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2. Trauma MCQs

Practice Set 197 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 3921

Topic: Upper Extremity Trauma
When performing elbow arthroscopy, it is often necessary to evaluate the posterior compartment. When entering the posterior compartment of the elbow, what are the two safest and most commonly used portals?
. The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps
. The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps
. The posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps and the posterior lateral portal created 3 cm from the tip of the olecranon and lateral to the triceps
. The posterior medial portal created 3 cm from the tip of the olecranon and the lateral portal made through the anconeus
. The posterior portal created at the tip of olecranon and the posterior medial portal just medial to the triceps

Correct Answer & Explanation

. The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps

Explanation

DISCUSSION: The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps are the “workhorse” portals of the posterior compartment and although relatively safe, risks exist. The radial nerve proximity averages 4.8 mm (3 to 8 mm) from the posterolateral portal. The central posterior portal is close to 20 mm from the ulnar nerve.

Question 3922

Topic: 2. Trauma
A 24-year-old female soccer player has had lateral joint line pain and a recurrent effusion in the left knee after sustaining a twisting injury 6 weeks ago. She reports that symptoms worsen with athletic activities. MRI scans are shown in Figures 2a through 2c. What is the most likely diagnosis?
. Osteochondral fracture of the lateral femoral condyle
. Trabecular injury of the lateral tibial plateau
. Lateral meniscal tear with a parameniscal cyst
. Fibular collateral ligament tear
. Discoid lateral meniscal tear

Correct Answer & Explanation

. Lateral meniscal tear with a parameniscal cyst

Explanation

DISCUSSION: The MRI scans show the typical findings of a torn discoid lateral meniscus. The average transverse diameter of the lateral meniscus is 11 or 12 mm. A discoid lateral meniscus is suggested when three or more contiguous 5-mm sagittal sections on the MRI scan show continuity of the meniscus between the anterior and posterior horns, or when two adjacent peripheral sagittal 5-mm sections show equal meniscal height. Normally the black “bow tie” would be seen on two contiguous sagittal sections. The presence of a discoid meniscus can be further confirmed if coronal views reveal increased width.

Question 3923

Topic: Lower Extremity Trauma
At the time of arthroscopy, a 9-year-old boy was found to have a Watanabe type II discoid lateral meniscus. What is the most appropriate treatment?
. Saucerization of the meniscus only
. Saucerization and stabilization of the meniscus
. Stabilization of the meniscus only
. Complete meniscectomy

Correct Answer & Explanation

. Saucerization of the meniscus only

Explanation

The Watanabe type II meniscus should only require saucerization for treatment because it is not unstable. The Watanabe classification defines 3 types of discoid menisci. In type I (stable, complete), the block-shaped lateral meniscus covers the entire lateral tibial plateau, whereas in type II (stable, partial), the lateral meniscus covers less than or equal to 80% of the tibial plateau. Type III discoid menisci (unstable, ligament of Wrisberg) appear to be normal except for a thickened posterior horn, but they lack posterior meniscal attachments, including the meniscotibial (ie, coronary) ligament. The type III discoid meniscus is stabilized only by the meniscofemoral ligament of Wrisberg. This results in hypermobility of the lateral meniscus at the posterior horn, which pulls into the intercondylar notch with knee extension, resulting in snapping knee syndrome. Complete meniscectomy should be avoided if possible.

Question 3924

Topic: 2. Trauma
A 17-year-old high school football player reports wrist pain 5 months after the conclusion of the football season. A radiograph and MRI scan are shown in Figures 29a and 29b. What is the recommended intervention?
. Pedicled vascularized bone graft
. Long arm thumb spica cast
. Percutaneous screw fixation
. Corticocancellous bone grafting via a volar approach (Matti-Russe)
. Open reduction and differential pitch screw placement via a dorsal approach

Correct Answer & Explanation

. Pedicled vascularized bone graft

Explanation

DISCUSSION: The patient has a nonunion of the proximal pole of the scaphoid. Acutely, this can be repaired with a screw alone, but as a nonunion, the proximal pole has very poor healing potential. Vascularized bone grafts have been successful for these challenging nonunions, particularly in adolescents. A cast can be used for nondisplaced acute waist fractures, and corticocancellous grafts can be used for nonunions of the waist. REFERENCES: Waters PM, Stewart SL: Surgical treatment of nonunion and avascular necrosis of the proximal part of the scaphoid in adolescents. J Bone Joint Surg Am 2002;84:915-920. Steinmann SP, Bishop AT, Berger RA: Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg Am 2002;27:391-401.

