Module III

In the language of fracture diagnosis, list common descriptive opposites (fill in the blank).

Example: Angulated versus Nonangulated

1. __________________ versus nondisplaced.

2. Compound versus ____________________.

3. Open versus _________________________.

4. Only two fragments versus __________________________ (descriptive term for more than two fragments).

True or False

T F 5. The Salter Classification System is a method of classifying fractures based on the anatomy of metaphysis, epiphysis, and the growth plate.

T F 6. A comminuted fracture is a fracture in which the bone fragments are not distracted.

T F 7. Descriptive terms form the basis of fracture management and prognosis.

T F 8. Compound fractures are fractures where the bone has been broken into more than two

pieces.

T F 9. Torus fractures frequently present as either transverse or oblique fractures of the bone

shaft.

T F 10. In terms of fracture complexity/severity, a Salter V is worse than a Salter I fracture.

T F 11. Nondisplaced, nonangulated fractures presenting with a normal neurovascular exam

may require operative management in as many as 20% to 30% of cases.

T F 12. Transverse fractures are equally or slightly less stable than spiral fractures.

T F 13. Subluxation could be described as a partial dislocation.

14. Recently published decision analysis studies on the indications for ordering or not order x-rays in cases of suspected ankle fracture have agreed that a “significant “ fracture would be defined as a fracture fragment greater than: (please circle one)

a. 1 mm c. 3 mm e. 5 mm

b. 2 mm d. 4 mm

Module IV

Needs Assessment (Feedback available by request) (Also, For Planning Elective Experiences)

15. The most commonly fractured bone in the body is:

a. The radius.

b. The ulna.

c. The clavicle.

d. The tibia.

e. None of the above.

16. Which is the most common bursitis in the body?

a. Olecranon bursitis.

b. Trochanteric bursitis (hip).

c. Pre-patellar.

d. Sacroiliac.

e. None of the above.

17. T F Palpation of the anatomical “snuff box” provides evidence for a possible fracture of

the hamate.

18. Which of the following facts are true regarding steroid injections?

a. Generalist physicians can acquire the skills to aspirate and inject most joints.

b. Joint injections with steroids rarely cause infections (less than 0.1%).

c. Systemic side-effects of joint injections are rare.

d. A good guideline to follow is to limit steroid injections, especially in weight bearing joints, to a total of three per joint unless consultation has been attained.

e. All of the above.

19. Which of the following would be the optimal combinations for doing shoulder injections?

a. 19 gauge needle, 5cc of 1% xylocaine with epinephrine, 0.5 to 1cc celestone.

b. 23 gauge needle, 0.5 to 1cc of celestone.

c. 23 gauge needle, 5cc of 1% xylocaine without epinephrine, 0.5 to 1cc of celestone.

d. 30 gauge needle, 5cc of 1% xylocaine without epinephrine, 0.5 to 1cc of celestone.

e. None of the above.

20. Circle the conditions where steroid injections may be indicated.

a. Rotator cuff tendonitis.

b. In-grown toenails.

c. Tennis elbow.

d. Non-healing fracture of radius.

e. Trigger points.

f. Plantar fascitis.

g. Sebaceous cyst.

21. Digital blocks can be accomplished with all but which of the following?

a. 1% xylocaine.

b. 2% xylocaine.

c. 0.5% Mepivicaine.

d. 1% xylocaine with epinephrine.

22. T F Flexor tendon injuries in the palm can easily be repaired in the office.

23. T F Mallet finger injuries should be splinted at 20 degree angle.

24. T F Immobilization of a lateral collateral ligament injury of the ankle should be treated with a short leg walking cast with a walking heel.

25. Pain caused by a cast being too snug can be relieved by which of the following:

a. “Windowing.”

b. Bivalving.

c. Removing the cast.

d. All of the above.

e. None of the above.

26. T F “Air-cast” is considered appropriate treatment for management of painful and severe

ankle sprains.

27. T F In general, the joint immediately proximal to a distal fracture should be immobilized.

28. T F Shin splints can be well managed with oral medication and physical therapy.

29. T F Simple, nondisplaced, nonangulated fibular fractures can be treated exclusively using

orthopedic braces, thereby allowing continued ambulation.

30. T F Risk of athletic injuries to the ankle can be decreased by pre-activity taping.

31. T F Splinting an injured digit should be done in full extension.

32. Purposes of adhesive strapping include which of the following?

a. Protection and securing of protective devices.

b. Support and stabilization.

c. Limitation of motion.

d. Holding dressings in place.

e. All of the above.

f. None of the above.

Module V

Joint and Soft Tissue Injections. Choose the single best answer.

