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2. Trauma MCQs

Practice Set 118 of 640

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 2341

Topic: 2. Trauma

A 60-year-old active female develops a symptomatic hypertrophic nonunion of a mid-shaft humeral fracture 8 months after treatment with a functional brace. Radiographs show abundant callus formation but a persistent fracture line and no bridging. She reports pain with activity and limited function. What is the most appropriate surgical management?

. Re-application of a functional brace with increased compression
. Intramedullary nailing without bone grafting
. Open reduction and internal fixation with a plate, decortication, and autogenous bone grafting
. External fixation with dynamic compression
. Percutaneous injection of corticosteroids

Correct Answer & Explanation

. Intramedullary nailing without bone grafting

Explanation

Correct Answer: BA hypertrophic nonunion is characterized by abundant callus formation, indicating that the fracture site has biological healing potential but lacks sufficient mechanical stability to bridge the fracture gap. In this scenario, the primary problem is mechanical, not biological. Therefore, the most appropriate surgical management is to provide rigid mechanical stability. Intramedullary nailing (Option B) is an excellent choice for hypertrophic nonunions of the humeral shaft. It provides a load-sharing, stable construct with minimal soft tissue disruption, which is ideal for stimulating the existing biological activity to bridge the gap. Since there is already abundant callus, bone grafting (which addresses biological deficiencies) is typically not required for hypertrophic nonunions.Re-application of a functional brace (Option A) is unlikely to be effective for an established nonunion. Open reduction and internal fixation with a plate, decortication, and autogenous bone grafting (Option C) is the gold standard foratrophicnonunions, where there is a biological deficiency and lack of callus. External fixation (Option D) is generally reserved for open fractures, infected nonunions, or as a temporary measure, not typically for definitive treatment of a closed hypertrophic nonunion. Percutaneous injection of corticosteroids (Option E) would inhibit bone healing and is contraindicated.

Question 2342

Topic: 2. Trauma

A 45-year-old male undergoes antegrade intramedullary nailing for a mid-shaft humeral fracture. Six months post-operatively, he complains of persistent shoulder pain, especially with overhead activities, and limited range of motion. Radiographs confirm union of the fracture. What is the most likely cause of his ongoing shoulder symptoms?

. Radial nerve irritation from the nail
. Nonunion of the humeral shaft
. Rotator cuff impingement or injury from the nail entry point
. Infection at the fracture site
. Distal locking screw loosening

Correct Answer & Explanation

. Rotator cuff impingement or injury from the nail entry point

Explanation

Correct Answer: CA well-recognized and common complication of antegrade intramedullary nailing for humeral shaft fractures is postoperative shoulder pain, stiffness, and rotator cuff impingement (Option C). The antegrade entry point for the nail typically involves breaching the rotator cuff (supraspinatus tendon) and potentially damaging the deltoid muscle. Hardware prominence at the entry site, or direct injury to the rotator cuff during insertion, can lead to chronic pain, impingement symptoms, and restricted shoulder motion, particularly with overhead activities, even after the fracture has healed. This is a significant disadvantage of antegrade nailing.Radial nerve irritation (Option A) is less common with IMN than with plating and would typically manifest as neurological symptoms in the forearm/hand, not shoulder pain. Nonunion (Option B) is ruled out by the question stating the fracture has united. Infection (Option D) would typically present with signs of inflammation, fever, and persistent pain, but not specifically shoulder impingement. Distal locking screw loosening (Option E) would cause pain at the fracture site or distal humerus, not typically shoulder pain or impingement.

Question 2343

Topic: 2. Trauma

A 28-year-old female sustains a closed, transverse mid-shaft humeral fracture. She is treated non-operatively with a functional brace. At 6 weeks follow-up, radiographs show the fracture has healed with 18 degrees of varus angulation and 2.5 cm of shortening. She has no pain and full functional use of her arm. Which of the following statements best describes this outcome?

. This is an unacceptable malunion requiring revision surgery.
. This is an acceptable outcome for non-operative management.
. The shortening is excessive and will lead to long-term functional deficit.
. The varus angulation is too severe and will cause shoulder impingement.
. This indicates a delayed union requiring further intervention.

Correct Answer & Explanation

. This is an acceptable outcome for non-operative management.

