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2. Trauma MCQs

Practice Set 188 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 3741

Topic: 2. Trauma

Pelvic packing for a hemodynamically unstable patient with a pelvic ring fracture is best described by which of the following techniques?

. Placing a pelvic external fixator followed by packing the pelvis with lap pads via a subumbilical incision
. Placing lap pads for packing via a subumbilical incision in the angiography suite
. Placing lap pads for packing using the lateral window of the ilioinguinal approach (anterior approach to the internal iliac fossa)
. Packing the retroperitoneum with lap pads after exploration of the abdomen by the general surgeons
. Direct exploration of the pelvic vasculature via a midline incision followed by packing with lap pads

Correct Answer & Explanation

. Placing a pelvic external fixator followed by packing the pelvis with lap pads via a subumbilical incision

Explanation

For the technique of pelvic packing patients are placed supine on an operating room table. For rotationally and/or vertically unstable fracture patterns, an external fixator is then placed to stabilize the pelvis so that the volume of the pelvis is decreased and the packing has counterforce acting against it. An approximately 6 cm to 8 cm midline incision is made extending upwards from the pubic symphysis and heading toward the umbilicus. The rectus fascia is then divided in the midline. The bladder is retracted to one side and three lap pads are packed deep to the pelvic brim. The bladder is retracted to the other side and three more lap pads are placed on that side as well. The first sponge is placed at the level of the sacroiliac joint, the second anterior to the first sponge, and the third in the retropubic space lateral and just deep to the bladder. All should be placed below the level of the pelvic brim. The fascia is then closed. If the patient is hemodynamically unstable after stabilization, then packing of the pelvis angiography should be considered.

Question 3742

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 0ยฐ to 90ยฐ and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted. What other finding may be noted in patients with this diagnosis?

. Symmetric knee pathology
. Excessive joint laxity
. Recurrent patella instability
. Extra-articular manifestations

Correct Answer & Explanation

. Symmetric knee pathology

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. Contralateraldiscoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

Question 3743

Topic: 2. Trauma
  • What is the most common nerve injury following a Monteggia fracture-dislocation of the forearm in adults?
. Posterior interosseous
. Anterior interosseous
. Radial
. Median
. Ulnar

Correct Answer & Explanation

. Posterior interosseous

Explanation

According to Rockwood and Green the most commonly injured nerve associated with a Monteggia fracture is the posterior interosseous nerve, a branch of the radial nerve.

Question 3744

Topic: 2. Trauma
A 45-year-old male falls off his motorcycle and injures his arm. AP and lateral radiographs reveal an ulnar shaft fracture, 30 degrees apex anterior, and a radial head dislocation. Which direction is the radial head most likely dislocated?
. Lateral
. Posterior
. Posterolateral
. Anterior
. Anteromedial

Correct Answer & Explanation

. Anterior

Explanation

DISCUSSION: A Monteggia fracture with apex anterior ulnar shaft fracture is associated with an anterior radial head dislocation. Bado initially described and classified these injuries. The most common injury pattern is an extension type 1 with anterior radial head dislocation and apex anterior ulnar shaft fracture. The apex of the ulna fracture determines the direction of the radial head subluxation or dislocation. Adults typically require ORIF of the ulna. These fractures in children are often treated non-operatively with closed reduction if the ulna fracture is transverse and stable, but may also require pinning if the fracture is oblique and unstable.

Question 3745

Topic: 2. Trauma
A 35-year-old male suffers an anterior column acetabular fracture during a motor vehicle collision, and subsequently undergoes percutaneous acetabular fixation. Intraoperatively, fluoroscopy is positioned to obtain an obturator oblique-inlet view while placing a supraacetabular screw. Which of the following screw relationships is best evaluated with this view?
. Intraarticular penetration of the screw
. Position of the screw cephalad to the sciatic notch
. Screw starting point at the anterior inferior iliac spine
. Screw starting point at the gluteal pillar
. Screw position between the inner and outer tables of the ilium

Correct Answer & Explanation

. Screw position between the inner and outer tables of the ilium

Explanation

DISCUSSION: The obturator oblique-inlet view best demonstrates the position of a supraacetabular screw or pin relative to the tables of the ilium.