Question 3925

Topic: 2. Trauma

A 14-year-old male soccer player was seen initially in the emergency room 1 week ago after an acute right hip injury during a soccer tournament. The patient reports that the hip pain has improved, but still requires crutches for long distance ambulation. His radiograph is seen in Figure A. What would be the next most appropriate step in management? Review Topic

. Admission for hip aspiration
. Admission for closed reduction and percutaneous pinning
. Non-weightbearing activities and crutches for 6 weeks total
. Weight-bearing as tolerated and crutches for 3 weeks total
. Urgent CT of the pelvis

Correct Answer & Explanation

. Weight-bearing as tolerated and crutches for 3 weeks total

Explanation

This patient has an avulsion fracture of the right anterior superior iliac spine. This injury should be treated with crutches and progressive weight-bearing, as tolerated.The diagnosis of an avulsion fracture of the anterior superior iliac spine is made on the basis of: 1. History (sudden contraction of the sartorial and tensor fasciae latae muscle), 2. Physical findings (tenderness over the anterior superior iliac spine [ASIS] and pain with straight-leg raise), 3. Patient's age (most commonly in adolescents or young adults), and 4. Radiographs (confirmed fracture on standard views of the pelvis). Treatment of these injuries is almost always conservative with crutches and progressive weight-bearing activities as tolerated. The relative indications for operative treatment include displacement of the fracture fragment > 3 cm or painful non-union.White et al. defined two types of anterior superior iliac spine avulsion fractures. A sartorius avulsion fracture (Type 1) usually occurs when sprinting. The fracture fragment is usually small and displaced anteriorly. The tensor avulsion fracture (Type 2) usually occurs when twisting the trunk (e.g. swinging a bat). This fragment is usually larger than Type 1 fractures and more likely to be displaced laterally.Holden et al. reviewed pediatric pelvic fractures. They state that avulsion fractures of the anterior superior iliac spine are usually low-energy injures, and are not associated with other life-threatening injuries. They do not require an extensive workup (e.g. CT scanning)Figure A is an antero-posterior view of the pelvis with a small right-sided avulsion fracture of the anterior superior iliac spine.Incorrect Answers:

Question 3926

Topic: 2. Trauma
A 14-year-old gymnast presents after a fall from the balance beam with a hyperextension injury to her left knee. She could ambulate with pain but was unable to continue exercise due to pain. On examination, she has a swollen knee with painful range of motion. Radiographs demonstrate a Meyers and McKeever Type II tibial spine fracture. Which of the following is the most appropriate management?
. Immediate weight-bearing as tolerated with hinged knee brace 0-90 degrees
. Transphyseal ACL reconstruction with hamstring autograft
. Physeal spearing ACL reconstruction with hamstring autograft
. Application of long leg cast following successful fluoroscopic closed reduction
. Application of long leg cast for 1-2 weeks with transition to hinged knee brace 0-90 degrees, progressive weight-bearing, and physical therapy for quadriceps strengthening

Correct Answer & Explanation

. Application of long leg cast following successful fluoroscopic closed reduction

Explanation

The patient has a mild to moderately displaced tibial eminence fracture, which can be treated with closed reduction, casting, and supportive care provided successful closed reduction is achieved. Wilfinger et al. provide the results of a closed reduction protocol including 38 patients with long-term follow-up. All patients underwent aspiration and closed reduction in the OR under fluoroscopic guidance followed by long leg casting in hyperextension and graduated weight-bearing over weeks. No patients complained of persistent pain, swelling, giving way, or disability at follow-up.

