JPOSNA May 2023: Trauma Quiz

Quiz Authors

Patrick Bosch, MD1; Philip McClure, MD2; Z. Deniz Olgun, MD3; Benjamin W. Sheffer, MD4; Trauma, Prevention, and Disaster Response Committee

1Alburquerque, NM; 2Rubin Institute for Advanced Orthopedics, International Center for Limb Lengthening at Sinai Hospital, Baltimore, MD; 3Pediatric Orthopaedic Division, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; 4Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN

Quiz Authors

Patrick Bosch, MD1; Philip McClure, MD2; Z. Deniz Olgun, MD3; Benjamin W. Sheffer, MD4; Trauma, Prevention, and Disaster Response Committee

1Alburquerque, NM; 2Rubin Institute for Advanced Orthopedics, International Center for Limb Lengthening at Sinai Hospital, Baltimore, MD; 3Pediatric Orthopaedic Division, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; 4Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN

An 8-year-old female suffers a femur fracture (Figure A) that was treated with plate fixation (Figure B). At four months, she had her implant removed (Figure C); one week later she fell during gymnastics and had a recurrent fracture (Figure D) that was treated with repeat ORIF with a plate. Six months later, her refracture is healed, but she is unhappy with gait/function and has vague leg pain with activities. Standing radiographs (Figure E) were obtained. The next best step in her evaluation or treatment is:

Fig. A
Fig.-A
Fig. B
Fig. B
Fig. C
Fig. C
Fig. D
Fig. D
Fig. E
Fig. E
A. Removal of plate and protected weight bear for three months
C. CT scan of lower extremities to document rotational alignment
B. Lateral distal femoral hemi-epiphysiodesis for slight genu varum
D. Dedicated pelvis x-rays to document acetabular dysplasia and consider PAO

A 6-year-old female fell onto her outstretched arm off balance beam and sustained injury to right arm (Figure A). She was taken to the operating room for surgical treatment. After the ulna was anatomically open reduced, a long Steinmann pin was placed to hold the reduction (Figure B). Intra-operative fluoroscopic image in supination was assessed (Figure C and D). The next step in her care is:

Fig. A

Fig, A

Fig. B

FigB

Fig. C

Q2. Fig. C

Fig. D

Q2. Fig. D

 

A. Open reduction of the radial-capitellar joint and repair of annular ligament
D. Removal of pin and anatomically plating ulna
B. Accepting reduction and casting in supination and hyperflexion
E. Pin across the radial-capitellar joint to hold reduction
C. Casting in supination and extension

A 16-year-old male dislocated his left hip after a football game pile up. A closed reduction was achieved under conscious sedation and post reduction radiographs (Figure A) and CT scan was obtained (Figure B and C). The next step in management of this injury is:

Fig. A

Fig. A

Fig. B

Fig. B

Fig. C

Fig. C

 
A. Posterior approach and ORIF of the acetabular fracture
D. Surgical hip dislocation (digastric osteotomy of the greater trochanter) allowing exposure of femoral head and reduction of posterior acetabulum
B. Application of hip abduction orthosis and strict use of THR precautions to avoid re-dislocation
E. MRI with contrast to document interposition of capsule/cartilage and then conservative management if no capsule is present in joint
C. Anterior approach with ORIF of the femoral head. Posterior approach to acetabulum if unstable after fixation

A 15-year-old boy was involved in a high-speed motor vehicle crash. He sustained an open comminuted tibia fracture (Figure A). He was admitted to the Neuro ICU with a GCS score of 5 with elevated intracranial pressures (ICPs) and an extra-ventricular drain was placed. Finally stable on post injury day 6, he was taken to the operating room for debridement and a 2x7 cm segment of de-vascularized bone was removed while the skin was able to be closed.    

What fixation method will be optimal for extended ICU cares while simultaneously minimizing intracranial pressure and risk of deep local infection?

Fig. A

Fig. A

 
A. Definitive treatment in long leg cast
D. Stabilization with an external fixator and delayed bone grafting when stable
B. Intramedullary nailing with flexible nails and BMP sponges placed at defect
E. Open reduction and plate fixation of the tibia with acute bone grafting and use of local vancomycin powder
C. Acute shortening with rigid intramedullary fixation

A 4-year-old male fell on the outstretched hand on the playground and sustained the injury seen in the below radiographs. Which of the following imaging modalities would add the most information to the diagnosis of this patient’s injury?  

Fig. A

Fig. A

Fig. B

Fig. B

A. Ultrasound
D. MRI elbow without contrast
B. Plain films of the contralateral side
E. 3D CT
C. Distal humerus “axial” view plain film

A 17-year-old healthy right-hand-dominant female sustains the below injury (Figure A and B) in the setting of polytrauma she elects to undergo operative fixation. Which of the following methods has been determined to have lower rates of reoperation due to fixation failure and/or implant irritation?

Fig. A

Fig. A

Fig. B

Fig. B

A. ORIF with 3.5 mm pre-contoured plate
D. ORIF with hook plate
B. K-wire fixation
E. Titanium elastic nail fixation
C. Dual-plating with modular mini-fragment plates
A 14-year-old female presents with left leg and ankle pain after attempting to slide foot first into home plate during her softball game. Radiographs are depicted in Figure A and select computerized tomography (CT) scan images are depicted in Figure B. She is neurovascularly intact and her pain is well controlled. What is the most appropriate method of treatment?
 
Fig. A-1
Fig. A-1
Fig. A-2
Fig. A-2
Fig. B-1
Fig. B-1
Fig. B-2
Fig. B-2
Fig. B-3
Fig. B-3
A. Submuscular plating of tibia fracture with internal rotation of foot to reduce Tillaux fragment
B. Long leg bivalved cast for one month then short leg cast
C. Flexible intramedullary nailing of tibia shaft fracture and the fibula
D. Rigid intramedullary nailing of the tibia shaft fracture with closed treatment of the ankle fracture
E. Rigid intramedullary nailing of the tibia shaft fracture with open reduction internal fixation of the ankle fracture
A 17-year-old male presents with a right knee injury after colliding his electric scooter with a parking meter. He was unable to ambulate on the scene. EMS reports right knee deformity with nonpalpable pedal pulses so he was placed into a traction device. Radiographs are depicted in Figure A and B. On arrival to the emergency department, he complains of isolated right knee pain. On exam, he has right knee tenderness and swelling, 5/5 strength with intact sensation distally, no pain with passive stretch, and his foot is cold and pale. What is the best next step in management?
 
 
Fig. A
Fig. A
 
Fig. B
Fig. B
A. Long leg cast application
B. Splinting and serial neurovascular exams
C. Emergent plate fixation and send to vascular lab for angiogram
D. Emergent CRPP with intraoperative vascular consultation
E. Splint in ED with MRI/MRA
A 13-year-old right-hand dominant female sustains the below pictured fracture (Figure A-C) in a fall during basketball. The next best step in treatment is:
 
Fig. A
Fig. A
Fig. B
Fig. B
Fig. C
Fig. C
A. Closed reduction in ED and shoulder spica cast
B. Open reduction and coaptation splint to prevent physeal arrest
C. Open reduction and plate fixation
D. MRI to assess for biceps tendon interposition
E. Closed reduction and flexible nail fixation
0
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