sefc-southeastern fracture symposium 2015 sample...
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SEFC Southeastern Fracture Symposium 2016
Scored and Recorded Examiantion
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Answer sheet when completed is to be emailed to [email protected] by January
25, 2016 for scoring. No credits will be issued until SAE process is complete.
Questions 1-100
1. Temporizing fixation of unstable pelvic ring injuries has been described using a
variety of constructs. Which form of temporary stabilization is the most cost
effective and does not necessitate the patient going to the operating room or use of
fluoroscopy?
a. Pelvic packing
b. Pelvic external fixation
c. Pelvic c-clamp
d. Pelvic sheeting
2. Management of femoral neck fractures in the elderly (age 60 and greater) can be
challenging. Open reduction and internal fixation has a relatively high failure rate
and in some reports over 30%. Which of the following is true in terms of one-year
mortality rates?
a. Internal fixation (closed reduction pinning and open reduction internal
fixation) has a near equal one-year mortality rate compared to arthroplasty
(hemi and total hips) of roughly 10-20%.
b. Internal fixation (closed reduction pinning and open reduction internal
fixation) has a near equal one-year mortality rate compared to arthroplasty
(hemi and total hips) of roughly 20-30%.
c. Internal fixation (closed reduction pinning and open reduction internal
fixation) has a near equal one-year mortality rate compared to arthroplasty
(hemi and total hips) of roughly 30-40%.
d. Internal fixation (closed reduction pinning and open reduction internal
fixation) has a greater one-year mortality rate (50%) compared to
arthroplasty (hemi and total hips) 20%.
e. Internal fixation (closed reduction pinning and open reduction internal
fixation) has a lower one-year mortality rate (10%) compared to arthroplasty
(hemi and total hips) of 40%.
3. A 25-year-old patient arrives in the ED after a high-speed motorcycle
collision. He has been intubated in the field and has no visible open wounds or
deformity of his arms or legs. On examination, his blood pressure is 80/50 and
heart rate is 120. What orthopedic injury is most likely to be responsible for this
scenario?
a. Comminuted humerus fracture
b. Lisfranc fracture-dislocation
c. Scapulothoracic dissociation
d. Unstable pelvic ring injury
e. Intra-articular distal femur fracture
4. Pauwel’s 3 femoral neck fracture may visualized best in obese patient with what
approach.
a. Watson-Jones.
b. Smith-Petersen.
c. Lateral.
d. Medial.
5. A 25 year old female undergoes operative fixation of a distal femur fracture and
goes onto uneventful union. 4 Months after her injury she presents to your office
with complaints of loss of motion. Specifically she lacks the terminal 20 degrees of
extension. X-rays demostrate anatomic reduction and bony union without evidence
for arthrosis. Upon scrutinizing the lateral x-ray you not several screws are distal
and posterior to Blumensaat’s line. The most likely reason for her lack of motion
is?
a. The iliotibial band is rubbing on the lateral plate
b. The lateral to medial screws are prominent on the medial side
c. The plate is too anterior
d. Intra-articular hardware
6. Clinical obesity is defined as a BMI of:
a. < 25
b. 25 ≤ X ≤ 29
c. 30 ≤ X ≤ 39
d. ≥ 40
7. What anatomic structure is at risk when utilizing the anterolateral (Acromial -
Deltoid Split) approach for operative fixation of proximal humerus fractures?
a. Arcuate artery
b. Anterior humeral circumflex artery
c. Axillary nerve
d. Acromial branch of the throacoacromial Artery
e. Musculocutaneous nerve
8. A 27-year-old male is involved in a high speed MVA. He sustains the injuries
demonstrated below. He is placed in a spanning external fixator and brought to the
operating room when his soft tissue was permissive. The fixation sequence for this
fracture should be?
a. Intra-articular coronal plane fracture, intra-articular sagittal plane fracture,
restoration of length, axis and rotation, attachment of articular block to
diaphysis.
b. Intra-articular sagittal plane fracture, intra-articular coronal plane fracture,
restoration of length, axis and rotation, attachment of articular block to
diaphysis.
c. Restoration of length, axis and rotation, attachment of articular block to
diaphysis, intra-articular coronal plane fracture, intra-articular sagittal plane
fracture.
d. Attachment of articular block to diaphysis, intra-articular sagittal plane
fracture, intra-articular coronal plane fracture, restoration of length, axis and
rotation.
9. The long-term outcome of the young patient with a femoral neck fracture is most
likely associated with.
a. Age.
b. Time to reduction.
c. Quality of reduction.
d. Type of fixation.
