Orthopedics Flashcards
- Long bone fractures can be described as the following recognized types EXCEPT
A. Convoluted
B. Transverse
C. Oblique
D. Spiral
Answer: A
Musculoskeletal injuries resulting from trauma include fractures of bones, damage to joints, and injuries to soft tissues.
Long bone fractures can be described as transverse, oblique, spiral, segmental, or comminuted.
(See Schwartz 10th ed., p. 1756.)
- Goals of fracture reduction include all of the following EXCEPT
A. Restore length
B. Restore marrow integrity
C. Restore rotation
D. Restore angulation
Answer: B
Reduction is performed with axial traction and reversal of the mechanism of injury in order to restore length, rotation, and angulation.
(See Schwartz 10th ed., p. 1757.)
- Which of the following is true concerning compartment syndrome?
A. Due to decreased intracompartmental pressure
B. Typified by hyperesthesia
C. Can be assessed by needles placed into affected compartment
D. Pain relieved by passive muscle stretching
Answer: C
Compartment syndrome is an orthopedic emergency caused by significant swelling within a compartment of an injured extremity that jeopardizes blood low to the limb.
Increased pressure within the compartment compromises perfusion to muscles and can cause ischemia or necrosis.
Patients complain of pain and numbness, and passive stretch of muscles within the compartment causes severe pain.
While the diagnosis is based on clinical examination, pressures can be measured with needles placed into the compartment, which is necessary in unconscious patients who will not show these examination findings.
(See Schwartz 10th ed., p. 1757.)
- Shoulder dislocations are frequently associated with all of the following EXCEPT
A. Injuries to labrum
B. Humeral head fractures
C. Seizures
D. Axillary vasculature disruptions
Answer: D
The shoulder is one of the most commonly dislocated joints and most dislocations are anterior.
They are often associated with injuries to the labrum (Bankart lesion), impression fractures of the humeral head (Hill-Sachs lesion), and rotator cuff tears.
Posterior dislocations are associated with seizures or electric shock.
Adequate radiographs are required to diagnose a shoulder dislocation, with the axillary view being the most critical.
(See Schwartz 10th ed., p. 1759.)
- Which of the following is NOT a component of the elbow dislocation “Terrible Triad”?
A. Elbow dislocation
B. Radial head fracture
C. Coronoid fracture
D. Radial nerve damage
Answer: D
A severe injury, known as the Terrible Triad, includes an elbow dislocation, a radial head fracture, and a coronoid fracture.
These are unstable injuries and require repair of the torn lateral collateral ligament (LCL), fixation or replacement of the radial head, and possible fixation of the coronoid depending on the size of the fracture fragment.
(See Schwartz 10th ed., p. 1759.)
Each of the following is associated with pelvic fractures, EXCEPT:
A. Prompt operative intervention for pubic rami
B. Life-threatening hemorrhage
C. Associated genitourinary (GU) injury
D. Displacement associated with two or more fractures in the pelvic ring
Answer: A
Pelvic fractures are indicative of high energy trauma and are associated with head, chest, abdominal, and urogenital injuries.
Hemorrhage from pelvic trauma can be life-threatening and patients can present with hemodynamic instability, requiring significant fluid resuscitation, and blood transfusions.
The bleeding that occurs is often due to injury to the venous plexus in the posterior pelvis, though it can also be due to a large vessel injury such as a gluteal artery. Other associated injuries are bladder and urethral injuries that manifest with bleeding from the urethral meatus or blood in the catheter and need to be assessed with a retrograde urethrogram.
The pelvis is a ring structure made up of the sacrum and the two innominate bones that are held together by strong ligaments. Because it is a ring, displacement can only occur if the ring is disrupted in two places.
Displaced sacral fractures and iliac wing fractures are treated with screws or plates, while pubic rami fractures can usually be managed nonoperatively.
(See Schwartz 10th ed., p. 1760.)
Which of the following is associated with hip fractures?
A. More common in men than women.
B. Mortality rate in first year after hip fracture is 25%.
C. Usually managed nonoperatively.
D. Traction with bed rest rather than early mobilization is the chief therapeutic goal.
Answer: B
Hip fractures are an extremely common injury seen in orthopedics and are associated with significant morbidity and mortality.
They most often occur in elderly patients after ground level falls, are much more common in women than men, and occur more commonly in patients with osteoporosis.
Patients who suffer hip fractures are at increased risk for many complications, including deep vein thrombosis, pulmonary embolism, pneumonia, deconditioning, pressure sores, and even death, as the mortality rate in the first year following a hip
fracture is around 25%.
