Musculoskeletal Trauma Scored and
Recorded Self-Assessment Examination 2020
,Question 1 of 100
Figure 1 is the radiograph of a 40-year-old man who had a 15-foot fall and now has foot pain. Medical
history is significant for diabetes and smoking two packs a day. You determine that a sinus tarsi
approach is necessary for surgical reconstruction. During the approach what structure is most at risk?
A. Peroneal tendons
B. Sural nerve
C. Superficial peroneal nerve
D. Abductor digiti quinti
R: A
The radiograph depicts an intra-articular displaced calcaneus fracture. The sinus tarsi approach uses an
incision 1 cm distal to the tip of the lateral malleolus and 2-3 cm distal along the lateral foot. The peroneal
tendons must be mobilized and retracted to visualize the anterolateral process, critical angle of Gissane, and
the posterior facet. The sural nerve is 1 cm posterior to the fibula and runs toward the base of the fifth
metatarsal. This structure would be remote from the incision unless a more posterior incision is used. The
superficial peroneal nerve is anterior and not involved with the approach. The abductor digiti quinti is plantar
to this incision and would not be encountered.
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?
A. Three cannulated screws
B. Long intramedullary nail
C. Sliding hip screw
D. Short intramedullary nail
,R: C
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.
Question 3 of 100
A 26-year-old man is involved in a high-speed motorcycle accident. He sustains a grade IIIB open tibia
fracture. Examination reveals a large soft-tissue defect and an insensate foot. What is the expected
outcome in this scenario?
A. Equal functional outcome when limb salvage is compared with amputation
B. Worse functional outcome with limb salvage than with primary amputation
C. Better functional outcome when amputation is compared with limb salvage
D. Permanent loss of plantar sensation
R: A
The Lower Extremity Assessment Project data have shown that absent plantar sensation is not an indication
for primary amputation. When looking at a comparison between an insensate salvage group and a sensate
salvage group at 2 years follow-up, both groups had an equal proportion (55%) of normal plantar sensation
and more importantly, functionally both groups were equivalent. Absent plantar sensation at initial evaluation
is not prognostic for long-term plantar sensory status or functional outcome.
Question 4 of 100
Figure 1 is the radiograph of a 36-year-old male bicyclist who was struck by a car. After reduction,
what should be the next step in the evaluation?
A. Ankle brachial index (ABI)
B. Venous duplex ultrasonography
C. CT scan without contrast
D. Angiogram of the lower extremity
R: A
, Knee dislocations have a high rate of vascular injuries (15% to 40%). All patients presenting with knee
dislocations should be urgently reduced. Use of ABI (range 0.9-1.1) will allow identification of patients with
subtle vascular injury. This can also be used as a screening tool for further workup including angiography.
Question 5 of 100
Two femoral shaft fractures are shown in Figure 1. Each is fixed identically with the same
intramedullary nail and interlocking screws. The fracture gap strain is higher in
A. A.
B. B.
C. neither; the strain is identical in A and B.
D. neither; the strain is dependent on femur length.
R: A
Fracture gap strain is defined as deformation of granulation tissue within the fracture gap when a given force
is applied. Normal strain is the change in length (Δ l) divided by the original length (l) when a given load is
applied. The amount of deformation that a tissue can tolerate while functioning varies greatly. Intact bone has
a normal strain tolerance of 2% (before it fractures), whereas granulation tissue has a strain tolerance of 100%.
Bony bridging between the distal and proximal callus can only occur when local strain (ie, deformation) is
less severe than the forming bone can tolerate. Therefore, treatment of fractures must optimize the strain
environment to enable healing.
Comminution, as shown in B, results in distribution of the motion between multiple fracture fragments. As a
result, each fracture gap experiences less motion and strain is decreased. In simple fracture patterns as shown
in A, small amounts of motion or even a small fracture gap results in a high-strain environment. Strain is
dependent upon the length of the fracture gap but not on the length of the bone.
Question 6 of 100
A 31-year-old man sustained an unstable closed left posterior hip dislocation in a motorcycle accident.
A postreduction radiograph is shown in Figure 1. 3-D CT scans are shown in Figures 2 and 3. What is
the optimal surgical approach that will allow for the most appropriate treatment?
