2012 Musculoskeletal Trauma Self-Assessment Examination by Dr.Dhahirortho
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,2012 Musculoskeletal Trauma Self-Assessment Examination by Dr.Dhahirortho
Q. 1Figure 1 is the radiograph of a 62-year-old woman who fell and sustained a left
hip fracture. A radiographis shown in Figure 1. Which of the following preoperative
risk factors is associated with the highest postoperative mortality rate?
1. Fracture pattern
2. Chronic renal failure
3. Female gender
4. Coronary artery disease
5. Diabetes mellitus
DISCUSSION: In the study by Bhattacharyya and associates in 2002, they retrospectively
reviewed over 43,000 in-patient orthopaedic procedures to identify preoperative risk
factors associated with postoperative mortality. Their study identified five “critical” risk
factors placing patients at increased risk for death. These included chronic renal failure,
congestive heart failure, chronic obstructive pulmonary disease, hip fracture, and age of
older than 70 years. Their study also demonstrated a linear increase in mortality observed
with the increased number of risk factors. The risk factors of diabetes, gender, fracture
pattern, coronary artery disease, peripheral vascular disease, septic arthritis, and
rheumatoid arthritis did not achieve significance. Identification of patients with risk factors
for mortality is important for individualizing treatment plans, accurate prognosis, and
informed consent.
PREFE RESPONSE: 2
2.A 37-year-old man fell from 24 feet and sustained a subarachnoid hemorrhage and
closed femoral shaft fracture. What is most likely to lead to an adverse outcome?
1. Intraoperative hypotension
2. Temporizing external fixation
3. Elevated cerebral perfusion pressure
4. Immediate reamed intramedullary nailing
5. Skeletal traction with intramedullary nailing in 72 hours
DISCUSSION: In patients with femoral fractures and associated closed head injuries, there
have been conflicting studies regarding timing of fracture care and eventual neurologic
outcome. It is known that an episode of hypotension and elevated intracranial pressure will
lower the cerebral perfusion pressure, which is known to be detrimental to the neurologic
outcome. Intraoperative hypoxia may also worsen the neurologic outcome and increased
fluid administration may elevate the intracranial pressure. If early fracture fixation is
necessary, the intracranial pressure should be monitored and the cerebral perfusion
pressure maintained during the procedure. Immediate reamed intramedullary nailing is
appropriate if the patient is hemodynamically stable and the cerebral perfusion pressure is
maintained. If not, external fixation would be appropriate treatment. Temporary skeletal
traction may be appropriate if the intracranial pressure is labile and precludes the patient
from going to the operating room.
PREFERRED RESPONSE: 1
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,2012 Musculoskeletal Trauma Self-Assessment Examination by Dr.Dhahirortho
Question 3Figure 3a Figure 3b Figure 3c Figure 3a is the initial radiograph of a 19-
year-old man who sustained a closed clavicle fracture. Figures 3b and 3c show
postoperative radiographs. If the patient had been treated nonsurgically, which of
the following would most likely occur?
1. Normal shoulder strength and function
2. Local sensory deficits
3. Fracture union
4. Infection
5. Malunion
DISCUSSION: Recent studies comparing surgical treatment with nonsurgical management
in displaced clavicle fractures have revealed a decreased rate of malunion and nonunion
with surgery. In addition,significant malunions can lead to functional deficits at the
shoulder. Thus, with open reduction and internal fixation and anatomic or near-anatomic
reduction, there should be a higher likelihood of
normal shoulder strength and function. Infection and local sensory deficits would not be
expected with nonsurgical management, whereas surgical treatment has a small risk of
infection and a high likelihood of sensory deficits from iatrogenic damage to the
supraclavicular nerves.PREFERRED RESPONSE: 5
Question 4-What is the most common anatomic location of the lateral femoral
cutaneous nerve?
1. Deep to the psoas muscle
2. Medial to the femoral vein
3. Under the inguinal ligament
4. Adjacent to the femoral nerve
5. Deep to the iliopectineal fascia
DISCUSSION: The lateral femoral cutaneous nerve most commonly originates from the
lumbar plexus and runs on the surface of the iliacus muscle and enters the thigh by
passing under the inguinal ligament before piercing the fascia lata. Its path can be
variable. PREFERRED RESPONSE: 3
5.Figures 5a and 5b are the radiographs of a 24-year-old obese woman who
sustained a knee dislocation in a fall. Postreduction radiographs and an angiogram
are shown in Figures 5c through 5e. Examination reveals a cold foot with no pedal
pulses. After vascular repair and four-compartment fasciotomy is performed by a
vascular surgeon, and while the patient is still in the operating room, you are
contacted and asked to evaluate the patient. The knee is grossly unstable. What is
the most appropriate initial
orthopaedic management?
