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2. Trauma MCQs

Practice Set 186 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 3701

Topic: 2. Trauma

A 26-year-old professional rodeo bull rider sustained a grade III midshaft femoral fracture after being thrown from his bull. He underwent closed interlocking intermedullary nailing with a titanium rod, and his recovery was uneventful. Prior to returning to competition, the patient must

. be able to run and walk without pain.
. refrain from vigorous activity for 6 months.
. achieve full hip and knee range of motion.
. achieve symmetric lower extremity strength.
. have radiographic evidence of a circumferential external bridging callus.

Correct Answer & Explanation

. be able to run and walk without pain.

Explanation

DISCUSSION: While it is recommended that a patient gain full range of motion, pain-free function, and symmetric strength prior to returning to vigorous activities, it is absolutely essential that radiographs of the fracture site reveal a circumferential external bridging callus to prevent refracture.  This is particularly important for comminuted femoral fractures with various sized fragments.  It is also recommended that a return to rodeo riding be postponed for atleast 1 year.REFERENCES: Brumback RJ, Ellison TS: Intermedullary nailing of femoral stress fractures.  J Bone Joint Surg Am 1992;74:106-112.Bucholz RW, Jones A: Fractures of the shaft of the femur.  J Bone Joint Surg Am1991;73:1561-1566.Butler MS, Brumback RJ: Interlocking nailing for ipsilateral fractures of the femur, femoral shaft, and distal part of the femur.  J Bone Joint Surg Am 1991;73:1492-1502.

Question 3702

Topic: Upper Extremity Trauma

Persistent symptoms and decreased function following distal clavicle resection, coracoacromial ligament transfer, and augmentation (modified Weaver-Dunn) are most likely related to Review Topic

. anterior-posterior translation.
. superior-inferior translation.3inadequate resection of the distal clavicle.
. excessive reduction of the clavicle relative to the coracoid.
. unrecognized instability of the sternoclavicular joint.

Correct Answer & Explanation

. anterior-posterior translation.

Explanation

Although multiple studies have reported good clinical results with the modified Weaver-Dunn reconstruction, others have suggested that the reconstruction does not restore the native stability to the acromioclavicular joint. In particular, persistent horizontal (anterior to posterior) instability may cause persistent symptoms following reconstruction. Anatomic repair and reconstruction techniques that preserve the distal clavicle may offer patients less risk of horizontal instability.

Question 3703

Topic: 2. Trauma
A 17-year-old girl is involved in a motor vehicle collision and sustains the injury shown in Figures 46a through 46c. She is neurologically intact in her bilateral lower extremities. Definitive treatment should consist of:
. Anterior reduction, stabilization, and fusion at L1-2.
. Anterior reduction, stabilization, and fusion at T12-L3.
. Posterior reduction, stabilization, and fusion at L1-2.
. Posterior reduction, stabilization, and fusion at T12-L4.

Correct Answer & Explanation

. Posterior reduction, stabilization, and fusion at T12-L4.

Explanation

DISCUSSION: The figures reveal a fracture-dislocation at L1-2. Proper treatment consists of posterior reduction, stabilization, and fusion 2 levels above and below the level of injury. Short-segment stabilization schemes do not stabilize the injury properly, and longer-segment constructs are not necessary. Anterior treatment is not indicated in fracture-dislocations.

Question 3704

Topic: 2. Trauma

Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0° to 90° and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted. Based on the pathology noted, which finding may be found on plain knee radiographs?

. Shallow trochlear groove
. Squaring of the lateral femoral condyle
. Deepening of the sulcus terminalis
. Medial joint space narrowing

Correct Answer & Explanation

. Shallow trochlear groove

Explanation

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatmentof a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

Question 3705

Topic: 2. Trauma

An 11-year-old basketball player reports that he felt a painful pop in the left knee when he stumbled while running. He is unable to bear weight on the extremity and cannot actively extend the knee against gravity. Examination reveals a large knee effusion. A lateral radiograph is shown in Figure 7. Management should consist of Review Topic

. physical therapy for quadriceps strengthening exercises.
. a long leg cast with the knee fully extended.
. excision of the fragment.
. suture reattachment of the patellar tendon to the tibial tuberosity.
. open reduction and tension band fixation.

Correct Answer & Explanation

. physical therapy for quadriceps strengthening exercises.

Explanation

The radiograph shows an avulsion fracture, or “sleeve fracture,” of the distal pole of the patella. The distal fragment is much larger than it appears on the radiograph because it largely consists of cartilage; therefore, excision of the fragment is contraindicated. The treatment of choice is open reduction and tension band fixation to correct patella alta and restore the extensor mechanism.

