SOAL SOAL ORTHOPEDI

1. A 30-year-old professional football player gets tackled on

his right shoulder and sustains a distal clavicle fracture. The

patient has no neurologic or vascular abnormalities on

physical exam and has no other injuries on physical exam.

Initial radiographic evaluation should include:

A. CT scan

B. Bone scan

C. Chest x-ray

D. AP clavicle including Zanca views

2. A 17-year-old high school tennis player trips while returning

a serve and sustains a right midshaft clavicle fracture. Which of

the following increases the risk of nonunion in the

nonoperative treatment of clavicle fractures?

A. Sling treatment

B. Figure-of-eight bandage treatment

C. Displacement and comminution

D. Male sex

3. A 53-year-old intoxicated man crashes his motorcycle into a

pole. In the emergency department, he is hemodynamically

stable and complains of right shoulder pain. Radiographs of the

affected site are seen in Figure 1. Which classification best

describes his injury?

Figure 1 : An AP radiograph of the left clavicle

A. Allman group I, type IIA

B. Allman group II, type I

C. Allman group III, type IIB

D. Allman group I, type II B

4. A 35-year-old man suffers a left ankle fracture after losing his

balance on a fast-moving treadmill. X-rays show an oblique

fracture of the medial malleolus with widening of the

syndesmosis and a high spiral fibular fracture. Which category

of Weber ankle fractures is most analogous to this fracture

pattern?

A. Weber A

B. Weber B

C. Weber C

D. None of the above

5. A 50-year-old male presents to the emergency department

with right ankle pain, an inability to bear weight, and swelling

over the lateral malleolus. The patient states that he twisted his

ankle tripping down a flight of stairs and is complaining of

“throbbing” lateral ankle pain. X-rays show a minimally

displaced lateral malleolus fracture (Weber B) with a medial

clear space of 3.5 mm. During your initial physical exam,

palpitation of the medial malleolus also elicits tenderness.

About which additional injury should you be concerned?

A. Fracture of the talar neck

B. Tear of the deltoid ligament

C. Fracture of the calcaneus

D. Tear of the anterior talofibular ligament

6. A 26-year-old athlete twists her right ankle while diving for a

soccer ball during her tenure as goalie for a local travel league.

She suffers a bimalleolar, minimally displaced closed ankle

fracture. Her skin is soft and minimally swollen, and she is

neurovascularly intact. Which of the following fracture

characteristics is most predictive of a need for surgical fixation?

A. Degree of initial fibular fracture displacement

B. Presence of an avulsion fracture of the medial malleolus

C. Level of the fibula fracture

D. Position of the talus in the ankle mortise

7. A 20-year-old male patient presents to the emergency department (ED) after falling off of his

mountain bike. He last ate 2 hours ago, about 15 minutes before he fell. He complains of left ankle

pain and has a markedly deformed ankle with exposed bone protruding through the skin. What is

the single most important and immediate step in the treatment of this injury

A. Thorough irrigation and debridement of gross contamination from the wound

B. Reduce and splint the fracture in ED

C. Administer intravenous antibiotics and a tetanus shot/booster when applicable

D. Place nasogastric tube and proceed to the operating room for surgical stabilization

8. A 24-year-old man is noted to have a urinalysis that is

positive for blood. The microscopic examination of the urine is

negative for casts or red blood cells. Which of the following is

the most likely diagnosis?

A. Nephritic syndrome

B. Hematuria

C. Renal cell carcinoma

D. Myoglobinuria

9. A 55-year-old woman is noted to have a traumatic injury to

her right thigh. Which of the following is most sensitive for the

diagnosis of compartment syndrome?

A. Pulselessness

B. Pallor

C. Pain

D. Paresthesias

10. A 22-year-old roofer is brought into the ED due to

hyperthermia. The urinalysis is positive for blood, and the

serum CPK is markedly elevated. The patient is noted to likely

have compartment syndrome and rhabdomyolysis. What is the

appropriate infusion rate for IV hydration for this patient?