One of the most important reasons for performing surgery is to prevent these complications, and getting patients out of bed and walking as soon as possible diminishes their risk.
Therefore, surgery is almost always the treatment of choice for hip fractures.
(See Schwartz 10th ed., pp. 1760–1761.)
Chronic unremitting back pain suggests all possibilities EXCEPT the following
A. Infection
B. Malignancy (primary)
C. Spinal cord infarction
D. Metastatic disease
Answer: C
Back pain occurs in the majority of adults but is usually self - limited resolving in 1 to 2 weeks.
Chronic unremitting back pain suggests the possibility of infection, malignancy, or metastatic disease.
(See Schwartz 10th ed., p. 1771.)
Scoliosis curves are classified as any of the following possibilities EXCEPT
A. Congenital
B. Covascular
C. Neurological
D. Myogenic
Answer: B
Scoliotic curves are classified as congenital, degenerative, metabolic (mucopolysaccharidoses), neurogenic (cerebral palsy), and myogenic curves (muscular dystrophy).
Idiopathic scoliosis is the most common form, and represents a spectrum of genetic disease. (See Schwartz 10th ed., p. 1771.)
Surgical management of arthritis includes all of the following EXCEPT
A. Arthroplasty
B. Osteotomy
C. Arthrodesis
D. Arthrolysis
Answer: D
A full description of surgical options can be found in section “Surgical Management of Arthritis.” (See Schwartz 10th ed., pp. 1772–1773.)
- For vascular injuries to the hand requiring tourniquet, the maximum time the tourniquet should be applied to prevent tissue necrosis is
A. 1 hour
B. 2 hours
C. 3 hours
D. 4 hours
Answer: B
Initial treatment for an actively bleeding wound should be direct local pressure for not less than 10 continuous minutes.
If this is unsuccessful, an upper extremity tourniquet inflated to 100 mmHg above the systolic pressure should be used.
One should keep this tourniquet time to less than 2 hours to avoid tissue necrosis.
Once bleeding is controlled well enough to evaluate the wound, it may be cautiously explored to evaluate for bleeding points. One must be very cautious in attempting to ligate these to ensure that adjacent structures, such as nerves, are not included in the ligature.
(See Schwartz 10th ed., p. 1799.)
Anesthetic agents with epinephrine should NOT be used in
A. The fingertip
B. The hand
C. The wrist
D. The forearm
Answer: A
A commonly held axiom is that epinephrine is unacceptable to be used in the hand.
Several recent large series have dispelled this myth. Epinephrine should not be used in the
fingertip and not in concentrations higher than 1:100,000 (ie, what is present in commercially available local anesthetic with epinephrine).
Beyond that, its use is acceptable and may be useful in an emergency room (ER) where tourniquet control may not be available.
Also, because most ER procedures are done under pure local anesthesia, many patients will not tolerate the discomfort of the tourniquet beyond 30 minutes.
Epinephrine will provide hemostasis and also prolong the effect of the local anesthetic.
(See Schwartz 10th ed.,p.1796.)
Most nondisplaced fractures do NOT require surgical treatment EXCEPT
A. Those of the lunate bone of the wrist.
B. Those of the capitate bone of the wrist.
C. Those of the scaphoid bone of the wrist.
D. All nondisplaced fractures require surgical treatment.
Answer: C
Most nondisplaced fractures do not require surgical treatment.
The scaphoid bone of the wrist is a notable exception to this rule. Due to peculiarities in its vascular supply, particularly vulnerable at its proximal end, nondisplaced scaphoid fractures can fail to unite in up to 20% o patients even with appropriate immobilization.
Recent developments in hardware and surgical technique have allowed stabilization of the
fracture with minimal surgical exposure.
One prospective randomized series of scaphoid wrist fractures demonstrated shortening of time to union by up to 6 weeks in the surgically treated group, but no difference in rate of union.
Surgery may be useful in the younger, more active patient who would benefit from an earlier return to full activity.
(SeeSchwartz10thed., pp. 1795–1796.)
A patient shown to have wasting at the interdigital web spaces, experiences numbness of the ring finger and exhibits Wartenberg sign on physical examination most likely is suffering from
A. Cubital tunnel syndrome
B. Carpal tunnel syndrome
C. Pronator syndrome
D. Anterior interosseous nerve syndrome
Answer: A
The ulnar nerve also innervates the dorsal surface of the small finger and ulnar side of the ring finger, so numbness in these areas can be explained by cubital tunnel syndrome.
The patient may also report weakness in grip due to effects on the flexor digitorum profundus (FDP) tendons to the ring and small fingers and the intrinsic hand muscles.