Question 3746

Topic: Upper Extremity Trauma

A 26-year-old weight lifter has had increasing pain in his left shoulder for 4 months. His symptoms do not improve with nonsurgical treatment that included activity modification, anti-inflammatory medication, and corticosteroid injections. He undergoes arthroscopic distal clavicle excision with resection of the distal 2.5 cm of clavicle. Three months after surgery, he reports persistent pain and popping in his shoulder. An examination demonstrates anterior and posterior instability of the distal clavicle without gross deformity. Radiographs are unremarkable. What is the most likely cause of distal clavicle instability after surgery?

. Release of the coracoacromial ligament
. Use of an arthroscopic rather than open technique
. Overresection of the distal clavicle
. Treatment with corticosteroid injections before surgery

Correct Answer & Explanation

. Overresection of the distal clavicle

Explanation

DISCUSSIONOverresection of the distal clavicle can result in disruption of the acromioclavicular ligamentous complex, which inserts at an average of 22.9 mm from the distal clavicle. A comparison of arthroscopic and open distal clavicle excision demonstrated less pain in the arthroscopic group, with no difference in patient satisfaction or shoulder function between groups. Injuries to the conoid and trapezoid ligaments occur with high-grade acromioclavicular separations, resulting in superior migration of the distal clavicle relative to the acromion. Release of the coracoacromial ligament typically is not performed during distal clavicle excision.

Question 3747

Topic: 2. Trauma
Figures 46a through 46d are the injury radiographs and postsurgical open treatment radiographs of a 13-year-old girl who fell while on a trampoline and sustained an injury to her right-dominant elbow. The skin is closed and she has normal vascular and neurologic examination findings. Which complication most likely could occur as a result of this injury and treatment?
. Compartment syndrome
. Loss of elbow motion
. Avascular necrosis (AVN) of the radial head
. Nonunion of the fracture site

Correct Answer & Explanation

. Loss of elbow motion

Explanation

DISCUSSION: This girl sustained a fracture dislocation of the elbow with a severely displaced and rotated radial neck fracture. Required treatment was open reduction and internal fixation (ORIF). Complications following ORIF of radial neck fractures in children include posterior interosseous neuropraxia, valgus angulation, premature closure of the radial head physis, AVN of the radial head, nonunion, and elbow stiffness. Stiffness is most common.

Question 3748

Topic: 2. Trauma
A 22-year-old patient sustained a jamming injury to the right little finger. The lateral radiograph shown in Figure 18 reveals comminution of the base of the middle phalanx, with palmar and dorsal metaphyseal cortical involvement. The articular surface also is disrupted. Management should consist of
. indirect fracture reduction via traction and early mobilization.
. volar plate arthroplasty.
. open reduction and internal fixation.
. closed reduction and percutaneous pin fixation.
. cast immobilization.

Correct Answer & Explanation

. indirect fracture reduction via traction and early mobilization.

Explanation

DISCUSSION: This fracture, known as a pilon fracture, represents comminution of the base of the middle phalanx with both palmar and dorsal cortical disruption. The treatment method that allows the best function and fewest complications is indirect reduction achieved through specific dynamic splinting or the use of specifically designed proximal interphalangeal joint external fixators. Early mobilization can be achieved by either of these techniques. Volar plate arthroplasty is indicated for a simple fracture-dislocation of the proximal interphalangeal joint with comminution of the volar fracture fragment and dorsal dislocation of the remaining articular surface. Open reduction and internal fixation or percutaneous pinning adds surgical risks and scarring and typically will not provide added stability. Cast immobilization will not achieve the goal of early range of motion.

