This practice set contains high-yield board review questions covering key concepts in 2. Trauma. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 2161
Topic: 2. Trauma
Following surgical fixation of an olecranon fracture, what is the *most common* long-term complication reported?
Correct Answer & Explanation
. Stiffness/loss of range of motion
Explanation
Correct Answer: DStiffness and loss of range of motion, particularly extension, is the most common long-term complication following olecranon fracture fixation, occurring in a significant percentage of patients. While nonunion (A), ulnar nerve neuropathy (B), infection (C), and hardware failure (E) can occur, elbow stiffness is a near-universal concern that requires diligent rehabilitation and patient compliance to minimize its impact.
Question 2162
Topic: 2. Trauma
A 48-year-old male sustains a comminuted intra-articular distal humerus fracture (AO/OTA 13-C3) after a high-energy fall. Clinical examination reveals significant swelling and tenderness, but no neurovascular deficits. Plain radiographs confirm the fracture pattern. Given the complexity and need for anatomical reduction, which surgical approach is generally considered the 'workhorse' for optimal visualization of the entire articular surface and both columns?
Correct Answer & Explanation
. Posterior approach with olecranon osteotomy
Explanation
Correct Answer: DFor complex, comminuted intra-articular distal humerus fractures (AO/OTA 13-C3), aposterior approach with an olecranon osteotomy(e.g., Chevron osteotomy) provides the most extensive and direct visualization of the entire distal humeral articular surface and both columns. This panoramic view is critical for achieving precise anatomical reduction of articular fragments and applying robust plate fixation. Without this level of exposure, accurate reduction of multiple small articular fragments can be extremely challenging, leading to poor functional outcomes and post-traumatic arthritis.Option A (Anterior approach)is generally reserved for specific fracture patterns like isolated capitellar fractures or for less complex supracondylar fractures, and does not provide adequate exposure for bicondylar C3 fractures.Option B (Medial approach)primarily exposes the medial column and is insufficient for comprehensive management of a bicondylar fracture.Option C (Lateral approach)primarily exposes the lateral column and capitellum, also insufficient for a C3 fracture.Option E (Triceps-sparing posterior approach), while avoiding an osteotomy, often provides a more limited visualization of the articular surface compared to an olecranon osteotomy, making it less ideal for severely comminuted intra-articular fractures where precise articular reduction is paramount.
Question 2163
Topic: 2. Trauma
Following open reduction and internal fixation (ORIF) of a bicondylar distal humerus fracture, a 68-year-old patient with known osteoporosis develops increasing pain and loss of reduction within the first few weeks post-operatively. Radiographs show screws backing out of the bone. What is the most likely cause of this early complication?
Correct Answer & Explanation
. Hardware pull-out due to poor bone quality
Explanation
Correct Answer: CIn osteoporotic patients, the primary concern for early mechanical complication after ORIF of a comminuted distal humerus fracture ishardware pull-out or failure. Poor bone quality provides inadequate purchase for screws, leading to loss of reduction and implant failure. This often necessitates specific techniques like locking plates, longer screws, and sometimes bone augmentation to achieve stable fixation. The scenario describes screws backing out, which is a direct manifestation of hardware pull-out.Option A (Infection)is a possible complication but typically presents with signs like erythema, warmth, drainage, and systemic symptoms, not primarily with hardware backing out.Option B (Heterotopic ossification)is a later complication that causes stiffness and new bone formation, not early hardware failure.Option D (Ulnar nerve entrapment)would cause neurological symptoms (paresthesia, weakness) rather than mechanical failure of the construct.Option E (Nonunion)is a failure of bone healing over a longer period (typically 6-9 months) and is not an early complication presenting within weeks with hardware pull-out.
Question 2164
Topic: 2. Trauma
A 35-year-old construction worker sustains a displaced intra-articular distal humerus fracture. Initial plain radiographs are obtained. What is the most crucial next step in the diagnostic workup to guide surgical planning for this type of injury?
Correct Answer & Explanation
. Order a CT scan with 3D reconstructions of the elbow
Explanation
Correct Answer: CFor intra-articular distal humerus fractures, aCT scan with 3D reconstructionsis crucial for operative planning. Plain radiographs often underestimate the degree of articular comminution, displacement, and the exact morphology of the fracture fragments. The CT scan provides detailed information about fragment size, location, and the extent of articular involvement, which is essential for guiding the choice of surgical approach, the sequence of reduction, and the fixation strategy. This detailed understanding helps the surgeon achieve anatomical reduction and stable fixation.Option A (Immediate surgical exploration and ORIF)without a CT scan is suboptimal, as it risks encountering unexpected fracture patterns that could prolong surgery or compromise the outcome.Option B (Application of a long-arm cast)is inappropriate for displaced intra-articular fractures, as it will not achieve or maintain anatomical reduction, leading to poor function and post-traumatic arthritis.Option D (Begin immediate active range of motion exercises)is contraindicated pre-operatively for a displaced fracture, as it could worsen displacement and soft tissue injury.Option E (Perform an MRI)is excellent for soft tissue and ligamentous injury but provides less detail on complex bony architecture than a CT scan, making it less critical for initial surgical planning of the fracture itself.