Question 3706

Topic: 2. Trauma

Figures 132a and 132b are the lateral and anteroposterior radiographs of a 15-year-old boy with a 6-month history of recurrent, activity-related posterior elbow pain when pitching. Two separate 6-week periods of rest have failed to provide relief. What is the next best step to enable him to return to play? Review Topic

. Physiotherapy
. Long-arm cast
. Cannulated screw fixation
. Plate fixation of the ulna
. Hinged-elbow bracing

Correct Answer & Explanation

. Physiotherapy

Explanation

Intramedullary screw fixation of the olecranon stress fracture is most likely to allow him to return to play. Stress fractures through a persistent olecranon apophysis have been well described in the literature. The AP radiograph reveals the other physes of the elbow to be closed. After patients fail to respond to appropriate periods of rest andcessation from throwing followed by appropriate physiotherapy, surgical management with cannulated screw fixation is appropriate and has been demonstrated to have favorable success rates. Hinged-elbow bracing will not facilitate healing or return to play. Long-arm casting is likely to result in stiffness and would not be unreasonable for a short duration at the onset of symptoms, but is less likely to be helpful at this point. Plate fixation is not indicated for treatment of this injury.

Question 3707

Topic: 2. Trauma
A 25-year-old man is brought to the emergency department following a motor vehicle accident. Extrication time was 2 hours, and in the field he had a systolic blood pressure by palpation of 90 mm Hg. Intravenous therapy was started, and on arrival in the emergency department he has a systolic blood pressure of 90 mm Hg with a pulse rate of 130. Examination reveals a flail chest and a femoral diaphyseal fracture. Ultrasound of the abdomen is positive. The trauma surgeons take him to the operating room for an exploratory laparotomy. At the conclusion of the procedure, he has a systolic pressure of 100 mm Hg with a pulse rate of 110. Oxygen saturation is 90% on 100% oxygen, and he has a temperature of 95.0° F (35° C). What is the recommended treatment of the femoral fracture at this time?
. Reamed intramedullary nail
. Unreamed intramedullary nail
. Percutaneous plate fixation
. Skeletal traction
. External fixation

Correct Answer & Explanation

. External fixation

Explanation

DISCUSSION: This is a “borderline trauma” patient where serious consideration for damage control orthopaedic surgery is required. His prolonged hypotension, abdominal injury, and chest injury put him at higher risk for serious postinjury complications. Further surgery, such as definitive fracture fixation, adds metabolic load and injury to his system. It is prudent to consider femoral fracture stabilization with an external fixator until he is physiologically recovered as evidenced by a normal base excess and/or lactate acid levels, as well as all other parameters of resuscitation. A borderline patient has been described as polytrauma with an ISS > 20 and thoracic trauma (AIS > 2); polytrauma and abdominal/pelvic trauma (Moore > 3) and hemodynamic shock (initial BP < 90 mm Hg); ISS > 40; bilateral lung contusions on radiographs; initial mean pulmonary arterial pressure > 24 mm Hg; pulmonary artery pressure increase during intramedullary nailing > 6 mm Hg. Factors that worsen the situation following surgery include multiple long bones and truncal injury (AIS > 2), estimated surgery time of more than 6 hours, arterial injury and hemodynamic instability, and exaggerated inflammatory response (e.g., IL-6 > 800 pg/mL). It is incumbent on the orthopaedic surgeon who is a member of the trauma team to make sure that he or she is aware of these factors and guides the team to the best patient care. REFERENCES: Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopaedic surgery. J Trauma 2002;53:452-461. Bosse M, Kellam JF: Orthopaedic decision making in the multiple trauma patient, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 133-146.

Question 3708

Topic: 2. Trauma
An 11-year-old girl is struck in the leg by a loaded sled while sledding and is seen in the emergency department; she is reporting severe knee pain. Radiographs are read as normal. Examination reveals that she is exquisitely tender over the proximal tibial physis. The neurovascular examination is normal. What is the next step in management?
. Splinting, admission, and frequent neurovascular checks
. Cylinder cast and discharge
. Four-compartment calf fasciotomy
. Non-weight-bearing, a knee immobilizer, and follow-up in 1 week

