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2. Trauma MCQs

Practice Set 12 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 221

Topic: 2. Trauma
A 10-year-old girl is seen for limb-length inequality. She has 10° of valgus of the left knee and a shortened left fibula. Her projected shortening at maturity is 1 cm in the left femur and 2.1 cm in the left tibia. Her left foot is normal in shape but one-half size smaller than the right. Her overall height and maturity are at the median for her age. For this patient, recommended treatment for limb-length inequality is:
. Observation
. Epiphysiodesis of the left tibia
. Epiphysiodesis of the right tibia
. Shortening of the right tibia
. Lengthening of the left tibia

Correct Answer & Explanation

. Epiphysiodesis of the right tibia

Explanation

This patient has a projected discrepancy at maturity of 3.1 cm. Most experts agree that the risk of later gait disturbance or back pain is increased above a normal threshold when limb length inequality exceeds 2.5 cm. A shoe lift is noninvasive but not likely to be permanently adopted. Epiphysiodesis of the right tibia is the least invasive and least complicated option for permanent equalization and should be performed in this patient. Shortening of the right tibia would be an option if the patient desired correction after skeletal maturity, but is a more invasive procedure with risk of compartment syndrome, nonunion, and pain. Lengthening of the left tibia is a valid option, which could also allow correction of the valgus and maintenance of stature. However, the procedure leaves scars and complications are more significant. Most surgeons would not think that it is worthwhile for gain of an inch because a left tibial hemiepiphysiodesis could easily correct the valgus.

Question 222

Topic: 2. Trauma
A 5-year-old sustains an isolated fracture of the proximal ulna. Radiographs reveal an anterior dislocation of the radial head. This injury is best classified as which Bado type?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type I

Explanation

A Bado Type I Monteggia fracture involves an anterior dislocation of the radial head with an associated fracture of the ulnar diaphysis. It is the most common type of Monteggia lesion in children.

Question 223

Topic: 2. Trauma

A 7-year-old falls on an outstretched hand and sustains a radial neck fracture. Up to what degree of angulation is generally acceptable for non-operative management without manipulative reduction in this age group?

. 10 degrees
. 15 degrees
. 30 degrees
. 45 degrees
. 60 degrees

Correct Answer & Explanation

. 30 degrees

Explanation

In children under 10 years of age, up to 30 degrees of angulation in a radial neck fracture is generally acceptable as it will remodel with growth. Angulation greater than 30 degrees typically requires closed or percutaneous reduction.

Question 224

Topic: 2. Trauma

A juvenile Tillaux fracture involves an avulsion of the anterolateral distal tibial epiphysis. Which ligament is primarily responsible for this avulsion?

. Deltoid ligament
. Posterior inferior tibiofibular ligament
. Anterior inferior tibiofibular ligament
. Calcaneofibular ligament
. Anterior talofibular ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

The anterior inferior tibiofibular ligament (AITFL) securely attaches to the anterolateral distal tibial epiphysis. During a severe external rotation injury, it avulses this unfused lateral portion of the epiphysis, resulting in a Tillaux fracture.

Question 225

Topic: 2. Trauma

In treating a 10-year-old with a radially displaced and angulated radial neck fracture, at what degree of initial angulation is reduction definitively indicated to prevent significant loss of forearm rotation?

. > 10 degrees
. > 15 degrees
. > 30 degrees
. > 60 degrees
. > 90 degrees

Correct Answer & Explanation

. > 30 degrees

Explanation

In older children (near 10 years old), angulation greater than 30 degrees is generally unacceptable because remodeling potential is limited. Reduction is required to prevent a significant mechanical block to pronation and supination.

Question 226

Topic: 2. Trauma

Which of the following is an absolute indication for open reduction and internal fixation of a medial epicondyle fracture in a 10-year-old child?

. Displacement greater than 5 mm
. Ulnar nerve neurapraxia
. Incarceration of the fragment within the elbow joint
. High-level competitive gymnastics involvement
. Valgus instability on stress testing

Correct Answer & Explanation

. Incarceration of the fragment within the elbow joint

Explanation

Absolute indications for operative fixation of medial epicondyle fractures include incarceration of the fragment within the joint and open fractures. Displacement magnitude and athletic demands are relative indications for surgery.

Question 227

Topic: 2. Trauma

A 7-year-old child sustains a both-bone forearm fracture. During the remodeling process over the next few years, which of the following deformities has the LEAST potential to remodel?

. Volar angulation in the distal third
. Dorsal angulation in the distal third
. Coronal plane translation
. Rotational malalignment
. Sagittal plane angulation in the middle third

Correct Answer & Explanation

. Rotational malalignment

Explanation

Rotational malalignment remodels very poorly in children and must be corrected during initial reduction. Angulation in the plane of adjacent joint motion (sagittal plane near the wrist) has the greatest remodeling potential.