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, 2012 Musculoskeletal Trauma Self-Assessment Examination by Dr.Dhahirortho
1. Spanning external fixation of the knee
2. Open lateral collateral ligament repair and delayed anterior cruciate
ligament/posterior cruciate ligament/medial collateral ligament reconstruction
3. Application of a cylinder cast
4. Arthroscopic anterior cruciate ligament/posterior cruciate ligament reconstruction and
open lateral cruciate ligament/medial cruciate ligament repair
5. Diagnostic knee arthroscopy
DISCUSSION: Knee dislocations are known to have a high risk for vascular injury.
Although the specific treatment of various combinations of ligamentous injuries is
controversial, the need for emergent revascularization is not. In this particular patient, after
vascular repair, the most important initial concern is protection of the vascular repair. A
spanning external fixator, especially in this patient with gross instability, will allow for easier
assessment of vascular status, evaluation of fasciotomy wounds,
and temporary stability of the knee. A cylinder cast can stabilize the knee but will not allow
wound assessment or room for inevitable post-injury/postoperative swelling. Diagnostic
knee arthroscopy is not necessary, and ligamentous repair/reconstruction should be
delayed until the vascular repair is stable. PREFERRED RESPONSE: 1
Question 6 Figures 6a and 6b are the
radiographs of a thin 23-year-old man who
sustained a closed injury to his left arm in a
fall. He has no other injuries and his
neurologic examination is normal. What is
the most appropriate treatment?
1. Intramedullary nailing
2. Hanging arm cast for 6 weeks
3. Shoulder immobilizer for 4 to 6 weeks
4. Open reduction and internal fixation
5. Coaptation splinting with conversion to a
fracture brace
DISCUSSION: The patient is a thin man with
an isolated left humerus fracture. The fracture
has bony apposition and should be amenable
to closed treatment; therefore the most
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,2012 Musculoskeletal Trauma Self-Assessment Examination by Dr.Dhahirortho
Q. 1Figure 1 is the radiograph of a 62-year-old woman who fell and sustained a left
hip fracture. A radiographis shown in Figure 1. Which of the following preoperative
risk factors is associated with the highest postoperative mortality rate?
1. Fracture pattern
2. Chronic renal failure
3. Female gender
4. Coronary artery disease
5. Diabetes mellitus
DISCUSSION: In the study by Bhattacharyya and associates in 2002, they retrospectively
reviewed over 43,000 in-patient orthopaedic procedures to identify preoperative risk
factors associated with postoperative mortality. Their study identified five “critical” risk
factors placing patients at increased risk for death. These included chronic renal failure,
congestive heart failure, chronic obstructive pulmonary disease, hip fracture, and age of
older than 70 years. Their study also demonstrated a linear increase in mortality observed
with the increased number of risk factors. The risk factors of diabetes, gender, fracture
pattern, coronary artery disease, peripheral vascular disease, septic arthritis, and
rheumatoid arthritis did not achieve significance. Identification of patients with risk factors
for mortality is important for individualizing treatment plans, accurate prognosis, and
informed consent.
PREFE RESPONSE: 2
2.A 37-year-old man fell from 24 feet and sustained a subarachnoid hemorrhage and
closed femoral shaft fracture. What is most likely to lead to an adverse outcome?
1. Intraoperative hypotension
2. Temporizing external fixation
3. Elevated cerebral perfusion pressure
4. Immediate reamed intramedullary nailing
5. Skeletal traction with intramedullary nailing in 72 hours
DISCUSSION: In patients with femoral fractures and associated closed head injuries, there
have been conflicting studies regarding timing of fracture care and eventual neurologic
outcome. It is known that an episode of hypotension and elevated intracranial pressure will
lower the cerebral perfusion pressure, which is known to be detrimental to the neurologic
outcome. Intraoperative hypoxia may also worsen the neurologic outcome and increased
fluid administration may elevate the intracranial pressure. If early fracture fixation is
necessary, the intracranial pressure should be monitored and the cerebral perfusion
pressure maintained during the procedure. Immediate reamed intramedullary nailing is
appropriate if the patient is hemodynamically stable and the cerebral perfusion pressure is
maintained. If not, external fixation would be appropriate treatment. Temporary skeletal
traction may be appropriate if the intracranial pressure is labile and precludes the patient
from going to the operating room.
