MUSCULOSKELETAL TRAUMA : SELF ASSESSEMENT EXAMINATION 1.

. A 26-year-old woman sustained a nondisplaccd femoral neck fracture and treatment consisted of use of percutaneous cannulated screws. At her 3-month folIow-up visit. Shereports hip pain and is unable to ambulate. A radiograph is shown in figure 1. What is the next most appropiate treatment? 1. Bone grafting and revision open reduction and internal fixation. 2. Hemiarthroplasty 3. Dynamic hip screw without angular correction. 4. Valgus intertrochanteric osteotomy 5. Core decompression. 2. Which of the following choices best decribes the fracture pattern shown in figures 2a through 2c? 1. Anterior column 2. Anterior wall 3. Posterior column 4. Both column 5. Transverse. 3. The correct starting point for an external fixation half pin placed into the anterior inferior iliac spine (AHS) is labeled by what letter in figure 3? 1. A 2. B 3. C 4. D 5. E 4. Figures 4a and 4b show the radiographs of a 53 year old woman who was injured in a fall. After initial closed reduction, what is the preferred treatment for this fracture? 1. Open reduction and internal fixation of the radial head and immobilization. 2. Medial collateral ligament repair. 3. Radial head replacement, ulnar nerve transposition, and external fixation. 4. Coronoid repair, radial head replacement, and lateral ligamentous repair. 5. Nonsurgical management in a hinged elbow brace. 5. A 25 year old semiprofessional football player sustain a hyperextension injury to the left foot. He is unable to bear weight. Examination reveals tenderness along the midfoot wtih swelling and plantar ecchymosis. Radiographs are negative. What is the next step in evaluation of this patient? 1. CT. 2. MRI 3. Standing radiographs 4. Measurement of the compartement pressures. 5. Bone scan. 6. A 52 year old woman slips in her bathroom and strikes her right hand on the cabinet. She notes swelling, ecchymosis, and pain with attempted motion. There are no open wounds. Radiographs are shown in figures 5a through 5c. What is the most appropriate treatment?

1. Immobilization of the hand with the metacarpophalangeal (MCP) joint in flexion and the interphalangeal (IP) joint in extension. 2. Immobilization of the hand with the MCP joint in extension and the IP joints in extension. 3. Percutaneus pinning of the proximal phalanx. 4. Open reduction and internal fixation of the proximal phalanx. 5. Early motion and pain management. 7. A 19 year old college student reports a 1 week history of wrist pain following an intramural rugby match. A PA radiograph is shown in figure 6. He denies any prior wrist injury. What is the best course of action? 1. Closed reduction and long arm cast immobilization 2. Closed reduction and short arm cast immobilization. 3. Closed reduction and percutaneus pinning. 4. Open reduction and internal fixation with Kirschner wires. 5. Open reduction and internal fixation with a headless, cannulated compression screw. 8. A 29 year old woman was injured in a high speed motor vehicle accident 3 hours ago. Radiographs are shown in Figures 7a through 7e. Her right foot injury is open and contaminated. Her associated injuries include a closed head injury and a ruptured spleen requiring resection. She has had 6 units of packed red blood cells and the trauma surgeon has turned her care over to you. Her current base deficit is 10 and her urinary output has averaged 0.4 mL/kg for the last 2 hours. What is the best treatment at this time? 1. Irrigation and debridement, external fixation of the ankle and foot, traction and pinning of the femur, open reduction and internal fixation of the forearm. 2. Irrigation and debridement, external fixation of the ankle, foot, and femur, splinting of the forearm. 3. Irigation and debridement and open reduction and internal fixation of the ankle and foot, intramedullary nailing of the femur, open reduction and internal fixation of the forearm. 4. Irrigation and debridement and open reduction and internal fixation of the ankle and foot, intramedullary nailing of the femur, splinting of the forearm. 5. Irrigation and debridement, external fixation of the foot and ankle, intramedullary nailling of the femur, open reduction and internal fixation of the forearm. 9. A 45 year old man who is a smoker has a significant hemothorax and bilateral closed femoral fractures. On insertion of a chest tube, 1,100 mL of blood was returned. He has had 75 mL of chest tube output over the last 2 hours while being resuscitated In the ICU. His base deficit is now 2 and his urine output has been 3 mL/kg over the last hour. What is thenext most appropriate step in management? 1. Continued skin traction. 2. Skeletal traction of both femurs. 3. External fixation of the bosth femurs. 4. Intramedullary nailing of one femur and external fixation and delayed nailing for the other femur.

