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2. Trauma MCQs

Practice Set 119 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 2361

Topic: 2. Trauma

During the staged management of a pilon fracture with an associated fibula fracture, the surgeon decides NOT to fix the fibula during the definitive tibial ORIF. Which specific fracture pattern most strongly justifies leaving the fibula unfixed to prevent secondary tibial deformity?

. Varus-impacted pilon fracture
. Valgus-impacted pilon fracture
. Anterior shear pilon fracture
. Posterior shear pilon fracture
. Spiraling distal third tibia fracture

Correct Answer & Explanation

. Varus-impacted pilon fracture

Explanation

In varus-impacted pilon fractures, plating the fibula out to length first can tension the lateral collateral structures and inadvertently pull the tibial block into valgus, complicating the tibial reduction. Many surgeons prefer to leave the fibula unfixed, or fix it last, in varus patterns.

Question 2362

Topic: 2. Trauma

During a deltopectoral approach for a proximal humerus fracture, the cephalic vein is identified. What is the most appropriate management of the cephalic vein to protect its primary drainage while exposing the fracture?

. Ligate the vein to prevent excessive bleeding
. Retract it medially with the pectoralis major
. Retract it laterally with the deltoid
. Exise the vein completely
. Dissect it free and let it fall into the wound bed

Correct Answer & Explanation

. Retract it laterally with the deltoid

Explanation

The cephalic vein is typically retracted laterally with the deltoid muscle during a deltopectoral approach. This protects its primary tributary branches, which predominantly arise from the deltoid, thereby minimizing the risk of avulsion and excessive bleeding.

Question 2363

Topic: 2. Trauma

A 28-year-old patient sustains a closed mid-shaft humeral fracture. Following application of a coaptation splint in the emergency department, the patient develops a complete wrist drop that was not present on the initial examination. What is the most appropriate next step in management?

. Immediate surgical exploration and nerve release
. Transition to a functional brace at 10-14 days and clinical observation
. Stat MRI of the humerus to evaluate the nerve
. Closed reduction under general anesthesia to relieve nerve tension
. Immediate EMG and nerve conduction studies

Correct Answer & Explanation

. Transition to a functional brace at 10-14 days and clinical observation

Explanation

Radial nerve palsy after closed reduction of a humerus fracture is generally observed, as the majority are neurapraxias that resolve spontaneously. Immediate exploration is typically reserved for open fractures, associated vascular injuries, or penetrating trauma.

Question 2364

Topic: 2. Trauma

When evaluating a proximal humerus fracture for the risk of avascular necrosis (AVN), which of the following Hertel criteria is the most reliable predictor of subsequent humeral head ischemia?

. Calcar length greater than 8 mm
. Disruption of the medial hinge
. Intact medial periosteum
. Fracture extension into the greater tuberosity
. Varus angulation greater than 20 degrees

Correct Answer & Explanation

. Disruption of the medial hinge

Explanation

Hertel's criteria for humeral head ischemia include a short metaphyseal head extension (calcar length < 8 mm), a disrupted medial hinge, and an anatomic neck fracture pattern. A disrupted medial hinge heavily compromises the medial blood supply.

Question 2365

Topic: 2. Trauma

A 55-year-old female presents with a highly comminuted, closed distal humerus bicolumnar fracture (AO Type 13-C3). Which surgical approach provides the greatest exposure of the articular surface for complex open reduction and internal fixation?

. Triceps-sparing approach
. Triceps-reflecting (Bryan-Morrey) approach
. Chevron transolecranon osteotomy
. Triceps-splitting approach
. Kocher lateral approach

Correct Answer & Explanation

. Chevron transolecranon osteotomy

Explanation

A chevron transolecranon osteotomy provides the widest and most complete visualization of the distal humeral articular surface. It is considered the gold standard for highly comminuted intra-articular fractures (Type C3).

