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2. Trauma MCQs

Practice Set 139 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 2761

Topic: 2. Trauma

The Canadian Orthopaedic Trauma Society (COTS) Randomized Controlled Trial (2001) significantly influenced the management of displaced intra-articular calcaneal fractures. What was the primary conclusion of this landmark study regarding operative versus non-operative management?

. A. Open reduction internal fixation (ORIF) universally provides superior functional outcomes for all patients.
. B. Non-operative management is always superior to ORIF due to lower complication rates.
. C. ORIF improved functional outcomes for specific subgroups (e.g., younger, non-smoking females) but not universally for all patients.
. D. The choice of management (operative vs. non-operative) has no impact on long-term functional outcomes.
. E. Minimally invasive approaches are superior to extensile lateral approaches for all fracture types.

Correct Answer & Explanation

. C. ORIF improved functional outcomes for specific subgroups (e.g., younger, non-smoking females) but not universally for all patients.

Explanation

Correct Answer: CExplanation:The case explicitly states under 'Summary of Key Literature / Guidelines' that the 'Canadian Orthopaedic Trauma Society (COTS) Randomized Controlled Trial (2001)... demonstrated that while ORIF improved functional outcomes for certain subgroups (e.g., younger, non-smoking females, patients not on Workers' Compensation), it did not show a universal benefit over non-operative care for all patients.' This highlights the importance of patient selection and comorbidities.A. Open reduction internal fixation (ORIF) universally provides superior functional outcomes for all patients:This contradicts the COTS trial's finding that there was no universal benefit.B. Non-operative management is always superior to ORIF due to lower complication rates:While non-operative management avoids surgical complications, the COTS trial did not conclude it was always superior, especially for specific patient subgroups who benefited from ORIF.D. The choice of management (operative vs. non-operative) has no impact on long-term functional outcomes:This is incorrect, as the study found improved outcomes for certain subgroups with ORIF.E. Minimally invasive approaches are superior to extensile lateral approaches for all fracture types:The COTS trial predates the widespread adoption and comparison of minimally invasive approaches and focused on operative versus non-operative management in general. The case mentions minimally invasive approaches as a growing area of literature, but not as a primary conclusion of COTS.

Question 2762

Topic: 2. Trauma

What is the primary anatomic structure evaluated to determine the Sanders classification for intra-articular calcaneal fractures on a coronal CT scan?

. Anterior process
. Calcaneocuboid joint
. Posterior facet
. Middle facet
. Sustentaculum tali

Correct Answer & Explanation

. Posterior facet

Explanation

The Sanders classification is based on the number and location of articular fracture lines through the posterior facet of the calcaneus, as visualized on coronal CT images.

Question 2763

Topic: 2. Trauma

According to the Essex-Lopresti classification of calcaneal fractures, what distinguishes a joint-depression type fracture from a tongue-type fracture?

. The presence of a sustentacular fracture line
. The secondary fracture line exiting posterior to the posterior facet
. The primary fracture line exiting the calcaneocuboid joint
. The secondary fracture line exiting the posterior tuberosity
. The involvement of the anterior process

Correct Answer & Explanation

. The secondary fracture line exiting posterior to the posterior facet

Explanation

In the Essex-Lopresti classification, a joint-depression fracture has a secondary fracture line that exits just posterior to the posterior facet. In contrast, a tongue-type fracture has a secondary line that exits posteriorly through the calcaneal tuberosity.

Question 2764

Topic: 2. Trauma
A 42-year-old male undergoes open reduction and internal fixation of a Sanders type III calcaneus fracture via a standard extensile lateral approach. Which of the following represents the most frequent complication associated with this specific surgical approach?
. A. Sural nerve transection
. B. Deep vein thrombosis
. C. Medial plantar nerve entrapment
. D. Wound edge necrosis and dehiscence
. E. Nonunion of the posterior facet

Correct Answer & Explanation

. D. Wound edge necrosis and dehiscence

Explanation

Wound complications, including edge necrosis, dehiscence, and infection, are the most common complications of the extensile lateral approach to the calcaneus. Meticulous soft tissue handling and creating full-thickness flaps are critical to minimize this risk.

