SOAL SOAL TRYOUT

ORTHOPEDI

1. A 27-year-old right-hand-dominant man sustains a right distal radius fracture after a trip and

fall. He is treated with closed reduction. Which radiographic parameter has the greatest bearing

on functional outcome?

A. Radial height

B. Radial inclination

C. Ulnar variance

D. Palmar tilt

E. Bauman angle

Maintaining this palmar tilt following fracture of the radius

has been linked to functional outcomes, including return of

pain free normal ROM.8

Frykman Classification of Colles

Fractures

2. A 50-year-old engineer suffers a comminuted distal radius fracture that fails an initial attempt at cast immobilization. He undergoes elective open-reduction internal fixation of the fracture with a dorsal plating technique. Which tendon is most likely to rupture after dorsal plate fixation of a distal radius fracture? A. Flexor carpi radialis B. Extensor pollicus longus

C. Abductor pollicus longus D. Extensor pollicus brevis E. Extensor digitorum

3. A 52-year-old female fell from her bicycle while trying to light a cigarette while navigating a busy intersection. She suffers a right-sided, dominant distal radius fracture. The fracture is closed and simple, extends into the radiocarpal joint, and is almost 100% displaced dorsally. On additional radiographs, she has a small, nondisplaced fracture of her ipsilateral radial head. Which of the following, if present, is associated with the highest risk of displacement after closed reduction and cast immobilization? A. Intraarticular involvement B. Age > 50 years old C. The severity of prereduction dorsal displacement

D. Ipsilateral fracture of the radial head E. Tobacco history

• Several factors have been associated with redisplacement following closed

manipulation of a distal radius fracture:

• The initial displacement of the fracture: The greater the degree of displacement

(particularly radial shortening), the more energy is imparted to the fracture

resulting in a higher likelihood that closed treatment will be unsuccessful.

• The age of the patient: Elderly patients with osteopenic bones tend to displace,

particularly late.

• The extent of metaphyseal comminution (the metaphyseal defect), as evidenced

by either plain radiograph or computerized tomography.

• Displacement following closed treatment is a predictor of instability, and repeat

manipulation is unlikely to result in a successful radiographic outcome

4. A 45-year-old driver is involved in a motor vehicle collision and sustains a posterior dislocation of the left hip. What is the most likely concomitant injury? A. Lumbar burst fracture B. Right knee meniscus tear C. Left knee anterior cruciate ligament tear

D. Subdural hematoma

5. A 28-year-old man is about to be discharged from the hospital after a motor vehicle collision in which he sustained a right hip dislocation. Before leaving, he asks to review what positions he can and cannot place his hip. You explain to him that posterior hip precautions prohibit: A. Leg crossing

B. Flexing the hip to greater than 90 degrees C. Twisting the hip inward

D. Hip extension E. A, B, and C

6. A 41-year-old woman sustains a left posterior hip dislocation. After a successful attempt at closed reduction in the emergency room using conscious sedation, what is the next step in management? A. CT scan of the hip and pelvis B. Hip spica cast application C. Further evaluation of hip stability via an exam under anesthesia in theoperating room D. Femoral skeletal traction pin

Anatomic classification

•posterior dislocation (90%)

•occur with axial load on femur, typically with hip flexed and adducted

•axial load through flexed knee (dashboard injury) •position of hip determines associated acetabular injury

•increasing flexion and adduction favors simple dislocation

•associated with

•osteonecrosis

•posterior wall acetabular fracture

•femoral head fractures

•sciatic nerve injuries

•ipsilateral knee injuries (up to 25%) •anterior dislocation

•associated with femoral head impaction or chondral injury

•occurs with the hip in abduction and external rotation

•inferior ("obturator") vs. superior ("pubic")

•hip extension results in a superior (pubic) dislocation

•Clinically hip appears in extension and external rotation

•flexion results in inferior (obturator) dislocation

•Clinically hip appears in flexion, abduction, and external rotation

•Symptoms •acute pain, inability to bear weight, deformity

•Physical exam •ATLS

•95% of dislocations with associated injuries

•posterior dislocation (90%)

