Multiple Choice Questions

Trauma

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60. Comparing manual traction and finger trap traction in reducing distal radius fracture

A)  Manual traction may better correct dorsal tilt
B)  Finger traction may better restore ulnar height
C)  There is lower incidence of CRPS with finger trap traction
D)  There is higher incidence of carpal tunnel syndrome with finger trap traction
E)  Manual pain cause less pain during reduction than finger trap reduction

Correct Answer: C

Two primary methods for closed reduction exist and have been evaluated in the literature: manual traction and finger trap traction. Both methods assist the provider to manipulate and reduce the fracture appropriately by restoring the radial length. Sosborg-Wurtz et al6 conducted a recent systematic review of the two methods and noted that reduction by manual traction may better correct volar tilt while finger trap traction may better restore radial length, although these results were not found to be clinically significant. Furthermore,finger trap traction may result in a lower incidence of complex regional pain syndrome (CRPS) and carpal tunnel syndrome and cause less pain during reduction.

Source / Further reading:

J Am Acad Orthop Surg 2021;29:e1105-e1116

DOI: 10.5435/JAAOS-D-20-01335

Author: Fouad Chaudhry

 

59. What percentage of women with osteoporotic fractures develop kyphosis:

A) 10%
B) 15%
C) 25%
D) 30%
E) 60%

Correct Answer: B

Approximately 15% of women with osteoporotic fractures develop kyphosis. 

This is often due to the presence of multiple vertebral compression fractures with segmental kyphosis at each level.

Author: Rajesh Bahadur Lakhey

 

58. An 18-year-old man presents to the emergency department after sustaining a high-velocity gunshot wound to the umbilical region of the abdomen. 

An exit wound is found at the L3-L5 region of the lower back. Neurological examination shows grade 0/5 strength in his tibialis anterior muscles, gastrocnemius/soleus muscles, and extensor hallucis longus muscles bilaterally. His quadriceps and hamstrings strength is grade 2/5 bilaterally. 

A bullet fragment was seen at L4 within the spinal canal on computed tomography (CT) imaging. The patient sustained significant gastrointestinal trauma as a result of the bullet traversing his body. 

Management should consist of:

A) Administration of a broad-spectrum antibiotic for 14 days
B) Removal of the bullet fragment at L4
C) Continued serial neurologic examinations
D) Intravenous administration of dexamethasone for 24 hours
E) A, B, and C

Correct Answer: E

Because the bullet entered the patient’s umbilical region of the abdomen, significant gastrointestinal damage is
suspected. When this occurs, administration of a broad-spectrum antibiotic for 7 to 14 days is indicated to prevent
infection and sepsis from gastrointestinal flora. 

The bullet fragment at L4 should be removed because studies have shown that removal of a bullet from a patient with complete or incomplete neural deficits at T12 to L4 is associated with statistically significant increases in motor recovery as compared to nonoperative management. 

Intravenous administration of dexamethasone is not indicated for gunshot wounds to the spine because the benefits of steroids do not outweigh the risks

Author: Rajesh Bahadur Lakhey

 

57. Which of the following statements regarding lesions of the spinal cord caused by bullet wounds is true:

A) Twenty-five percent of patients with complete lesions recover one motor level after 1 year
B) Thirty-three percent of patients with incomplete lesions usually have a partial or complete recovery after 1 year
C) Complete lesions occur in more than 50% of all gunshot wounds to the spine
D) 75% of patients in whom the bullet has passed through the spinal canal will experience a complete lesion
E) All of the above

Correct Answer: E

All of the statements are true. Knowledge of these facts is important in decision-making and management of patients
who are victims of gunshot wounds to the spine

Author: Rajesh Bahadur Lakhey

 

56. 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.

Author: Rajesh Bahadur Lakhey

 

55. A type 3 traumatic spondylolisthesis of the axis, as classified by Levine and Edwards, is best treated with which of the following:

A) Soft collar immobilization
B) Hard Philadelphia cervical orthosis
C) Halo vest immobilization
D) Open reduction and operative posterior stabilization
E) Gardner-Wells tongs application and awake reduction, then posterior stabilization

Correct Answer: D

The Levine classification of traumatic spondylolisthesis or Hangman fractures involving C2 .In the type 3 injury has a combined bilateral facet dislocation at C2-C3 as well as the traumatic spondylolisthesis of the axis. 

Closed reduction could not be performed secondary to the traumatic spondylolisthesis at the C2 isthmus.

Author: Rajesh Bahadur Lakhey

 

54. What are the main findings of medial tibial stress syndrome on a bone scan?

A) Delayed uptake of tracer and nonfocal uptake over the posteromedial tibial border
B) Lack of uptake of tracer in all phases
C) Focal uptake of tracer in early phase only
D) Focal uptake of tracer in delayed phases
E) Nonspecific uptake of tracer in all phases

Correct Answer: A

 

Medial tibial stress syndrome (MTSS), commonly known as “shin splints,” is a frequent injury of the lower extremity and one of the most common causes of exertional leg pain in athletes.

Medial tibial stress syndrome has a characteristic finding on bone scan of uptake only in the delayed phase. Uptake is
nonfocal and is along the posteromedial border of the tibia. 

These findings contrast with a stress fracture, which has focal uptake in the early phase.

 

Nuclear medicine bone scan demonstrating diffuse longitudinal periositis (a) of stress reactions (arrows) bilaterally in the tibiae, in contrast to (b) which shows a more focal uptake ssociated with stress fracture

Author: Rajesh Bahadur Lakhey

 

53. Which best describes a type IIA distal clavicle fracture?

A) The fracture is lateral to the coracoclavicular ligaments
B) The fracture involves intra-articular injury of the acromioclavicular joint
C) The fracture line is between the conoid and trapezoid ligaments
D) The fracture is medial to the coracoclavicular ligaments
E) The fracture involves comminuted distal clavicle fracture

Correct Answer: D

A type IIA distal clavicle fracture occurs medial to the coracoclavicular ligaments. 

Type I is an extra-articular fracture lateral to the coracoclavicular ligaments. 

Type III is an intra-articular injury of the acromioclavicular joint.