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2. Trauma MCQs

Practice Set 189 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 3761

Topic: 2. Trauma
A 5-year-old boy reports intermittent left elbow pain. History reveals that he injured his elbow 4 months ago, but had no treatment. He is now using his arm normally but reports pain almost daily. Examination reveals tenderness over the lateral epicondyle and a prominence is evident. Range of motion is from -5 degrees to 120 degrees. Radiographs are shown in Figure 67. Management should include:
. open reduction and internal fixation.
. cast immobilization.
. percutaneous pin fixation.
. observation, with follow-up in 3 months.
. an MRI scan of the elbow.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

The patient has a nonunion of the lateral condyle of the left humerus. Observation or cast treatment at this stage is not likely to lead to healing of the fracture. MRI will not add any additional information. Open reduction, with minimal posterior soft-tissue stripping, is recommended to establish union of the fracture. Local or other bone graft may also be required. There are no studies that indicate that the displaced fracture will heal with late percutaneous fixation.

Question 3762

Topic: 2. Trauma
When treating a stable 2-part intertrochanteric hip fracture with a sliding hip screw construct, what is the minimum amount of screw holes that are needed in the side plate for successful fixation?
. One
. Two
. Three
. Four
. Five

Correct Answer & Explanation

. Two

Explanation

A two-part stable intertrochanteric femur fracture can be treated with a sliding hip screw, with good biomechanical and clinical results. The referenced article by Bolhofner et al reviews a series of 69 patients with a sliding hip screw and two-hole side plate and notes that they did not have any failure of the side plate construct. The referenced article by McLoughlin et al is a biomechanical evaluation of 2 versus 4 hole plates and found that peak load in the failure test was not found to be statistically different between the two-hole and four-hole designs. In cyclic testing, the two-hole configuration exhibited statistically smaller fragment migration in both shear and distraction than the four-hole design.

Question 3763

Topic: 2. Trauma
While obtaining informed consent for a lateral closing-wedge osteotomy, what complication should be discussed with the patient as exclusive to this procedure and not encountered in medial opening-wedge osteotomy?
. Compartment syndrome
. Plate breakage
. Neurologic injury
. Proximal tibiofibular joint disruption

Correct Answer & Explanation

. Proximal tibiofibular joint disruption

Explanation

DISCUSSION: With lateral closing-wedge osteotomy, proximal tibiofibular disruption can occur. This is not seen in medial opening-wedge osteotomy. A technique has been developed to prevent this complication; a fibular osteotomy is performed at the same time as the tibial osteotomy. The other complications listed are seen in both techniques, with nonunion and plate breakage more common in opening-wedge high tibial osteotomy (HTO) and neurologic injury more common in closing-wedge HTO (with issues related to the common peroneal nerve most prevalent). Compartment syndrome is a devastating complication that can occur with any osteotomy, and a high index of suspicion should be maintained during the postsurgical course for patients who develop this condition.

Question 3764

Topic: 2. Trauma

A 20-year-old man is brought to the emergency department after a high-speed motor vehicle accident. His initial blood pressure is 70/40 mm Hg. He is currently receiving intravenous fluids as well as blood. His Focused Assessment with Sonography for Trauma examination did not show any free fluid in his abdomen and his chest radiograph is unremarkable. An AP pelvis radiograph is shown in Figure 15. What is the next most appropriate step in the management of his pelvic injury? Review Topic

. Inlet and outlet views of the pelvis to better delineate the injury
. Angiography
. Laparotomy
. Open reduction and internal fixation of the pelvis
. Placement of a pelvic binder around the patient

Correct Answer & Explanation

. Inlet and outlet views of the pelvis to better delineate the injury

Explanation

This hypotensive patient has an obvious open book injury of the pelvic ring on the AP pelvis radiograph and further radiographs are not needed prior to the initiation of treatment. Although angiography may be indicated if he does not respond to stabilization of his pelvis and fluid/blood administration, temporary stabilization of the pelvis with a sheet or binder should be performed first because it is simple, quick, and has been shown to be effective. This patient does not need a laparotomy at this point since the FAST examination did not show any free intra-abdominal fluid and his chest radiograph was unremarkable, leaving the most likely source of bleeding the pelvic fracture. Open reduction with internal fixation of a pelvic injury is not indicated in an acutely ill patient.