•most common

•associated with posterior wall and anterior femoral head fracture

•hip and leg in slight flexion, adduction, and internal rotation •detailed neurovascular exam (10-20% sciatic nerve injury)

•examine knee for associated injury or instability

•chest X-ray ATLS workup for aortic injury

• •anterior dislocation

•hip and leg in extension, abduction, and external rotation

•Radiographs

•recommended views

•AP

•cross-table lateral

•used to differentiate between anterior vs. posterior dislocation

•scrutinize femoral neck to rule out fracture prior to attempting closed reduction

•obtain AP, inlet/outlet, judet views after reduction

•findings

•loss of congruence of femoral head with acetabulum

•disruption of shenton's line

•arc along inferior femoral neck + superior obturator foramen

•anterior dislocation

•femoral head appears larger than contralateral femoral head

•femoral head is medial or inferior to acetabulum

•posterior dislocation

•femoral head appears smaller than contralateral femoral head

•femoral head superimposes roof of acetabulum

•decreased visualization of lesser trochanter due to internal rotation of femur

•CT

•helps to determine direction of dislocation, loose bodies, and associated fractures

•anterior dislocation

•posterior dislocation

•post reduction CT must be performed for all traumatic hip dislocations to look for

•femoral head fractures

•loose bodies

•acetabular fractures

•MRI

•controversial and routine use is not currently supported

•useful to evaluate labrum, cartilage and femoral head vascularity

7. A 42-year-old man complains of right hip pain after being ejected from an allterrain vehicle. He denies neurologic changes or other symptoms. His right leg does not appear to be shortened or externally rotated. Right hip radiographs demonstrate a complete, nondisplaced transcervical fracture. What is the most appropriate treatment for this patient? A. Nonoperative observation with pain control, limited weightbearing, and close follow-up B. Percutaneous pinning

C. Bipolar hemiarthroplasty D. Total hip arthroplasty

8. A 66-year-old avid cross-country skier sustains a displaced femoral neck fracture after a fall down an icy embankment. What is the best treatment option for this patient? A. Bipolar hemiarthroplasty B. Open reduction internal fixation C. Unipolar hemiarthroplasty D. Nonoperative treatment with close follow-up E. Total hip arthroplasty

9. A 72-year-old man sustains a completely displaced, subcapital femoral neck fracture after tripping over a step on a neighbors porch. Awake and lucid in the ED, he is most likely to assume which of the following positions for his fractured extremity? A. Flexion and external rotation B. Extension and external rotation C. Flexion and neutral rotation and flexion D. Extension and neutral rotation E. Flexion and internal rotation

Femoral Neck Fractures

• Pathophysiology healing potential

• femoral neck is intracapsular, bathed in synovial fluid

• lacks periosteal layer

• callus formation limited, which affects healing

Type I: 30 degrees

Type II: 50 degrees

Type III: 70 degrees

Type I: Incomplete/valgus impacted

Type II: Complete and nondisplaced on AP and lateral

views

Type III: Complete with partial displacement; trabecular

pattern of the femoral head does not line up with

that of the acetabulum

Type IV: Completely displaced; trabecular pattern of the

head assumes a parallel orientation with that of

the acetabulum

CLASSIFICATION Anatomic Location

•Subcapital

•Transcervical

•Basicervical

Pauwel

This is based on the angle of fracture from the horizontal

(Increasing shear forces with increasing angle lead to more fracture instability.