Question 2366

Topic: 2. Trauma

In the staged treatment of high-energy pilon fractures, initial spanning external fixation is followed by definitive ORIF. What is the most reliable clinical indicator that the soft tissues are ready for the definitive surgical approach?

. Resolution of fracture blisters within 7 days
. Return of capillary refill to less than 2 seconds
. Normalization of acute phase reactants (ESR and CRP)
. Decrease in leg circumference by exactly 10%
. Presence of skin wrinkling upon active or passive ankle motion

Correct Answer & Explanation

. Presence of skin wrinkling upon active or passive ankle motion

Explanation

The appearance of the "wrinkle sign" reliably indicates that soft tissue swelling has sufficiently subsided. Proceeding with definitive surgery once this sign is present minimizes the risk of wound dehiscence and deep infection.

Question 2367

Topic: 2. Trauma

A 34-year-old man falls onto an outstretched hand, sustaining a coronal shear fracture of the distal humerus involving the capitellum and extending into the trochlea (McKee modification Type IV). What is the preferred method of internal fixation?

. Excision of the articular fragments
. Lateral column plating alone
. Tension band wiring of the lateral column
. Headless compression screws placed from anterior to posterior
. Bridge plating of the distal humerus

Correct Answer & Explanation

. Headless compression screws placed from anterior to posterior

Explanation

Headless compression screws or countersunk lag screws placed from anterior to posterior are the standard treatment for coronal shear fractures. This technique achieves rigid interfragmentary compression while burying the hardware beneath the articular cartilage.

Question 2368

Topic: 2. Trauma

What is the maximum acceptable coronal and sagittal plane angulation for the non-operative management of a middle-third humeral shaft fracture using a Sarmiento functional brace?

. 10 degrees anterior/posterior and 10 degrees varus/valgus
. 20 degrees anterior/posterior and 30 degrees varus/valgus
. 30 degrees anterior/posterior and 10 degrees varus/valgus
. 45 degrees anterior/posterior and 45 degrees varus/valgus
. 15 degrees anterior/posterior and 15 degrees varus/valgus

Correct Answer & Explanation

. 20 degrees anterior/posterior and 30 degrees varus/valgus

Explanation

Humeral shaft fractures managed with functional bracing can tolerate up to 20 degrees of anterior/posterior angulation and 30 degrees of varus/valgus angulation. Additionally, up to 3 cm of shortening is acceptable without significant functional deficit.

Question 2369

Topic: 2. Trauma

A 40-year-old male undergoes definitive ORIF of a type C pilon fracture. Three weeks postoperatively, he develops a deep wound infection over the anteromedial tibia with exposed hardware. The fracture remains unstable. What is the most appropriate next step in management?

. Intravenous antibiotics for 6 weeks followed by hardware removal
. Immediate hardware removal, placement of an antibiotic spacer, and application of a circular frame
. Operative debridement, retention of stable hardware, and early soft tissue coverage (e.g., free flap)
. Immediate below-knee amputation
. Application of a split-thickness skin graft directly over the exposed hardware

Correct Answer & Explanation

. Operative debridement, retention of stable hardware, and early soft tissue coverage (e.g., free flap)

Explanation

In the setting of an acute deep infection with exposed hardware, stable internal fixation should be retained to allow fracture healing. Aggressive serial debridements followed by early soft tissue coverage (often a free flap for the distal third of the tibia) are standard of care.

Question 2370

Topic: 2. Trauma

An 82-year-old female presents with a severely comminuted intra-articular distal humerus fracture. She has multiple comorbidities, severe osteoporosis, and requires a walker for ambulation. Which of the following is the most appropriate surgical treatment?

. Triceps-sparing ORIF with dual plating
. Closed reduction and long arm casting
. Total elbow arthroplasty (TEA)
. Hemiarthroplasty of the elbow
. Fragment excision and ulnar nerve transposition

Correct Answer & Explanation

. Total elbow arthroplasty (TEA)

Explanation

Total elbow arthroplasty (TEA) is highly effective for severely comminuted, osteoporotic distal humerus fractures in elderly, low-demand patients. It allows for immediate postoperative range of motion and weight-bearing through the joint.