Correct Answer & Explanation

. Splinting, admission, and frequent neurovascular checks

Explanation

DISCUSSION: The anatomic lesion in this patient is not exactly defined, but she has most likely sustained an injury about the knee. A Salter-Harris type I proximal tibial physeal fracture is likely. The normal radiograph reading can be misleading because these injuries may displace and spontaneously reduce. The child is at risk of compartment syndrome although she is currently not displaying signs of it. Thus, even though this injury may seem trivial by radiographic findings, it should be treated like a knee dislocation with a risk of late developing compartment syndrome. MRI or CT may be necessary to define the injury. She does not require emergent treatment, but merits close observation for possible compartment syndrome. Any of the possible injuries about the knee can be unstable and require internal fixation after reduction. REFERENCES: McGuigan JA, O’Reilly MJ, Nixon JR: Popliteal arterial thrombosis resulting from disruption of the upper tibial epiphysis. Injury 1984;16:49-50. Burkhart SS, Peterson HA: Fractures of the proximal tibial epiphysis. J Bone Joint Surg Am 1979;61:996-1002.

Question 3709

Topic: 2. Trauma
  • Which of the following factors is used to determine torsional rigidity of a long bone fracture under internal or external fixation?
. Bone rotation versus torque applied
. Bone deflection versus bending moment applied
. Axial displacement versus tension applied
. Lateral translation versus shear force applied
. Fracture gap closing versus compressive force applied

Correct Answer & Explanation

. Bone rotation versus torque applied

Explanation

Torque is defined as: T=r x F, where r is the moment arm and F is the force applied. The moment arm is the perpendicular distance from the line of action or axis of rotation. Thus torque is a vectorquantity having a magnitude and direction. Torsion involves shear and tensile stresses that cause deformation. Thus torsional rigidity is related to bone rotation and the torque applied to it.

Question 3710

Topic: 2. Trauma
A 22-year-old woman injured her ankle when she fell off a ladder. Radiographs reveal a displaced large posterior malleolus fracture of about 45% of the joint. What is the best definitive treatment?
. Open reduction and internal fixation with absolute stability
. Open reduction and internal fixation with relative stability
. Closed reduction with casting
. Reamed locked intramedullary nailing
. External fixation

Correct Answer & Explanation

. Open reduction and internal fixation with absolute stability

Explanation

With regards to articular fractures, anatomic reduction and rigid stabilization are required to achieve the best results and allow for fracture healing. This environment also allows for the best chance of the cartilage repair process to form 'hyaline-like' cartilage. Open reduction and internal fixation with absolute stability is the mainstay of treatment for partial articular fractures such as split depression tibial plateau fractures and posterior malleolus fractures involving greater than about 25% to 30% of the joint.

Question 3711

Topic: 2. Trauma
Which of the following conditions is associated with palmoplantar pustulosis?
. Condensing osteitis
. Sternoclavicular hyperostosis
. Friedreich’s disease
. Scleroderma
. Reiter syndrome

Correct Answer & Explanation

. Sternoclavicular hyperostosis

Explanation

DISCUSSION: Sternoclavicular hyperostosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis. REFERENCES: Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA, WB Saunders, 2004, vol 2, pp 608-609. Sonozaki H, Azuma A, Okai K, et al: Clinical features of 22 cases with inter-sterno-costo-clavicular ossification: A new rheumatic syndrome. Arch Orthop Trauma Surg 1979;95:13-22.

Question 3712

Topic: 2. Trauma
What vessel is marked with an asterisk in Figure 44?
. Obturator artery
. Inferior epigastric artery
. Superior gluteal artery
. Internal pudendal artery
. Lateral sacral artery

Correct Answer & Explanation

. Superior gluteal artery

Explanation

DISCUSSION: The superior gluteal artery is a branch of the posterior division of the internal iliac artery and exits the pelvis through the greater sciatic notch. It can be injured as a result of a pelvic ring fracture or acetabular fracture that has a fracture of the posterior column. REFERENCES: Agur AM, Dalley AF (eds): Grant’s Atlas of Anatomy, ed 12. Philadelphia, PA, Lippincott Williams and Wilkins, 2008. Uflacker R: Atlas of Vascular Anatomy: An Angiographic Approach, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2006.

Question 3713

Topic: 2. Trauma

Which of the following factors is associated with the highest rate of nonunion of a midshaft clavicle fracture?