Question 2165
Topic: 2. Trauma
A 72-year-old female with a sedentary lifestyle and multiple medical comorbidities (including severe osteoporosis) presents with a highly comminuted, unreconstructible intra-articular distal humerus fracture (AO/OTA 13-C3). She desires pain relief and the ability to perform basic activities of daily living. What is the most appropriate surgical treatment option for this patient?
Correct Answer & Explanation
. Total elbow arthroplasty (TEA)
Explanation
Correct Answer: DFor elderly, low-demand patients with severe osteoporosis and highly comminuted, unreconstructible intra-articular distal humerus fractures,Total Elbow Arthroplasty (TEA)is an increasingly accepted and often preferred option. TEA provides immediate stability, allows for early range of motion, and typically results in good pain relief and functional outcomes for basic activities of daily living. Attempting ORIF in such a scenario often leads to poor fixation due to bone quality, high rates of nonunion, and prolonged rehabilitation with a high risk of stiffness.Option A (Aggressive ORIF)is often technically challenging and prone to failure in severe osteoporosis and comminution, especially in the elderly.Option B (Non-operative management)for an unreconstructible, displaced intra-articular fracture would lead to severe malunion, pain, and extremely poor function.Option C (Elbow arthrodesis)results in a stiff elbow, which is highly disabling for activities of daily living and generally reserved for specific indications like chronic infection or failed TEA in younger, high-demand patients.Option E (Excision arthroplasty)creates a flail, unstable, and often painful elbow, which is rarely performed today due to poor outcomes.
Question 2166
Topic: 2. Trauma
A patient undergoes ORIF of a distal humerus fracture. Six months post-operatively, radiographs show stable hardware but no evidence of bony bridging across the fracture site, and the patient reports persistent pain and limited function. This clinical and radiographic presentation is most consistent with which complication?
Correct Answer & Explanation
. Nonunion
Explanation
Correct Answer: CThe scenario describes a fracture that has not healed after a reasonable period (6 months post-ORIF), with stable hardware but no radiographic signs of bony union, accompanied by persistent pain and limited function. This is the classic definition and presentation of anonunion. A nonunion is a failure of a fracture to heal after a sufficient time period, typically considered 6-9 months, with no further signs of progression towards healing.Option A (Malunion)refers to a fracture that has healed, but in an anatomically unacceptable position (e.g., angulation, rotation, shortening), leading to deformity and functional impairment.Option B (Heterotopic ossification)involves the formation of new bone in soft tissues where bone does not normally exist, leading to stiffness and pain, but not necessarily a failure of the fracture itself to unite.Option D (Chronic infection)would typically present with signs such as persistent drainage, erythema, warmth, and possibly systemic symptoms, which are not mentioned as primary complaints.Option E (Hardware failure)would be evident on radiographs as broken plates, bent screws, or screws pulled out of the bone, which is distinct from stable hardware without union.
Question 2167
Topic: 2. Trauma
What is the primary biomechanical principle that makes orthogonal plating (e.g., a medial plate and a posterior/posterolateral plate) a superior construct for complex bicondylar distal humerus fractures compared to parallel plating?
Correct Answer & Explanation
. It provides multiplanar stability, resisting axial, varus/valgus, and torsional forces.
Explanation
Correct Answer: CThe primary biomechanical advantage of orthogonal plating (typically a medial plate and a posterior or posterolateral plate) for bicondylar distal humerus fractures is that it providesmultiplanar stability, resisting axial, varus/valgus, and torsional forces. By placing plates at approximately 90 degrees to each other (relative to the distal humerus, not necessarily the bone's long axis), the construct effectively buttresses both columns and provides robust resistance to the complex forces acting on the elbow. This enhanced stability is crucial for allowing early range of motion and preventing loss of reduction in comminuted fractures.Option A (Less rigid fixation)is incorrect; orthogonal plating aims for rigid fixation to allow early motion.Option B (Simplifies plate contouring)is generally incorrect; contouring two plates in an orthogonal fashion can be more challenging than parallel plating, depending on the fracture morphology.Option D (Maximizes interfragmentary compression)is a goal of fracture fixation, but it's not theprimaryunique advantage of orthogonal plating over other stable constructs; rather, it's the multiplanar stability that sets it apart.Option E (Reduces implant weight)is not a primary biomechanical principle or advantage of orthogonal plating; the total weight of two plates is generally similar to two parallel plates.