Question 3927

Topic: 2. Trauma

A 30-year-old male is evaluated for increasing leg pain following a high-energy closed tibial shaft fracture. Which of the following continuous pressure measurements is the most reliable threshold for diagnosing acute compartment syndrome and indicating the need for fasciotomy?

. Absolute compartment pressure of 20 mmHg
. Diastolic blood pressure minus compartment pressure < 30 mmHg
. Mean arterial pressure minus compartment pressure < 40 mmHg
. Systolic blood pressure minus compartment pressure < 30 mmHg
. Absolute compartment pressure of 15 mmHg

Correct Answer & Explanation

. Absolute compartment pressure of 20 mmHg

Explanation

The differential pressure, or delta pressure (Diastolic Blood Pressure - Compartment Pressure), is the most reliable indicator for acute compartment syndrome. A delta pressure of less than 30 mmHg indicates inadequate tissue perfusion and is the standard threshold for proceeding with fasciotomy.

Question 3928

Topic: 2. Trauma

An obturator oblique radiograph of the pelvis in a patient with an acetabular fracture demonstrates an intact segment of the ilium protruding posteriorly, independent of the articular surface. This radiographic 'spur sign' is pathognomonic for which type of acetabular fracture?

. Anterior column posterior hemitransverse fracture
. T-type fracture
. Transverse fracture
. Both-column fracture
. Isolated posterior wall fracture

Correct Answer & Explanation

. Anterior column posterior hemitransverse fracture

Explanation

The spur sign represents the posterior portion of the intact iliac wing (the strut connecting the sacroiliac joint to the rest of the axial skeleton) extending superiorly and posteriorly to the displaced articular fracture fragments. It is pathognomonic for a both-column acetabular fracture.

Question 3929

Topic: 2. Trauma

A 28-year-old male sustains a Hawkins Type II talar neck fracture. Eight weeks post-operatively, an anteroposterior radiograph of the ankle reveals a subchondral radiolucent band in the dome of the talus. What is the clinical significance of this finding?

. It indicates avascular necrosis of the talar body
. It suggests indolent septic arthritis of the ankle joint
. It represents nonunion of the talar neck
. It indicates an intact vascular supply to the talar body
. It suggests impending subchondral collapse and severe post-traumatic arthritis

Correct Answer & Explanation

. It indicates avascular necrosis of the talar body

Explanation

The Hawkins sign is a subchondral radiolucent band seen in the talar dome 6 to 8 weeks after a talar neck fracture. It represents disuse osteopenia (subchondral atrophy), which can only occur if there is active bone resorption mediated by an intact vascular supply. Its presence is highly predictive of talar body viability.

Question 3930

Topic: 2. Trauma

Recent anatomical studies have fundamentally changed the understanding of the blood supply to the proximal humerus, an important consideration in the surgical management of proximal humerus fractures. Which vessel is now recognized as providing the majority of the blood supply to the humeral head?

. Anterior humeral circumflex artery via the arcuate artery
. Posterior humeral circumflex artery
. Suprascapular artery
. Thoracoacromial artery
. Subscapular artery

Correct Answer & Explanation

. Anterior humeral circumflex artery via the arcuate artery

Explanation

Historically, the arcuate branch of the anterior humeral circumflex artery was believed to be the primary blood supply to the humeral head. However, modern cadaveric studies (e.g., Hettrich et al.) have demonstrated that the posterior humeral circumflex artery actually provides the majority (up to 64%) of the blood supply.

Question 3931

Topic: Upper Extremity Trauma

During an ulnar collateral ligament (UCL) reconstruction using the docking technique in a baseball pitcher, the surgeon aims to anatomically restore the anterior bundle of the UCL. What is the anatomic insertion site of this anterior bundle on the ulna?

