture is midshaft.

Author: Fouad Chaudhry

 

24. A 25-year-old soccer player sustained a closed tibia fracture when his planted leg was struck by another player. 

Which of the following would be the most common fracture pattern and mechanism:

A) Short spiral fracture — torsion 
B) Oblique fracture — uneven bending 
C) Transverse fracture — pure bending 
D) Oblique fracture with a butterfly fragment — bending and compression 
E) Segmental fracture — four-point bending 

Correct Answer: C

A transverse fracture is secondary to a pure bending force.

The other patterns included:

  • Oblique fracture — uneven bending: This type of injury typically occurs following motorcycle accidents when the tibia is subjected to uneven bending forces.

  • Segmental fracture — four-point bending: This injury most commonly follows a high-energy injury, such as a pedestrian being struck by a car bumper.

  • Oblique fracture with a butterfly fragment — bending and compression: This is a common fracture that occurs with low- and high-speed injuries. These fractures may occur from car bumpers and motorcycles.

  • Short spiral fracture — torsion: This mechanism is usually from a low velocity skiing injury.

Author: Fouad Chaudhry

 

23. Following a traumatic nerve injury, in which time period would a physician find denervation activity with fibrillation and positive sharp waves in the affected muscles:

A) Immediately following the injury 
B) 7 to 10 days following injury 
C) 2 to 5 weeks following injury 
D) 6 to 8 weeks following injury 
E) 12 weeks following injury 

Correct Answer: C

Nerve conduction studies can help distinguish between the three principle types of nerve injury: neuropraxia, axonotmesis, and neurotmesis.

The following is the sequence of events following traumatic nerve injury:

Timing

Electrophysiologic abnormality

Onset of injury

Conduction block across nerve injury site

7 to 10 days

Reduced amplitudes on distal stimulation

2 to 5 weeks

Denervation changes on electromyographic (EMG)
(fibrillation, positive sharp waves)

6 to 8 weeks

Re-innervation on EMG

Author: Fouad Chaudhry



 

22. 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 neurologic examina-ption. AP and lateral radiographs are shown in figures attached. 

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 tuber-osity 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.

Author: Salam Al-Abayachi

 

21. A 6y old child sustained a closed nondisplaced proximal tibial metaphyseal fracture 1 year ago. She was treated with a long leg cast with a varus mold, and the fracture healed uneventfully. She now has a 15° valgus deformity. 

What is the next step in management?

A) Proximal tibial/fibular osteotomy with acute correction and pin f xation
B) Proximal tibial/fi bular osteotomy with gradual correction and external fi xation
C) MRI of the proximal tibial physis
D) Medial proximal tibial hemiepiphysiodesis
E) Continued observation

Correct Answer: E

The tibia has grown into valgus secondary to the proximal fracture. This occurs in about one half of these injuries, and maximal deformity occurs at 18 months postinjury. The deformity gradu-ally improves over several years, with minimal residual deformity. Therefore, treatment at this age is unnecessary because there is a high rate of recurrence and complications regardless of technique. 

The valgus deformity is not a result of physeal injury or growth arrest. Medial proximal tibial hemiepiphys-iodesis is an excellent method of correcting the residual deformity but is best reserved until close to the end of growth.

Author: Salam Al-Abayachi

 

20. A 6y old girl is referred for the elbow injury seen in figure atrached. 

What is the most appropriate treatment?

A) Immobilization in a long arm cast for 3 weeks
B) Immobilization in a long arm cast for 8 weeks
C) Open reduction and immobilization in a long-arm cast for 3 weeks
D) Open reduction and internal fixation with smooth pins
E) Open reduction and internal fixation with a screw

Correct Answer: D

The patient has a displaced lateral condyle fracture; therefore, simple immobilization for 3 to 8 weeks is likely to result in malunion or nonunion. Closed reduction of such injuries is rarely successful. The fracture is unstable, so fixation is required after open reduction. Because the fixation must cross the physis, smooth pins are indicated for the skeletally immature elbow. Open reduction with fixation has been shown to reduce the risk of delayed union and malunion.