10. A 42-year-old male has been found to have a pelvic ring injury on radiographs
after a high-speed motor vehicle collision. His injuries include a right superior and
inferior pubic ramus fracture that are minimally displaced, a right zone I sacral
fracture that is minimally displaced, and a right L5 transverse process fracture.
The best way to assess whether or not the patient’s injury is stable is:
a. Measurement of radiographic displacement of fractures
b. Fluoroscopic stress examination of pelvis under anesthesia
c. Manual examination of pelvis to evaluate level of pain reported by patient
d. Computed tomography scan of pelvis
e. Standing one-legged stress radiographs of pelvis
11. When evaluating a patient for compartment syndrome following an acute fracture
of the tibia shaft, what does delta p (∆P) stand for?
a. The patients mean arterial pressure minus the diastolic blood pressure.
b. The change in compartment pressure measurements over time.
c. The difference between pressure measurements in different compartments.
d. The difference between the diastolic blood pressure and the measured
compartment pressure.
e. The difference between the systolic blood pressure and the measured
compartment pressure.
12. The use of Cox-2 inhibitors in conjunction with a morphine PCA has shown what
affect on pain management in patients following total knee arthroplasty?
a. Increased narcotic usage secondary to inhibitory affect of Cox-2 on the
central nervous pathway.
b. No statistically significant decrease in opioid/morphine usage at 24 hours
but a significantly lower pain score at 6 hours versus morphine alone.
c. Statistically significant decrease in opioid/morphine usage at 24 hours but no
difference in pain scores at 6 hours versus morphine alone.
d. Statistically significant decrease in opioid/morphine usage at 24 hours and a
significantly lower pain score at 6 hours versus morphine alone.
e. No difference in pain outcomes at any time point and no difference in
opioids required for pain management.
13. The valgus impacted femoral neck fracture is a stable fracture pattern. Non-
operative management can be expected to result in which of the following?
a. A secondary displacement rate of roughly 10% overall and nearly 50% in
the over 80 year old age group.
b. A secondary displacement rate of roughly 20% overall and nearly 50% in
the over 80 year old age group.
c. A secondary displacement rate of roughly 40% overall and nearly 50% in
the over 80 year old age group.
d. A secondary displacement rate of roughly 20% overall and nearly 50% in
the 60-80 year old age group.
e) A secondary displacement rate of roughly 40% overall and nearly 50% in
the 60-80 year old age group.
14. A 24-year-old woman arrives at the ED after a fall while hiking. She has a blood
pressure of 90/50 and a heart rate of 110. She is found to have weakness and decreased
pulses in her left leg. She is found to have a pelvic ring injury. This is most likely what
type of pelvic ring injury:
a. Lateral compression
b. Open book
c. Vertical shear
d. Spinopelvic dissociation
15. A young patient with a vertical femoral neck fracture should be reduced to
decrease the risk of AVN in what time frame:
a. Less than 6 hours.
b. Less than 12 hours.
c. Less than 24 hours.
d. As soon as safe and feasible.
16. The most relevant signs that a pelvic ring may be unstable include bladder and
urethral injuries, open pelvic fractures, and
a. Patient pain at presentation
b. Mechanism of original injury
c. Radiographic displacement of the pelvic ring
d. FAST exam findings of retroperitoneal bleeding
17. A 27-year-old male who suffered a trimalleolar ankle fracture has come to the pre-
operative holding area for surgery. He has heard from friends he should receive ‘a
block’ for anesthesia as this provides better pain management and less narcotic
usage. You agree that this is a potential option, however, counsel him that?
a. there actually is no difference in pain scores between those patients who
receive a block and those who do not.
b. patients who receive a block typically have better pain relief within the first
12 hours, however, this affect is lost after 12 hours from those who did not
receive a block.
c. patients who receive a block have increased risk of complications following
ankle fracture surgery.
d. patients who receive a block have better pain scores at all time points
following surgery.
e. patients who receive a block have prolonged hospital stays/recovery times
than those who did not receive a block.
18. The definition of atypical femur fracture (AFF) requires that at least four major
criteria be met. Which of the following is NOT an acceptable major criteria?
a. fracture location limited to subtrochanteric region
b. minimal trauma causation
c. non or minimally comminuted fracture pattern
d. localized lateral cortical thickening or beaking
e. transverse or short oblique fracture orientation
19. What efforts do not help decrease radiation exposure to personnel involved in
fluoroscopic procedural interventions?
a. standing on the side of the intensifier when the fluoroscope is in any oblique
or horizontal position
b. standing closer to the patient
c. flipping the fluoroscope to anterior to posterior position with a supine
positioned patient
d. Taking live fluoroscopic images as opposed to discrete pictures
20. Which of the following T-Score values is indicative of diagnosis of osteoporosis?
a. > 1.5
b. < 0.5
c. < -2.5
d. < -1.0
e. > -2.0
21. Risk of AVN in a young patient with a femoral neck fracture status post ORIF with
good reduction is closest to what.
a. 0%.
b. 15%.
c. 50%.
d. 75%.
e. 100%.
