OITE Review

1. OITE Review Selected by Waleed Awwad, MD, FRCSC

2. 1997

3. Year:1997 Question # 7 Figure 2 shows the lateral radiograph of the left hindfoot and ankle of a patient who fell 10 feet and landed on his left foot. The most predictable advantage of open reduction and internal fixation compared with closed management without reduction is a. an earlier return to function. b. decreased subtalar range arthrosis. c. increased ankle dorsiflexion. d. increased subtalar range of motion. e. restoration of height and width of the heel.

5. Correct Answer:e Explanation: Remember, when the calcaneus fractures it loses height, widens, shortens, and falls into varus. None of the first four answers are very "predictable" and that`s what they ask for. In butress plating, you can restore much of the height and width

6. Year:1997 Question # 10 What is the most appropriate biomechanical fixation method/device for a reverse oblique intertrochanteric fracture? a. Ender pins b. Sliding hip screw c. 95-degree fixed angle device d. Cerclage wire with interfragmentary fixation e. Medial displacement osteotomy with sliding hip screw

7. Correct Answer:c Too proximal for Enders. The fracture line would be parallel to a DHS screw; so that would be bad AO fundamentals. Cerlage wiring and interfrags is a pretty weak construct. Medial displacementosteotomies (Fig.18-31 attached) are done mainly for intertrochs where the Gr. Troch is fractured off or where there is no posteromedial bone (calcar) continuity. There is, however, a "notching" that can be done to make a reverse intertroch more stable. (Fig. 18-25 attached)

8. Year:1997 Question Figure 5a shows the radiograph of a 22-year-old man 3 years after undergoing reduction and fixation for a fracture of the radius and ulna with two plates secured with 4.5 mm screws. A postoperative radiograph after the plate removal is shown in Figure 5b. Which of the following factors increases the risk of re-fracture? a. Young age b. Incomplete healing c. Use of a large plate d. Bony overgrowth around the plate e. Insufficient amount of time between fracture and plate removal

10. Correct Answer:c Young age would decrease the risk (not #1). There`s no evidence of incomplete healing (npt #2). They used 4.5 mm screws where a 3.5 mm would have been adequate. Bony overgrowth is evident and could potentially be a stress riser, but not nearly as much as those empty 4.5 mm screw holes (not #4). 3 years is plenty of time before plate removal can be done (not #5).

11. Year:1997 Question # 28 Figures 7a and 7b show the wound and radiograph of a 44-year-old man who underwent plating for a closed fracture of his tibia 7 months ago. The wound has been draining for 4 months, and cultures are positive for Staphylococcus aureus. In addition to antibiotics, metal removed, and debridement, treatment should include a. electrical stimulation and casting. b. soft-tissue coverage and re-plating with a bone graft. c. bone grafting, soft-tissue coverage, and application of a cast. d. external fixation, staged soft-tissue coverage, and bone grafting. e. intramedullary rodding, staged soft-tissue coverage, and bone grafting.

13. Correct Answer:d Osteomyelitis, or inflammation of the bone, can result from hematogenous seeding, from direct inoculation (ie, following open fractures or following open reduction and internal fixation of fractures), or from the contiguous spread of bacteria from infected structures. Early diagnosis and effective surgical and antibiotic management can control the infection; suppression of its activity may last a lifetime. Basic treatment should include thorough debridement, irrigation, wound management (external fixation, staged soft-tissue coverage), and bone grafting.

14. Year:1997 Question # 32 Figures 10a and 10b show radiographs of a 27 year-old woman who sustained an injury to her left, nondominant forearm as a result of a motor vehicle accident. Under anesthesia, it is noted that the distal radioulnar joint is unstable but reducible in supination. Treatment should include a. closed reduction, followed by splint immobilization with the limb in supination. b. closed reduction and external fixation of the radius, followed by splint immobilization with the limb in supination. c. open reduction and external fixation of the radius, with fixation of the radioulnar joint. d. open reduction and internal plate fixation of the radius, with fixation of the distal radioulnar joint. e. open reduction and internal plate fixation of the radius, with immobilization of the distal radioulnar joint in supination.