. younger patients
. female gender
. simple fracture pattern
. sling immobilization
. early range-of-motion

Correct Answer & Explanation

. younger patients

Explanation

The risk of nonunion in patients sustaining middle 1/3 clavicle fractures is increased in female patients.Clavicle fractures are often secondary to direct blows to the lateral aspect of the shoulder. Physical examination is important to ascertain the status of theskin and neurovascular structures to help guide treatment management. Although most non-displaced middle 1/3 clavicle fractures may be treated successfully with conservative measures, the risk for non-union (1-5%) increases with increasing comminution, female gender, shortening greater than 2 cm and an advanced age of the patient.Robinson et al. reviewed 581 patients treated non-operatively for midshaft clavicle fractures. A nonunion rate of 4.5 % was identified at 24 weeks after the injury. They identified four factors that contributed to non-union, including: female gender, lack of cortical apposition, comminution of the fracture fragments and advancing age.Zlowdzki et al. reviewed 2144 clavicle fracture cases in a comprehensive meta-analysis. They report displacement as the highest risk factor for nonunion (15.1%) in nonoperatively treated clavicle fractures, and simple slings were favored over figure of 8 braces. They also report an 86% reduction in the nonunion rate when operative fixation is chosen over nonoperative treatment for displaced clavicle fractures.Illustration A shows the presence of a non-union of a midshaft clavicle fracture. A video is provided that reviews management of clavicle injuries.Incorrect AnswersOrthoCash 2020

Question 3714

Topic: 2. Trauma

The condition shown in Figures 9a and 9b is most likely the result of

. infection.
. uric acid deposition.
. trauma.
. a virus.
. severe cold exposure.

Correct Answer & Explanation

. infection.

Explanation

The clinical photograph and radiograph show gout, which is the result of urate deposition in the joint and soft tissues. Radiographs frequently reveal periarticular erosions. The crystals are intracellular and negatively birefringent under the polarized microscope. Treatment for acute flares include colchicines, indomethacin, and corticosteroids (including injections). Medications such as allopurinol help prevent recurrent flares. Tophi such as that seen in this patient are often confused with and associated with infection.

Question 3715

Topic: Pelvic & Acetabular Trauma
Figure 36 shows the hip arthrogram of a newborn. Which of the following structures is enclosed by the circle?
. Limbus
. Pulvinar
. Ligamentum teres
. Transverse acetabular ligament
. Acetabular labrum

Correct Answer & Explanation

. Acetabular labrum

Explanation

DISCUSSION: The structure enclosed by the circle is the acetabular labrum. It is visible as the white point of tissue outlined by the darkly radiopaque contrast. The appearance of the contrast surrounding the sharp white point of a normal labrum is called the “rose thorn sign.” The limbus is the term reserved for a rounded, infolded labrum seen with arthrography. The pulvinar is the fatty tissue seen in the empty acetabulum when the hip is dislocated. The ligamentum teres is seen as a white stripe outlined by contrast coursing from the central acetabulum to the dislocated femoral head. The transverse acetabular ligament courses across the inferior portion of the acetabulum and is not clearly seen with arthrography. REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 532-533. Severin E: Contribution to the knowledge of congenital dislocation of the hip joint. Acta Chir Scand 1941;84:1.

Question 3716

Topic: 2. Trauma
Figure 22 shows the radiograph of a 7-year-old boy who underwent retrograde elastic nailing of a femoral shaft fracture. What is the most common problem following this procedure?
. Unacceptable shortening
. Osteonecrosis of the femoral head
. Malunion
. Persistent pain and irritation at the nail insertion site
. Rotational malalignment

Correct Answer & Explanation

. Persistent pain and irritation at the nail insertion site

Explanation

DISCUSSION: Several large clinical studies have shown that the most common problem after elastic nailing of a femoral shaft fracture is persistent pain and irritation at the nail insertion site. Unacceptable shortening and malunion are very rare in a 7-year-old patient. Rotational malalignment also is unusual. Osteonecrosis has been reported in solid antegrade nailing but not with elastic nailing of femoral shaft fractures in skeletally immature patients. REFERENCES: Flynn JM, Luedtke LM, Ganley TJ, et al: Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg Am 2004;86:770-777. Flynn JM, Hresko T, Reynolds RA, et al: Titanium elastic nails for pediatric femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4-8. Ligier JN, Metaizeau JP, Prevot J, et al: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.

Question 3717

Topic: 2. Trauma
A 32-year-old woman sustained an injury to her left upper extremity in a motor vehicle accident. Examination reveals a 2-cm wound in the mid portion of the dorsal surface of the upper arm and deformities at the elbow and forearm; there are no other injuries. Her vital signs are stable, and she has a base deficit of -1 and a lactate level of less than 2. Radiographs are shown in Figures 9a and 9b. In addition to urgent debridement of the humeral shaft fracture, management should include
. closed management of the medial condyle and humeral shaft fractures and open reduction and internal fixation of the both bones forearm fracture.
. closed management of the humeral shaft fracture and open reduction and internal fixation of the medial condyle and the both bones forearm fractures.
. open reduction and internal fixation of the humeral shaft, medial condyle, and the both bones forearm fractures.
. open reduction and internal fixation of the medial condyle and both bones forearm fractures, and external fixation of the humeral shaft fracture.
. delayed stabilization of all fractures after the open wound has healed.