33. DeQuervain’s disease or stenosing tenosynovitis.

a. Is not helped by injection therapy.

b. Primarily affects the radial artery and nerve.

c. Usually involves the flexor tendons of the thumb.

d. Can be confirmed by Finkelstein’s test (clasping the thumb in the palm with ulnar deviation of the wrist).

34. After withdrawing a large effusion from the knee joint, corticosteroid injection generally is accomplished by:

a. Withdrawing the aspiration needle and syringe and inserting a second needle attached to the injection syringe.

b. Placing a needle into the opposite side of the knee joint.

c. Stabilizing the needle with a hemostat, removing the aspiration syringe, and attaching a medication syringe to the needle.

d. Removing the plunger from the syringe and pouring the medication into the syringe attached to the needle still within the joint.

35. Ganglions on the dorsum of the wrist.

a. May be palliated or reduced in size by drainage and injection of corticosteroids.

b. Represent a contraindication to wrist joint injection.

c. Require high doses of intralesional corticosteroids.

d. Generally can be aspirated using a 32 gauge needle.

36. Femoral trochanteric bursitis.

a. Produces enough hip pain to make 50% of patient’s limp at the time of presentation.

b. Responds well to injection of 40 mg of methylprednisolone acetate and 2-3 cc of 2% xylocaine into the bursa.

c. Produces pain over the pubic symphysis.

d. Does not produce lateral leg pain extending distally to the knee.

37. Therapeutic goals for a joint injection include all of the following except:

a. Provide rapid pain relief in an affected joint.

b. Achieve chemical suppression of the inflammatory response.

c. Provide the benefits of corticosteroids without many of the side effects of systemic corticosteroid therapy.

d. Induce long-lasting total body remission of severe systemic arthritis.

38. Practical ways to avoid tendon rupture or cartilage injury when performing arthrocentesis and therapeutic injections include all of the following except:

a. Performing the procedures with large, 14-16 gauge needles.

b. Avoid injecting directly into a tendon, placing medication instead in the tendon sheath.

c. Only injecting against low resistance (the plunger moves easily when administering the medication).

d. Limiting injection into any structure to no more than three times a year.

39. Proper management of olecranon bursitis generally involves.

a. Drainage of the bursa with a 6 cm transverse incision.

b. Aspiration to exclude infection before corticosteroid injection.

c. Corticosteroid injection without removing any fluid.

d. Placement of a long-arm cast.

40. All of the following statements about large knee effusions are true except.

a. Removal of the effusion can provide immediate pain relief.

b. Corticosteroid injection may reduce the inflammatory process.

c. It is very dangerous to apply pressure to the opposite side of the knee to push fluid toward the point of entry of the needle.

d. Bloody effusions after injury can indicate cartilage injury or fracture.

41. Lateral epicondylitis:

a. Should be referred to an orthopedic specialist for appropriate care.

b. Is also known as pitcher’s elbow or golfer’s elbow.

c. Can be treated with corticosteroid administration into the extensor aponeurosis and radial collateral ligament.

d. Produces pain with flexion of the PIP joint of the thumb against resistance.

Module VI

Case A

A 17-year-old black female passenger in a MVA is brought to your 100-bed hospital ED. The estimated speed of impact was 50 mph, and the impact was on the passenger side. Patient denies LOC and has no remarkable physical findings except for unrelenting severe pain especially on movement of the right leg. For the purposes of discussion of this case, assume that all laboratory and all x-rays are normal with the exception of the views presented. Vital signs are normal.

42. The images are digitized and transported to an orthopedic consultant. He gives his opinion that this is not an operative case. He describes the fracture as a nondisplaced fracture of the right inferior pubic ramus with an extension into the acetabulum. Please describe the best management of this case from the following choices.

A. Transfer by helicopter to referral hospital/ED 40 miles away.

B. Refer orthopedics consult 40 miles away (go by car).

C. Admit to your hospital service for observation and pain management with surgery/orthopedics consultation in the morning.

D. Discharge to home with visit from nurse in AM.

43. Regarding pain management for the first 24-hours, the following choices would be reasonable (more than one choice may be correct):

A. The patient controlled analgesia pump, if available.

B. Demerol 75mg to 125mg IM q3h prn nursing judgment.

C. Demerol 75mg to 125 mg IV q3h prn nursing judgment.

D. Demerol 50mg IM q3-4h prn.

E. All of the above.

F. None of the above.

EXTRA CREDIT

45. T F I have read the handout on the Language of Fractures from beginning to end.

46. T F “The incorrect use of language not only is a fault unto itself, it also corrupts the

soul.” –Socrates- (Knowledge begins with good definitions—WMR)