Explanation

Correct Answer: BFor closed humeral shaft fractures treated non-operatively, generally accepted radiographic outcomes include up to 20 degrees of angulation in any plane (varus/valgus, anterior/posterior) and up to 3 cm of shortening. In this patient, the fracture has healed with 18 degrees of varus angulation and 2.5 cm of shortening. Both of these measurements fall within the acceptable limits for non-operative management. Furthermore, the patient is asymptomatic with full functional use of her arm. Therefore, this is an acceptable outcome for non-operative management (Option B).Options A, C, and D are incorrect because the angulation and shortening are within the accepted parameters and the patient is asymptomatic. Malunion (Option A) would imply healing in an unacceptable position, which is not the case here. Excessive shortening (Option C) or severe angulation (Option D) would be true if the measurements exceeded the 3 cm or 20-degree thresholds, respectively. Delayed union (Option E) refers to a fracture that has not healed within the expected timeframe but still shows signs of healing, which is not applicable here as the fracture has united.

Question 2344

Topic: 2. Trauma

A 25-year-old male sustains a closed, transverse mid-shaft humeral fracture in a motor vehicle accident. He also has a severe traumatic brain injury (TBI) and is currently intubated and sedated in the ICU. He is expected to be non-ambulatory for an extended period. What is the optimal treatment for the humeral fracture in this polytrauma setting?

. Functional bracing, as it is non-invasive and avoids surgical risks.
. Hanging cast for alignment and pain control.
. Open reduction and internal fixation (ORIF) with a plate.
. Intramedullary nailing.
. Skeletal traction for 4-6 weeks.

Correct Answer & Explanation

. Intramedullary nailing.

Explanation

Correct Answer: DIn a polytrauma patient, especially one with a severe traumatic brain injury (TBI) who is intubated and non-ambulatory, early and stable fixation of long bone fractures is crucial. This strategy, often referred to as 'damage control orthopedics,' aims to minimize pain, facilitate nursing care (e.g., turning, hygiene), allow for easier transfers, reduce the risk of complications like pneumonia or pressure ulcers, and potentially mitigate the systemic inflammatory response, which can positively impact TBI recovery. Non-operative methods like functional bracing (Option A) or a hanging cast (Option B) are generally unsuitable for uncooperative, sedated, or non-ambulatory TBI patients, as maintaining reduction and alignment would be extremely challenging and lead to poor outcomes.Both open reduction and internal fixation (ORIF) with a plate (Option C) and intramedullary nailing (Option D) are viable surgical options. However, intramedullary nailing is often preferred in this setting. IMNs are load-sharing devices, which can allow for earlier protected weight-bearing and mobilization. They also involve less soft tissue dissection compared to plating, potentially reducing surgical morbidity in an already compromised patient. While plating can provide rigid fixation, IMN's load-sharing and less invasive nature often make it the optimal choice for early, stable fixation in polytrauma patients with TBI, facilitating their overall recovery and rehabilitation.

Question 2345

Topic: 2. Trauma

What is the primary biomechanical advantage of a Sarmiento-type functional brace over a hanging cast for the non-operative management of a humeral shaft fracture?

. Hanging casts are more prone to skin irritation.
. Functional braces provide better fracture compression and prevent shortening.
. Hanging casts increase the risk of radial nerve palsy.
. Functional braces are lighter and more comfortable for patients.
. Hanging casts lead to higher rates of nonunion.

Correct Answer & Explanation

. Functional braces provide better fracture compression and prevent shortening.

Explanation

Correct Answer: BThe primary biomechanical advantage of a Sarmiento-type functional brace over a hanging cast is its ability to provide circumferential compression to the fracture site (Option B). The functional brace acts as an external pneumatic splint, using the hydraulic pressure of the surrounding soft tissues to compress the fracture fragments. This constant compression helps to maintain reduction, prevent shortening, and stimulate callus formation, thereby promoting union. Functional braces also offer better control over rotational alignment compared to hanging casts.Hanging casts, in contrast, rely on gravity for traction and alignment. However, they provide poor rotational control and can exacerbate apex anterior angulation (sagging) if the cast is too heavy or the elbow is held in excessive flexion. While comfort (Option D) can be a factor, it's not the primary biomechanical advantage. Neither method inherently increases the risk of radial nerve palsy (Option C). While nonunion rates can be higher with improperly used hanging casts or for inappropriate fracture patterns, the core biomechanical difference lies in compression versus traction. Skin irritation (Option A) can occur with both if not properly fitted or managed.