Question 2168
Topic: 2. Trauma
A 28-year-old male sustains an open distal humerus fracture (Gustilo Type II) after a motorcycle accident. He is hemodynamically stable. What is the most critical initial management step once the patient is in the emergency department?
Correct Answer & Explanation
. Emergent surgical debridement, copious irrigation, and intravenous broad-spectrum antibiotics.
Explanation
Correct Answer: CFor an open fracture, the most critical initial management step, once the patient is hemodynamically stable, isemergent surgical debridement, copious irrigation in the operating room, and the administration of broad-spectrum intravenous antibiotics. This is a surgical emergency aimed at minimizing contamination, removing devitalized tissue, and reducing the high risk of deep infection, which can be devastating for limb salvage and function. The 'golden period' for debridement is typically considered to be within 6 hours of injury.Option A (Oral antibiotics and discharge)is completely inadequate for an open fracture and would lead to severe infection.Option B (Splint and physical therapy)is insufficient; while splinting is part of initial stabilization, it does not address the open wound or infection risk.Option D (Primary wound closure)is generally contraindicated for open fractures, especially Gustilo Type II or higher, as it can trap bacteria and increase infection risk. Wounds are often left open for delayed primary closure or secondary healing after repeat debridements.Option E (MRI)is not an emergent diagnostic modality for an acute open fracture; the priority is infection control and surgical debridement.
Question 2169
Topic: 2. Trauma
In the early post-operative period (first 3-7 days) following stable open reduction and internal fixation (ORIF) of a distal humerus fracture, what is the primary goal of rehabilitation?
Correct Answer & Explanation
. Initiate early active range of motion (AROM) exercises to prevent stiffness.
Explanation
Correct Answer: CWith stable open reduction and internal fixation (ORIF) of a distal humerus fracture, the primary goal in the early post-operative period (typically within the first week) is toinitiate early active range of motion (AROM) exercises. This is crucial for preventing debilitating elbow stiffness, which is a very common and challenging complication after distal humerus fractures. The stability achieved by rigid internal fixation allows for controlled motion without jeopardizing the fracture healing.Option A (Achieve full elbow extension)is an eventual goal, but attempting it immediately is unrealistic and potentially harmful.Option B (Resisted strengthening exercises)are introduced much later in the rehabilitation process (typically 6-12 weeks), once significant bone healing has occurred.Option D (Rigid immobilization for 6 weeks)would almost certainly lead to severe elbow stiffness and is generally avoided after stable ORIF.Option E (CPM for 12 hours daily)is a modality that can be used, but the primary goal is active patient participation in motion, and CPM is not universally indicated or the sole focus of early rehab.
Question 2170
Topic: 2. Trauma
A 35-year-old male sustains a high-energy blunt trauma to his shoulder resulting in an isolated scapula fracture. Which of the following parameters represents a generally accepted absolute or relative indication for operative reduction and internal fixation of a scapular body or neck fracture?
Correct Answer & Explanation
. Medialization of the lateral border of the scapula by > 20 mm
Explanation
Operative indications for scapula neck and body fractures include > 20 mm of medial translation, > 45 degrees of angular deformity, a glenopolar angle < 22 degrees, or severe intra-articular glenoid displacement > 5 mm.
Question 2171
Topic: 2. Trauma
A 28-year-old male sustains a midshaft clavicle fracture. Which of the following fracture characteristics or patient demographics has the highest predictive value for the development of a nonunion if managed nonoperatively?
Correct Answer & Explanation
. Fracture displacement > 100% (lack of cortical contact)
Explanation
Risk factors for nonunion in nonoperatively managed midshaft clavicle fractures include completely displaced fractures (> 100% displacement), significant comminution, advanced age, female sex, and smoking.
Question 2172
Topic: 2. Trauma
A 65-year-old female presents with a displaced 4-part proximal humerus fracture.
Which of the following arteries is currently recognized in the literature as providing the predominant blood supply to the humeral head, and is most critical to evaluate for disruption regarding avascular necrosis risk?
Correct Answer & Explanation
. Posterior humeral circumflex artery (PHCA)
Explanation
Recent perfusion studies have challenged the traditional teaching that the AHCA is the primary supply, demonstrating instead that the posterior humeral circumflex artery (PHCA) provides up to 64% of the blood supply to the humeral head.