Question 2765

Topic: 2. Trauma

A 35-year-old smoker sustains a closed Sanders Type II calcaneal fracture with significant soft tissue swelling and fracture blisters. What is the most appropriate timing for open reduction and internal fixation via an extensile lateral approach?

. Within 12 hours of injury
. Within 48 hours to prevent cartilage necrosis
. Once the fracture blisters have ruptured and drained completely
. When the skin wrinkles and the "wrinkle sign" is present
. At 6 weeks post-injury

Correct Answer & Explanation

. When the skin wrinkles and the "wrinkle sign" is present

Explanation

Surgery for calcaneus fractures via an extensile lateral approach is delayed until soft tissue swelling resolves, typically indicated by the return of skin creases (wrinkle sign). This usually takes 10-14 days and is vital to decrease wound complications.

Question 2766

Topic: 2. Trauma
According to the Buckley et al. randomized controlled trial comparing operative versus nonoperative treatment of displaced intra-articular calcaneal fractures, which patient demographic demonstrated significantly better functional outcomes with operative management?
. A. Workers' compensation patients
. B. Men older than 65 years
. C. Women over the age of 50
. D. Patients with an initial Böhler's angle less than 0 degrees
. E. Young females who were not receiving workers' compensation

Correct Answer & Explanation

. E. Young females who were not receiving workers' compensation

Explanation

The landmark Buckley study showed no overall significant difference between operative and nonoperative groups. However, subset analysis demonstrated that younger patients, females, patients not receiving workers' compensation, and those with a higher initial Böhler's angle had better outcomes with surgery.

Question 2767

Topic: 2. Trauma

When applying a lateral locking plate for a calcaneus fracture via an extensile lateral approach, screw placement into the sustentaculum tali must be carefully directed to avoid injury to which of the following medial structures?

. Flexor hallucis longus tendon
. Medial plantar nerve
. Posterior tibial artery
. Tibialis anterior tendon
. Deltoid ligament

Correct Answer & Explanation

. Flexor hallucis longus tendon

Explanation

Screws directed from lateral to medial into the sustentaculum tali must not be overly long. Over-penetration risks injury to the flexor hallucis longus (FHL) tendon, which runs in a groove directly beneath the sustentaculum tali.

Question 2768

Topic: 2. Trauma

A 40-year-old roofer falls 20 feet, sustaining bilateral intra-articular calcaneal fractures. Due to the axial loading mechanism of injury, what is the approximate incidence of associated spinal fractures in this patient population?

. Less than 1%
. 10%
. 25%
. 50%
. 75%

Correct Answer & Explanation

. 10%

Explanation

Due to the high-energy axial loading mechanism typical of calcaneal fractures (e.g., falls from height), approximately 10% of patients will have an associated thoracolumbar spine fracture. A thorough secondary survey is essential.

Question 2769

Topic: 2. Trauma

According to the Essex-Lopresti classification of calcaneal fractures, which of the following defines a "tongue-type" fracture pattern?

. A primary fracture line exiting the calcaneocuboid joint without posterior extension
. A primary fracture line running coronally through the sustentaculum tali
. A secondary fracture line exiting posteriorly through the calcaneal tuberosity
. A secondary fracture line exiting dorsally just behind the posterior facet
. A purely extra-articular avulsion of the Achilles tendon insertion

Correct Answer & Explanation

. A secondary fracture line exiting posteriorly through the calcaneal tuberosity

Explanation

In a tongue-type calcaneal fracture, the secondary fracture line exits posteriorly through the calcaneal tuberosity, creating a posterior fragment attached to the Achilles tendon. In contrast, a joint depression fracture features a secondary line exiting dorsally just behind the posterior facet.