Garden

This is based on the degree of valgus displacement

• Symptoms

• impacted and stress fractures

• slight pain in the groin or pain referred along the medial side of

the thigh and knee

• displaced fractures

• pain in the entire hip region

• Physical exam

• impacted and stress fractures

• no obvious clinical deformity

• minor discomfort with active or passive hip range of motion,

muscle spasms at extremes of motion

• pain with percussion over greater trochanter

• displaced fractures

• leg in external rotation and abduction, with shortening

10. A patient with an intertrochanteric hip fracture undergoes open reduction and sliding hip screw application. Postoperative radiographs demonstrate that the lag screw is inferiorly and anteriorly positioned in the femoral head, with a tipapex distance of 44 mm. This patient is at greatest risk for which of the following complications? A. Lag screw cutout B. Lag screw loosening C. Nonunion

D. Periprosthetic fracture E. Lag screw breakage

Sliding hip compression screw •technique

•must obtain correct neck-shaft relationship

•lag screw with tip-apex distance >25 mm is associated with increased failure rates

•4 hole plates show no benefit clinically or biomechanically over 2 hole plates

Intramedullary hip screw (cephalomedullary nail) •indications

•stable fracture patterns

•unstable fracture patterns

•reverse obliquity fractures •56% failure when treated with sliding hip screw

•subtrochanteric extension

•lack of integrity of femoral wall •associated with increased displacement and collapse when treated with sliding hip screw

•increased risk of lateral wall fracture with decreasing lateral wall thickness •outcomes

•equivalent outcomes to sliding hip screw for stable fracture patterns

•use has significantly increased in last decade

11. A 49-year-old woman with no significant past medical history is involved in a motor vehicle accident in which she sustains a reverse obliquity- type intertrochanteric femur fracture. What is the most appropriate treatment for her injury? A. Total hip arthroplasty B. Bipolar hemiarthroplasty C. External fixation D. Sliding hip screw E. Cephalomedullary nail fixation

12. Which of the following most typically represents the patient demographic and scenario in which intertrochanteric femur fractures occur in the United States? A. High-speed motor vehicle ejection accident in a 26-year-old man B. Fall from standing in a 69-year-old woman C. Fall from 3-story balcony in a 56-year-old man D. Soccer-related internal rotation twisting injury in a 19-year-old woman E. Twenty-year-old male pedestrian struck by a vehicle directly over the greater trochanter

1.Type AL

2.Type AG

3.Type BI 4.Type B2 5.Type C

Figure 1 AP radiograph of the left hip demonstrating a periprosthetic femur fracture surrounding a bipolar hemiarthroplasty.

13. An 82-year-old man with a history of a prior left hip fracture treated with a bipolar hemiarthroplasty was in his usual state of health when he sustained another fall onto his left hip. He is neurovascularly intact and complains only of left hip pain. An AP left hip radiograph was taken and is shown in Figure 1. According to the Vancouver classification system, what type of periprosthetic fracture has this patient suffered?

14. A 75-year-old woman who is 2 years removed from a right total hip arthroplasty sustains a fall and a nondisplaced greater trochanter fracture. The femoral stem appears stable on both anteroposterior and lateral radiographs of the hip and femur. Which of the following is the most appropriate treatment?

A. Open reduction and internal fixation of the fracture using a greater trochanter plate and cables B. Resume all activities as tolerated, with no restrictions C. Weightbearing as tolerated, but with no passive adduction past midline and no active abduction of the lower extremity

D. Nonweightbearing to the right lower extremity

15. A 79-year-old woman undergoes successful treatment of a Vancouver B2 periprosthetic femur fracture with a long porous-coated cementless stem, cables, and a cortical strut allograft. Which of the following complications is she at an increased risk for as compared with those patients who have undergone primary total hip arthroplasty? A. Infection B. Dislocation C. Deep vein thrombosis D. A and B E. A, B, and C

16. A 22-year-old basketball player feels a painful "pop" in his knee when landing from a rebound. Immediate swelling, pain, and inability to extend his knee ensue. Radiographs depict patella alta. Treatment should include: A. Long leg casting in extension B. Application of a knee immobilizer followed by a slow return to play C. Primary patella tendon repair D. Intraarticular corticosteroid injection

17. Which of the following structures is not part of the knee's extensor mechanism? A. Quadriceps tendon B. Patella tendon C. Biceps femoris D. Tibial tubercle