Question 2173
Topic: 2. Trauma
A 30-year-old male sustains a Holstein-Lewis fracture of the distal third of his humerus. He demonstrates an inability to extend his wrist and fingers upon presentation. At what specific anatomic location is the nerve most commonly entrapped or injured in this fracture pattern?
Correct Answer & Explanation
. As it pierces the lateral intermuscular septum from the posterior to the anterior compartment
Explanation
A Holstein-Lewis fracture is a spiral fracture of the distal third of the humeral shaft. The radial nerve is tethered as it pierces the lateral intermuscular septum, making it uniquely susceptible to entrapment or laceration between the fracture fragments.
Question 2174
Topic: 2. Trauma
A 60-year-old female undergoes tension band wiring for a displaced transverse olecranon fracture. Six months postoperatively, her fracture is healed, but she complains of focal pain at the surgical site. What is the most common complication following tension band wiring of the olecranon?
The most common complication of tension band wiring for olecranon fractures is symptomatic prominent hardware due to the subcutaneous nature of the proximal ulna, requiring removal in up to 40-80% of patients.
Question 2175
Topic: 2. Trauma
A 45-year-old male sustains a Bado Type I Monteggia fracture-dislocation. What is the most appropriate definitive management strategy for this adult patient?
Correct Answer & Explanation
. Open reduction and rigid internal fixation of the ulnar shaft, with indirect or direct reduction of the radial head
Explanation
Unlike pediatric Monteggia injuries which may be treated closed, adult Monteggia fractures mandate open reduction and rigid plate fixation of the ulna. Anatomic restoration of ulnar length and alignment typically results in spontaneous reduction of the radial head.
Question 2176
Topic: 2. Trauma
A 22-year-old male sustains a scaphoid fracture after a fall on an outstretched hand. Which of the following anatomic locations of the scaphoid has the highest inherent risk of progressing to a nonunion and avascular necrosis?
Correct Answer & Explanation
. Proximal pole
Explanation
The scaphoid receives its primary blood supply retrogradely via branches of the radial artery entering the dorsal ridge near the waist. Therefore, proximal pole fractures have the poorest blood supply and the highest rates of avascular necrosis and nonunion.
Question 2177
Topic: 2. Trauma
A 32-year-old male is involved in a high-speed motorcycle collision. He sustains an isolated, displaced scapular body fracture. Which of the following parameters is an accepted indication for operative fixation of a scapular body fracture?
Correct Answer & Explanation
. Medial/lateral displacement > 20 mm
Explanation
Operative indications for extra-articular scapula fractures include medial/lateral displacement > 20 mm, glenopolar angle < 22 degrees, and angular deformity > 45 degrees.
Question 2178
Topic: 2. Trauma
A 65-year-old female sustains a comminuted intra-articular distal humerus fracture. The surgeon elects to perform an open reduction internal fixation (ORIF) via a posterior approach with an olecranon osteotomy. Which of the following is the most common complication specifically associated with this surgical approach?
Correct Answer & Explanation
. Symptomatic hardware at the osteotomy site
Explanation
While all listed are potential complications, symptomatic hardware at the osteotomy site is the most common complication specific to the olecranon osteotomy approach, often requiring hardware removal once healed. Osteotomy nonunion is relatively rare when proper tension band or plate fixation techniques are utilized.
Question 2179
Topic: 2. Trauma
A 25-year-old male sustains a minimally displaced fracture of the scaphoid waist. He opts for non-operative management with cast immobilization. The scaphoid is at high risk for nonunion and avascular necrosis due to its tenuous blood supply. The primary blood supply to the proximal pole of the scaphoid is derived from which of the following?
Correct Answer & Explanation
. Dorsal carpal branches of the radial artery entering the dorsal ridge
Explanation
The primary blood supply to the scaphoid comes from the dorsal carpal branch of the radial artery, which enters at the dorsal ridge (waist/distal pole region) and flows in a retrograde fashion to the proximal pole. This retrograde perfusion is why proximal pole fractures have a higher rate of avascular necrosis.
Question 2180
Topic: 2. Trauma
A 55-year-old female presents with a displaced proximal humerus fracture after a fall. According to Hertel's radiographic criteria, which of the following isolated features is the strongest predictor of humeral head ischemia?
Correct Answer & Explanation
. Metaphyseal extension (calcar length) less than 8 mm
Explanation
Hertel identified a metaphyseal extension (calcar length) of less than 8 mm, a disrupted medial hinge (greater than 2 mm), and an anatomic neck fracture pattern as the strongest predictors of humeral head ischemia. An intact medial hinge and longer calcar length are protective.
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