This practice set contains high-yield board review questions covering key concepts in Upper Extremity Trauma. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 261
Topic: Upper Extremity Trauma
A 28-year-old cyclist falls directly onto his shoulder. Radiographs demonstrate superior displacement of the distal clavicle by 150% relative to the acromion. Which ligaments must be completely disrupted in this injury pattern?
Correct Answer & Explanation
. Acromioclavicular ligaments only
Explanation
A Type III or greater acromioclavicular (AC) joint separation features complete disruption of both the AC ligaments and the coracoclavicular (CC) ligaments, leading to significant superior clavicle displacement.
Question 262
Topic: Upper Extremity Trauma
An 18-month-old girl presents with a painless limp. Examination reveals a positive Galeazzi sign and limited abduction of the right hip. Radiographs confirm a developmental dislocation of the right hip. What is the most appropriate initial surgical management?
Correct Answer & Explanation
. Pavlik harness application
Explanation
In children over 18 months of age with a completely dislocated hip, open reduction is generally required. Pelvic and/or femoral osteotomies are frequently added to correct secondary bony dysplasia and stabilize the joint.
Question 263
Topic: Upper Extremity Trauma
A newborn is examined in the nursery. The examiner places the infant's hips in 90 degrees of flexion and gently abducts them while applying an anteriorly directed force on the greater trochanter, resulting in a palpable "clunk." What is this provocative test called?
Correct Answer & Explanation
. Barlow maneuver
Explanation
The Ortolani maneuver reduces a dislocated hip by elevating the greater trochanter and abducting the hip. The Barlow maneuver attempts to dislocate a reducible hip by applying posterior force during adduction.
Question 264
Topic: Upper Extremity Trauma
A 30-year-old male cyclist falls directly on his shoulder. Radiographs reveal a Type V acromioclavicular (AC) joint injury. Which of the following accurately describes the pathologic anatomy of this injury pattern?
Correct Answer & Explanation
. Sprain of the AC ligaments with intact coracoclavicular (CC) ligaments
Explanation
A Type V AC joint injury involves complete disruption of both the AC and CC ligaments along with the deltotrapezial fascia, resulting in >100% (and up to 300%) superior displacement of the clavicle relative to the acromion.
Question 265
Topic: Upper Extremity Trauma
A 28-year-old cyclist crashes over his handlebars and lands on his shoulder point. Radiographs reveal an acromioclavicular (AC) joint separation with the distal clavicle displaced superiorly by 150% compared to the acromion. Which two ligaments are primarily disrupted in this injury?
Correct Answer & Explanation
. Coracoacromial and acromioclavicular ligaments
Explanation
A Type III or higher AC separation involves complete disruption of both the acromioclavicular ligaments and the coracoclavicular (CC) ligaments. The CC ligaments consist of the medially based conoid ligament and the laterally based trapezoid ligament.
Question 266
Topic: Upper Extremity Trauma
A 24-year-old male falls directly onto his shoulder. Examination shows a prominent distal clavicle, and radiographs confirm a Rockwood Type V acromioclavicular (AC) joint separation with 150% superior displacement. What is the recommended management?
Correct Answer & Explanation
. Broad arm sling for 6 weeks
Explanation
Type V AC joint injuries, characterized by severe superior displacement and stripping of the deltotrapezial fascia, generally require surgical reconstruction of the coracoclavicular ligaments to restore anatomy and function.
Question 267
Topic: Upper Extremity Trauma
A 25-year-old male falls directly onto his acromion. Radiographs reveal 150% superior displacement of the distal clavicle relative to the acromion, and an axillary view shows the clavicle displaced posteriorly into the trapezius fascia. What is the Rockwood classification of this acromioclavicular joint injury?
Correct Answer & Explanation
. Type II
Explanation
A Rockwood Type IV AC joint injury is characterized by posterior displacement of the distal clavicle into or through the trapezius fascia. Type V injuries feature >100-300% superior displacement but without the hallmark posterior fascial displacement seen in Type IV.
Question 268
Topic: Upper Extremity Trauma
The coracoclavicular ligament complex is crucial for acromioclavicular joint stability. Which of the following describes the specific biomechanical function of the conoid ligament?
Correct Answer & Explanation
. Primary restraint to superior displacement of the clavicle
Explanation
The conoid ligament is the primary restraint to superior clavicular displacement. The trapezoid ligament is positioned anterolateral to the conoid and provides resistance against posterior translation and axial compression.
Question 269
Topic: Upper Extremity Trauma
In an acromioclavicular (AC) joint dislocation, the coracoclavicular (CC) ligaments are disrupted. Which of the following describes the correct anatomy and primary biomechanical function of the conoid ligament?
