OT-UNHAS-MH
1
, OT-UNHAS-MH
Question 1 of 100
A 36-year-old man has right shoulder pain after a fall from a bicycle. What is the most
likely complication of nonsurgical treatment of the injury shown in Figure 1?
1. Nonunion
2. Symptomatic malunion
3. Skin breakdown
4. Acromioclavicular joint arthrosis
Discussion
The patient has a Neer type II distal clavicle fracture with radiographic evidence of coracoclavicular
ligament disruption. With non-surgical treatment, the most commonly reported complication is
nonunion, with rates reported to be as high as 44%. However, many patients with distal clavicular
nonunion remain asymptomatic. Symptomatic malunion and skin breakdown over the fracture site
are certainly possible, but are less common than nonunion. Because the fracture does not extend
into the acromioclavicular joint, post-traumatic arthrosis would not be expected.
➔ 1. Nonunion
Question 2 of 100
A 99-year-old woman sustains the injury shown in Figure 1 after falling from a standing
position. What is the most cost-effective treatment?
1. Three cannulated screws
2. Long intramedullary nail
3. Sliding hip screw
4. Short intramedullary nail
2
, OT-UNHAS-MH
Discussion
Intertrochanteric hip fractures remain a common injury that orthopaedic surgeons manage. The
optimal form of surgical stabilization for these injuries has been a topic of debate over the years.
Recent studies have demonstrated equivalent outcomes between the use of sliding hip screws and
intramedullary nails for stable fracture patterns. Recent guidelines have suggested that the use of
sliding hip screws for stable fracture patterns can have a significant reduction in cost per case.
➔ 3 Sliding hip screw
Question 3 of 100
CLINICAL SITUATION
Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain
in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision.
On examination, she has well-healed scars and a well-healed flap on the medial aspect at
the level of the fracture. She reports having an infection after the initial surgery, which
resulted in debridement of the soft tissue and need for the local rotational flap. There are
no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is
healthy and has no comorbidities.
What is the best next step in the patient’s evaluation?
1. Complete metabolic workup
2. Advanced imaging with a CT scan
3. Laboratory studies for CBC, ESR and CRP
4. Nuclear medicine studi
Discussion
The patient had an open fracture that was initially treated with what appears to be appropriate
irrigation and debridement and intramedullary nail placement. The post-operative infection and
need for rotational flap is worrisome, but she has not had any issues since the flap. She has
abundant callus formation but the fracture line is still visible and unchanged on 2 sets of
radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no
underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable
utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated.
A CT scan is not warranted because the sequential radiographs show persistent fracture lines and
no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment
and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone
3
, OT-UNHAS-MH
grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs
more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing.
Based on successive radiographs and the lack of healing, observation is probably just delaying the
inevitable. Plating with retention of the nail can be useful in recalcitrant long bone nonunions,
especially in the femur.
➔ 3. Laboratory studies for CBC, ESR and CRP
Question 4 of 100
CLINICAL SITUATION
Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain
in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision.
On examination, she has well-healed scars and a well-healed flap on the medial aspect at
the level of the fracture. She reports having an infection after the initial surgery, which
resulted in debridement of the soft tissue and need for the local rotational flap. There are
no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is
healthy and has no comorbidities.
Based on the radiographs shown in Figures 1 and 2, her tibia is a
1. pseudarthrosis.
2. hypertrophic nonunion.
3. healed fracture.
4. atrophic nonunion.
Discussion
The patient had an open fracture that was initially treated with what appears to be appropriate
irrigation and debridement and intramedullary nail placement. The post-operative infection and
need for rotational flap is worrisome, but she has not had any issues since the flap. She has
abundant callus formation but the fracture line is still visible and unchanged on 2 sets of
radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no
underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable
utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated.
A CT scan is not warranted because the sequential radiographs show persistent fracture lines and
no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment
and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone
grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs
more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing.