5. Intramedullary nailing of the both femur. 10. A 47 year old woman falls and sustain a direct blow to her middle finger. She notes pain and swelling and is unable to move the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints. Radiographs are shown in figures 8a through 8c. Proper management should consist of 1. Closed reduction and splintting in metacarpophalangeal (MCP) joint and PIP joint extension. 2. Closed reduction and splintting in MCP joint flexion and PIP joint extension. 3. Reduction and percutaneous intramedullary Kirschner wire fixation. 4. Reduction and lag screw fixation. 5. Buddy taping and early range of motion. 11. Figures 9a and 9b show the radiographs ofa 4-year-old child who sustained an elbow injury. What is the most likely complication resulting from this fracture if treated in a cast? 1. Elbow stifness. 2. Nonunion. 3. Osteonecrosis. 4. Varus malunion from overgrowth. 5. Fishtail deformity. 12. Which of the following is most commonly associated with an open clavicular fracture? 1. Scapulothoracic dissociation. 2. Closed head injury. 3. Calcaneus fracture. 4. Pelvic ring injury. 5. Open tibial fracture. 13. A 22 year old woman injures her neck in a motor vehicle accident. Examination revelas no sensory or motor function below T8. Radiographs and an MRI scan show a burst fracture at T7. Forty-eight hours later, the bulbocavernosus reflex is present but there is no evidence of motor or sensory recovery in the lower extremities. What is the most likely diagnosis? 1. Spinal shock. 2. Anterior cord syndrome. 3. Cauda equina syndrome. 4. Complete cord syndrome. 5. Brown-sequard syndrome. 14. A 26 year old man falls off a motorcycle and injures his left wrist. There are no open wounds and neurovascular examination is normal. Radiographs are shown in figures 10a and 10b. Definitive management should consist of 1. Closed reduction and casting. 2. External fixation and percutaneous pinning of the distal radius. 3. Open reduction and internal fixation of the distal radius. 4. Open reduction and internal fixation of the distal radius and open repair of the ulnar styloid. 5. Non bridging external fixation of the distal radius. 15. Which of the following studies best increase the ability to diagnose femoreal neck fractures in patient with femoral shaft fractures? 1. MRI 2. Fine cut CT Scan. 3. Bone scan.

4. AP radiograph of the femur. 5. AP radiograph of the pelvis. 16. The axis of forearm rotation occurs between what two anatomic points? 1. Radial heads, radial styloid. 2. Radial heads, ulnar styloid. 3. Radial head, ulnar head. 4. Coronoid, sigmoid notch. 5. Coronoid, radial styloid. 17. Figure 11 shows the radiograph of a 26 year old man with type 1 diabetes mellitus who was struck by a motor vehicle. What is the most common complication associated with this pelvic fracture? 1. Infection. 2. Sciatic nerve palsy. 3. Heterotopic ossification 4. Deep venous thrombosis. 5. Degenerative arthritis. 18. Which of the following factors is a significant predictor of reoperation following open reduction and intemal fixation of intertrochanteric fractures with a sliding-compression hip-screw device? 1. Standard obliquity fracture pattern. 2. Tip-apex distance of 15 mm. 3. Fracture through the lateral femoral cortex 4. Sliding-compression hip-screw device with a two-hole side plate. 5. Fracture of the lesser trochanter. 19. Following fixation of a displaced intra-articular fracture of the distal humerus through a posterior approach. What is the expected outcome? 1. Development of arthritic changes at 1 year. 2. Restoration of full elbow range of motion. 3. Loss of approximately 25% of elbow flexion strength. 4. Posterolateral rotatory instability 5. Olecranon nonunion. 20. A 15 year old boy falls from his bicycle and sustain an injury to his elbow. Prereduction readiographs are shown in figure 12a. Closed reduction is performed without difficulty and postreduction radiographs are shown in figure 12b. What is the next most appropiate step in treatment? 1. Conversion to east immobilization for 6 weeks. 2. Application of an articulated external fixator. 3. Begin early motion as soon as pain resolves. 4. Open reduction. 5. MRI to assess ligament integrity. 21. A 7 year old boy is seen in the emergency departement with an isolated and displaced supracondylar humerus fracture and absent radial and ulnar pulses. Despite a moderately painful attempt at realignmem. Examination revelas that his hand remains pulseless. What is the next most appropriate step in management? 1. Order an urgent angiogram and then procced to the OR. 2. Repeat the reduction in the emergency department and reassess. 3. Perform open reduction through an anterior approach. 4. Perform closed reduction and pinning in the OR and reassess the vascular status. 5. Perform arterial repair and the stabilize the fracture.