16. Correct Answer:e The Galeazzi eponym, originally defined as fracture of the distal third of the radial shaft with an associated dislocation of the distal radioulnar joint (DRUJ), has been applied when referring to a fracture anywhere along the radial shaft as well as to fractures to both radius and ulna that occur in conjunction with a DRUJ injury. Monteggia and Galeazzi lesions require anatomic reduction of the diaphyseal fracture component in order to restore the normal axial interrelationship of the forearm bones and allow reduction of the dislocation. Fracture fixation is accompanied best by plating. Residual instability of a reduced DRUJ after anatomic plating of the radius can usually be addressed by immobilizing the limb in supination for 6 weeks postoperatively. Temporary pin fixation of the DRUJ is rarely required. Cast immobilization after surgical treatment of closed, unstable single bone forearm injuries has not been shown to have any detrimental effect on functional outcome.

17. Year:1997 Question # 37 The incidence of vascular injury after an anterior knee dislocation is a. less than 5%. b. 10% to 25%. c. 30% to 50%. d. 60% to 80% e. greater than 95%.

18. Correct Answer:c Knee dislocation are classified relative to the position of the tibia, and there are five types. Anterior knee dislocation occur most frequently (40%), followed by posterior (33%), lateral (18%), and other (5%). The incidence of vascular injury after an anterior or posterior knee dislocation has been reported to be 20% - 35%. (Most studies quote 30%). Neurologic injuries most frequently involve the common peroneal nerve nerve because of its tethered proximity to the fibular head. Lateral and posterolateral dislocations are the most frequent causes of common peroneal nerve injury. Overall, incidence of neurologic injuries varies between 16% and 40%. Less than 50% of patients will have partial or complete recovery from a peroneal nerve.

19. Year:1997 Question # 40 A 45-year-old man sustains an injury to his pelvic ring as a result of a motor vehicle accident. Radiographs are shown in Figures 11a through 11c, and a CT scan is shown in Figure 11d. Examination reveals that he is hemodynamically stable and has no associated injuries. Management should include a. anterior sacroiliac plate fixation. b. anterior fixation of the pubic symphysis. c. posterior fixation of the left sacroiliac joint. d. early mobilization and weight bearing without internal fixation. e. combined anterior fixation to the pubic symphysis and posterior fixation of the left sacroiliac joint.

21. Correct Answer:b Disruptions of the symphysis pubis are variable. The symphyseal ligaments, the pubic meniscus, and the arcuate ligament may be disrupted. For isolated disruptions of the symphysis pubis, most authors advocate closed, nonsurgical management, especially when the symphysis diastasis is less than 2.5 cm. In cases where the diastasis exceeds this limit, stabilization should be pursued.

22. Year:1997 Question # 41 Radiographs of a 24-year-old man who sustained an open tibial frature 11 months ago are shown in Figures 12a and 12b. Examination shows an anteromedial draining wound over the midtibia. Which of the following methods will most accurately identify the pathologic microorganisms? a. Swab culture of the sinus tract b. Operative sampling of the sinus tract c. Operative sampling of the posterolateral sequestrum d. Operative sampling of deep specimens from multiple foci e. Needle aspiration of the distal tibial metaphyseal abscess

24. Correct Answer:d In a recent study, pathogens that were identified on cultures of material obtained by swabbing of the superficial aspect of a wound and needle biopsy were compared with those that were isolated from material that was obtained at debridement. The cultures of material that was obtained by superficial swabbing of the wound and needle biopsy were inadequate for prediction of the presence of aerobic organisms. Moreover, the failure to isolate anaerobies from the material obtained by needle biopsy did not rule out the presence of anerobic organisms, nor does it rule out the possibility that osteomyelitis may be reactivated after intramedullary nailing with reaming. Therfore, tissue for culture of aerobic and anerobic organisms must be obtained during operative debridement in order to identify all pathogenic organisms. Other studies have shown that cultures must be taken from multiple sites in chronic osteomyelitis of long bones in order to properly treat all varieties of bacteria present.