Question 2371

Topic: 2. Trauma

A 25-year-old male suffers a high-energy distal tibia fracture extending into the diaphysis. Intramedullary nailing is planned. Which intraoperative technique is most critical to prevent the common complication of primary malalignment during nail passage?

. Using an unreamed solid nail
. Immediate postoperative full weight-bearing
. Placing Poller (blocking) screws in the distal metaphysis prior to nail passage
. Performing proximal interlocking before distal interlocking
. Using the smallest diameter nail available

Correct Answer & Explanation

. Placing Poller (blocking) screws in the distal metaphysis prior to nail passage

Explanation

Distal tibia fractures are notoriously prone to valgus and procurvatum deformities during nailing. Poller (blocking) screws placed adjacent to the intended track of the nail help centralize the implant and maintain anatomic alignment.

Question 2372

Topic: 2. Trauma

A 30-year-old presents with a closed spiral fracture of the distal third of the humeral shaft (Holstein-Lewis pattern). He has an intact radial nerve pulse and normal motor function. What anatomical characteristic makes this fracture pattern prone to radial nerve injury during closed reduction?

. The nerve is firmly tethered as it passes through the lateral intermuscular septum
. The nerve is located entirely anteriorly and subcutaneously at this level
. The nerve pierces the medial head of the triceps adjacent to the fracture
. The fracture predictably propagates proximally into the spiral groove
. The nerve intimately adheres to the brachialis muscle fascia at the fracture site

Correct Answer & Explanation

. The nerve is firmly tethered as it passes through the lateral intermuscular septum

Explanation

In a Holstein-Lewis fracture, the radial nerve is at a high risk of entrapment or laceration because it is tethered as it passes from the posterior to the anterior compartment through the lateral intermuscular septum.

Question 2373

Topic: 2. Trauma

During the operative fixation of a complex pilon fracture, the surgeon identifies a large "Volkmann fragment." Based on standard anatomic nomenclature, where is this fragment located?

. Anterolateral distal tibia
. Anteromedial distal tibia
. Posterolateral distal tibia
. Medial malleolus
. Central articular impaction zone

Correct Answer & Explanation

. Posterolateral distal tibia

Explanation

The Volkmann fragment refers to the posterolateral articular fragment of the distal tibia. It is the site of attachment for the posterior inferior tibiofibular ligament (PITFL).

Question 2374

Topic: 2. Trauma

A 45-year-old male presents with a painful atrophic nonunion of a humeral shaft fracture initially treated with a functional brace 8 months ago. What is the gold standard surgical management for this condition?

. Intramedullary nailing with dynamic locked screws
. Exchange functional bracing with a bone stimulator
. Open reduction, rigid compression plating, and autologous bone grafting
. Spanning external fixation with compression
. Vascularized free fibular graft

Correct Answer & Explanation

. Open reduction, rigid compression plating, and autologous bone grafting

Explanation

The gold standard treatment for an atrophic humeral shaft nonunion is rigid internal fixation (typically using compression plating) combined with autologous bone grafting. This addresses both the mechanical instability and the biological deficit.

Question 2375

Topic: 2. Trauma

In the definitive surgical management of severe pilon fractures, when utilizing a standard anteromedial incision for the tibia and a posterolateral incision for the fibula, what is a primary concern regarding surgical site planning?

. Potential iatrogenic injury to the great saphenous vein
. Ensuring an adequate skin bridge (typically at least 7 cm) to prevent necrosis
. Avoiding complete disruption of the sural nerve
. Ensuring adequate visualization of the lateral joint line through the medial incision
. Preventing postoperative compartment syndrome

Correct Answer & Explanation

. Ensuring an adequate skin bridge (typically at least 7 cm) to prevent necrosis

Explanation

When performing dual incisions for pilon and fibula fractures, maintaining a sufficient skin bridge (historically recommended to be at least 7 cm) is critical to preserve angiosome perfusion. This minimizes the significant risk of wound necrosis and soft tissue breakdown.