Question 3765

Topic: 2. Trauma
A 30-year-old elite marathon runner reports chronic pain over the lateral aspect of the distal right leg and dysesthesia over the dorsum of the foot with active plantar flexion and inversion of the foot. Examination reveals a tender soft-tissue fullness approximately 10 cm proximal to the lateral malleolus. The pain is exacerbated by passive plantar flexion and inversion of the ankle. There is also a positive Tinelโ€™s sign over the site of maximal tenderness. There is no motor weakness, and deep tendon reflexes are normal. Radiographs and MRI of the leg are normal. What is the next most appropriate step in management?
. Biopsy of the soft-tissue mass
. Epidural corticosteroid injection into the lumbar spine
. Four-compartment fasciotomy of the leg
. Fascial release and neurolysis of the superficial peroneal nerve
. Closure of the fascial defect of the superficial peroneal nerve

Correct Answer & Explanation

. Fascial release and neurolysis of the superficial peroneal nerve

Explanation

The patient has entrapment of the superficial peroneal nerve against its fascial opening in the distal leg. It is typically exacerbated by passive or active plantar flexion and inversion of the foot, which leads to traction of the nerve as it exits this opening. Treatment involves release of the fascial opening to reduce this traction phenomenon. Closure of the defect will only aggravate the condition and potentially result in an exertional compartment syndrome. A four-compartment fasciotomy is only indicated for an established compartment syndrome of the leg.

Question 3766

Topic: 2. Trauma

A 20-year-old unrestrained driver sustained a midshaft femur fracture in a high-speed motor vehicle accident. The femoral neck was evaluated with a CT scan with 2-mm cuts through the hip; no fracture was identified. What additional studies (if any) should be performed to minimize the risk of having an undiagnosed femoral neck fracture?

. Postoperative MRI scan
. Postoperative bone scan
. Preoperative AP pelvic radiograph
. No additional imaging studies are needed
. Intraoperative fluoroscopic images of the femoral neck

Correct Answer & Explanation

. Postoperative MRI scan

Explanation

Nondisplaced femoral neck fractures may occur concurrently with high-energy injuries of the femur. Preferably, these are identified prior to or during surgery so that the fracture can be stabilized to prevent displacement and minimize the risk of osteonecrosis. However, the diagnosis of these injuries can be difficult. Tornetta and associates reported on standardized protocol that involved preoperative radiographs and CT scans with fine cuts through the femoral head. This protocol improved the detection of femoral neck fractures compared with situations with no set protocol. Of the 16 fractures detected, 13 were identified preoperatively. Of the three fractures that were missed by the screening, one was iatrogenic, one of these was detected at the time of surgery with intraoperative internal/external views of the femoral neck, and one had a late displacement. The overall rate of nondisplaced femoral neck fractures in this study was 7.5%, of which 91% were treated at the time of initial surgery having been identified on preoperative and/or intraoperative radiographs. Care must be taken not to neglect careful scrutiny of the femoral neck at the time of surgery even if preoperative imaging studies do not detect a fracture. No one method has been shown to have a 100% success rate. Postoperative bone scans and MRI scans are not routinely used.

Question 3767

Topic: 2. Trauma

A patient is seen in the emergency department after a motor vehicle accident. He reports right hip pain and chest pain. Initial hypotension has responded to a fluid bolus. Radiographs reveal a posterior hip dislocation with a small posterior acetabular wall fracture. You are called at home and informed of the findings. What is the next most appropriate step in management? Review Topic

. Obtain a CT scan to assess the injury.
. Obtain an MRI scan to assess for osteonecrosis.
. Reduce the hip and evaluate hip stability.
. Perform open reduction of the hip in the operating room.
. Ask the emergency room physician to transfer the patient to a higher level trauma center.

Correct Answer & Explanation

. Obtain a CT scan to assess the injury.

Explanation

An immediate reduction of the hip is required. Transfer to a trauma center may be indicated to treat a possible chest injury and the acetabular fracture. Reduction of the hip dislocation should be considered emergent and should be performed prior to transfer. Additional diagnostic studies prior to hip reduction are not necessary. Most hip dislocations can be reduced closed and this is the preferred management.