Question 2346

Topic: 2. Trauma

A 30-year-old male presents with a closed, highly displaced distal third humeral shaft fracture after a fall. Clinical examination reveals diminished radial pulse and pallor in the hand. What is the most appropriate immediate next step in management?

. Obtain an urgent CT scan of the humerus.
. Perform immediate closed reduction and reassess vascular status.
. Administer broad-spectrum antibiotics and elevate the limb.
. Prepare for immediate surgical exploration of the brachial artery.
. Apply a functional brace and monitor for 24 hours.

Correct Answer & Explanation

. Perform immediate closed reduction and reassess vascular status.

Explanation

Correct Answer: BA highly displaced distal third humeral shaft fracture with signs of vascular compromise (diminished radial pulse, pallor) is a surgical emergency. The brachial artery is particularly vulnerable in the distal arm due to its close proximity to the humerus. The immediate priority is to restore blood flow to the limb. The most appropriate first step is to attempt a gentle closed reduction of the fracture (Option B). Often, the vascular compromise is due to kinking or compression of the brachial artery by the displaced fracture fragments. Reducing the fracture can decompress the artery and restore perfusion. After reduction, the vascular status must be immediately reassessed.If the pulse returns and perfusion improves, the limb can be temporarily splinted, and definitive fixation can be planned. If the pulse does not return or perfusion remains compromised after reduction, then immediate surgical exploration of the brachial artery (Option D) is indicated to repair the vessel. An urgent CT scan (Option A) is too time-consuming for an acute vascular emergency. Antibiotics (Option C) are not the primary treatment for vascular compromise. Applying a functional brace (Option E) is inappropriate and dangerous in the setting of acute vascular compromise, as it delays critical intervention.

Question 2347

Topic: 2. Trauma

A 28-year-old male sustains a distal-third spiral humeral shaft fracture. Upon presentation, he has a dense radial nerve palsy. Closed reduction is performed, but post-reduction radiographs show an entrapped fracture fragment, and his nerve palsy persists. What is the most appropriate next step in management?

. Application of a functional fracture brace and clinical observation for 3 months
. EMG and nerve conduction studies
. Immediate surgical exploration and internal fixation
. Skeletal traction
. Re-manipulation under procedural sedation

Correct Answer & Explanation

. Immediate surgical exploration and internal fixation

Explanation

A Holstein-Lewis fracture pattern with an entrapped fragment or a secondary radial nerve palsy developing after an attempted closed reduction are absolute indications for immediate surgical exploration. Observation is strictly reserved for primary palsies that do not worsen or present with radiographic entrapment.

Question 2348

Topic: 2. Trauma

Which of the following radiographic findings is the strongest predictor of avascular necrosis (AVN) following a multi-part proximal humerus fracture?

. Greater tuberosity displacement > 5 mm
. Varus angulation of 20 degrees
. Surgical neck translation of 1 cm
. Metaphyseal medial hinge length of < 2 mm
. Disruption of the bicipital groove

Correct Answer & Explanation

. Metaphyseal medial hinge length of < 2 mm

Explanation

A medial metaphyseal hinge length of less than 8 mm, disruption of the medial periosteal hinge, and an anatomic neck fracture pattern are the most reliable predictors of ischemia and subsequent AVN. A hinge < 2 mm signifies severe disruption of the posterior humeral circumflex artery blood supply.

Question 2349

Topic: 2. Trauma

In the surgical management of a pilon fracture, initial internal fixation of the associated fibula fracture is commonly performed to restore limb length. In which of the following scenarios is 'fibula-first' fixation relatively contraindicated?

. Transverse midshaft fibula fracture
. Distal third spiral fibula fracture
. Severe metaphyseal comminution of the distal tibia with a severely comminuted fibula
. A fracture pattern requiring an anterolateral approach to the tibia
. Presence of an intact medial malleolus

Correct Answer & Explanation

. Severe metaphyseal comminution of the distal tibia with a severely comminuted fibula

Explanation

If both the tibia and fibula are highly comminuted, fixing the fibula first can malreduce the fracture into valgus or incorrect length. It is safer to reconstruct the tibial articular surface first to establish the correct spatial orientation before addressing the fibula.