Correct Answer & Explanation
. It is located lateral to the trapezoid and primarily resists anterior clavicular translation
Explanation
The conoid ligament is the medial and posterior component of the CC ligament complex. It acts as the primary restraint to superior translation of the distal clavicle.
Question 270
Topic: Upper Extremity Trauma
A 22-year-old rugby player sustains an acromioclavicular (AC) joint separation. During surgical reconstruction, the surgeon reconstructs the coracoclavicular (CC) ligaments. Which of the following accurately describes the anatomy of the native CC ligaments?
Correct Answer & Explanation
. The conoid ligament inserts anterolaterally on the clavicle.
Explanation
The conoid ligament inserts posteromedially on the clavicle and is the primary restraint to superior clavicular translation. The trapezoid ligament inserts anterolaterally and primarily resists axial compression of the AC joint.
Question 271
Topic: Upper Extremity Trauma
Historically, the anterior circumflex humeral artery was considered the primary blood supply to the humeral head. Based on modern quantitative cadaveric perfusion studies, which vessel is now recognized as providing the predominant blood supply to the articular segment of the proximal humerus?
Correct Answer & Explanation
. Anterior circumflex humeral artery
Explanation
Recent anatomical and perfusion studies have demonstrated that the posterior circumflex humeral artery provides the dominant blood supply (approximately 64%) to the humeral head, challenging older literature.
Question 272
Topic: Upper Extremity Trauma
A 35-year-old male sustains a Type III acromioclavicular (AC) joint separation requiring surgical reconstruction. To accurately recreate the coracoclavicular ligaments, the surgeon must identify their native footprints. What is the average distance from the distal end of the clavicle to the conoid and trapezoid tuberosities, respectively?
Correct Answer & Explanation
. 15 mm and 25 mm
Explanation
The conoid tuberosity is located approximately 45 mm medial to the distal clavicle, while the trapezoid tuberosity is more lateral, at roughly 30 mm. Anatomic reconstruction relies on accurate placement of these drill holes.
Question 273
Topic: Upper Extremity Trauma
A 30-year-old rugby player sustains an injury to his shoulder after falling directly onto the tip of his shoulder. Radiographs demonstrate a complete dislocation of the acromioclavicular (AC) joint with significant superior displacement of the clavicle, disrupting both the AC and coracoclavicular (CC) ligaments. The deltoid and trapezius muscles are detached from the distal clavicle. Which Rockwood classification type does this describe, and what is the MOST appropriate management?
Correct Answer & Explanation
. Type III; Closed reduction and sling immobilization
Explanation
The description of a complete dislocation of the AC joint with significant superior displacement of the clavicle, disruption of both AC and CC ligaments, AND detachment of the deltoid and trapezius muscles from the distal clavicle corresponds to a Rockwood Type V AC joint injury. This is a severe injury with gross instability. While Rockwood Type III injuries are often managed non-operatively, Types IV, V, and VI are generally treated surgically due to significant displacement and associated soft tissue disruption, leading to poor functional outcomes with non-operative management. Type IV involves posterior displacement of the clavicle through the trapezius. Type VI involves inferior displacement. For Type V, surgical stabilization, often involving CC ligament reconstruction or repair, is the recommended treatment to restore stability and function. Distal clavicle excision is typically for chronic AC joint arthritis, not acute instability.
Question 274
Topic: Upper Extremity Trauma
A 32-year-old male presents with profound elbow stiffness 5 months after surgical management of a terrible triad injury (radial head arthroplasty, LCL repair, coronoid fixation). Radiographs demonstrate heterotopic ossification (HO) bridging the radiocapitellar joint with mature, sharp cortical margins and distinct trabecular patterns. His clinical range of motion has plateaued despite aggressive therapy. What is the most appropriate management regarding surgical excision?
Correct Answer & Explanation
. Immediate excision, as waiting increases the risk of joint degeneration
Explanation
Historically, surgical excision of heterotopic ossification (HO) was delayed until 12-18 months when bone scans showed metabolic quiescence. However, contemporary evidence demonstrates that early excision (typically between 4 to 6 months) is safe and effective once the HO is radiographically mature (showing distinct trabeculae and sharp margins) and the patient's clinical range of motion has plateaued. Early excision allows for earlier rehabilitation and does not have an increased rate of recurrence compared to delayed excision, provided proper prophylaxis (NSAIDs or radiation) is used postoperatively.
Question 275
Topic: Upper Extremity Trauma
A 25-year-old hockey player sustains a direct blow to the superior aspect of his right shoulder. Clinical examination reveals marked prominence of the distal clavicle. Radiographs confirm a Type V acromioclavicular (AC) joint separation, with the clavicle displaced superiorly by 200% relative to the acromion. Which anatomical structure represents the primary static restraint to superior translation of the distal clavicle?