Question 3768

Topic: 2. Trauma
Anterior perforation of the distal femur from antegrade femoral nailing has been attributed to what factor?
. Non-anatomic reduction
. Mismatch of the radius of curvature of implant and bone
. Usage of too large an implant
. Lateral patient positioning
. Lateral proximal starting point

Correct Answer & Explanation

. Mismatch of the radius of curvature of implant and bone

Explanation

DISCUSSION: Anterior perforation of the femur has been attributed to a simple mismatch in the radius of curvature of implants and the apex anterior bowed femur. The radius of curvature is generally smaller (114-120 cm) than many earlier generation femoral nails (up to 300 cm). The difference in femoral anteroposterior bow between the bone and the implant is a contributing factor to distal femoral anterior cortex penetration in intramedullary nailing of subtrochanteric fractures.

Question 3769

Topic: 2. Trauma
A 30-year-old man has pain in the left arm after a motor vehicle accident. His neurovascular examination is intact, and radiographs are shown in Figures 25a and 25b. What is the best course of management?
. Closed reduction and cast immobilization for 4 weeks, followed by therapy directed at regaining motion
. Open reduction and internal fixation of the olecranon fracture, functional bracing of the humeral fracture, and therapy directed at regaining motion initiated at 2 weeks after surgery
. Open reduction and internal fixation of the olecranon and humeral fractures, followed by therapy directed at regaining motion
. Open reduction and internal fixation of the olecranon and humeral fractures, and splint immobilization for 4 weeks followed by therapy directed at regaining motion
. Open reduction and internal fixation of the olecranon fracture, functional bracing of the humeral fracture, and therapy directed at regaining motion initiated at 4 weeks after surgery

Correct Answer & Explanation

. Open reduction and internal fixation of the olecranon and humeral fractures, followed by therapy directed at regaining motion

Explanation

DISCUSSION: The floating elbow is best managed with early open reduction and internal fixation of the humeral and forearm fractures, followed by early range of motion. These fractures predispose the elbow to stiffness, and early range of motion is recommended.

Question 3770

Topic: Pelvic & Acetabular Trauma

A 35-year-old man who has had a 6-month history of low back pain and tenderness now reports worsening pain and stiffness in the hips and entire back. An AP radiograph of the pelvis demonstrates fusion of the sacroiliac joints bilaterally. What is the next most appropriate step in management? Review Topic

. Anesthetic injections in both sacroiliac joints
. Sacroiliac fusion with plate fixation
. Anti-inflammatory medications, physical therapy, and HLA-B27 testing
. Patient reassurance and follow-up as needed
. Immediate bilateral sacroiliac joint aspiration and culture

Correct Answer & Explanation

. Anesthetic injections in both sacroiliac joints

Explanation

The patient has a classic presentation of early ankylosing spondylitis. Sacroiliac joint fusion is the earliest radiographic finding and is typically followed by cephalad spinal progression. Early treatment of ankylosing spondylitis consists of nonsteroidal anti-inflammatory drugs and physical therapy to preserve spinal motion. HLA-B27 testing is positive in most (about 95%) patients; however, it is not pathognomonic because it can be positive with other conditions. Considering the progressive nature of thisdisease, further work-up in a patient with potential ankylosing spondylitis is not warranted. Sacroiliac joint anesthetic injections and sacroiliac fusion are not recommended treatments for early ankylosing spondylitis. Aspiration of the sacroiliac joints can be done if sacroiliac joint infection is suspected; however, in the absence of fever or other constitutional symptoms, infection is unlikely.

Question 3771

Topic: Upper Extremity Trauma
A 26-year-old weightlifter had increasing pain in his left shoulder for 4 months. Nonsurgical treatment consisting of anti-inflammatory medication failed. Which of the following structures must be preserved during a Mumford procedure to prevent posterior translation of the acromioclavicular joint?
. 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 3772

Topic: 2. Trauma
Figure 18a shows the clinical photograph of a 2-year-old boy who has a deformity of the right leg. Examination reveals eight cutaneous markings similar to those shown in Figure 18b. Radiographs are shown in Figure 18c. Management should consist of
. fragmentation, realignment, and intramedullary nailing of the tibia.
. resection of the dysplastic region of the tibia and insertion of a vascularized fibula.
. supplemental vitamin D and phosphate.
. a clamshell orthosis.
. observation for spontaneous remodeling.

Correct Answer & Explanation

. a clamshell orthosis.