Question 2350

Topic: 2. Trauma

A 35-year-old male sustains an intra-articular distal humerus fracture. Preoperative CT planning reveals extensive coronal shear comminution of the trochlea. Which surgical approach provides the most extensile visualization of the distal humeral articular surface?

. Triceps-reflecting anconeus pedicle (TRAP)
. Triceps-splitting
. Olecranon osteotomy
. Paratricipital
. Lateral Kocher

Correct Answer & Explanation

. Olecranon osteotomy

Explanation

An olecranon osteotomy provides the highest percentage of articular visualization (up to 57%) for complex intra-articular distal humerus fractures compared to triceps-sparing or reflecting approaches. It is preferred for extensive articular comminution requiring precise anatomic reduction.

Question 2351

Topic: 2. Trauma

A 40-year-old male is managed with a functional Sarmiento brace for a closed, midshaft transverse humeral fracture. At his 8-week follow-up, radiographs show a 4 mm fracture gap, 10 degrees of varus, and 15 degrees of anterior angulation. Clinically, he has gross motion at the fracture site. What is the most significant risk factor for nonunion in this patient?

. 10 degrees of varus angulation
. 15 degrees of anterior angulation
. The transverse fracture pattern and persistent fracture gap
. Age of the patient
. Use of functional bracing instead of primary plating

Correct Answer & Explanation

. The transverse fracture pattern and persistent fracture gap

Explanation

Transverse fracture patterns are at a higher risk of nonunion with functional bracing because they lack the large surface area of spiral fractures and can easily be distracted by gravity or soft tissue interposition. Angulation parameters (<20 degrees anterior, <30 degrees varus) are within acceptable limits.

Question 2352

Topic: 2. Trauma

A classical four-part pilon fracture involves the medial malleolus, the anterolateral fragment, the posterolateral fragment, and the die-punch fragment. Which major ligamentous structure remains attached to the posterolateral (Volkmann's) fragment?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Deltoid ligament
. Calcaneofibular ligament
. Interosseous membrane

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) remains solidly attached to the posterolateral (Volkmann's) fragment. In contrast, the AITFL attaches to the anterolateral (Chaput) fragment.

Question 2353

Topic: 2. Trauma

What is the most frequent late complication associated with the operative management of severe (AO/OTA 43-C3) pilon fractures despite achieving anatomic articular reduction?

. Deep venous thrombosis
. Avascular necrosis of the talus
. Post-traumatic tibiotalar osteoarthritis
. Nonunion of the fibula
. Rupture of the tibialis anterior tendon

Correct Answer & Explanation

. Post-traumatic tibiotalar osteoarthritis

Explanation

Despite anatomic reduction of the articular surface, post-traumatic osteoarthritis is the most common late complication of severe pilon fractures. This often occurs secondary to the initial irreversible chondral damage sustained at impact, and arthrodesis is frequently required in symptomatic cases.

Question 2354

Topic: 2. Trauma

During the anterolateral approach for ORIF of a pilon fracture, which neurovascular structure is at the greatest risk of iatrogenic injury during superficial dissection?

. Deep peroneal nerve
. Superficial peroneal nerve
. Sural nerve
. Anterior tibial artery
. Saphenous nerve

Correct Answer & Explanation

. Superficial peroneal nerve

Explanation

The superficial peroneal nerve crosses the surgical field in the anterolateral approach to the distal tibia and must be carefully identified and protected. The deep peroneal nerve and anterior tibial artery lie deeper and more medial, between the tibialis anterior and extensor hallucis longus.

Question 2355

Topic: 2. Trauma

In evaluating a proximal humerus fracture for the risk of avascular necrosis (AVN), which of the following radiographic findings described by Hertel et al. is the best predictor of ischemia to the humeral head?