25. Year:1997 Question A 37-year-old man who sustained a type IIIB open fracture of the middle third of the tibia after a severe crush injury has significant contusions and some necrosis of the posterior muscles. Treatment consists of debridement and external fixation. Which of the following muscle flaps should be used for soft-tissue coverage of the exposed anteromedial tibia? a. Soleus b. Fasciocutaneous c. Medial gastrocnemius d. Lateral gastrocnemius e. Free vascularized muscle

26. Correct Answer:e Grade IIIB indicates initial soft-tissue loss and extensive areas of denuded bone that make later flap coverage necessary. All grade IIIB and many grade IIIC wounds require flap coverage. For the proximal third of the leg, such coverage is best achieved with a gastrocnemius flap; a soleus flap will cover soft-tissue defects extending towards the mid-aspect of the tibia, but a free flap is required for more distal defects. If the solius or gastrocnemius muscles have been damaged, they are unsuitable for local coverage and a free flap must be substituted.

27. Year:1997 Question # 44 A previously active 36-year-old woman who fractured her right ankle 10 years ago and was treated with 6 weeks of cast immobilization now has had pain and swelling for the past year and is no longer able to play tennis or jog. Examination shows swelling and a 10-degree loss of dorsiflexion when compared with the normal, contralateral ankle. Radiographs show shortening of the fibula, widening of the ankle mortise, lateral tilt of the talus, and slight narrowing of the tibiotalar joint space. Treatment should include a. ankle fusion. b. osteotomy of the fibula. c. deltoid ligament reconstruction. d. a custom-made plastic shoe insert. e. nonsteroidal anti-inflammatory drug therapy

28. Correct Answer:b Patients who had reconstructive surgery for a malunion of a displaced fracture of the fibula were evaluated. In these patients who had pain, swelling of the ankle, and stiffness at an average of six years after the injury, the malunions were classified radiographically as either occult or overt. An occult malunion was one in which the talus remained in its normal position, but the lateral malleolus showed residual displacement, characterized byexternal rotation and shortening. In an overt malunion, there were similar changes in the lateral malleolus to correct the external rotation and shortening, to reduce the lateral subluxation or the anterior aspect of the tibiofibular joint, and to restore the stability of the talus.

29. Year:1997 Question # 61 A 38-year-old woman who sustained multiple blunt injuries, including a unilateral lateral compression injury to the pelvic ring as a result of a motor vehicle accident, is awake, alert, and normotensive; however, she has a decreased pulse pressure, a pulse of 110/min and a urine output of 20 mL/hr. She responds to an initial fluid bolus; however, after the fluids are slowed, perfusion begins to deteriorate. An increase in fluids and blood administration is instituted. To evaluate the abdomen as a potential bleeding source, management should include a. obtaining a CT scan of the abdomen. b. obtaining lateral decubitus radiographs of the abdomen. c. obtaining a crosstable lateral radiograph of the abdomen. d. performing an exploratory laporatomy. e. performing a supraumbilical diagnostic peritoneal lavage.

30. Correct Answer:e This question is for the initial evaluation of hemodynamic instability in a multitrauma patient with pelvic fractures. This question specifically asks for the test to evaluate the abdomen as a source of bleeding. While a CT scan can help us identify the pelvic fracture, a DPL is the quickest way to identify intra-abdominal bleeding, and the trauma surgeons can tell pretty quickly whether a patient needs to go to OR based on the outflow color from the DPL.

31. Year:1997 Question # 64 An 18-year-old woman has a closed femoral shaft fracture and facial trauma. Cervical spine radiographs are normal. Because of moderate facial edema, internal fixation of the femur is delayed. Two days later, the patient is noted to have mental confusion and dyspnea. The lungs are clear to auscultation with normal breath sounds. Vital signs are pulse, 100/min; respiration, 35/min; blood pressure, 140/95 mm Hg. Arterial blood gases are pO2, 70; pCO2, 45. The pH was 7.35. The most likely diagnosis is a. occult head injury. b. pulmonary embolism. c. spontaneous pneumothorax. d. fat embolism. e. upper airway obstruction

32. Correct Answer:d This scenario is pointing to fat embolism from the beginning. This is a young patient with a long bone fracture, two days out. The abg suggests acute hyppoxemia, without a compensated metabolic situation. While the confusion can be associated with a head injury, the abg is not. Confusion from hypoxemia is probably causal, and dyspnea too, is associated with fat embolism. The three most worrisome problems are listed, being PE, pneumothorax, and acute upper airway obstruction. The breath sounds woulkd all be affected in these however.