Author: Salam Al-Abayachi

 

19. A 46y old man fell 20 feet and sustained the injury shown in the figure attached. The injury is closed; however, the soft tissues are swollen and ecchymotic with blisters. 

The most appropriate initial management should consist of 

A) long leg cast.
B) a short leg cast.
C) immediate open reduction and internal fi xation.
D) a temporizing spanning external fi xator.
E) primary ankle fusion.

Correct Answer: D

Although this is a fracture of the medial and lateral malleoli, the degree of displacement and comminution of the medial dome indicate that this injury is similar to a pilon fracture. Initial management should consistent of stabilization to allow for soft-tissue healing. The use of temporizing spanning external fi xation should be the initial step, fol-lowed by limited or more extensive open reduction and internal fi xation when the soft-tissue status will allow. Initial placement in either a short or long leg cast does not provide the needed stability and does not allow for care and monitoring of soft tissues. In addition, maintaining reduction of the talus may be very diffi cult. Immediate open reduction and internal fi xation through an injured soft-tissue envelope adds the risk of diffi culties with incision healing and a higher risk of deep infection. In the acute setting, a primary ankle fusion through this soft-tissue envelope is not indicated.

Author: Salam Al-Abayachi

 

18. A collegiate golfer sustained a hook of the hamate #. After 12 wks of splinting and therapy, the hand is still symptomatic. 

What is the most appropriate management to allow return to competitive activity?

A) Continued observation
B) Open reduction and internal fi xation of the fracture
C) Excision of the hook of the hamate
D) Carpal tunnel release
E) Guyon canal release

Correct Answer: C

Excision of the fracture fragment typically leads to rapid return to function. Fixation techniques are diffi cult to perform because of the size of the bone; hardware prominence is common. Nerve defi cits are not typically noted in this injury. The motor branch of the ulnar nerve in Guyon canal must be protected during the surgical approach.

Author: Salam Al-Abayachi

 

17. 20y old man sustained a closed tibial # and is treated with a reamed intramedullary nail. 

What is the most common complication associated with this treatment?

A) Nonunion
B) Malunion
C) Infection
D) Knee pain
E) Compartment syndrome

Correct Answer: D

The most common complication is anterior knee pain (57%). The knee pain is activity related (92%) and exacerbated by kneeling (83%). Although knee pain is the most common complica-tion, most patients rate it as mild to moderate and only 10% are unable to return to previous employ-ment. Some authors report less knee pain with a peritendinous approach when compared to a tendon-splitting approach. 

In one study, nail removal resolved pain in 27%, improved it in 70%, and made it worse in 3%. The incidence of the other complications was: infection 0% to 3%, nonunion 0% to 6%, and malunion 2% to 13%. Compartment syndrome is rare after nailing.

Author: Salam Al-Abayachi

 

16. 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 complica-tion 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.

Author: Salam Al-Abayachi

 

15. 36y woman sustained a tarsometatarsal joint fracture-dislocation in a motor vehicle accident. The patient is treated with ORIF. 

What is the most common complication?

A) Posttraumatic arthritis
B) Infection
C) Fixation failure
D) Malunion
E) Nonunion

Correct Answer: A

The most common complication associated with tarsometatarsal joint injury is posttrau-matic arthritis. In one series, symptomatic arthritis developed in 25% of the patients and half of those went on to fusion. In another series, 26% had painful arthritis. Initial treatment should consist of shoe modifi cation, inserts, and anti-infl ammatory drugs. Fusion is reserved for failure of nonsurgical manage-ment. Hardware failure may occur, but it is clinically unimportant.

Author: Salam Al-Abayachi

 

14. What is the most appropriate indication for replantation in an otherwise healthy 35y old man?

A) Isolated transverse amputation of the thumb through the middle of the nail bed
B) Isolated transverse amputation of the index fi nger through the proximal phalanx
C) Isolated transverse amputation of the ring fi nger through the proximal phalanx
D) Isolated transverse amputation of the hand at the level of the wrist
E) Forearm amputation with a 10-hour warm ischemia time

Correct Answer: D

Vascular anastomoses are exceedingly diffi cult with amputations distal to the nail fold because the digital vessels bifurcate or trifurcate at this level, and little functional benefi t is gained compared to other means of soft-tissue coverage. Single-digit amputations, other than the thumb, are a relative contraindication for replantation. Replantations at the level of the proximal phalanx lead to poor motion of the proximal interphalangeal joint. In a healthy, active adult, an amputation through the wrist is an appropriate situation to proceed with a replantation. A transverse forearm amputation is a good indication with a warm ischemia time of less than 6 hours.