Correct Answer & Explanation

. open reduction and internal fixation of the humeral shaft, medial condyle, and the both bones forearm fractures.

Explanation

With a severe injury to the upper extremity, the best opportunity for achieving a good functional result for a floating elbow is immediate debridement of the open fracture, followed by internal fixation of the fractures. The ability to do this depends on the patient’s physiologic status. In this patient, the procedure is acceptable because she has normal vital signs and no chest or abdominal injuries, and normal physiologic parameters (base excess and lactate) show adequate peripheral perfusion. The surgical approaches will be determined by the associated injury patterns and open wounds. In this patient, the humerus was debrided and stabilized through a posterior approach as was the medial condyle fracture. The ulna was fixed through an extension of the posterior incision and the radius through a separate dorsal approach.

Question 3718

Topic: 2. Trauma
A right-handed 20-year-old college baseball pitcher has had a 6-month history of vague right elbow pain while pitching. Examination reveals full flexion of the elbow and a loss of only a few degrees of full extension. The elbow is stable, but palpation reveals tenderness over the olecranon. Plain radiographs are inconclusive. MRI and CT scans are shown in Figures 20a and 20b. Management should consist of
. repair of a triceps tendon avulsion.
. arthroscopy of the elbow for removal of loose bodies.
. arthroscopic removal of a posteromedial olecranon osteophyte.
. internal fixation of an olecranon stress fracture.
. rest, rehabilitation, and resumption of pitching when the fracture is healed.

Correct Answer & Explanation

. rest, rehabilitation, and resumption of pitching when the fracture is healed.

Explanation

The patient has a stress fracture of the olecranon that occurs with repetitive throwing motions. If the fracture is not displaced, the initial treatment of choice is rest and rehabilitation to maintain elbow motion, followed by aggressive strengthening at 6 to 8 weeks. A light throwing program generally can begin at 8 to 12 weeks. Complete recovery may require 3 to 6 months. If the fracture is displaced or if nonsurgical management fails, surgery is indicated for internal fixation of the stress fracture.

Question 3719

Topic: 2. Trauma
Which of the following pelvic injury types has the highest reported mortality rate?
. Anterior posterior compression (APC) III injury
. Lateral compression (LC) III injury
. Transverse-posterior wall acetabular fracture
. Vertical Shear
. Combined mechanical injury (CMI)

Correct Answer & Explanation

. Anterior posterior compression (APC) III injury

Explanation

Anterior posterior compression (APC) injuries have the highest mortality rates of the fracture patterns listed. APC injuries have high rates of concomitant thoracic and abdominal visceral injuries leading to the highest rates of mortality among pelvic fractures. Lateral compression (LC) fractures have particularly high incidences of associated brain and head injury with lower mortality than APC injuries. Overall, as the grade of pelvic ring injury increases the rates of associated injuries increases, regardless of exact mechanism of injury. The overall mortality rate for any pelvic trauma is roughly 15%, with APC III mortality around 37%, and overall APC mortality rates around 26%. LC of any grade has an estimated mortality around 13%. Vertical shear and CMI have estimated mortality of 25% and 17.1%, respectively. The lowest mortality rates are following acetabular fractures with estimates around 1.5%.

Question 3720

Topic: 2. Trauma

A 77-year-old woman underwent semiconstrained right total elbow arthroplasty 4 weeks ago through a Bryan-Morrey approach. Her recovery was uneventful until 2 days ago when she began her physical therapy session at an outpatient clinic. During resisted extension exercises, she felt a "pop" in her elbow, accompanied with pain and inability to extend her elbow against resistance. What is the most likely cause of her symptoms? Review Topic

. Fracture of the ulnar component
. Disengagement of the axle of the prosthesis
. Failure of the triceps mechanism repair
. Periprosthetic fracture of the humerus
. Periprosthetic fracture of the ulna

Correct Answer & Explanation

. Fracture of the ulnar component

Explanation

During a Bryan-Morrey approach for total elbow arthroplasty, the triceps is dissected free from its ulnar insertion and reflected laterally. At the conclusion of the procedure, the triceps tendon is reattached to the ulna through drill holes. Whereas motion can be initiated postoperatively, 6 to 8 weeks of protection are recommended before initiation of resistance exercises to protect the triceps repair. A periprosthetic fracture or component failure is rare in the absence of more significant trauma, and they are usually late complications.

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