Based on successive radiographs and the lack of healing, observation is probably just delaying the
4
1
, OT-UNHAS-MH
Question 1 of 100
A 36-year-old man has right shoulder pain after a fall from a bicycle. What is the most
likely complication of nonsurgical treatment of the injury shown in Figure 1?
1. Nonunion
2. Symptomatic malunion
3. Skin breakdown
4. Acromioclavicular joint arthrosis
Discussion
The patient has a Neer type II distal clavicle fracture with radiographic evidence of coracoclavicular
ligament disruption. With non-surgical treatment, the most commonly reported complication is
nonunion, with rates reported to be as high as 44%. However, many patients with distal clavicular
nonunion remain asymptomatic. Symptomatic malunion and skin breakdown over the fracture site
are certainly possible, but are less common than nonunion. Because the fracture does not extend
into the acromioclavicular joint, post-traumatic arthrosis would not be expected.
➔ 1. Nonunion
Question 2 of 100
A 99-year-old woman sustains the injury shown in Figure 1 after falling from a standing
position. What is the most cost-effective treatment?
1. Three cannulated screws
2. Long intramedullary nail
3. Sliding hip screw
4. Short intramedullary nail
2
, OT-UNHAS-MH
Discussion
Intertrochanteric hip fractures remain a common injury that orthopaedic surgeons manage. The
optimal form of surgical stabilization for these injuries has been a topic of debate over the years.
Recent studies have demonstrated equivalent outcomes between the use of sliding hip screws and
intramedullary nails for stable fracture patterns. Recent guidelines have suggested that the use of
sliding hip screws for stable fracture patterns can have a significant reduction in cost per case.
➔ 3 Sliding hip screw
Question 3 of 100
CLINICAL SITUATION
Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain
in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision.
On examination, she has well-healed scars and a well-healed flap on the medial aspect at
the level of the fracture. She reports having an infection after the initial surgery, which
resulted in debridement of the soft tissue and need for the local rotational flap. There are
no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is
healthy and has no comorbidities.
What is the best next step in the patient’s evaluation?
1. Complete metabolic workup
2. Advanced imaging with a CT scan
3. Laboratory studies for CBC, ESR and CRP
4. Nuclear medicine studi
Discussion
The patient had an open fracture that was initially treated with what appears to be appropriate
irrigation and debridement and intramedullary nail placement. The post-operative infection and
need for rotational flap is worrisome, but she has not had any issues since the flap. She has
abundant callus formation but the fracture line is still visible and unchanged on 2 sets of
radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no
underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable
utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated.
A CT scan is not warranted because the sequential radiographs show persistent fracture lines and
no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment
and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone
3
, OT-UNHAS-MH
grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs
more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing.
Based on successive radiographs and the lack of healing, observation is probably just delaying the
inevitable. Plating with retention of the nail can be useful in recalcitrant long bone nonunions,
especially in the femur.
➔ 3. Laboratory studies for CBC, ESR and CRP
Question 4 of 100
CLINICAL SITUATION
Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain
in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision.
On examination, she has well-healed scars and a well-healed flap on the medial aspect at
the level of the fracture. She reports having an infection after the initial surgery, which
resulted in debridement of the soft tissue and need for the local rotational flap. There are
no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is
healthy and has no comorbidities.
Based on the radiographs shown in Figures 1 and 2, her tibia is a
1. pseudarthrosis.
2. hypertrophic nonunion.
3. healed fracture.
4. atrophic nonunion.
Discussion
The patient had an open fracture that was initially treated with what appears to be appropriate
irrigation and debridement and intramedullary nail placement. The post-operative infection and
need for rotational flap is worrisome, but she has not had any issues since the flap. She has
abundant callus formation but the fracture line is still visible and unchanged on 2 sets of
radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no
underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable
utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated.
A CT scan is not warranted because the sequential radiographs show persistent fracture lines and
no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment
and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone
grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs
more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing.
Based on successive radiographs and the lack of healing, observation is probably just delaying the
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