Explanation

The diagnosis of neurofibromatosis may be based on the presence of at least six cafe-au-lait spots larger than 5 mm in diameter and the osseous lesion shown in Figure 18c. Neurofibromatosis occurs in 50% of patients who have an anterolateral bowing deformity of the tibia, and this bowing may be the first clinical manifestation of this disorder. The patient has anterolateral bowing of the tibia and fibula that warrants concern for a possible fracture and pseudarthrosis; therefore, the limb should be protected in a total contact orthosis to prevent fracture. In contradistinction to posteromedial bowing of the tibia and fibula, spontaneous remodeling of an anterolateral bowing deformity is not expected. Intramedullary nailing or the use of a vascularized fibula is reserved for the treatment of a congenital pseudarthrosis of the tibia.

Question 3773

Topic: 2. Trauma

You design a research study in which you ask patients who have a nonunion of the tibia to fill out a questionnaire in which they report on a variety of medical conditions and social/behavioral practices. You compare these findings to a similar group who did not develop a nonunion in order to identify medical and/or social conditions that might be risk factors for the development of tibial nonunions. This would be an example of what type of study?

. Case series
. Meta-analysis
. Case control study
. Retrospective cohort study
. Prospective cohort study

Correct Answer & Explanation

. Case series

Explanation

A case control series starts with the occurrence of a specific disease or observation, and then compares data on those individuals to a similar group without the disease (control group) in order to identify potential risk factors for the development of the disorder. A case series is an observational study in which an investigator follows a series of patients who received a specific treatment, recording the results and outcomes of that treatment. A meta-analysis is the combination of several separate studies that look at similar hypotheses in an effort to create a larger patient population for analysis. A cohort study looks for the incidence of a specific outcome in two groups (cohorts) of patients who are similar with the exception of a particular research variable (risk factor).

Question 3774

Topic: Upper Extremity Trauma

The MRI scan shown in Figure 33 reveals the sequelae of an acute traumatic anteroinferior shoulder dislocation. The image reveals the typical separation of what two commonly injured structures? Review Topic

. Anteroinferior labrum from the bony glenoid
. Anteroinferior labrum from the cartilaginous surface of the glenoid
. Biceps tendon from its origin on the supraglenoid tubercle
. Anterior capsule from the proximal humerus
. Posteroinferior labrum from the bony glenoid

Correct Answer & Explanation

. Anteroinferior labrum from the bony glenoid

Explanation

The MRI scan reveals the sequelae of an anteroinferior dislocation, specifically separation of the anteroinferior labrum from the bony glenoid. The separation does not classically occur only at the cartilage-labral junction, but extends to the bony surface of the medial glenoid neck. Separation of the biceps tendon from its origin on the supraglenoid tubercle (SLAP lesion) or separation of the anterior capsule with the proximal humerus (HAGL lesion) may occur but are not the most common sequelae and are not demonstrated in this MRI image. Anteroinferior shoulder dislocations normally do not affect the posterior labral structures. In their landmark study, Rowe and associates noted that this demonstrated lesion was the most common lesion, present in 85% of their series.

Question 3775

Topic: 2. Trauma

-are the anteroposterior (AP) and lateral radiographs of the right elbow of a 7-yearold boy who fell off the monkey bars onto his outstretched right hand. Immediate pain and swelling were noted around his elbow; there were no other injuries. His hand was neurovascularly intact. What is the best treatment for this fracture?

. Closed reduction and casting in the emergency department
. Closed reduction and percutaneous pinning of the fracture
. Open reduction and plate fixation of the fracture in the operating room with early mobilization and no cast
. Cast immobilization in the emergency department with the expectation that this injury will heal and remodel uneventfullyDISCUSSION-Displaced supracondylar fractures are best treated with surgical closed reduction and pin fixation followed by casting for 3 weeks. Closed reduction alone requires hyperflexion to hold the reduction and poses higher risk for compartment syndrome and Volkmann ischemia. Plate fixation in this age group is unnecessary considering robust periosteum and rapid healing with pin fixation.Casting the fracture without reduction will lead to a malunion that does not usually remodel. Theradiographs reveal that the anterior humeral line does not intersect the capitellum in the lateral view, and the Baumann angle is disrupted in the AP view.

Correct Answer & Explanation

. Closed reduction and casting in the emergency department

Explanation

Question 3776

Topic: 2. Trauma

During a percutaneous plating of a proximal tibia fracture requiring a 13-hole minimally invasive locking plate system, the placement of the distal most screws should be done through a small open incision to avoid injury to what structure?