Question 228

Topic: 2. Trauma
A 6-year-old boy falls on an outstretched hand and sustains a Monteggia fracture-dislocation. According to the Bado classification, which type is most common in the pediatric population and what is the direction of the radial head dislocation?
. Type I, Anterior dislocation
. Type II, Posterior dislocation
. Type III, Lateral dislocation
. Type IV, Anterior dislocation
. Type I, Lateral dislocation

Correct Answer & Explanation

. Type I, Anterior dislocation

Explanation

Bado Type I is the most common Monteggia fracture variant in children, accounting for over 70% of cases. It is characterized by an anterior dislocation of the radial head and a fracture of the ulnar diaphysis with anterior angulation.

Question 229

Topic: 2. Trauma

A 5-year-old boy sustains an ipsilateral supracondylar humerus fracture and a distal radius fracture (floating elbow). This injury pattern places the patient at highest risk for which of the following complications?

. Nonunion of the humerus
. Compartment syndrome of the forearm
. Complex regional pain syndrome
. Premature physeal closure of the distal radius
. Heterotopic ossification of the elbow

Correct Answer & Explanation

. Compartment syndrome of the forearm

Explanation

A pediatric 'floating elbow' (ipsilateral supracondylar humerus and forearm fracture) has a significantly elevated risk of acute compartment syndrome. Emergent reduction and pinning are typically required to stabilize the limb and restore volume to the compartment.

Question 230

Topic: 2. Trauma

A 10-year-old child sustains a highly angulated, greenstick fracture of the radius and ulna. Following closed reduction, the surgeon decides to cast the arm. What physical principle governs the placement of a three-point mold in the cast?

. One point of pressure at the fracture apex on the tension side, and two points on the compression side at the proximal and distal ends
. One point of pressure at the fracture apex on the compression side, and two points on the tension side at the proximal and distal ends
. Three equal points of circumferential pressure around the fracture site
. Two points of pressure at the apex and one point at the elbow joint
. Pressure solely over the radioulnar interosseous membrane to prevent synostosis

Correct Answer & Explanation

. One point of pressure at the fracture apex on the tension side, and two points on the compression side at the proximal and distal ends

Explanation

A proper three-point mold requires one point of pressure placed directly over the apex of the fracture deformity (the tension or convex side), countered by two points of pressure at the proximal and distal ends on the opposite (compression or concave) side.

Question 231

Topic: 2. Trauma

Which of the following fracture patterns is considered highly specific for child abuse (non-accidental trauma) in an infant?

. Clavicle fracture
. Midshaft femur fracture
. Spiral tibia fracture
. Posterior rib fractures
. Linear skull fracture

Correct Answer & Explanation

. Clavicle fracture

Explanation

Posterior rib fractures, metaphyseal corner fractures, and scapular fractures are highly specific for non-accidental trauma. While spiral fractures of long bones can occur in child abuse, they are less specific than posterior rib fractures.

Question 232

Topic: 2. Trauma

An 11-year-old boy sustains a proximal humerus fracture. What is the primary reason that large amounts of angulation and displacement can be treated non-operatively in this age group?

. The proximal humerus physis contributes 80% of longitudinal growth to the humerus
. Gravity naturally reduces the fracture over time
. The robust periosteum prevents malunion
. The shoulder joint's limited range of motion masks deformity
. The distal humerus physis compensates for proximal deformities

Correct Answer & Explanation

. The proximal humerus physis contributes 80% of longitudinal growth to the humerus

Explanation

The proximal humerus physis contributes 80% of the longitudinal growth of the humerus and has immense remodeling potential. Therefore, considerable angulation and displacement are well tolerated and can be treated non-operatively in children.

Question 233

Topic: 2. Trauma
A 6-year-old boy sustains a supracondylar fracture of the humerus. The 2 fragments are not completely displaced, but there is some overlap of the medial column and a gap on the lateral column of the distal humerus. Baumann's angle measures 85°. The alignment on the lateral film shows no significant translation, but approximately 15° of increased extension. The recommended treatment is:
. Accept this and treat in a long arm cast
. Closed reduction with supination of the forearm and application of long arm cast
. Closed reduction with the elbow in extension to better monitor the angulation
. Closed reduction and percutaneous pin fixation
. Open reduction and medial and lateral plate fixation

Correct Answer & Explanation

. Closed reduction and percutaneous pin fixation

Explanation

Closed reduction should allow regain of alignment and percutaneous pin fixation will allow it to be maintained. The elbow is in 10°-15° of varus and this will be an objectionable appearance in the future. Supination will increase the varus. Extension will exacerbate the deformity seen on the lateral and will cause further loss of contact of the fracture fragments. Medial and lateral plate fixation is needed in adolescents and adults with intercondylar fractures to allow early range of movement but is excessive treatment for this fracture in young children.