22. An 87 year old female with diabetes, chronic renal insufficiency, CAD, and
hypertension sustained a ground level fall and suffered a left intertrochanteric hip
fracture. She underwent successful osteosynthesis with a sliding hip screw without
complication and was returned to the post-operative floor for rehabilitation and
monitoring. Post-operative day one the patient did well and worked with physical
therapy without problem. Post-operative day two, the nurse calls and states the
patient has sustained a change in mental status and, is, at times, lethargic and
difficult to arouse. Pertinent medications include insulin, Norvasc, Lovenox,
Vicodin and morphine for pain control. A medical work-up is done and no under-
lying medical etiology is found for the patients lethargy and change in mental
status. What is the most likely cause of the patients altered mental status?
a. Use of morphine in an elderly patient with renal insufficiency and build-up
of morphine 6-glucuronide.
b. Missed under-lying dementia diagnosis vs. sun-downing.
c. Prolonged affect of surgical anesthesia/re-bound affect.
d. Fat embolism syndrome.
e. The practitioner should keep looking for an under-lying metabolic/medical
cause.
23. A patient with a closed, distal one third spiral humeral shaft fracture cannot extend
his wrist upon his presentation to the Emergency Room. The patient wants to know
what his chances are of extending his wrist again and his radial nerve recovering:
a. 25%
b. 50%
c. 75%
d. Greater than 90%
24. Which of the following radiographic predictors has not been shown to be associated
with development of compartment syndrome in tibia plateau fractures?
a. Amount of widening of the tibial metaphysis.
b. Bicondylar Schatzker V and VI fractures.
c. Depth of articular depression.
d. Tibio-Femoral displacement.
e. Medial plateau fracture dislocations.
25. What age range patient is most likely to have Pauwel’s 3 femoral neck fracture.
a. 10 to 20.
b. 21 to 30.
c. 50 to 60.
d. 70 to 80.
26. The use of NSAIDs has been implicated as potential cause of fracture
nonunion/delayed healing. The proposed mechanism of this nonunion is secondary
to NSAIDs affect on
a. RANK-L
b. osteoprotegrin
c. prostaglandins
d. histamines
e. VEGF
27. In comparing the treatment of obese patients with femoral shaft fractures to non-
obese patients, the use of retrograde nail is associated with:
a. Increased infection rate
b. Iatrogenic meniscus injury
c. Increased surgical time
d. Increased blood loss
e. Similar fluoroscopy time
28. Which of the following is likely to increase the rate of varus collapse after plate
and screw fixation of proximal humerus fractures using locking plate technology?
a. Placement of the inferomedial head (“calcar”) screws
b. Humeral shaft lateralization
c. Incorporation of an endosteal fibular allograft in the plate /screw construct
d. Anatomic reduction of the medial calcar
29. Compared to the management of typical femoral shaft fractures, certain
complications affiliated with the surgical treatment of atypical femur fractures (AFF)
have been identified including all of the following except:
a. high percentage of plate implant failure
b. increased time to union
c. valgus malalignment following intramedullary nail placement
d. persistent pain
30. A 33 year old female patient sustained a distal radius fracture and subsequently
underwent an uncomplicated open reduction, internal fixation. She returns to your clinic
for her 2 week post-op visit stating her pain has been severe over the past two weeks.
She has been taking oxycodone around the clock with minimal relief. Her pain is
described as burning and tingling throughout her hand. Her physical exam is significant
for some skin changes, namely her skin is shiny and sensitive to touch. Her wound is
benign. What additional medication may help this patient’s pain?
a. Admission for peripheral nerve block.
b. Addition of a long-acting opioid such as Oxycontin.
c. Addition of a different short/medium acting narcotic, such as hydrocodone
which the patient may alternate with the oxycodone.
d. Addition of an anti-histamine.
e. Addition of an anti-epileptic such as Neurontin or Lyrica
31. Which of the following most closely correlates with the development of an atypical
femur fracture (AFF) when using bisphosphonates long-term for the treatment of
osteoporosis?
a. prodromal thigh pain
b. Caucasian female
c. osteoporosis
d. low body mass index (BMI)
32. A 45 year old woman is involved in a MVA and sustains the fracture shown below.
Prior to her accident she had no problems or pain with her knee. She underwent
ORIF with the below shown construct (figure1, 2). She returns to your office 6
months later with continued pain and inability to bear weight (figure2, 3).