Question 3749

Topic: 2. Trauma
Your 25-year-old patient complains of anterior knee pain after retrograde femoral nailing for a diaphyseal fracture and asks you why you didn't perform antegrade nailing as he has seen on the internet. You tell him that retrograde nailing is your preferred technique over antegrade nailing for diaphyseal femoral fractures because it has been shown to have?
. Increased rate of union
. Decreased rate of infection
. Shorter operative time
. Lower rates of hip pain
. Lower rates of knee pain

Correct Answer & Explanation

. Lower rates of hip pain

Explanation

DISCUSSION: Patients with retrograde femoral nails commonly have knee pain, while antegrade nails commonly have hip pain, abductor weakness, and heterotopic ossification of the abductors. Ostrum's randomized prospective study of 100 patients with reamed femoral nails found 22% of antegrade nail patients had proximal hip pain, weak hip abductors, or Trendelenburg gait. No significant difference was found in set-up time, operative time, knee motion or pain, or infection rates. Ricci performed a retrospective study of 293 fractures and found that the antegrade femoral nail group had more hip pain (10% vs 4%) and the retrograde nail group had more knee pain (36% vs 9%). There was no difference in healing, malunion, non-union, or other complications. Tornetta performed a randomized controlled comparison of 69 femur fractures and found more problems of length and rotation using a retrograde nailing. There was no difference in time to union, operating time, blood loss, complications, size of nail or reamer, or transfusion requirements.

Question 3750

Topic: 2. Trauma
Increased hip intracapsular pressures can lead to diminished femoral head perfusion. What leg position has been shown to create the lowest intracapsular hip pressures after femoral neck fracture?
. Flexion and internal rotation
. Extension and external rotation
. Flexion, abduction, and external rotation
. Extension, adduction, and internal rotation
. There are no differences in hip pressures with any position

Correct Answer & Explanation

. Flexion, abduction, and external rotation

Explanation

DISCUSSION: In the referenced study by Bonnaire et al, extension and internal rotation had the highest intracapsular pressure. They found that the greatest decrease in pressure was found with flexion, abduction, and external rotation. This is a possible etiology to the common position in which these patients will present to the emergency room. Traction was shown to increase pressure in the joint capsule.

Question 3751

Topic: 2. Trauma
An 18-year-old man was in a motor vehicle accident and sustained a closed head injury, right displaced scapular body and glenoid fractures, a right proximal humeral fracture, fractures of ribs one through three, facial fractures, and bilateral pubic rami fractures with minimal displacement. He has a systolic blood pressure of 80/40 mm Hg despite fluid resuscitation. A radiograph is shown in Figure 17. Spiral CT does not identify any thoracic or abdominal injuries. What is the next most appropriate step in management?
. Pelvic angiography
. Intracranial pressure monitoring
. Pelvic external fixation
. Evaluation of peripheral pulses
. Urgent open stabilization of the clavicular and humeral fractures

Correct Answer & Explanation

. Evaluation of peripheral pulses

Explanation

The patient has sustained high-energy upper extremity and chest injuries. He continues to remain hemodynamically unstable with no obvious thoracic or abdominal injury responsible for bleeding. The pelvic fracture is unlikely to be causing significant bleeding. A scapulothoracic dissociation and possible disruption of one of the great vessels of the upper extremity should be considered. Evaluation of peripheral pulses or blood pressure indices bilaterally in the upper extremities is a simple way to evaluate the need for further work-up. If there is any discrepancy or further concern, angiography of the involved extremity is necessary.

Question 3752

Topic: 2. Trauma
A 4-year-old boy sustained a nondisplaced, but complete, fracture of the left proximal tibial metaphysis 1 year ago. The fracture healed uneventfully in an anatomic position. Examination of the injured extremity now reveals 18ยฐ of valgus compared with 3ยฐ of valgus on the opposite side. Management should now include
. observation.
. a knee-ankle-foot orthosis.
. a medial proximal tibial epiphyseodesis.
. a proximal tibial osteotomy.
. lateral proximal tibial stapling.

Correct Answer & Explanation

. observation.

Explanation

The development of a valgus deformity after this type of fracture is a well-known occurrence, and the patientโ€™s parents should be informed about this risk. In a patient who is age 4 years, the natural history is one of gradual correction by the development of a physiologic varus deformity at the distal tibial physis; therefore, no active intervention is needed at this time. Bracing has no effect on the deformity, and the child is too young for any procedure on the growth plate. Proximal tibial osteotomy is reserved until the patient nears skeletal maturity because of the risk of recurrence of the deformity. Lateral stapling can be done near skeletal maturity if the deformity persists, but this is unlikely to be necessary.