A. 4 mL/kg/% body surface area affected

B. 4 mL/kg/hr for the first 10 kg + 2 mL/kg/hr for the next

10 kg + 1 mL/kg/hr for each subsequent kilogram

C. Titrated to urine output of 0.5 mL/kg/hr

D. Titrated to urine output of 1 mL/kg/hr

Prevention and Treatment

The primary therapeutic goal is to prevent the factors that cause ARF, i.e. volume

depletion, tubular obstruction, aciduria, and free radical release. The ideal fluid regimen for

patients with rhabdomyolysis consists of half isotonic saline (0.45%, or 77 mmol/L sodium),

to which 75 mmol/L sodium bicarbonate is added. This combination may be complemented

by 10 ml/h of mannitol 15%, if sufficient urinary flow is still present (Table 5). Once overt

renal failure has developed, the only reliable therapeutic modality is extracorporeal blood

purification.

11. An 8-year-old boy fell while riding his bike, landing on his outstretched right hand.

Radiographs confirm a middle-third diaphyseal both bone forearm fracture with end-to-

end cortical apposition and 12 degrees of dorsal angulation. What is the preferred method

of treatment for this injury?

A. Percutaneous pinning of both the radius and ulna

B. Closed reduction and long-arm cast application in supination

C. Closed reduction and long-arm cast application in neutral

D. Short-arm cast application

position of cast: - position of wrist in cast varies w/ position of

fracture;

- most proxial 1/3 frx need to be immobilized in

supination;

- most middle 1/3 frx should be placed in neutral;

- most distal 1/3 frx require immobilization in

pronation;

12. Which of the following is most accurate regarding bone remodeling in children?

A. The distal radial epiphysis will correct angular deformity at approximately 20 degrees per year,

independent of age, as long as the physis remains open.

B. As the bones lengthen through growth, remodeling will also occur and lead to decreased angulation.

C. Intramembranous apposition on the convex side and resorption on the concave side of bone lead to

remodeling.

D. Children older than 11 years are more effective at correcting bone angulation than younger children

13. A 13-year-old girl sustains a both bone forearm fracture after a fall. Which of the following statements is

most accurate regarding the radiographic evaluation of anatomic forearm alignment after reduction?

A. On the AP radiograph, the ulnar styloid and the coronoid process are oriented 270 degrees apart.

B. On the AP radiograph, the radial styloid and tuberosity are oriented 180 degrees apart.

C. On the lateral radiograph, the ulnar styloid and the coronoid process are oriented 90 degrees apart.

D. On the AP radiograph, the radial styloid and tuberosity are oriented 90 degrees apart.

There are 6 ossification centers around the elbow joint. The mnemonic

of the order of appearance of the individual ossification centers is C-R-I-

T-O-E: Capitellum, Radial head, Internal (medial) epicondyle, Trochlea,

Olecranon, External (lateral) epicondyle. Remember that the anatomic

position of the body places the upper extremities in external rotation

(supination at the elbows) such that the antecubital fossa faces anteriorly.

Thus, the external epicondyle is on the radial side of the elbow, while the

internal epicondyle is on the ulnar side of the elbow. The ages at which

these ossification centers appear are highly variable, but as a general

guide, remember 1-3-5-7-9-11 years.

14. A 10-year-old girl reports right elbow pain after a fall while running from a school bully. She has no

other injuries and refuses to move the elbow out of fear of pain. Radiographs are notable for a positive

fat pad sign, but show no obvious fracture line. Contralateral images of the left, unaffected elbow are

obtained for comparison. Which of the following elbow apophyses is the last to appear on elbow

radiographs?

A. Trochlea

B. Lateral epicondyle

C. Medial epicondyle

D. Radial head

15. An 8-year-old boy falls from the playground slide on a flexed left elbow and suffers a flexion type, fully

displaced closed flexion-type supracondylar fracture. He complains of some finger numbness in the

emergency department, but will not let anybody close enough to examine his arm. Which of the following is

most likely injured in this fracture?

A. Brachial artery

B. Anterior interosseous nerve

C. Radial nerve

D. Ulnar nerve

Although extension-type fractures are associated more with brachial artery and anterior

interosseous nerve injury, the flexion-type fractures, in contrast, are associated with

ulnar nerve injury

16. A 5-year-old boy falls from a highchair during a rowdy game of “Go Fish” and falls

onto an outstretched right hand. He presents to the emergency department with

complaints that he can’t move his arm. X-rays reveal a Gartland type III extension-type

supracondylar fracture. His fingers are warm and well perfused, but no radial pulse is

palpable. On careful examination, with which of the following motions is he most likely

to have difficulty?