Endocrine workup, infectious indices and vitamin D levels are all within normal
limits. What may have led to more reliable bony union?
a. Double plate fixation including plating of the medial side
b. Longer plate with and non-locking screws on the diaphyseal side of the
fracture
c. Use of a plate with variable angle screws
d. Cerclage wire fixation at the level of the fracture in addition to plate fixation
Figure1 Figure 2
Figure 3 Figure 4
33. A recent retrospective study comparing closed treatment versus ORIF of isolated
humeral shaft fractures found:
a. A higher malunion rate in fractures treated closed
b. A higher nonunion rate in fractures treated with open reduction and internal
fixation
c. A longer time to heal in the ORIF group
d. A higher rate of infection in those treated closed
34. Which of the following regimens is appropriate for daily Calcium and Vitamin D
supplementation in post-menopausal women?
a. 600 mg Calcium / 600 IU Vit D3
b. 1000 mg Calcium / 400 IU Vit D3
c. 400 mg Calcium / 400 IU Vit D3
d. 1000 mg Calcium / 1000 IU Vit D3
e. 1000 mg Calcium / 600 IU Vit D3
35. Allodynia refers to:
a. Pain resulting in laughter
b. Pain due to heat
c. Pain due to pinprick
d. Pain due to nonpainful stimulus
e. Pain due to pressure
36. A 39 year old motorcyclist lost control and hit a tree. He is diagnosed in the ER with
a displaced femoral neck (Pauwel’s III), He is cleared at 1AM for treatment, you would
recommend the following management
a. Emergency closed reduction and fixation of the fracture
b. Emergency open reduction and fixation of the fracture
c. Open reduction and fixation the following day
d. Closed reduction and fixation the following day
37. Which of the following internal fixation constructs do you think is the most
suitable fixation for a displaced femoral neck fracture with posterior fragmentation
in a 30 year female?
a. 3 parallel partially threaded cancellous screws
b. 3 parallel partially threaded cancellous screws with a 4th screw obliquely
placed from the greater trochanter to the inferior neck
c. Compression hip screw
d. Compression hip screw with derotation cancellous screw
38. If you have decided to nail a subtrochanteric fracture in a 35 year male
intubated for pulmonary problems, how would you position the patient?
a. Supine on a regular operating table
b. Supine in skeletal traction on a fracture table
c. Lateral position on a radiolucent table
d. Lateral position in skeletal traction on a fracture table
39. A 30 year old professional cyclist crashes and presents with a displaced transverse
fracture of his femur at the level of the lesser trochanter. What would your implant of
choice be to treat this fracture?
a. Antegrade locked nail
b. A cephalomedullary nail with a trochanteric starting point
c. A compression hip screw
d. A 95 degree angled plate device
40. In which of the following segmental fracture patterns would it be best to use one
implant to stabilize both fractures?
a. A displaced femoral neck associated with a displaced femoral shaft fracture
b. A displaced distal femoral intra-articular fracture with associated displaced
femoral shaft
c. A displaced intertrochanteric fracture with an associated femoral shaft
fracture
d. An undisplaced femoral neck fracture with an associated femoral shaft
fracture
41. You are treating a displaced femoral neck with an associated displaced femoral shaft
fracture in a 38 year male, which of the following implant(s) would you chose?
a. Piriformis start nail with multiple cancellous screws into the neck
b. A trochanteric start cephalomedullary nail
c. A compression hip screw with derotation screw and retrograde femoral nail
d. Multiple cancellous screws for the neck and a retrograde femoral nail
e. A compression hip screw with a long side plate
42. A 65 year old woman feels a sudden pop in her left femur while playing tennis. She
was diagnosed with osteoporosis 5 years earlier. Her radiographs taken one month prior
at her primary care physician’s office are shown below. Which medication most likely
contributed to this fracture?
a. Neurontin
b. Teriparatide
c. Lithium
d. Alendronate
43. A 20 year old male sustains the injury shown below after a fall on an outstretched
hand. Evaluation in the ED reveals a normal vascular status and no signs of compartment
syndrome. He is able to flex his fingers. However he cannot actively extend his fingers
and his wrist deviates in a radial direction upon attempts at extension. After fracture
reduction there is no improvement in his symptoms. What is the most appropriate next
step in management?
a. Observation
b. Acute ulnar nerve exploration
c. Acute posterior interosseous nerve exploration
d. Nerve conduction studies
44. A 33 year old female sustains a right acetabular fracture as a result of a motor
vehicle collision. She undergoes a closed reduction in the emergency
department. Her post-reduction CT is shown below. The best most
appropriate step in management is?