Question 3753

Topic: 2. Trauma
A 23-year-old man who was the restrained driver in a car involved in a high-speed motor vehicle accident sustained the closed injury shown in Figures 32a through 32c. Which of the following factors has the greatest impact on the risk of osteonecrosis?
. Surgical stabilization within 6 to 8 hours of injury
. Extent of initial fracture displacement
. Nicotine use
. Posterior-to-anterior screw fixation
. Anatomic fracture reduction

Correct Answer & Explanation

. Extent of initial fracture displacement

Explanation

The incidence of osteonecrosis following displaced talar neck fractures is most related to the extent of initial fracture displacement. With increasing fracture displacement, the tenuous vascular supply to the talar body is more at risk for damage, thereby increasing the risk of osteonecrosis. Although displaced talar neck fractures have historically been considered a surgical emergency, recent studies have shown that the timing of surgical intervention bears no impact on the development of osteonecrosis. While nicotine use has an influence on fracture healing, it has never been shown to be a factor in osteonecrosis, nor has posterior-to-anterior screw fixation or the quality of fracture reduction.

Question 3754

Topic: 2. Trauma
Which of the following is considered a contraindication to cement injection techniques, such as kyphoplasty or vertebroplasty, in the treatment of osteoporotic compression fractures?
. Patient age of more than 85 years
. Retropulsion of the posterior vertebral wall
. Acute fracture in a hospitalized patient
. Prior compression fracture
. Fracture age of 4 months

Correct Answer & Explanation

. Retropulsion of the posterior vertebral wall

Explanation

When retropulsion of the posterior vertebral wall is present, nothing prohibits the cement from following the path of least resistance into the canal or from pushing a bone fragment further into the canal; most clinicians consider it a contraindication to these techniques. Patient age itself is not a contraindication as long as there are no medical contraindications to surgery. An acute fracture in a patient who remains immobile and hospitalized because of pain may be a good indication for such a technique. Prior compression fracture and older compression fractures are not contraindications, but pain relief may be less predictable.

Question 3755

Topic: Upper Extremity Trauma
A 26-year-old weightlifter has increasing pain in his left shoulder for 4 months. Nonsurgical treatment consisting of anti-inflammatory medication, corticosteroid injections, and rest fails to alleviate his symptoms. He undergoes an arthroscopic distal clavicle resection with excision of the distal 8 mm of clavicle (Mumford procedure). Three months after surgery, he reports mild pain and popping by his clavicle. His clavicle demonstrates mild posterior instability on examination without any obvious deformity on his radiographs. What structures were compromised during his excision?
. Anterior and superior acromioclavicular joint ligaments
. Posterior and superior acromioclavicular joint ligaments
. Conoid ligament
. Trapezoid ligament

Correct Answer & Explanation

. Posterior and superior acromioclavicular joint ligaments

Explanation

The posterior and superior acromioclavicular ligaments provide the most restraint to posterior translation of the acromioclavicular joint and must be preserved during a Mumford procedure. Anterior and superior acromioclavicular joint ligaments are the opposite of the preferred response and prevent anterior translation of the clavicle. Injuries to the conoid and trapezoid ligaments are more pronounced with grade III or higher acromioclavicular separations, with superior migration of the clavicle relative to the acromion.

Question 3756

Topic: 2. Trauma
A 28-year-old male sustains a fall on icy ground and fractures his ankle. An intraoperative fluoroscopy image is shown in Figure A. This fixation suggests that the mechanism of injury was one of
. Pronation-abduction
. Supination-adduction
. Pronation-external rotation
. Supination-external rotation
. Dorsiflexion-axial loading

Correct Answer & Explanation

. Supination-adduction

Explanation

The fixation of the medial malleolus in the figure consists of a contoured reconstruction plate placed in buttress (antiglide) mode with screws running parallel to the joint surface and perpendicular to the fracture line. This fixation is indicated for vertical fractures of the medial malleolus from a supination-adduction (SA) shearing force. A vertical fracture of the medial malleolus is characteristic of a Lauge-Hansen SA fracture.