Question 234

Topic: 2. Trauma
The 7-year-old patient shown in this image (Slide 1) is most likely presenting with:
. Atlas fracture
. Spondylolysis of the axis
. Facet subluxation
. Fracture of C3
. Fracture and subluxation

Correct Answer & Explanation

. Fracture and subluxation

Explanation

This patient has a spondylolisthesis of the axis, which is also known as a Hangman's fracture. Additionally, a subluxation of the C2-C3 facet is present on the right side. Such a subluxation often accompanies a Hangman's fracture. The comparison image (Slide 2) of the opposite facet is shown as a reference to demonstrate the normal alignment.

Question 235

Topic: 2. Trauma

The 12-year-old boy shown in the radiographs (Slide 1, Slide 2) sustained his injury during a motor vehicle accident. Which of the following most accurately describes the injury:

. Oblique proximal ulna metaphyseal fracture
. Oblique proximal ulna fracture and elbow dislocation
. Type 1 Monteggia fracture
. Type I Galeazzi fracture
. Maisonneuve fracture

Correct Answer & Explanation

. Type 1 Monteggia fracture

Explanation

This patient has a proximal ulna fracture and an anterior dislocation of the radial head. The ulna-trochlea relationship is intact. On the lateral film, theradial head does not articulate with the capitellum. On the anteroposterior film, the radial head points to the capitellum, but the joint space is absent in contrast to that of the ulna-trochlear joint, which is normal. This injury is a type 1 (anterior) Monteggia fracture. The dislocation is clearly visible on Slide 3. A Galeazzi fracture refers to a distal radioulnar dislocation with a radial fracture. A Maisonneuve fracture is a related concept in the lower extremity: a proximal fibular fracture with an ankle mortise injury.

Question 236

Topic: 2. Trauma

A 4-year-old child sustains an isolated spiral fracture of the femoral shaft after a low-energy fall. Length is preserved with 1 cm of shortening. What is the standard of care for this injury?

. Flexible intramedullary nailing
. Rigid reamed intramedullary nailing
. Early spica casting
. External fixation
. Plate osteosynthesis

Correct Answer & Explanation

. Early spica casting

Explanation

Early spica casting is the standard of care for isolated femoral shaft fractures in children aged 6 months to 5 years with acceptable shortening (< 2 cm). Flexible nails are typically reserved for children older than 5 years.

Question 237

Topic: 2. Trauma

A 6-year-old boy sustains a diaphyseal fracture of the proximal third of the ulna.

Which associated injury must be specifically evaluated for and excluded?

. Distal radius physeal fracture
. Dislocation of the radial head
. Rupture of the distal radioulnar joint
. Fracture of the lateral condyle of the humerus
. Median nerve entrapment

Correct Answer & Explanation

. Dislocation of the radial head

Explanation

A Monteggia fracture-dislocation consists of a fracture of the ulnar shaft with an associated dislocation of the radial head. The radiocapitellar line must be carefully evaluated on all views.

Question 238

Topic: 2. Trauma

A 9-year-old boy sustains a pathologic fracture through a centrally located, purely lytic lesion in the proximal humerus metaphysis.

A "fallen leaf" sign is noted. What is the definitive treatment after the fracture has healed if the lesion persists?

. En bloc resection and endoprosthetic reconstruction
. Curettage and bone grafting with or without adjuvant therapy
. Amputation
. Radiation therapy
. Prolonged immobilization

Correct Answer & Explanation

. Curettage and bone grafting with or without adjuvant therapy

Explanation

The "fallen leaf" sign is pathognomonic for a Unicameral Bone Cyst (UBC). If the cyst does not heal after fracture, treatment involves aspiration/injection or curettage and bone grafting to prevent recurrence.

Question 239

Topic: 2. Trauma

A 10-year-old child presents with a spiral fracture of the distal third of the tibia and an intact fibula. Over the next few weeks, what complication should be closely monitored regarding the varus/valgus alignment?

. Progressive valgus deformity
. Progressive varus deformity
. Anterior bowing
. Procurvatum deformity
. Rotational malalignment

Correct Answer & Explanation

. Progressive varus deformity

Explanation

An isolated fracture of the distal tibia with an intact fibula in a child often leads to a varus deformity. The intact fibula acts as a strut, causing asymmetric growth or settling.

Question 240

Topic: 2. Trauma

A 13-year-old gymnast presents with acute medial elbow pain after a fall. Radiographs demonstrate a displaced medial epicondyle fracture. Which of the following is universally considered an absolute indication for open reduction and internal fixation?

. Displacement greater than 5 mm
. Presence of ulnar nerve paresthesias
. Fracture occurring in the dominant arm
. Incarceration of the fracture fragment within the elbow joint
. Valgus instability on examination under anesthesia

Correct Answer & Explanation

. Incarceration of the fracture fragment within the elbow joint

Explanation

Incarceration of the medial epicondyle fragment within the joint mechanically blocks reduction and articulation, making it an absolute indication for operative extraction and internal fixation.

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