a. Bed rest with weekly x-rays to see if the fragment moves
b. Emergency open reduction and fragment removal
c. Nonoperative management and crutch mobilization
d. Skeletal traction and open reduction when safest for patient
45. There is a high rate of delayed or non unions of multifragmented high energy distal
femoral fractures treated with locked plates, The purposed reason for this is?
a. Surgical technique
b. Lack of appropriate biology about the fracture to promote healing
c. The implant constructs are too flexible to allow secondary bone healing
d. The metal with which the plate is made (titanium alloy versus stainless steel)
makes no difference
46. A 25 year old male gets his left foot caught underneath an ATV while riding at a high
rate of speed. He notes swelling and an immediate inability to bear weight. Radiographs
in the emergency department reveal a Lisfrance fracture dislocation. When counseling
this patient regarding the long term outcome of this injury you indicate that he is most at
risk for.
a. Amputation
b. Peripheral neuropathy
c. Difficulty with shoe wear
d. Post-Traumatic arthritis
47. A 30 year old male falls 10 feet from a roof while cleaning his gutters. His
radiographs are shown below. Upon evaluation in the emergency department his skin is
shiny and he has several areas of clear and blood filled blisters. The next most
appropriate step in management is?
a. Closed reduction and casting
b. Urgent open reduction and internal fixation
c. Temporizing external fixation
d. Splinting in situ
48. An elderly individual falls and sustains a compression fracture of the thoracic spine.
Failure to treat any underlying osteoporosis or vitamin D deficiency puts this individual
most at risk for what injury?
a. Proximal humerus fracture
b. Subtrochanteric femur fracture
c. 5th
Metatarsal fracture
d. Hip fracture
e. Pubic ramus fracture
49. A 40 year old female sustains the injury below. Compared with plate and screw
fixation use of an intramedullary device is associated with which of the following?
a. Lower risk of radial nerve injury
b. Higher risk of infection
c. Higher risk of re-operation
d. Lower risk of shoulder pain
50. A 40 year old female is placed in a thin wire fixator for definitive management of a
bicondylar tibial plateau fracture. 3 weeks later she presents to the ED with a red, hot and
swollen knee and is diagnosed with a septic knee. The risk of placing an intra-articular
wire is most pronounced at what portion of the knee?
a. Antero-medial
b. Antero-lateral
c. Postero-medial
d. Postero-lateral
51. What is the most common complication of iliac crest bone graft harvesting?
a. Infection at graft harvest site
b. Herniation of abdominal contents
c. Vascular injury
d. Deep hematoma requiring surgical intervention
e. Neurologic injury at graft harvest site
52. Induced membranes for reconstruction of long bone defects are MOST
effective because they have which of the following properties:
a. Membranes generate new arterial inflow to the graft
b. Membranes act as a sleeve to hold bone graft
c. Membranes are biomechanically strong and rigid
d. Membranes secrete growth factors such as BMP-2 and VEGF
e. Membranes decrease infection while bone his healin
53. Which growth factor is FDA-approved for the treatment of tibia nonunions?
a. BMP-2
b. VEGF
c. BMP-7
d. DBM
e. TGF-β
54. Which technique may be helpful in preventing the deformity shown in the image
below? a. Larger diameter nail
b. Nail with more proximal interlocking options
c. Blocking screw technique
d. Femoral distractor use
55. What measure of physiologic status best estimates resuscitation when making
decisions regarding acute definitive stabilization of long bone injuries in the multiply
injured patient?
a. Heart rate les then 100 beats per minute
b. Urine output of 10ml/kg/hr or greater
c. Systolic blood pressure greater than 90mmHg
d. Serum lactate of less than 2.5 mmol/L
56. The corona mortise is a vascular communication most commonly occurring between
what two vessels?
a. Internal iliac and the superior gluteal
b. Obturator and external iliac
c. Internal iliac and external iliac
d. Vesicular and superior gluteal
57. The Smith-Peterson approach utilizes the internervous plane between what two
nerves?
a. Sciatic and superior gluteal
b. Femoral and sciatic
c. Obturator and femoral
d. Superior gluteal and femoral
58. A patient undergoes a Smith-Peterson approach and complains of burning and
numbness on the lateral aspect of the thigh. This is most likely a result of an injury to
which structure?
a. Femoral nerve
b. Lateral femoral cutaneous nerve
c. Sciatic nerve
d. Peri-incisional cutaneous nerves
59. During development of the interval between the tensor fascia lata and the sartorius
brisk bleeding is noted coming from just superficial to the rectus femoris muscle. What
artery has mist likely been injured?