. The supinator crest
. The tip of the olecranon
. The sublime tubercle
. The base of the coronoid process, lateral to the brachialis insertion
. The radial notch

Correct Answer & Explanation

. The supinator crest

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow. It originates on the anterior undersurface of the medial epicondyle and inserts on the sublime tubercle, which is located on the anteromedial facet of the coronoid process of the ulna.

Question 3932

Topic: 2. Trauma

A 24-year-old male polytrauma patient presents with severe bilateral pulmonary contusions, a borderline Glasgow Coma Scale score, and a closed midshaft femur fracture. To minimize his risk of developing Acute Respiratory Distress Syndrome (ARDS), what is the most appropriate initial orthopaedic management of the femur fracture?

. Immediate reamed antegrade intramedullary nailing
. Immediate unreamed antegrade intramedullary nailing
. Skeletal traction for 3 weeks followed by planned intramedullary nailing
. Temporary external fixation with planned delayed conversion to intramedullary nailing
. Open reduction and internal fixation with a dynamic compression plate

Correct Answer & Explanation

. Immediate reamed antegrade intramedullary nailing

Explanation

In severely polytraumatized patients, particularly those with significant chest trauma ('borderline' or 'unstable' patients), the systemic inflammatory response is profound. Damage control orthopedics (DCO) utilizing temporary external fixation prevents the 'second hit' phenomenon associated with intramedullary nailing, thereby minimizing the risk of ARDS and multiorgan failure.

Question 3933

Topic: 2. Trauma

Following a severe tibial plateau fracture, a patient develops impending acute compartment syndrome of the leg. In the deep posterior compartment, which muscle is most vulnerable to ischemia and contracture due to its central location and bipennate structure?

. Flexor hallucis longus
. Flexor digitorum longus
. Tibialis posterior
. Soleus
. Popliteus

Correct Answer & Explanation

. Flexor hallucis longus

Explanation

The tibialis posterior muscle is located centrally within the deep posterior compartment. Its bipennate architecture and tightly confined fascial boundaries make its blood supply exceptionally vulnerable to increased intracompartmental pressure, making it the most susceptible muscle to ischemic necrosis and subsequent contracture if fasciotomy is delayed.

Question 3934

Topic: Lower Extremity Trauma

A 45-year-old male sustains a Schatzker IV tibial plateau fracture with a large, displaced posteromedial fragment. The surgeon elects to buttress this fragment using a standard posteromedial approach with the patient prone. Which anatomic interval is utilized to access the posteromedial tibial plateau?

. Between the medial head of the gastrocnemius and the semimembranosus
. Between the medial head of the gastrocnemius and the pes anserinus
. Between the popliteus and the soleus
. Between the semitendinosus and the medial collateral ligament
. Between the tibialis posterior and the flexor digitorum longus

Correct Answer & Explanation

. Between the medial head of the gastrocnemius and the semimembranosus

Explanation

The standard posteromedial approach to the tibial plateau uses the interval between the medial head of the gastrocnemius (which is retracted laterally along with the neurovascular bundle to protect it) and the pes anserinus tendons (which are retracted medially). This safely exposes the posteromedial cortex of the proximal tibia.

Question 3935

Topic: 2. Trauma
A 30-year-old female sustains a vertically oriented, Pauwels Type III femoral neck fracture after a fall from a height. Because of the vertical fracture line, the fracture is subject to extremely high shear forces. Which of the following internal fixation constructs provides the highest biomechanical stability against shear forces for this fracture pattern?
. Three parallel fully threaded cancellous screws
. Two parallel partially threaded cancellous screws
. A sliding hip screw (fixed-angle device) with a supplemental derotational screw
. A standard short cephalomedullary nail
. Multiple divergent Knowles pins

Correct Answer & Explanation

. A sliding hip screw (fixed-angle device) with a supplemental derotational screw

Explanation

Pauwels Type III fractures (>50 degree angle to the horizontal) are highly unstable due to significant vertical shear forces. Biomechanical studies have consistently shown that fixed-angle devices, such as a sliding hip screw supplemented with a derotational cancellous screw, provide superior resistance to shear and varus collapse compared to multiple parallel cancellous screws.