22. A 28 year old cowgirl was injured while herding cattle 1 week ago. A radiograph and CT scan are shown in figures 13a through 13c. What is the most appropriate management for this injury? 1. Nonsurgical management and gradual weight bearing as tolerated. 2. Nonsurgical management and restricted weight bearing. 3. Placement of a plevic binder. 4. Open reduction and internal fixation of the symphysis. 5. Open reduction and internal fixation of the symphysis and iliosacral screws. 23. As reflected by the SF-36 scores, patients with which of the following conditions demonstrate the most disability in physical function? 1. AIDS 2. Polyt rauma 3. Pelvic fracture 4. Pilon fracture 5. Acute myocardial infarction (AMI). 24. A 25-year-old man is involved in a motor vehicle accident and brought to the emergency department at 4 am on Sunday morning. He has a closed distal third femoral shaft fracture. His leg is initially pulseless but after applying inline traction, a distal pulse can be palpated and the limb appears to be viable. The pulse in the injured limb "feel different than the pulse in the uninjured limb. What is the next step in assessing the vascular status of this limb? 1. Serial physical examination. 2. Angiography. 3. Duplex ultrasound examination. 4. Ankle-brachial index (ABI). 5. Measurement of compartement pressures. 25. What is the most appropriate treatment for a 50 year old woman who sustain the injury shown in figure 14a and 14b? 1. Total elbow athroplasty. 2. Functional hinge braching. 3. Long arm casting. 4. Crossed Kirschner wires. 5. Dual column plates. 26. A 20 year old man is brought to the emergency department after a high spedd motor vehicle accident. His initial blood pressure is 70/40mmHg. He is currently receiving intravenous fluids as well as blood. His focused assessemnet with sonography for trauma examination did not show any free fluid in his abdomen and his chest radiograph in unremarkable. An AP pelvis radiograph is shown in figure 15. What is the next most appropriate step in management of his pelvic injury? 1. Inlet and outlet views of the pelvis to better delineate the injury. 2. Angiography. 3. Laparotomy. 4. Open reduction and internal fixation of the pelvis. 5. Placement of a pelvis binder aroudn the patient. 27. A 7 year old girl is hit by a motor vehicle and sustains the isolated ipsilateral injuries shown in figures 16a and 16b. What is the optimal definitive method of treatment? 1. Spica cast immobilization. 2. Rigid reamed nailing of the femur and a short leg cast.

3. Flexible nailing of the femur and tibia. 4. Reamed nails of the femur and tibia. 5. Spanning external fixator. 28. What is the most common cause of errors that harm patients? 1. Communication breakdown. 2. Equipment breakdown. 3. Nursing competence. 4. Patient noncompliance. 5. Physician cometence. 29. A 220-lb 20-year-old man was involved in a motor vehicle accident. His work-up reveals that he has multiple long bone fracture as well as a splenic injury that is currently being managed nonsurgically. His initial blood pressure in the trauma bay was 70/30mmHg after receving 4 liters of.........Currently 110/70, his heart rate is 100, his urine output is 90 ml/h(normal 0.5 to 1 ml/kg/h), and his core temperature is 97.9 degree F (36,5 degrees C). At this point the patient resuscitation can be described as which of the following? 1. Complete based on the normalization of his blood pressure, urine output and heart rate. 2. Cannot be determined based on the data presented. 3. Incomplete based on his fluid requirement calculated using his initial blood preassure as a measure of blood volume loss. 4. Incomplete since he will need surgery on the long bone fractures and should be tanked up prior to losing blood in the operating room. 5. Incomplete based on his heart rate. 30. A 30 year old man who sustained a work related injury 6 week ago reports persistent bank and left sided buttock pain that has been attributed to lumbar transverse process fractures. A pelvic radiograph and CT scans obtained 2 days ago are seen in figures 17a through 17c. What is the best treatment for his injury? 1. Continued nonsurgical management. 2. Posterior open reduction and internal fixation with tension band plating. 3. Posterior iliosacral screws. 4. Anterior open reduction and internal fixation. 5. Anterior open reduction and internal fixation and posterior fixation. 31. A 36 year old woman was injured in a train derailment. She has a significant open depressed skull fracture with active bleeding. A hematopenumothorax. And blood in the left upper quadrant and colic gutter by focused assessment with sonography for trauma (FAST) examination. Additionally, she has the pelvic injury senn on the CT scans in figure 18a and 18b. The mortality rate for this patient approaches. 1. Less than 10% 2. 30% 3. 50% 4. 70% 5. Greater than 90%. 32. A 19-year-old collegiate baseball player injures the ring finger on his dominant hand while sliding headfirst into second base. He reports that he is unable to actively flex or extend the distal interphalangeal joint of the finger. Radiographs arc shown in Figures19a and 19b. What is the anatomic lesion leading to this injury? 1. Rupture of the teoninal extensor tendon 2. Avulsion of the volar plate 3. Rupture of the sagittal bands 4. Rupture of the spiral oblique retinacular ligaments