PREFERRED RESPONSE: 1
2
2
,2012 Musculoskeletal Trauma Self-Assessment Examination by Dr.Dhahirortho
Question 3Figure 3a Figure 3b Figure 3c Figure 3a is the initial radiograph of a 19-
year-old man who sustained a closed clavicle fracture. Figures 3b and 3c show
postoperative radiographs. If the patient had been treated nonsurgically, which of
the following would most likely occur?
1. Normal shoulder strength and function
2. Local sensory deficits
3. Fracture union
4. Infection
5. Malunion
DISCUSSION: Recent studies comparing surgical treatment with nonsurgical management
in displaced clavicle fractures have revealed a decreased rate of malunion and nonunion
with surgery. In addition,significant malunions can lead to functional deficits at the
shoulder. Thus, with open reduction and internal fixation and anatomic or near-anatomic
reduction, there should be a higher likelihood of
normal shoulder strength and function. Infection and local sensory deficits would not be
expected with nonsurgical management, whereas surgical treatment has a small risk of
infection and a high likelihood of sensory deficits from iatrogenic damage to the
supraclavicular nerves.PREFERRED RESPONSE: 5
Question 4-What is the most common anatomic location of the lateral femoral
cutaneous nerve?
1. Deep to the psoas muscle
2. Medial to the femoral vein
3. Under the inguinal ligament
4. Adjacent to the femoral nerve
5. Deep to the iliopectineal fascia
DISCUSSION: The lateral femoral cutaneous nerve most commonly originates from the
lumbar plexus and runs on the surface of the iliacus muscle and enters the thigh by
passing under the inguinal ligament before piercing the fascia lata. Its path can be
variable. PREFERRED RESPONSE: 3
5.Figures 5a and 5b are the radiographs of a 24-year-old obese woman who
sustained a knee dislocation in a fall. Postreduction radiographs and an angiogram
are shown in Figures 5c through 5e. Examination reveals a cold foot with no pedal
pulses. After vascular repair and four-compartment fasciotomy is performed by a
vascular surgeon, and while the patient is still in the operating room, you are
contacted and asked to evaluate the patient. The knee is grossly unstable. What is
the most appropriate initial
orthopaedic management?
3
3
, 2012 Musculoskeletal Trauma Self-Assessment Examination by Dr.Dhahirortho
1. Spanning external fixation of the knee
2. Open lateral collateral ligament repair and delayed anterior cruciate
ligament/posterior cruciate ligament/medial collateral ligament reconstruction
3. Application of a cylinder cast
4. Arthroscopic anterior cruciate ligament/posterior cruciate ligament reconstruction and
open lateral cruciate ligament/medial cruciate ligament repair
5. Diagnostic knee arthroscopy
DISCUSSION: Knee dislocations are known to have a high risk for vascular injury.
Although the specific treatment of various combinations of ligamentous injuries is
controversial, the need for emergent revascularization is not. In this particular patient, after
vascular repair, the most important initial concern is protection of the vascular repair. A
spanning external fixator, especially in this patient with gross instability, will allow for easier
assessment of vascular status, evaluation of fasciotomy wounds,
and temporary stability of the knee. A cylinder cast can stabilize the knee but will not allow
wound assessment or room for inevitable post-injury/postoperative swelling. Diagnostic
knee arthroscopy is not necessary, and ligamentous repair/reconstruction should be
delayed until the vascular repair is stable. PREFERRED RESPONSE: 1
Question 6 Figures 6a and 6b are the
radiographs of a thin 23-year-old man who
sustained a closed injury to his left arm in a
fall. He has no other injuries and his
neurologic examination is normal. What is
the most appropriate treatment?
1. Intramedullary nailing
2. Hanging arm cast for 6 weeks
3. Shoulder immobilizer for 4 to 6 weeks
4. Open reduction and internal fixation
5. Coaptation splinting with conversion to a
fracture brace
DISCUSSION: The patient is a thin man with
an isolated left humerus fracture. The fracture
has bony apposition and should be amenable
to closed treatment; therefore the most
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