Question 3936

Topic: 2. Trauma
A 25-year-old male sustains a vertically oriented (Pauwels type III) femoral neck fracture. Which of the following internal fixation constructs provides the greatest biomechanical stability for this fracture pattern?
. Three parallel cancellous screws
. Sliding hip screw with an anti-rotation screw
. Short cephalomedullary nail
. Two parallel cancellous screws
. Dynamic condylar screw

Correct Answer & Explanation

. Sliding hip screw with an anti-rotation screw

Explanation

Biomechanical studies have demonstrated that for unstable, vertically oriented (Pauwels III) femoral neck fractures, a sliding hip screw (with or without an anti-rotation screw) provides superior biomechanical stability and higher failure loads compared to multiple parallel cancellous screws, primarily by better resisting the high shear forces.

Question 3937

Topic: 2. Trauma

A 40-year-old male sustains a Schatzker IV tibial plateau fracture. Imaging demonstrates a displaced posteromedial shear fragment. Which surgical approach is most appropriate for direct visualization and stable buttress plating of this specific fragment?

. Anterolateral approach
. Direct anterior approach via patellar tendon split
. Posteromedial approach
. Direct lateral approach
. Posterolateral approach

Correct Answer & Explanation

. Anterolateral approach

Explanation

The posteromedial fragment in a Schatzker IV fracture pattern typically involves a coronal shear component that cannot be adequately reduced or plated via standard anterior or anterolateral approaches. A posteromedial approach allows for direct visualization of the fracture apex and the application of an anti-glide or buttress plate to counteract the deforming shear forces.

Question 3938

Topic: 2. Trauma
According to classic trauma literature (e.g., Godina), free tissue transfer for soft tissue coverage of a Gustilo-Anderson type IIIB open tibia fracture should ideally be performed within what timeframe to minimize deep infection and flap failure?
. 12 hours
. 72 hours
. 7 days
. 14 days
. 21 days

Correct Answer & Explanation

. 72 hours

Explanation

Godina's classic 1986 study demonstrated that early microsurgical reconstruction (within 72 hours of injury) of complex lower extremity trauma with open fractures significantly reduces the rates of flap failure, deep infection, and nonunion compared to delayed coverage.

Question 3939

Topic: Pelvic & Acetabular Trauma
Which of the following ligamentous structures remains intact in an anteroposterior compression type II (APC-II) pelvic ring injury but is disrupted in an APC-III injury?
. Anterior sacroiliac ligament
. Sacrotuberous ligament
. Sacrospinous ligament
. Iliolumbar ligament
. Posterior sacroiliac ligament

Correct Answer & Explanation

. Posterior sacroiliac ligament

Explanation

In APC-II injuries, the symphysis opens and the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments are disrupted. However, the strong posterior sacroiliac ligaments remain intact, providing vertical stability. In APC-III injuries, the posterior SI ligaments are also disrupted, leading to complete global (rotational and vertical) hemipelvic instability.

Question 3940

Topic: 2. Trauma

A 35-year-old female sustains a coronal shear fracture of the distal femur (Hoffa fracture). Which condyle is most commonly involved, and what is the preferred direction of lag screw fixation to optimally capture the fragment while minimizing articular cartilage damage?

. Medial condyle; anterior-to-posterior screws
. Medial condyle; posterior-to-anterior screws
. Lateral condyle; anterior-to-posterior screws
. Lateral condyle; posterior-to-anterior screws
. Lateral condyle; medial-to-lateral screws

Correct Answer & Explanation

. Medial condyle; anterior-to-posterior screws

Explanation

Hoffa fractures most commonly involve the lateral femoral condyle. The standard internal fixation utilizes anterior-to-posterior directed lag screws (often headless and countersunk). They are placed from the non-articular anterior surface into the posterior fragment, oriented perpendicular to the fracture plane to maximize compression without violating the weight-bearing articular cartilage of the posterior condyle.

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