A. Wrist extension

B. “Thumbs up”

C. “A-okay” sign

D. Thumb-small finger opposition

17. A 3-year-old girl presents shortly after a right arm injury. The patient’s father reports that he was playing with his

daughter by swinging the girl in circles while holding on to her arms when she suddenly complained of pain in the

left arm. The patient immediately held the injured arm close to her body with the help of her noninjured arm. Which

of the following is most accurate regarding this injury?

A. Represents child abuse

B. Requires a skeletal survey

C. Is a common accidental injury

D. Is inconsistent with the described mechanism of injury

18. Osteogenesis imperfecta (OI) may present similarly to child maltreatment. However,

there are features of OI that may help differentiate the 2, including blue sclera and

osteopenia. Which of the following is another distinguishing feature?

A. Polydactyly

B. Patent foramen ovale

C. Multiple fractures in the setting of minimal trauma

D. Dental involvement

Pathophysiology

•can result from

•decreased collagen secretion

•production of abnormal collagen

•leads to insufficient osteoid production

•physeal osteoblasts cannot form sufficient osteoid

•periosteal osteoblasts cannot form sufficient osteoid and

therefore cannot remodel normally

19. The pediatrician of a 2-year-old girl orders a skeletal survey because of suspected

abuse. The imaging identifies multiple fractures, including the right humerus, left

tibia, and right femur. Because it is important to distinguish between those that are

acute versus those that are older and already healing, the pediatrician calls her

colleagues in the Orthopaedics Department, who reviews with her the age-based

features of fracture healing. At what point does new periosteal bone formation

become apparent on plain radiographs?

A. 4 to 14 days

B. 1 to 2 months

C. 1 year

D. Within hours

20. A 13-year-old boy is referred to your office with a right-sided SCFE after workup over several weeks by his

pediatrician for insidious right knee pain. On exam, he has obligatory external rotation with hip flexion and is refusing to

bear weight. His TSH is 8.5 mIU/mL. Which of the following is the most appropriate treatment for this patient?

A. Percutaneous pinning of the right hip

B. Open reduction and capsulotomy of the right hip with plate and screw fixation

C. Percutaneous pinning of the left hip

D. Percutaneous pinning of bilateral hips

21. Through which of the following physeal zones does the disruption in SCFE typically

occur?

A. Reserve zone

B. Proliferative zone

C. Hypertrophic zone

D. Zone of provisional calcification

22. An 8-year-old obese girl of Pacific Island ancestry is referred to your office for a right-sided unstable SCFE

lesion after a fall while playing kick-ball. She had no previous pain in this extremity. On examination, she has an

externally rotated right lower extremity that is severely painful with passive range of motion. Frog-leg lateral x-

rays show a displaced right SCFE lesion with a normal-appearing left femoral head. Which of the following

factors is indication to prophylactically fix this patient’s left hip?

A. Obesity

B. Age

C. Unstable nature of the right-sided SCFE

D. Acute, traumatic right-sided SCFE without preexisting symptoms

23. A 15-month-old girl presents to your office for evaluation of her right hip. Which of

the following is most associated with a diagnosis of developmental hip dysplasia?

A. Negative Barlow maneuver

B. Asymmetry of hip abduction

C. Negative Ortolani maneuver

D. Increased hip abduction

24. Which of the following is associated with developmental dysplasia of the hip?

A. Male sex

B. Vertex occiput posterior delivery

C. Polydactyly

D. First born

25. An otherwise healthy 5-month-old infant diagnosed with developmental dysplasia of the right hip

is treated in a Pavlik harness with the hips flexed to 90 degrees and abduction of 50 degrees. An AP

radiograph of the pelvis at 4-week follow-up shows that the hip remains dislocated. What is your next

step in management?

A. Continue treatment as is; the hip should reduce within the next 2 weeks

B. Closed reduction with hip arthrogram and hip spica casting

C. Open reduction with femoral shortening osteotomy

D. Open reduction with pelvic acetabular osteotomy