A. Surgical dislocation
B. Watson-Jones approach
C. Smith-Peterson approach
Recorded Self-Assessment Examination 2020
,Question 1 of 100
Figure 1 is the radiograph of a 40-year-old man who had a 15-foot fall and now has foot pain. Medical
history is significant for diabetes and smoking two packs a day. You determine that a sinus tarsi
approach is necessary for surgical reconstruction. During the approach what structure is most at risk?
A. Peroneal tendons
B. Sural nerve
C. Superficial peroneal nerve
D. Abductor digiti quinti
R: A
The radiograph depicts an intra-articular displaced calcaneus fracture. The sinus tarsi approach uses an
incision 1 cm distal to the tip of the lateral malleolus and 2-3 cm distal along the lateral foot. The peroneal
tendons must be mobilized and retracted to visualize the anterolateral process, critical angle of Gissane, and
the posterior facet. The sural nerve is 1 cm posterior to the fibula and runs toward the base of the fifth
metatarsal. This structure would be remote from the incision unless a more posterior incision is used. The
superficial peroneal nerve is anterior and not involved with the approach. The abductor digiti quinti is plantar
to this incision and would not be encountered.
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?
A. Three cannulated screws
B. Long intramedullary nail
C. Sliding hip screw
D. Short intramedullary nail
,R: C
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.
Question 3 of 100
A 26-year-old man is involved in a high-speed motorcycle accident. He sustains a grade IIIB open tibia
fracture. Examination reveals a large soft-tissue defect and an insensate foot. What is the expected
outcome in this scenario?
A. Equal functional outcome when limb salvage is compared with amputation
B. Worse functional outcome with limb salvage than with primary amputation
C. Better functional outcome when amputation is compared with limb salvage
D. Permanent loss of plantar sensation
R: A
The Lower Extremity Assessment Project data have shown that absent plantar sensation is not an indication
for primary amputation. When looking at a comparison between an insensate salvage group and a sensate
salvage group at 2 years follow-up, both groups had an equal proportion (55%) of normal plantar sensation
and more importantly, functionally both groups were equivalent. Absent plantar sensation at initial evaluation
is not prognostic for long-term plantar sensory status or functional outcome.
Question 4 of 100
Figure 1 is the radiograph of a 36-year-old male bicyclist who was struck by a car. After reduction,
what should be the next step in the evaluation?
A. Ankle brachial index (ABI)
B. Venous duplex ultrasonography
C. CT scan without contrast
D. Angiogram of the lower extremity
R: A
, Knee dislocations have a high rate of vascular injuries (15% to 40%). All patients presenting with knee
dislocations should be urgently reduced. Use of ABI (range 0.9-1.1) will allow identification of patients with
subtle vascular injury. This can also be used as a screening tool for further workup including angiography.
Question 5 of 100
Two femoral shaft fractures are shown in Figure 1. Each is fixed identically with the same
intramedullary nail and interlocking screws. The fracture gap strain is higher in
A. A.
B. B.
C. neither; the strain is identical in A and B.
D. neither; the strain is dependent on femur length.
R: A
Fracture gap strain is defined as deformation of granulation tissue within the fracture gap when a given force
is applied. Normal strain is the change in length (Δ l) divided by the original length (l) when a given load is
applied. The amount of deformation that a tissue can tolerate while functioning varies greatly. Intact bone has
a normal strain tolerance of 2% (before it fractures), whereas granulation tissue has a strain tolerance of 100%.
Bony bridging between the distal and proximal callus can only occur when local strain (ie, deformation) is
less severe than the forming bone can tolerate. Therefore, treatment of fractures must optimize the strain
environment to enable healing.
Comminution, as shown in B, results in distribution of the motion between multiple fracture fragments. As a
result, each fracture gap experiences less motion and strain is decreased. In simple fracture patterns as shown
in A, small amounts of motion or even a small fracture gap results in a high-strain environment. Strain is
dependent upon the length of the fracture gap but not on the length of the bone.
Question 6 of 100
A 31-year-old man sustained an unstable closed left posterior hip dislocation in a motorcycle accident.
A postreduction radiograph is shown in Figure 1. 3-D CT scans are shown in Figures 2 and 3. What is
the optimal surgical approach that will allow for the most appropriate treatment?
A. Surgical dislocation
B. Watson-Jones approach
C. Smith-Peterson approach