Patients with advanced disease may complain of inability to fully extend the ring and small finger interphalangeal (IP) joints.
Physical examination or cubital tunnel syndrome begins with inspection. Look for wasting in the hypothenar eminence and the interdigital web spaces.
When the hand rests flat on the table, the small finger may rest in abduction with respect to the other fingers; this is called Wartenberg sign.
Tinel sign is often present at the cubital tunnel.
Elbow flexion test will often be positive. Grip strength and finger abduction strength should be compared to the unaffected side.
Froment sign can be tested by placing a sheet of paper between the thumb and index finger and instructing the patient to hold on to the paper while the examiner pulls it away without flexing the finger or thumb (this tests the strength of the adductor pollicis and first dorsal interosseous muscles).
If the patient must flex the index finger and/or thumb (FDP-index and flexor pollicis longus [FPL], both median nerve supplied) to maintain traction on the paper, this is a positive response.
(See Schwartz 10th ed., p. 1806.)
The most common primary malignant tumor of the hand is:
A. Melanoma
B. Basal cell carcinoma
C. Squamous cell carcinoma (SCC)
D. Epithelioid sarcoma
Answer: C
Squamous cell carcinoma (SCC) is the most common primary malignant tumor of the hand, accounting for 75 to 90% of all malignancies of the hand.
Eleven percent of all cutaneous SCC occurs in the hand.
It is the most common malignancy of the nail bed.
Risk factors include sun exposure, radiation exposure, chronic ulcers, immunosuppression, xeroderma pigmentosa, and actinic keratosis.
(See Schwartz 10th ed., p. 1817.)
Necrotizing infections
A. Often present with pain out of proportion to findings.
B. Often have discharge present.
C. Debridement should begin following confirmation by way of radiograph findings.
D. Oral antibiotics should begin immediately.
Answer: A
Bacteria spread along the fascial layer, resulting in the death of soft tissues, which is in part due to the extensive blood vessel thrombosis that occurs.
An inciting event is not always identified. Immunocompromised patients and those who abuse drugs or alcohol are at greater risk, with intravenous drug users having the highest increased risk.
The infection can by mono- or polymicrobial, with group A β-hemolytic Streptococcus being the most common pathogen, followed by α-hemolytic Streptococcus, Staphylococcus aureus, and anaerobes.
Prompt clinical diagnosis and treatment are the most important factors for salvaging limbs and saving life.
Patients will present with pain out of proportion with findings. Appearance of skin may range from normal to erythematous or maroon with edema, induration, and blistering.
Crepitus may occur if a gas-forming organism is involved.
“Dirty dishwater fluid” may be encountered as a scant grayish fluid, but often there is little to no discharge.
There may be no appreciable leukocytosis.
The infection can progress rapidly and can lead to septic shock and disseminated intravascular coagulation.
Radiographs may reveal gas formation, but they must not delay emergent debridement once the diagnosis is suspected.
Intravenous antibiotics should be started immediately to cover gram-positive, gram-negative, and anaerobic bacteria.
Patients will require multiple debridements, and the spread of infection is normally wider than expected based on initial assessment.
Necrotizing myositis, or myonecrosis, is usually caused by Clostridium perfringens due to heavily contaminated wounds.
Unlike necrotizing fasciitis, muscle is universally involved and found to be necrotic.
Treatment includes emergent debridement of all necrotic tissue along with empirical intravenous antibiotics. (See Schwartz 10th ed., p. 1811.)
The majority of acute cases of infections of flexor tenosynovitis (FTS) are due to
A. Systemic lupus erythematosus
B. Chronic inflammation as a result of diabetes
C. Rheumatoid arthritis (RA)
D. Purulent infection
Answer: D
Flexor tenosynovitis (FTS) is a severe pathophysiologic state causing disruption of normal flexor tendon function in the hand.
A variety of etiologies are responsible for this process. Most acute cases of FTS are due to purulent infection.
FTS also can occur secondary to chronic inflammation as a result of diabetes, rheumatoid arthritis, crystalline deposition, overuse syndromes, amyloidosis, psoriatic arthritis, systemic lupus erythematosus, and sarcoidosis.
(See Schwartz 10th ed., pp. 1811–1812.)
The most common soft tissue tumor of the wrist
A. Mucous cyst
B. Ganglion cyst
C. Lipoma
D. Schwannoma
Answer: B
Ganglion cyst is the most common soft tissue tumor of the hand and wrist, comprising 50 to 70% of all soft tissue tumors in this region.
They can occur at any age but are most common in the second to fourth decades with a slight predilection toward females.
(SeeSchwartz10thed.,p.1815.)