18. A 55-year-old male slips on a patch of ice and falls on a hyperflexed knee. He reports hearing a "pop" during the fall and was unable to bear weight on the knee immediately after the injury. He has a large knee effusion on examination and is unable to perform a straight leg raise. You appreciate his patella baja on radiographic examination and an Insall-Salvati ratio of 0.7. What is the likely diagnosis? A. Patellar dislocation B. Quadriceps tendon rupture C. Patellar tendon rupture D. Anterior cruciate ligament (ACL) tear

19. A 24-year-old construction worker falls 8 feet and presents to the emergency department with complaints of left wrist and knee pain. He reports landing on his left leg first, with his knee buckling inward. Given this patient's age and mechanism, which of the following best describes his risk for injury?

1. A. Increased chance of lateral plateau injury, increased chance of pure depression fracture, and increased chance of ligamentous and/or meniscal damage B. Increased chance of medial plateau injury, increased chance of pure depression fracture, and increased chance of ligamentous damage C. Increased chance of lateral plateau injury, increased chance of split fracture, and increased chance of ligamentous damage D. Increased chance of medial plateau injury, increased chance of split fracture, and increased chance of ligamentous damage E. Increased chance of lateral plateau injury, increased chance of split fracture, and decreased chance of ligamentous damage

20. A 55-year-old taxation lawyer with no significant past medical history is involved in a head-on motor vehicle collision at approximately 45 miles an hour and suffers the injury shown in Figure 2. He has palpable pulses distally and is neurovascularly intact. Aside from abrasions and a concussion, he has no other significant injuries. He exhibits only mild swelling at the knee. Which of the following is the best treatment for his injury?

A. Brace immobilization with early weightbearing B. External fixation for 8 to 12 weeks, early weightbearing with fixator, active range-of-motion knee exercises C. Closed reduction and casting, nonweightbearing for 8 to 12 weeks D. Open reduction, internal fixation with screws and/or plates, non- weightbearing for 8 to 12 weeks E. Functional bracing with gradual weightbearing and active range-of-motion knee exercises

21. A 44-year-old woman is involved in a high-speed motor accident and suffers a right-sided tibial plateau fracture. She is neurovascularly intact, and her compartments are soft. She has no other significant injuries, except for a minor concussion and several broken ribs. Which of the following, if present, is an indication for operative fixation? A. Articular step-off 5 mm B. Lateral meniscal tear on follow-up MRI C. ACL tear on follow-up MRI D. Condylar widening < 3 mm E. Ipsilateral ankle fracture

22. A 42-year-old man is brought to the trauma center after a 6-foot fall off a ladder. Physical exam shows a slightly deformed left lower extremity with a 0.5-cm soft tissue defect over the anterolateral aspect of his leg. The wound appears relatively clean with no gross contaminants present. Radiographs depict a short oblique proximal one-third diaphyseal tibia fracture. What is his Gustilo open fracture classification grade? A. I B. II C. III a D. III b E. V

23. What antibiotic should the patient in question 22 receive? A. Vancomycin B. Penicillin C. Levaquin

D. Cefazolin E. Cephalexin

24. A 70-year-old woman is brought to the trauma center with a significantly deformed right lower extremity with a 4-cm wound over the posteromedial portion of her leg. She is found to have a Gustilo and Anderson type 3A fracture. Which of the following interventions has been shown to decrease the risk of infection at the fracture site? A. Irigating with high-pressure pulsatile lavage B. Immediate prophylactic antibiotic administration C. Application of a wound VAC of the soft tissue defect in the ED D. Operative debridement within 6 to 8 hours of injury

25. A proximal humerus fracture has the following morphology. There is 1.5 - cm displacement at

the surgical neck and fracture lines involving both the greater and lesser tuberosities, but without

displacement. According to the Neer classification, what would this fracture be classified as?

A. One pat

B. Two part

C. Three part

D. Four part

E. None of the above

Neer classification •based on anatomic relationship of 4 segments

•greater tuberosity

•lesser tuberosity

•articular surface

•shaft

•considered a separate part if

•displacement of > 1 cm

•45° angulation