a. Profunda femoris
b. Common femoral
c. Ascending branch of lateral femoral circumflex
d. Descending branch of lateral femoral circumflex
60. A patient undergoes a washout of a traumatic arthrotomy via a medial parapatellar
arthrotomy. The patient returns to clinic 6 weeks later and complains of a painful
neuroma on the medial aspect of the knee which likely represents and injury to a branch
of which nerve?
a. Sural
b. Saphenous
c. Femoral
d Superficial peroneal
61. A patient requires acute fasciotomies for lower extremity compartment syndrome.
How many fascial compartments will you release?
a. 1
b. 2
c. 3
d. 4
62. What structure is not in the deep posterior compartment?
a. Tibialis posterior
b. Flexor hallucis longs
c. Posterior tibial artery
d. Sural nerve
63. A patient with a developing compartment syndrome complains of pain in his first
dorsal web space. This most likely represents nerve compression in which compartment?
a. Anterior
b. Lateral
c. Posterior
d. Anterolateral
64. The posterolateral approach to the ankle utilizes the interval between which two
nerves?
a. Deep personal and superficial peroneal
b. Superficial peroneal and tibial
c. Sural and saphenous
d. Sural and tibial
65. While doing a posterolateral approach for fixation of a tri-malleolar ankle fracture a
strong ligamentous attachment is encountered between the distal posterior fibula and the
posterior malleolus. What is this structure?
a. Anterior inferior tibiofibular ligaments
b. Interosseos membrane
c. Posterior inferior tibiofibular ligaments
d. Posterior talofibular ligaments
66. In the distal portion of a posterolateral approach to the ankle the sural nerve is
visualized most commonly running adjacent to the?
a. Common saphenous
b. Peroneus brevis
c. Short saphenous
d. Peroneus longus
67. A 45 year old male sustains a 4-part proximal humerus fracture after falling from a
platform at a construction site. Open reduction internal fixation was performed. There is
concern for injury to the axillary nerve at follow-up. Which of the following is a clinical
finding which could support this suspicion?
a. Decreased external rotation strength against resistance
b. Inability to lift the back of the hand off the posterior waist
c. Decreases strength against resistance at 90 degrees abduction and 90
degrees external rotation
d. Inability to perform a shoulder shrug against resistance
68. A 45 year old male sustains a 4-part proximal humerus fracture after falling from a
platform at a construction site. Inability to reconstruct the proximal humerus fracture
anatomically forces the surgeon to perform a hemiarthroplasty. Secondary to the surgical
neck fracture and loss of the medial calcar, the attending surgeon is confused as how best
to determine the height of the prosthesis. He turns to the resident who clearly knows the
answer is:
a. 8mm below the inferior border of the acromion
b. 4.5cm above the level of the surgical neck fracture
c. 5.6cm above the level of the superior border of pectoralis major tendon
d. 8-10mm above the greater tuberosity
69. A 45 year old male sustains a 4-part proximal humerus fracture after falling from a
platform at a construction site. Identification of the axillary nerve is critical. In which of
the following planes is the nerve identifiable?
a. Superior border of the subscapularis and posterior to the superior
glenohumeral ligament
b. Inferior border of the subscapularis and anterior to the conjoined tendon
c. Between the pectoralis major muscle and anterior to the conjoined tendon
d. Inferior border of the subscapularis and posterior to the conjoined tendon
70. When performing the Gerwin approach to the humerus (modified posterior
approach), what nerve is used as a landmark to trace back and find the radial nerve?
a) Medial brachial cutaneous nerve
b) Lower lateral brachial cutaneous nerve
c) Lateral antebrachial cutaneous nerve
d) Radial superficial sensory branch
71. The anterolateral approach to the humerus takes advantage of the fact the brachialis
muscle can be split longitudinally due to dual innervation by the
a) Musculocutaneous nerve and radial nerve
b) Median nerve and musculocutaneous nerve
c) Median nerve and radial nerve
d) Median nerve and ulnar nerve
72. The radial nerve crosses the posterior humerus what distance from the lateral and
medial humeral condyles respectively?
a) 14 cm medial condyle, 8 cm lateral condyle
b) 8 cm lateral condyle, 14 cm medial condyle
c) 20 cm lateral condyle, 14 cm medial condyle
d) 14 cm lateral condyle, 14 cm medial condyle
73. The last muscle innervated by the posterior interosseous nerve (and therefore the last
to recover in a radial nerve palsy) is what muscle?