Author: Salam Al-Abayachi

 

13. A 9y old child sustains a proximal tibial physeal fracture with a hyperextension mechanism. 

What structure is at most risk for serious injury?

A) Tibial nerve
B) Popliteal artery
C) Common peroneal nerve
D) Posterior cruciate ligament
E) Popliteus muscle

Correct Answer: B

The most serious injury associated with proximal tibial physeal fracture is vascular trauma. The popliteal artery is tethered by its major branches near the posterior surface of the proximal tibial epiphysis. During tibial physeal displacement, the popliteal artery is susceptible to injury. Injuries to the other structures are less common.

Author: Salam Al-Abayachi

 

12. In patients with displaced radial neck fractures treated with ORIF with a plate and screws, the plate must be limited to what surface of the radius to avoid impingement on the proximal ulna?

A) 2 cm distal to the articular surface of the radial head
B) 1 cm distal to the articular surface of the radial head
C) Within a 90° arc or safe zone
D) Within a 120° arc or safe zone
E) Within a 180° arc or safe zone

Correct Answer: C

The radial head is covered by cartilage on 360° of its circumference. However, with the normal range of forearm rotation of 160° to 180°, there is a consistent area that is nonarticulating. This area is found by palpation of the radial styloid and Lister tubercle. The hardware should be kept within a 90° arc on the radial head subtended by these two structures.

Author: Salam Al-Abayachi

 

11. An 18 month old boy is brought with clawing deformity of his right hand. The parent’s informed that he was born full term after a difficult delivery by shoulder dystocia. The patient had right clavicle fracture. A week later the parents noticed the child did not flex the fingers of his right hand. After 2 years the child is brought to you. On Examination, his right hand has extension at all the metacarpophalangeal joint  of the fingers while his PIP and DIP joints are flexed. His thumb is adducted and is difficult to passively bring it to full abduction. There is obvious wasting of the hand and Forearm. The child is able to move the arm well with no abnormalities of the shoulder, elbow and wrist. There is no evidence of horner’s syndrome, diaphragmatic palsy and absent grasp reflex. 

The diagnosis of the boy’s condition is:

A) Erb’s Palsy
B) Cerebrovascular Accident
C) Klumpke’s palsy
D) Ulnar and Median combined nerve injury
E) Pseudoparalysis

Best answer: C

This is a case of obstetric Brachial palsy involving C8, T1 (Klumpke's Palsy).

Erb's palsy involves upper roots only. 

Combined nerve injuries can present in a similar fashion; however, low ulnar and Median nerve lesions will not have weakness of FDP and FDS. 

Author : Dr. S Mohamed Azeem

 

10. Regarding an open tibial shaft fracture in a patient presenting to a hospital without onsite plastic surgery available. The best cause of an action is:

A) Resuscitation of the patient and early (within 6 hours) debridement of the wound without stabilisation and Plastics review of the patient at an elective clinic
B) Resuscitation and early transfer of the patient to an appropriate specialist centre for combined Plastics and Orthopaedic intervention
C) Resuscitation of the patient, debridement and skeletal stabilisation with no plan in place for definitive soft tissue coverage
D) Washout with 2L saline and hydrogen peroxide within resus and plan for formal debridement by Plastic surgeons available within 24 hours
E) Debridement and skeletal stabilisation at local centre with plan in place for transfer to centre with Plastics for definitive soft tissue coverage within 72 hours

Best Answer B

BOAST 4 - guidelines

Although the last option is commonly occurs, this is not considered optimal treatment and is only suitable if patient cannot be transferred to specialist centre before need for initial debridement

 

9.  A 34 year old male is being resuscitated in Accident & Emergency department following a road traffic accident. 

What is the most important test to assess adequacy of fluid replacement resuscitation?