. Metaphyseal head extension (calcar length) less than 8 mm
. Displacement of the greater tuberosity by more than 1 cm
. Comminution of the lateral wall
. Angulation of the surgical neck greater than 45 degrees
. An intact medial hinge

Correct Answer & Explanation

. Metaphyseal head extension (calcar length) less than 8 mm

Explanation

Hertel identified a metaphyseal head extension (calcar length) of less than 8 mm, disruption of the medial hinge, and a basicervical fracture pattern as the strongest independent predictors for humeral head ischemia and subsequent AVN.

Question 2356

Topic: 2. Trauma

A 35-year-old female requires ORIF for a highly comminuted OTA/AO Type 13C3 distal humerus fracture. To maximize articular visualization, an olecranon osteotomy is planned. Which osteotomy configuration is biomechanically superior and minimizes the risk of nonunion?

. Transverse osteotomy exactly at the bare area
. Chevron osteotomy with the apex pointing distally
. Chevron osteotomy with the apex pointing proximally
. Oblique osteotomy from dorsal to volar-proximal
. Step-cut osteotomy directed laterally

Correct Answer & Explanation

. Chevron osteotomy with the apex pointing distally

Explanation

An apex-distal chevron osteotomy provides excellent articular visualization and creates a stable construct with a large surface area for healing. It is biomechanically superior to transverse osteotomies and is typically directed into the bare area of the sigmoid notch.

Question 2357

Topic: 2. Trauma

In the context of a pilon fracture, the anterolateral fracture fragment of the distal tibia is commonly referred to as the Chaput fragment. Which major ligamentous structure attaches to this specific fragment?

. Posterior inferior tibiofibular ligament
. Anterior inferior tibiofibular ligament
. Deltoid ligament
. Interosseous membrane
. Calcaneofibular ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

The Chaput fragment (anterolateral distal tibia) serves as the tibial attachment site for the Anterior Inferior Tibiofibular Ligament (AITFL). The corresponding fibular attachment of the AITFL is on the Wagstaffe fragment.

Question 2358

Topic: 2. Trauma

A 40-year-old male presents with a distal third spiral humerus fracture (Holstein-Lewis type). He has an intact radial nerve exam upon presentation. Following closed reduction and splinting in the emergency department, he completely loses active wrist and finger extension. What is the most appropriate next step in management?

. Remove the splint, accept the deformity, and re-examine
. Obtain an immediate EMG/NCS
. Proceed with operative exploration and fracture fixation
. Wait 3 months for spontaneous nerve recovery
. Perform closed reduction again under conscious sedation

Correct Answer & Explanation

. Proceed with operative exploration and fracture fixation

Explanation

A secondary radial nerve palsy that develops strictly after closed reduction of a Holstein-Lewis fracture strongly suggests iatrogenic nerve entrapment within the fracture site or lateral intermuscular septum. Immediate surgical exploration and internal fixation are indicated.

Question 2359

Topic: 2. Trauma

Despite an anatomic articular reduction and successful soft tissue management, what is the most common long-term complication following operative fixation of an OTA/AO type 43C pilon fracture?

. Nonunion of the metaphyseal-diaphyseal junction
. Chronic osteomyelitis
. Deep vein thrombosis
. Post-traumatic ankle osteoarthritis
. Complex regional pain syndrome

Correct Answer & Explanation

. Post-traumatic ankle osteoarthritis

Explanation

Post-traumatic ankle osteoarthritis is the most common long-term complication after severe pilon fractures, occurring in up to 50% of cases. It develops secondary to the initial irreversible cartilage impact injury, even when anatomic articular reduction is achieved.

Question 2360

Topic: 2. Trauma

A 25-year-old female sustains a coronal shear fracture of the distal humerus involving the capitellum and the lateral half of the trochlea (McKee modification of Bryan-Morrey Type IV). Which surgical approach is most appropriate for direct visualization and headless compression screw fixation?

. Posterior approach with olecranon osteotomy
. Extended lateral (Kocher) approach
. Medial approach
. Anterior approach (Henry)
. Triceps-reflecting anconeus pedicle (TRAP) approach

Correct Answer & Explanation

. Extended lateral (Kocher) approach

Explanation

Coronal shear fractures involving the capitellum and lateral trochlea are best approached via an extended lateral approach (utilizing the Kocher or Kaplan interval). This allows direct anterior articular visualization for anterior-to-posterior placement of headless compression screws.

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