a) Extensor pollicis brevis
b) Extensor indices proprius
c) Abductor pollicis brevis
d) Extensor pollicis longus
74. When performing an anterior approach to the forearm (approach of Henry), the
proximal dissection lies between the brachoradialis and the pronator teres, which is an
interval between which two nerves.
a) Axillary and musculocutaneous
b) Musculocutaneous and radial
c) Radial and median
d) Median and ulnar
75. There are, classically, how many compartments in the forearm?
a) 4
b) 3
c) 5
d) 2
76. A 7 year old male falls and sustains a type III supracondylar humerus fracture. He is
treated in a cast but requires excessive elbow flexion to maintain reduction. He presents
to an orthopedist in a different location 2 years after this injury and complains of a
flexion deformity if the hands and wrist. What is the name of this deformity?
a. Volkmann’s
b. Chaput
c. Tillaux
d. Segond
77. Which extensor compartment of the wrist is the only compartment to contain both
tendon and nerve?
a) 2
b) 3
c) 4
d) 5
78. The posterior interosseous nerve runs through the _____ muscle. When exposing the
radial head via a posterior-lateral approach, the arm should be held in _____ to help
avoid injury to the PIN.
a) Extensor carpi radialis brevis, pronate
b) Extensor carpi radialis brevis, supinate
c) Supinator, pronation
d) Supinator, supination
79. In a volar approach to the distal radius, the ____ nerve is at risk as it runs along the
ulnar side of the flexor carpi radialis muscle.
a) Motor branch of median nerve
b) Radial superficial sensory branch
c) Palmar cutaneous branch of median nerve
d) Median nerve
80. The posterior approach to the radius (Thompson approach) utilizes the interval
between ____ and the ____, innervated by the radial nerve and the PIN.
a) Extensor carpi radialis longus, Extensor digitorum communis
b) Extensor digitorum communis, Extensor carpi radialis brevis
c) Extensor carpi radialis longus, Extensor carpi radialis brevis
d) Brachioradialis, Extensor carpi radialis brevis
81. For Proximal Femoral Periprosthetic Fractures, ORIF with cerclage cables and/or
locking plates is least appropriate for:
1) Fracture of the greater trochanter
2) Fracture around the stem or just below it with a stem that is well fixed
3) Fracture occurring in the shaft, 1 inch below the hip stem
4) Fracture occurring around the stem or just below it with stem poorly fixed
82. The least important parameter of those listed below in preoperative planning for a
proximal femoral periprosthetic fracture is:
1 fracture location
2 implant stability
3 bone quality
4 history of type II diabetes
5. presence of cement
83. A 68 year old male falls in his home and has a partial dislodgement (0.5cm) of the
tibial component of his total knee replacement and a minimally displaced (no offsetting
of axis or alignment) proximal tibial fracture. Prior to the fall, the patient had no knee
complaints. The most appropriate treatment is:
1 ORIF of the proximal tibial fracture
2 Long leg cast
3 Revision with a long stem tibial component which bypasses the fracture
4 Locking Plate
5 Thin wire external fixation
84. The proximal fragment in a displaced (two part) subtrochanteric fracture is typically
positioned in:
1) Abduction, internal rotation, extension
2) Abduction, external rotation, extension
3) Abduction, internal rotation, flexion
4) Abduction, external rotation, flexion
5) Adduction, external rotation, flexion
85. .Regarding an adult, with a closed subtrochanteric femoral fracture, and a simple two
part pattern located one centimeter below lesser trochanter. Which fixation construct best
addresses this injury and allows for early weight bearing:
1) A Dynamic hip screw
2) Retrograde nailing, unlocked
3) Thin wire external fixation
4) Periarticular Plate Fixation
5) Cephalomedullary Nailing
86. A “Peritrochanteric” Fracture:
1) is an intertrochanteric fracture with an extension to the femoral head.
2) is a subtrochanteric fracture with an extension to the head.
3) is an intertrochanteric fracture with an accompanying hip dislocation.
4) is an intertrochanteric fracture with subtrochanteric extension.
5) is a subtrochanteric fracture attributable due to medication which hampers the
function of osteoclasts.
.
87. Which “muscle-action” pair is not applicable to fracture position in a displaced two
part subtrochanteric fracture?
1) Gluteus medius - abduction
2) Iliopsoas - hip flexion
3) Iliopsoas - external rotation
4) Quadriceps - internal rotation
5) Adductors-shortening and varus
88. A 40 year old male is involved in a motor vehicle collision. Upon arrival in the
emergency department he is noted to have a shortened internally rotated extremity. BP is
120/80, HR is 90, his lactate is normal and he is making good urine. X-rays are shown
below. The intervention of choice for this fracture is what?