A) Lactic acid < 2 mmol/L
B) Urine output of 0.25 ml/kg/hr
C) Stability of Glasgow Coma Score
D) Decreased pulse pressure
E) Increased heart rate

Best answer: A

Rapid fluid resuscitation with crystalloid isotonic solution is the mainstay therapy for hypovolemic shock. Blood replacement is also indicated if the estimated blood loss is greater than 30% of the total volume (class III).

Adequate response to fluid resuscitation includes increased urinary output (> 0.5ml/kg/hr), improved Glasgow Coma Score, Decreased capillary refill, increased blood pressure, increased Mean arterial pressure, and decreased heart rate. 

The important blood test is lactic acid, which is increased if the shock is severe enough to cause anaerobic metabolism. Successful resuscitation in a shock patient will lead to a falling lactate levels (<2.0mmol/L).

Author : Firas Arnaout

 

8.  A 25 years old man was assaulted with a knife in the axillary region. He presented with weakness of shoulder abduction. Which nerve branch of the brachial plexus is most likely to have been transacted? 

A) Thoracodorsal nerve of the posterior cord
B) Musculocutaneus nerve of the lateral cord
C) Ulnar nerve of the medial cord
D) Suprascapular nerve of the superior trunk
E) Axillary nerve of the posterior cord

Best answer: E

The brachial plexus is formed from the ventral rami of C5-T1 nerve roots. Thoracodorsal nerve of the posterior cord innervates latisimus dorsi. Musculocutaneous nerve from lateral cord supply biceps, coracobrachialis and brachialis.The ulnar nerve from the medial cord supplies muscles to the wrist and hand only. The supra scapular nerve is a branch of the superior trunk and supplies the supraspinatus.therefore will cause weakness of abduction. However,this nerve emerges in the neck between anterior and middle scalene muscles ,and more likely to be transacted in neck injuries. 

The axillary nerve of the posterior cord supplies the deltoid muscle which is the main shoulder abductor.

Author : Firas Arnaout

 

7.  A 55 -years-old man sustains an open fracture of the radius which was treated with open reduction and internal fixation. This operation was complicated with radial nerve injury which did not improve at follow up. 

Which of the following treatments will best restore function?

A)Transfer of pronator teres to extensor carpi radialis brevis
B)Transfer of deltoid to triceps
C)Transfer of the flexor carpi radialis to extensor digitorum and the palmaris longus to the extensor pollicis longus 
D)Transfer of pectoralis major to biceps
E)Transfer of common flexors tendon to the humerus

Best answer: C

 

For radial nerve palsy in the forearm palsy, the most beneficial transfers include transferring the flexor carpi radialis to the finger extensors (to restore finger extension) and palmaris longus to the extensor pollicis longus (to restore extension of the thumb).

In radial nerve palsy in the forearm, the patient has adequate wrist extension due to intact ECRL (providing radial wrist extension) supplied by the radial nerve proximal to the elbow.

Transfer of pronator teres to extensor carpi radialis brevis,and Transfer of deltoid to triceps are indicated in radial nerve palsy .

Transfer of pectoralis major to biceps and transfer of common flexors tendon to the humerus are both indicted in musculocutaneous nerve palsy. 

Ref: Ropars M, Dréano T, Siret P, Belot N, Langlais F. Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis. J Hand Surg Br. 2006 Oct; 31(5):502-6.

Author :Firas Arnaout

 

6.  A football player fell on his flexed knee with the foot in plantar flexion. On examination, he has a positive quadriceps active test .

Which knee ligament in most likely injured in this patient?

 A) Anterior cruciate ligament (ACL)
B) Posterior cruciate ligament (PCL)
C) Lateral collateral ligament (LCL)
D) Medial collateral ligament (MCL)
E) Posterolateral corner complex (PLC)

Best answer: B

The PCL extends from the medial femoral condyle to the tibial sulcus Overall the most common mechanism of PCL injury is a direct blow to the proximal aspect of the tibia such as dash board injury. 

The most common mechanism of PCL injury in athletes is a fall onto the flexed knee with the foot in plantar flexion, which places posterior forces on the tibia and leads to rupture of the PCL.