Question 2770

Topic: 2. Trauma

Which of the following best describes the basis of the Sanders classification system for intra-articular calcaneal fractures?

. The degree of comminution of the calcaneal tuberosity on a lateral radiograph
. The number and location of articular fragments on a coronal CT image through the widest part of the posterior facet
. The amount of joint depression on a sagittal CT image
. The involvement of the calcaneocuboid joint on an axial CT scan
. The disruption of the medial wall evaluated on a Harris axial view

Correct Answer & Explanation

. The number and location of articular fragments on a coronal CT image through the widest part of the posterior facet

Explanation

The Sanders classification relies on coronal CT slices through the widest portion of the posterior facet. It categorizes the fracture based on the number of articular fracture lines and the resulting number of primary articular fragments.

Question 2771

Topic: 2. Trauma

A 45-year-old heavy smoker sustains a displaced intra-articular calcaneal fracture. The surgeon plans an extensile lateral approach. The viability of the full-thickness lateral soft tissue flap is most heavily dependent on blood supply from which of the following arteries?

. Sural artery
. Lateral calcaneal artery
. Anterior tibial artery
. Medial plantar artery
. Dorsalis pedis artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The lateral calcaneal artery, a branch of the peroneal artery, provides the primary vascular supply to the lateral flap in the extensile lateral approach. Protecting this angiosome is critical to preventing devastating wound necrosis.

Question 2772

Topic: 2. Trauma

A 55-year-old male presents to the emergency department with a severe heel injury after falling from a roof. Clinical examination reveals profound posterior skin blanching over the heel. Radiographs demonstrate a tongue-type calcaneus fracture. What is the most critical next step in management?

. Discharge with a boot and outpatient follow-up in 2 weeks
. Urgent closed reduction or surgical fixation
. Immediate application of a tight compressive dressing
. Electromyography to assess sural nerve function
. Fasciotomies for suspected compartment syndrome

Correct Answer & Explanation

. Urgent closed reduction or surgical fixation

Explanation

Tongue-type calcaneus fractures can cause severe superior displacement of the posterior tuberosity, leading to pressure on the posterior heel skin. Urgent reduction is mandated to prevent impending soft tissue necrosis.

Question 2773

Topic: 2. Trauma
According to the landmark Buckley et al. randomized controlled trial comparing non-operative versus operative treatment for displaced intra-articular calcaneus fractures, which patient subgroup demonstrated significantly better outcomes with surgical fixation?
. A. Men receiving workers' compensation
. B. Patients older than 50 years
. C. Heavy manual laborers
. D. Women
. E. Patients with a Böhler's angle less than 0 degrees

Correct Answer & Explanation

. D. Women

Explanation

The Buckley trial found that while outcomes were similar overall, specific subgroups including women, younger patients, non-workers' compensation patients, and those with higher initial Böhler's angles had significantly better functional outcomes with surgery.

Question 2774

Topic: 2. Trauma
What is the most reliable clinical indicator that the soft tissues are amenable to a safe extensile lateral approach for definitive open reduction and internal fixation of a closed calcaneus fracture?
. A. Appearance of the 'wrinkle sign'
. B. Resolution of fracture blisters
. C. Normalization of ESR and CRP
. D. 48 hours post-injury
. E. Restoration of Böhler's angle via closed reduction

Correct Answer & Explanation

. A. Appearance of the 'wrinkle sign'

Explanation

The appearance of skin wrinkling (the 'wrinkle sign') indicates that post-traumatic edema has subsided sufficiently to safely perform an extensile lateral approach, typically occurring 10-14 days after the injury.

Question 2775

Topic: 2. Trauma

The Sanders classification system is widely used for preoperative planning of calcaneal fractures. This classification is primarily based on the number and location of fracture lines through which of the following structures on a coronal CT scan?