33. Year:1997 Question # 74 A 25-year-old woman who has multiple injuries, including closed femoral and tibial shaft fractures, is initially awake and alert, but during resusitation she becomes somnolent. A chest radiograph shows three rib fractures on the right side, and an AP view of the pelvis shows a 3-cm pubic diastasis. She has a systolic blood pressure of 220 mm Hg and a pulse rate of 38/min. Treatment should include a. pelvic angiography. b. diagnostic peritoneal lavage. c. emergency CT scan of the head and a neurosurgical consultation. d. administration of 2 L of crystalloid and blood type and crossmatching. e. insertion of a chest tube in the midclavicular line of the second intercostal space.

34. Correct Answer:c Although hypotension could be the cause of her somnolence, her SBP is quite high indicating that this is not likely, also she is not tachycardic which is a hallmark of hypovolemic shock. Cardiac Tamponade or tension ptx is another thought but this is not mentioned on the CXR. The only other source for somnolence to consider is neurogenic. Choices 1,2,4 all pertain to diagnosis of a hypovolemic origin. Choice 3 is best as it directly deals with a neurogenic origin as is likely in this case scenario.

35. Year:1997 Question # 88 Initial radiographs of a 56-year-old man who sustained a closed fractue of the distal tibia in a motor vehicle accident are shown in Figures 24a and 24b. Figure 24c shows a clinical photograph of the injured foot and ankle in the operating room 8 days later. The chances of surgical wound complications are most likely to be minimized by a. avoiding plate fixation of the distal tibia. b. keeping the incisions spread by more than 7 cm. c. using low-profile malleable plates. d. using a "pilon" fracture incision and a femoral distractor. e. using a topical antibiotic cream and delaying surgery for 3 to 5 more days

37. Correct Answer:a Several studies over the last several years have concluded that limited internal fixation (usually lateral) combined with external fixation reduce the risk of soft tissuue insult in pilon fxs. Choice 2, keeping the incisions 7 cm apart is correct but it is even better to not make 2 incisions at all. Choice 3, using low profile plates is also a good idea, but again, no plate is even better. Choice 4, using a pilon fracture incision and a femoral distractor indicates the intent for ORIF, which would be best avoided. Choice 5, using a topical antibiotic cream and delaying surgery for 3 to 5 more days is only partially true. Abx cream is not recommende nor helpful. Most authors do recommend delaying any open surgery until 10-14 days after the trauma to allow the soft tissue swelling to subside. **JAAOS 1994 Nov./Dec. 297-305**References:Keywords:Question 16 of 145

38. Year:1997 Question # 120 An 18-year-old active duty soldier sustains a 6-cm segmental loss to the tibial diaphysis from an antipersonnel mine. Treatment consists of a fine wire circular external fixator with bone transport, and the immediate postopertive course is uneventful. The patient is given instructions in advancing the frame during a convalescent leave. A radiograph taken 5 weeks postoperatively shows a gain of 4.5 cm and a radiolucent linear area transversely through the middle of the regenerate bone. This finding is most likely the result of a. a fracture. b. a pin tract infection. c. advancing the frame too fast. d. advancing the frame to slowly. e. infection within the regenerate

39. Correct Answer:c The Ilizarov method of distraction osteosynthesis typically calls for lengthening/distracting at a rate of 1mm/day. At 7 weeks out, the radiographs show 4.5cm of distraction. This is 1cm longer than it should be distracted and accounts for the radiolucency in the regenerate bone. There is no history which is consistent with refracture or infection.