Treatment of isolated PCL injury is mainly focused on protected weight bearing, followed with quadriceps rehabilitation

Ref:Janousek AT, Jones DG, Clatworthy M, Higgins LD, Fu FH. Posterior cruciate ligament injuries of the knee joint. Sports Med 1999; 28:429-441

Author : Firas Arnaout

 

5.  A 13 year-old boy sustains a tibia fracture following a fall from a swing. The fracture is reduced and placed in an above knee back slab in the accident and emergency department.

What is considered to be the most important early indicating symptom of a developing compartment syndrome of the leg?

A) Decreased sensation in the foot
B) Pain out of proportion to injury
C) Decreased pulses in the foot
D) Inability to move the toes
E) Pale appearance of the foot

Best answer: B

The single most important symptom of impending compartment syndrome is pain out of proportion to the injury. Children requiring frequent analgesia or complaining of increasing pain should be examined very carefully for possible compartment syndrome.

The key word in this question is “early symptom”. Pulselessness, paralysis, pallor, and parasthaesia are all late symptoms and signs. 

The most reliable sign of a developing compartment syndrome is severe pain with passive stretching of the involved compartment.

Author : Firas Arnaout

 

4.  A 33 years old female basketball player felt a pop and sustained non contact pivoting injury when to her knee when she landed from a rebound. She is complaining of knee pain immediate clinical examination shows haemoarthrosis. 

What is the most likely damaged structure?

A) Patella dislocation
B) Anterior cruciate ligament tear
C) Posterior cruciate ligament tear
D) Posterolateral complex
E) Lateral collateral ligament

Best answer: B

ACL injuries are more common in female athletes due to valgus leg alignment and quadriceps dominant control. The anterior cruciate ligament runs upwards and backwards from the anterior part of the tibial spine towards the lateral condyle of the femur. It prevents forward displacement of the tibia. The posterior cruciate ligament, runs from the posterior part of the tibia towards the medial condyle of the femur, and prevents backward displacement of the tibia especially at 90 degrees of flexion. The lateral and medial collateral ligaments prevent varus and vlagus displacement at 30 degrees of flexion respectively. The clinical tests for ACL injuries are Lachman test and pivot shift test. And the investigation of choice is MRI scan 

Garrick, JG (ED): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 169-181 

Author :Firas Arnaout

 

3 .  A 28 years old man was involved in a motorbike road traffic accident sustaining head injury resulting in a coma and hip fracture. 

Indomethacin is indicated here to prevent which complication?

A) Non union
B) Infection
C) Vascular compromise
D) Pressure ulcers
E) Heterotopic ossification 

Best answer:  E

Heterotopic ossification is formation of bone in the soft tissues, may occur spontaneously or following trauma .It is usually not painful, but presents with loss of movements. Prolonged ventilation time, brain injury, spinal cord injury, burns, and amputation thru the zone of injury in a patient injured in a blast are all literature proven risk factors for development of heterotopic ossification. 

Prophylaxis is with the use of Bisphosphonates and Indomethacin and raditherpay.Surgical excision could be performed if there is sever loss of movements.

Ref: Pape HC, Lehmann U, van Griensven M, Gänsslen A, von Glinski S, Krettek C. Heterotopic ossifications in patients after severe blunt trauma with and without head trauma: incidence and patterns of distribution. J Orthop Trauma. 2001 May; 15(4):229-37

Author :Firas Arnaout

 

2.  25 years old rugby player sustained posterior hip dislocation when several players landed on his back with the hip flexed to 90 degrees, resulting in posterior hip dislocation. 

Hip Dislocation – Core EM

What is the most common complication of hip dislocation?

A) Posttraumatic arthritis
B) Avascular necrosis
C) Sciatic nerve injury
D) Recurrent dislocation
E) Femoral artery occlusion

Best answer: B

 

All the above are recognised complication of hip dislocation. Arthritis incidence is up to 20% and is dependent on the severity of dislocation and associated fractures.

Sciatic nerve injury is up to 20% and increases with longer time to reduction.

AVN incidence is up to 40% and recurrent dislocation is 2%

Author :Firas Arnaout

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