Correct Answer & Explanation
. Acromioclavicular ligaments
Explanation
The coracoclavicular (CC) ligaments, consisting of the conoid and trapezoid ligaments, act as the primary static restraints to superior and inferior translation of the clavicle relative to the scapula. The acromioclavicular (AC) ligaments are the primary restraints to anteroposterior translation. A Type V AC separation involves complete disruption of both the AC and CC ligaments, along with tearing of the deltotrapezial fascia, leading to severe superior displacement of the clavicle (100% to 300% of the contralateral side).
Question 276
Topic: Upper Extremity Trauma
A 31-year-old male bodybuilder feels a sudden, painful 'pop' in his anterior chest while performing a heavy bench press. He presents with extensive ecchymosis over the anterior axilla, swelling, and a loss of the normal anterior axillary fold contour. Examination reveals severe weakness in adduction and internal rotation of the humerus. Which of the following anatomical locations is the most common site of rupture for this injury?
Correct Answer & Explanation
. Sternal origin
Explanation
Pectoralis major ruptures almost exclusively occur in males lifting heavy weights, particularly during the eccentric phase of the bench press. The most common site of rupture is an avulsion of the tendon from its insertion on the proximal humerus (specifically, the lateral lip of the bicipital groove). The sternocostal head is most frequently involved, as it is subjected to maximal stretch during eccentric loading. Surgical repair via anatomic reattachment to the humerus using suture anchors or cortical buttons provides superior functional and cosmetic outcomes in young, active individuals compared to nonoperative treatment.
Question 277
Topic: Upper Extremity Trauma
During a posterior approach with an olecranon osteotomy for open reduction and internal fixation of a comminuted intra-articular distal humerus fracture (AO/OTA type 13C3), which of the following osteotomy configurations is recommended to optimize stability upon repair and minimize articular step-off?
Correct Answer & Explanation
. Transverse osteotomy at the center of the bare area
Explanation
When performing an olecranon osteotomy for distal humerus exposure, a chevron-shaped osteotomy with the apex directed distally (V-shape pointing toward the diaphysis) is recommended. The cut should be made in the center of the 'bare area' (the non-articular portion of the greater sigmoid notch). The distally directed apex provides maximal inherent stability against medial-lateral and rotational translation when compressed, facilitating anatomic restoration and rigid fixation at closure.
Question 278
Topic: Upper Extremity Trauma
A 30-year-old cyclist falls directly onto his shoulder. Clinical examination reveals significant superior displacement of the clavicle with a prominent step-off. Radiographs show superior displacement of the clavicle by 150% compared to the contralateral side.
According to the Rockwood classification, what specific anatomical disruption distinguishes this injury from a Type III AC joint separation?
Correct Answer & Explanation
. Disruption of the deltotrapezial fascia
Explanation
This patient has a Rockwood Type V acromioclavicular (AC) joint injury, which is defined by greater than 100% (up to 300%) superior displacement of the clavicle relative to the acromion. Both Type III and Type V injuries involve complete tears of the AC and CC ligaments. However, Type V is distinguished by the complete disruption and stripping of the deltotrapezial fascia from the distal clavicle. Type IV involves posterior displacement, and Type VI involves inferior displacement.
Question 279
Topic: Upper Extremity Trauma
During the biomechanical evaluation of the acromioclavicular (AC) joint complex, which specific ligamentous structure provides the primary restraint against superior displacement of the distal clavicle?
Correct Answer & Explanation
. Conoid ligament
Explanation
The coracoclavicular (CC) ligaments consist of the conoid and trapezoid ligaments. The conoid ligament is located more medially and posteriorly, and it provides the primary restraint to superior displacement of the clavicle. The trapezoid ligament is located more laterally and anteriorly, primarily resisting axial compression into the acromion. The AC capsular ligaments primarily provide restraint to anteroposterior translation.
Question 280
Topic: Upper Extremity Trauma
A 28-year-old cyclist falls directly onto his shoulder. Radiographs show superior displacement of the distal clavicle.
Measurements reveal the coracoclavicular distance is increased by 150% compared to the contralateral side. According to the Rockwood classification, what type of acromioclavicular (AC) joint injury is this, and what is the typical recommended management?
Correct Answer & Explanation
. Type III; urgent surgical repair
Explanation
A coracoclavicular (CC) distance increased by 100% to 300% relative to the contralateral side indicates a Rockwood Type V AC joint injury. This is accompanied by severe soft-tissue stripping, including detachment of the deltoid and trapezius from the distal clavicle. Unlike Type III injuries (up to 100% displacement), which are usually treated nonoperatively, Type V injuries generally require surgical reconstruction to restore shoulder biomechanics and relieve severe symptoms.
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