40. Year:1997 Question A patient undergoes anatomic reduction and stable fixation of a spiral distal fibula fracture that is 4.5 cm above the joint. With which of the following concomitant injuries is the patient most likely to benefit from placement of a syndesmosis screw? a. Deltoid ligament rupture b. Wagstaffes avulsion fracture c. Rupture of the anterior inferior tibiofibular ligament d. Oblique medial malleolus fracture that has been reduced and stabilized e. Transverse medial malleolus fracture that has been reduced and stabilized

41. Correct Answer:a In 1991, J Soleri, et al performed a biomechanical cadaveric study to investigate the need for syndesmotic screws in a Weber C ankle fracture. Their results supported earlier studies which showed that the medial complex (medial malleolus and deltoid ligament) is the primary stabilizer of the talus in the ankle mortise. As a result, they recommended the placement of a syndesmotic screw in Weber C ankle fractures with deltoid ligament insufficiency.

42. Year:1997 Question A 25-year-old man sustains multiple injuries, including a pelvic ring disruption, in a motor vehicle accident. He is hemodynamically stable. Attempts to pass a urinary catheter are unsuccessful. What diagnostic test should be obtained next? a. CT scan b. Cystogram c. Urinalysis d. Excretory urogram e. Retrograde urethrogram

43. Correct Answer:e In pelvic trauma, inability to pass a urinary catheter may be a sign of urethral trauma. A retrograde urethrogram is sthe diagnositic study of choice.

44. Year:1997 Question A 35-year-old man sustains a closed Galeazzi fracture-dislocation and a fracture of the ulnar styloid process as a result of a high-speed motor vehicle accident. The radius fracture is anatomically fixed with a plate; however, the ulnar head remains dislocated. What structure is most likely responsible for preventing reduction? a. Radioulnar capsule b. Pronator Quadratus c. Flexor carpi ulnaris d. Extensor carpi ulnaris e. Triangular fibrocartilage complex

45. Correct Answer:d Difficulty with reduction of the ulnar head may be caused by interposition of the ECU. Due to its firm attachment to the triangular fibrocartilage complex by its fibro-osseous sheath, it is usually the structure that prevents reduction

46. Year:1997 Question Examination of a construction worker who received an accidental electric shock while on the job reveals that he is awake, alert, and holding his arm tightly against the chest and holding his forearm tightly to the front of the trunk. External rotation and abduction are severely limited and painful. Which of the following injuries best accounts for these findings? a. Luxatio erecta b. Anterior dislocation of the glenhumeral joint c. Superior dislocation of the glenhumeral joint d. Posterior dislocation of the glenhumeral joint e. Greater tuberosity fracture of the proximal humerus

47. Correct Answer:d Common causes of failure to externally rotate shoulder are DJD, adhesive capsulitis, and posterior dislocation. Seizures are the most common cause of posterior dislocations.

48. Year:1997 Question A 30-year-old soccor player has pain and swelling 4 hours after being kicked in the anterior compartment of the leg. Which of the following physical findings best indicates increased compartment pressure? a. Anterior compartment tenderness b. Pain with active ankle dorsiflexion c. Pain with passive flexion of the toes d. Pain with passive extension of the toes e. Decreased sensation on the dorsum of the foot

49. Correct Answer:c Severe pain, out of proportion to the injury, with passive stretching of a muscle is indicative of increased compartment pressures. Toe flexion would stretch the EHL and EDC muscles which reside in the anterior compartment. This compartment as well as the deep post. compartment are the most commonly involved. Generally speaking, compartment syndrome usually occurs in less than 24 hours. Ischemic injury starts when the pressures reach 10 - 20 mmHg below DBP. Paralysis and sensory changes can occur within one hour of the ischemia. Within the first 4 hours of ischemia only noepraxic injury occurs, but after 8 hours there is axonotmesis which is irreversible. Also, the area of highest pressure is not always palpable but is generally at the level of the fracture.

50. Year:1997 Question A 31-year-old woman has had instability of the right ankle for the past 10 years. Stress radiographs show asymmetrical anterior drawer translation, excess lateral opening, and a unilateral os subfibulare on the affected side. In this patient, the os subfibulare represents a. a supernumary bone. b. an unfused accessory ossification center. c. a nonunion of an avulsion fracture of the talus. d. a nonunion of an avulsion fracture of the fibula. e. a nonunion of an avulsion fracture of the calcis.