5. Rupture of the profundus insertion 33. A 72 year old man was onvolved in an automobile accident 4 weeks ago. Initially he noted pain about his nondominant left shoulder. Which resolved within a few weeks after the accident. He now describes trouble with gripping and carrying items in his left hand. Radiographs are shown in figure 20a through 20c. His sign and symptoms are the result of injury to which of the following ligament? 1. Volar scapholunate interosseous. 2. Dorsal scapholunate interosseous. 3. Long radiolunate. 4. Short radiolunate. 5. Dorsal intercarpal. 34. To avoid an injury to the L5 nerve root when placing an S1 sacroiliac screw, what area of the sacrum should be avoided on the lateral C arm image shown in figure 21? 1. A. 2. B 3. C 4. D 5. E. 35. An otherwise healthy 37-year-old man fell off the flatbed of a delivery truck and landed directlv on his dominant left hand. Surgical stabilization of a distal radius fracture is perfomed. An intraoperative radiograph is shown in Figure 22. What is the next most appropriate step in management? 1. Immobilization of the wrist in ulnar deviation for 4 weeks before starting range of-motion exercises. 2. In situ Kirschner wire fixation of the carpal bones for 6 weeks. 3. Extending the volar incision used for fracture fixation and repairing the injured structures in addition to percutaneous Kirschner wire fixation. 4. Perfoming a separate dorsal incision and repairing the injured structures in addition to percutaneous Kirschner wire fixation 5. Arthroscopic repair of the injured structures and percutaneous Kirschner wire fixation. 36. A 36-year-old woman is placed in a short arm cast for a nondisplaced extra-articular distal radius fracture. Seven weeks later she notes the sudden inability to extend her thumb. What is the most likely cause of her condition? 1. Posterior interosseous nerve palsy. 2. Cervical disk herniation. 3. Entrapment of the flexor pollicis longus tendon. 4. Rupture of the extensor pollicis longus tendon. 5. Metacarpophalangeal joint dislocation 37. In Gustillo type III open tibial diaphyseal fractures, which of the following factors is associated with an increase risk of a poor functional outcome? 1. Soft-tissue coverage within 3 days of injury. 2. Bone grafting 3 months after injury. 3. Wound debridement within 6 to 24 hours from injury. 4. Definitive treatment with external fixation. 5. Free tissue transfer for soft-tissue coverage. 38. Figures 23a and 23b show the radiographs of a 75-year-old woman who sustained an injury to her nondominant hand. Initial treatment should consist of 1. Closed reduction and splinting. 2. Open reduction and internal fn:ation through a volar approach.