Question 2376

Topic: 2. Trauma

A 45-year-old male sustains a high-energy closed pilon fracture. Initial management consists of a spanning external fixator. Which of the following clinical signs is the most reliable indicator that the soft tissue envelope is ready for definitive open reduction and internal fixation (ORIF)?

. Resolution of all ecchymosis
. Epithelialization of fracture blisters and return of skin wrinkling
. Decreased dependent rubor after 5 minutes of elevation
. Erythrocyte sedimentation rate (ESR) returning to normal limits
. Absence of pitting edema over the medial malleolus

Correct Answer & Explanation

. Epithelialization of fracture blisters and return of skin wrinkling

Explanation

The return of skin wrinkling and the epithelialization of fracture blisters indicate that soft tissue swelling has subsided sufficiently to safely allow surgical incisions. Operating through swollen, tense tissue significantly increases the risk of wound dehiscence and deep infection.

Question 2377

Topic: 2. Trauma

Based on the Hertel criteria, which of the following radiographic findings is the strongest predictor of humeral head ischemia in a proximal humerus fracture?

. Greater tuberosity displacement greater than 5 mm
. Head-split fracture pattern
. Metaphyseal head extension (calcar length) less than 8 mm
. Varus angulation of 20 degrees
. Lesser tuberosity comminution

Correct Answer & Explanation

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

Explanation

Hertel identified a metaphyseal head extension (calcar length) of < 8 mm, disruption of the medial hinge (> 2 mm), and an anatomic neck fracture as the most reliable predictors of humeral head ischemia. A short calcar length indicates severe disruption of the critical medial blood supply.

Question 2378

Topic: 2. Trauma

A 32-year-old male presents with a closed, distal third spiral fracture of the humeral shaft (Holstein-Lewis fracture). Upon initial examination in the emergency department, he is unable to extend his wrist or fingers. What is the most appropriate initial management?

. Immediate surgical exploration of the radial nerve and plate fixation
. Application of a coaptation splint and clinical observation
. Electromyography (EMG) followed by delayed fixation
. Immediate intramedullary nailing to restore alignment
. Closed reduction and percutaneous pinning of the fracture

Correct Answer & Explanation

. Application of a coaptation splint and clinical observation

Explanation

A primary radial nerve palsy in the setting of a closed humeral shaft fracture is managed nonoperatively with a coaptation splint and observation. Over 85% of primary radial nerve palsies recover spontaneously, and immediate exploration is generally reserved for open fractures or penetrating injuries.

Question 2379

Topic: 2. Trauma

During the pre-operative CT evaluation of a complex pilon fracture, a large anterolateral articular fragment is identified. This specific fragment (Chaput fragment) is primarily stabilized by its attachment to which of the following structures?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

The anterolateral (Chaput) fragment of a pilon or ankle fracture serves as the tibial attachment site for the Anterior Inferior Tibiofibular Ligament (AITFL). Understanding these ligamentous attachments is critical for indirect reduction techniques.

Question 2380

Topic: 2. Trauma

Recent quantitative anatomical studies evaluating the vascular supply to the proximal humerus have demonstrated that the predominant blood supply to the humeral head is provided by which of the following?

. Anterior circumflex humeral artery
. Arcuate artery
. Posterior circumflex humeral artery
. Thoracoacromial artery
. Suprascapular artery

Correct Answer & Explanation

. Posterior circumflex humeral artery

Explanation

While older literature emphasized the anterior circumflex humeral artery (via the arcuate artery), recent quantitative studies show that the posterior circumflex humeral artery supplies approximately 64% of the blood to the humeral head. This highlights its critical role in head viability following fracture.

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