. Anterior process
. Middle facet
. Sustentaculum tali
. Posterior facet
. Calcaneocuboid joint

Correct Answer & Explanation

. Posterior facet

Explanation

The Sanders classification evaluates coronal CT images at the widest point of the posterior facet of the calcaneus. The type is determined by the number of fracture lines entering the posterior facet.

Question 2776

Topic: 2. Trauma

A 35-year-old male falls from a height of 15 feet, sustaining a comminuted calcaneus fracture. Given the mechanism of axial loading, what is the most common associated skeletal injury that the treating surgeon must routinely screen for?

. Cervical spine facet dislocation
. Thoracolumbar burst or compression fracture
. Pelvic ring disruption
. Bilateral distal radius fractures
. Femoral neck fracture

Correct Answer & Explanation

. Thoracolumbar burst or compression fracture

Explanation

Due to the high-energy axial loading mechanism (e.g., fall from height), calcaneus fractures are associated with a 10% rate of concomitant thoracolumbar spine fractures, necessitating thorough clinical and radiographic screening of the spine.

Question 2777

Topic: 2. Trauma

Which of the following describes the primary advantage of utilizing a sinus tarsi approach rather than an extensile lateral approach for the open reduction and internal fixation of a displaced calcaneal fracture?

. Superior visualization of the entire medial calcaneal wall
. Ability to easily place a traditional large lateral perimeter plate
. Significantly decreased rate of soft tissue wound complications
. Complete avoidance of the peroneal tendons
. Better functional outcomes in Sanders Type IV fractures

Correct Answer & Explanation

. Significantly decreased rate of soft tissue wound complications

Explanation

The sinus tarsi approach is a minimally invasive technique that significantly reduces the incidence of devastating wound edge necrosis and deep infection compared to the traditional extensile lateral approach.

Question 2778

Topic: 2. Trauma
A 28-year-old male sustains a Sanders Type III calcaneal fracture. Which of the following findings on an axial CT scan represents the most common direction of displacement for the primary posterolateral (tuberosity) fragment?
. Superior, medial, and varus
. Superior, lateral, and valgus
. Inferior, medial, and varus
. Superior, lateral, and varus
. Inferior, lateral, and valgus

Correct Answer & Explanation

. Superior, medial, and varus

Explanation

During an intra-articular calcaneus fracture, the tuberosity fragment typically displaces superiorly, translates laterally, and rotates into varus. Reduction requires reversing these deformities (distraction, medial translation, and valgus stress).

Question 2779

Topic: 2. Trauma

A 45-year-old male undergoes open reduction and internal fixation of a calcaneal fracture via an extensile lateral approach. Which of the following arterial structures is most at risk during the creation of the full-thickness subperiosteal flap, and provides the primary blood supply to the corner of this flap?

. Medial calcaneal artery
. Lateral calcaneal artery
. Sural artery
. Peroneal artery
. Dorsalis pedis artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The lateral calcaneal artery, a branch of the peroneal artery, provides the primary vascular supply to the lateral flap in the extensile lateral approach. Injury to this artery increases the risk of wound edge necrosis.

Question 2780

Topic: 2. Trauma
According to the Canadian Orthopaedic Trauma Society (Buckley et al.) multicenter randomized controlled trial on displaced intra-articular calcaneal fractures, which patient cohort demonstrated significantly better clinical outcomes with operative management compared to non-operative management?
. Patients receiving Workers' Compensation
. Males performing heavy manual labor
. Patients over the age of 50
. Women, and patients not receiving Workers' Compensation
. Patients with an initial Böhler's angle less than 0 degrees

Correct Answer & Explanation

. Women, and patients not receiving Workers' Compensation

Explanation

Buckley et al. demonstrated that women, patients not receiving Workers' Compensation, younger patients, and those with a higher initial Böhler's angle had significantly better outcomes with surgical management. Patients receiving Workers' Compensation did poorly regardless of treatment.

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