1.) External fixator
2.) Retrograde, reamed, unlocked intramedullary nailing
3.) Antegrade, reamed, locked intramedullary nailing
4.) Submuscular plating
5.) Spica casting
.
89. Which of the following diagnostic modalities has not been shown to be useful in
diagnosing occult femoral neck associated with ipsilateral femur fracture in the acute
trauma situation?
1) MRI
2) CT scan
3) Plain radiograph with the hip in internal rotation
4) Scrutinizing intraoperative fluoro views
90. A 25 year old man is involved in a moped accident. Radiographs demonstrate a
displaced femoral neck fracture and a comminuted femoral shaft fracture. What is the
most appropriate treatment of this fracture combination?
1) Cephalomedullary nail to fix both fractures
2) Cannulated screw fixation of femoral neck and external fixation of femoral
shaft
3) Antegrade femoral nail with a “miss the nail” technique around the nail
4) Cannulated screws to fix the femoral neck and retrograde femoral nailing
91. A 25 year old male sustains a fall on an outstretched hand while skateboarding. He
notes immediate pain and deformity to his elbow. Radiographs in the emergency
department reveal a simple elbow dislocation. He undergoes a closed reduction in the ED
under conscious sedation. Subsequent examination reveals the elbow to be stable
throughout range of motion. The most subsequent next step in management is?
1) Immediate reconstruction of the lateral elbow ligaments
2) Immediate reconstruction of the lateral elbow ligament s and application of
a hinged elbow fixator
3) Immediate return to activity without restriction
4) Long arm splint for 2 weeks followed by progressive ROM
92. A 34 year old female sustains a type 2 open tibial shaft fracture. The open wound is
approximately 2 cm in length and located over the anteromedial aspect of her tibia. There
is minimal contamination and the patient does not manifest any signs of compartment
syndrome. Which statement is most true regarding debridement in this patient?
1) It should be done on an emergent basis
2) The quality and not timing of the debridement is most important
3) It should be done prior to administration of antibiotics in order to increase the
yield of intraoperative culture
4) It is should be performed in the emergency department followed by
immediate wound closure
:
93. A patient presents with the radiographs shown in Figure 1 a. and 1 b. You choose to
perform an ORIF. What is the most important determinant of the patient’s outcome?
a. Use of a nail with locking proximal fixation
b. Restoration of the calcar
c. Preservation of the cephalic vein
d. Biceps tenodesis at the bicipital groove.
94. An 80 year old female with hypertension presents with the radiographs shown below .
In discussing her treatment options with her which one of the following statements is
true?
a. ORIF of her fracture has a rate of reoperation of less than 10%
b. Studies show no significant difference in pain relief between
hemiarthroplasty and reverse shoulder arthroplasty
c. Non operative treatment has a high non union rate
d. A deltoid splitting approach is superior to a deltopectoral approach
95. A 22 year old Marine presents with a displaced clavicle fracture after a motorcycle
accident. He has no past medical history but admits to cigarette smoking. Which of the
following statements is true about his return of function?
a. His risk of nonunion is the same regardless of treatment
b. He can return to duty faster with non operative treatment
c. His functional outcome at one year is equivalent for ORIF vs. non
operative.
d. Intramedullary fixation will give a superior functional result
96. Injury to the nerves overlying the clavicle results in which one of the following?
a. Loss of function of the pectoralis muscle
b. Decreased range of motion of the sterno-clavicular joint
c. Loss of sensation to the anterior chest
d. Decreased pulmonary function
97. What structure inserts on the greater tuberosity of the humeral head?
a. The long head of the biceps tendon
b. Supraspinatus tendon
c. Subscapularis tendon
d. Inferior glenohumeral ligament
98. Non operative treatment of a proximal humerus fracture is indicated for which of the
following?
a. The fracture is tenting the skin
b. A CT scan shows a greater tuberosity fracture with 15mm displacement
c. A surgical neck fracture with less than 1 cm displacement
d. A displaced fracture involving the articular surface of the humeral head
99. A 25 year old cyclist presents to your office with a displaced clavicle fracture. You
have a long a detailed discussion with the patient and he elects to proceed with surgical
fixation of this injury. His main reason for choosing operative management is so he can
get back on his bike as soon as possible. Which of the following fixation methods has the
highest potential risk of failure?
a. Precontoured clavicle plate
b. Application of a standard compression plate on the anterior surface of the
clavicle
c. Application of a one third tubular plate on the anterior clavicle
d. Use of a locking plate on the anteroinferior surface of the clavicle
100. The deltoid musculature inserts on which part of the clavicle?
a. Medial one third
b. Distal one third
c. Middle one third
d. Anterior margin
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