Question 3757

Topic: 2. Trauma
A 32-year-old male sustains a posterior wall acetabulum fracture as the result of a high-speed motor vehicle collision. Improved patient-reported outcomes after surgical treatment are associated with which of the following variables?
. Increased age
. Increased hip flexion-extension arc
. Immediate weight-bearing
. Increased hip strength
. Decreased stride length

Correct Answer & Explanation

. Increased hip strength

Explanation

Patient functional outcomes after acetabular fractures have been shown to be related to postoperative hip strength, regardless of surgical approach. The reference by Borrelli et al evaluated muscle strength and outcomes after acetabular surgery via an anterior approach. They report that hip extension strength was affected least (6%), whereas abduction, adduction, and flexion strength was affected to a greater degree. They note that hip muscle strength after operative treatment of a displaced acetabular fracture directly influences patient outcome. The reference by Engsberg et al is a review of patients that underwent ORIF of acetabular fractures through anterior or posterior approaches. They report that maximizing hip muscle strength may improve gait, and improvement in hip muscle strength and gait is likely to improve functional outcome. Worsening functional outcomes were correlated with decreased gait kinematics and stride length.

Question 3758

Topic: 2. Trauma
Which of the following hip fracture patterns is at increased risk of proximal fragment flexion malreduction with dynamic hip screw fixation?
. Right-sided unstable intertrochanteric fracture
. Left-sided unstable intertrochanteric fracture
. Left-sided stable intertrochanteric fracture
. Right-sided stable intertrochanteric fracture
. All unstable intertrochanteric fractures

Correct Answer & Explanation

. Left-sided unstable intertrochanteric fracture

Explanation

Left-sided unstable intertrochanteric hip fractures are at increased risk of malreduction compared to unstable right-sided fractures fixed with dynamic hip screws. In left-sided fractures, the rotational torque imparted to the proximal head and neck fragment can cause loss of reduction leading to potential failures of fixation. With these left-sided injuries, the rotational torque can cause an anterior spike, whereas with right-sided injuries the rotational torque causes compression and reduction of the fracture. In addition, if a nail is used for these injuries and the proximal fracture fragment is not being held by the nail itself, this phenomenon can be seen as well. Mohan et al conducted a study to assess the effect of clockwise rotational torque onto the fracture configuration in unstable and stable intertrochanteric fractures fixed with a dynamic hip screw construct. They found that 11 out of 30 unstable fractures showed an anterior spike (flexion malreduction) in left-sided fixations due to clockwise torque. This malreduction was not present in right-sided or stable fractures.

Question 3759

Topic: 2. Trauma
All of the following techniques can help to prevent valgus angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:
. Use of a blocking screw lateral to midline in the proximal segment
. Use of a blocking screw lateral to midline in the distal segment
. Use of a lateral tibial nail starting point
. Use of supplementary plate and screw fixation
. Suprapatellar nailing portal

Correct Answer & Explanation

. Suprapatellar nailing portal

Explanation

Proximal tibial shaft fractures treated with intramedullary nails are most commonly malreduced with apex anterior and valgus deformities. Several techniques are available to overcome this malalignment: proximal and lateral nail starting point, usage of a femoral distractor or temporary plating, suprapatellar nailing, and lateral parapatellar approaches. Suprapatellar nailing portals do not affect coronal angulation; they only affect the apex anterior deformity. A final technical trick is the usage of blocking (Poller) screws. These should be placed in the lateral aspect of the proximal and distal fragments when needed.

Question 3760

Topic: 2. Trauma
An 8-year-old boy sustains nondisplaced midshaft fractures of the tibia and fibula after being struck by a car while he was riding his bicycle. No other injuries are noted, but the patient reports pain with passive motion of his toes. His neurovascular examination is otherwise normal. What is the best course of action?
. Hospital admission with a referral to social services for evaluation for child neglect
. Long leg casting and reevaluation in 24 hours
. Short leg casting and reevaluation in 24 hours
. Electrical studies of nerve function in 3 to 6 weeks if there is no improvement
. Compartment pressure measurements and inpatient treatment as indicated

Correct Answer & Explanation

. Compartment pressure measurements and inpatient treatment as indicated

Explanation

Pain with passive motion of the toes is a recognized early sign of increased compartment pressures. At a minimum, a baseline evaluation of the leg compartment pressures should be obtained. While it is normal for the patient to have pain related to the associated muscle contusions, any significant concerns should be addressed immediately in light of the severe consequences likely when a compartment syndrome occurs.

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