3. External fixation and Kirschner wire fixation. 4. Intrafocal pinning and casting. 5. Acceptance of alignment and bracing. 39. A 43-year-old man sustained a closed. Intra-articular pilon fracture. It has now been 1 year since he underwent open reduction and internal fixation. Which of the following statements most accurately describes his perceived outcorne? 1. His clinical outcome will correlate closely with his initial reduclion. 2. His outcome will correlate with his radiographic score on the Ankle Osteoarthritis Score. 3. He will likely require a late ankle arthrodesis. 4. He will demonstrate marked limitations with regard to recrcreational activities. 5. He will perceive improvement for a period of over 2 years. 40. The injury shown in Figure 24 was most likely caused by what mechanism of injury? 1. Anterior posterior compression. 2. Lateral compression. 3. Vertical shear. 4. Combined mechanism. 5. Flexion-rotation. 41. A 21-year-old college student fell from a balcony and landed on his outstrerched right hand. He is seen in the emergency department 4 hours later and reports wrist pain and diffuse hand numbness. The volar forearm compartment is soft and there is no pain with passive finger extension. Radiographs are shown in Figures 25a and 25b. Definitive treatment should consist of 1. Closed reduction and cast immobilization. 2. Closed reduction. carpal tunnel release, and cast immobilization. 3. Open reduction and ligament repair via a dorsal approach. 4. Open reduction and ligament repair via a volar approach. 5. Open reduction and ligament repair via dorsal and volar Approaches and an extended carpal tunnel release. 42. A 9-year-old boy falls from a scooter and sustains the injury shown in the radiographs in Figure 26. After closed reduction and cast immobilization. what is the most likely complication that can result? 1. Growth arrest of the distal ulna. 2. Growth arrest of the distal rasdius. 3. Compartement syndrome. 4. Radioulnar synostosis. 5. Entrapment of the extensor pollocos longus (EPL) tendon. 43. A 69-year-old man sustain a traumatic amputation to the distal phalanx of his little finger while working with power tools. Radiographs are shown in figures 27a and 27b. The patient was instructed how to perform wet-to-dry dressing changed in the emergency departement. Clinical pictures taken in the offices are shown in figures 27c through 27e. What is the most appropriate management of this soft-tissue wound? 1. Contiunue wet-to-dry dressing until the wpund heals by secondary intention. 2. Perform a volar advancement flap (ie, Moberg flap). 3. Perform a V-Y advancement flap. 4. Perform a thenar flap. 5. Perform a cross-finger flap to the ring finger.

44. A 32-year-old man has an open comminuted humeral shaft fracture. Examination revelas absence of sensation in the first web space and he is unable to fully extend the thumb, fingers, and wrist. What is the recommended treatment following irrigation and debridement of the fracture? 1. Functional bracing. 2. Hanging long arm cast immobilization. 3. Intramedullary nailing. 4. Open reduction and internal fixation, radial nerve exploration. 5. External bone stimulator. 45. Which of the following complications is associated with the use of a short cephalomedullary nail for fixation of intertrochanteric hip fractures? 1. Increased risk of deep venous thrombosis. 2. Increased risk of posoperative ipsilateral femoral fracture. 3. Increased blood loss when compared to a sliding-compression hip-screw. 4. Increased risk of nonunion. 5. Increased Mortality. 46. A 19-year-old man sustaine the isolated injury senn in figure 28a. He is adequatly resucitated. A closed reduction was perform in the emergency departement, and postreduction radiographs are shown in figures 28b and 28c. What is the most appropriate step in management? 1. Urgent open reduction and internal fixation. 2. Placement of a knee immobilizer and delayed open reduction and internal fixation. 3. Placement of the distal femoral traction pin and delayed open reduction and internal fixation. 4. Delayed open reduction and internal fixation. 5. Nonsurgical management and restricted weight bearing. 47. The iliopectineal fascia runs between which of the following structures? 1. Iliopsoas muscle and the iliac vessel/remoral nerve. 2. Lateral femoral cutaneous nerve and the iliac vessels. 3. Iliopsoas muscle/femoral nerve and the iliac vessels. 4. Iliac wing and the iliopsoas muscle. 5. Pubic symphysis and the iliac vessels. 48. Which of the following is most predictive of a medial side ankle injury in the presence of a fibula fracture above the level of the joint? 1. Severe medial ankle tenderness. 2. Severe medial ankle ecchymosis. 3. Stress radiographs showing the medial clear space measuring 6 mm and the superior joint space measuring 3 mm. 4. Inability to ambulate. 5. Medial ankle swelling. 49. Figure 29 shows the radiograph of a 10-year-old boy who injured his knee playing football. What is the most appropriate initial treatment? 1. Closed reduction and casting. 2. Flexible Nailing. 3. Blade plate fixation. 4. Anatomic reduction and smooth pin fixation with supplemental casting. 5. Open or closed reduction and screw fixation. 50. A 35-year-old man sustained 1 inch stab incision in his proximal forearm while trying to use a screw driver 2 weeks ago. The laceration was routinly closed. And no problem

about the incision site were noted. He now reports that he has benn unable to straigten his fingers or thumb completely since the injury. Clinical photographs shown in figures 30a and 30b show the man passively flexing the wrist. What is the most appropriate management? 1. Nerve conduction velocity studies and electromyography. 2. Extension splinting of the fingers. 3. Exploration and repair of the extensor tendon laceration. 4. Exploration and repair of the posterior interosseous nerve. 5. Observation.