. Superficial peroneal nerve
. Saphenous nerve
. Posterior tibial artery
. Peroneal artery
. Peroneal tendons

Correct Answer & Explanation

. Superficial peroneal nerve

Explanation

The superficial and deep peroneal nerves are consistently at risk near the distal holes of long locking proximal tibia plates but can be avoided with a small open incision for those screws. The peroneal tendons are more posterior at that level. The saphenous nerve is medial. The peroneal artery runs behind the fibula and is not at risk. The posterior tibial artery is posterior to the tibia.

Question 3777

Topic: Pelvic & Acetabular Trauma
A patient with severe rheumatoid arthritis reports progressive hip pain. Serial hip radiographs will most likely show which of the following findings?
. Asymmetric joint space narrowing
. Sacroiliac joint ankylosis
. Progressive superior and lateral migration of the femoral head
. Periarticular osteopenia
. Hip synovitis

Correct Answer & Explanation

. Periarticular osteopenia

Explanation

DISCUSSION: Radiographic findings in patients with rheumatoid arthritis include symmetric joint space narrowing, periacetabular and femoral head erosions, and diffuse periarticular osteopenia. In advanced stages, protrusio acetabuli is a common finding. Ranawat and associates have shown a rate of superior femoral head migration of 4.5 mm per year and medial (axial) migration of 2.5 mm per year. Asymmetric joint space narrowing is a classic radiographic finding of degenerative arthrosis. Sacroiliac joint ankylosis commonly occurs in ankylosing spondylitis. Hip synovitis is a pathologic diagnosis, not a radiographic finding. REFERENCES: Lachiewicz PF: Rheumatoid arthritis of the hip. J Am Acad Orthop Surg 1997;5:332-338. Stuchin SA, Johanson NA, Lachiewicz PF, Mont MA: Surgical management of inflammatory arthritis of the adult hip and knee, in Zuckerman JS (ed): Instructional Course Lectures 48. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 93-109.

Question 3778

Topic: 2. Trauma
The main arterial supply to the humeral head is provided by which of the following arteries?
. Anterior humeral circumflex
. Posterior humeral circumflex
. Thoracoacromial
. Subscapular
. Deep (profunda) brachial

Correct Answer & Explanation

. Anterior humeral circumflex

Explanation

The main arterial supply to the humeral head is provided by the ascending branch of the anterior humeral circumflex artery and its intraosseous continuation, the arcuate artery. There are significant intraosseous anastomoses between the arcuate artery, the posterior humeral circumflex artery through vessels entering the posteromedial aspect of the proximal humerus, the metaphyseal vessels, and the vessels of the greater and lesser tuberosities. Four-part fractures and dissection during exposure affect perfusion of the humeral head.

Question 3779

Topic: 2. Trauma
A 26-year-old man is involved in a high-speed motorcycle accident. He sustains a grade IIIB open tibia fracture. Examination reveals a large soft-tissue defect and an insensate foot. What is the expected outcome in this scenario?
. Equal functional outcome when limb salvage is compared with amputation
. Worse functional outcome with limb salvage than with primary amputation
. Better functional outcome when amputation is compared with limb salvage
. Amputation within 6 months of injury
. Permanent loss of plantar sensation

Correct Answer & Explanation

. Equal functional outcome when limb salvage is compared with amputation

Explanation

The Lower Extremity Assessment Project data have shown that absent plantar sensation is not an indication for primary amputation. When looking at a comparison between an insensate salvage group and a sensate salvage group at 2 years follow-up, both groups had an equal proportion (55%) of normal plantar sensation and functionally both groups were equivalent. Absent plantar sensation at initial evaluation is not prognostic for long-term plantar sensory status or functional outcome.

Question 3780

Topic: 2. Trauma
  • To maximally resist apex anterior angulation in the tibia, the pins of a unilateral external fixator should be oriented in which of the following planes?
. Coronal
. Sagittal
. Anteromedial, midway between the sagittal and the coronal
. Proximal pins sagittal, distal pins coronal
. Proximal pins coronal, distal pins sagittal

Correct Answer & Explanation

. Coronal

Explanation

The structural and geometric fixator properties that best neutralize the prevailing anteroposterior and transverse bending moments at a tibial fracture site were analyzed in anatomic specimens. Clinically and mechanically, anterior unilateral frames were most effective, particularly when applied with relatively stiff components with a maximal spread between the pins in each main bony fragment and with placement of the longitudinal rod.

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