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2. Trauma MCQs

Practice Set 201 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 4001

Topic: 2. Trauma
A 32-year-old man sustained a fracture of his upper arm in a motor vehicle accident. Radiographs are shown in Figure 32. Because of other associated injuries, surgical stabilization is chosen. What technique will result in the least complications and the best outcome?
. Retrograde locked intramedullary nail
. Antegrade reamed locked intramedullary nail
. Flexible nails
. Open reduction and plate fixation
. External fixation

Correct Answer & Explanation

. Open reduction and plate fixation

Explanation

Most humeral fractures will heal with nonsurgical functional brace management. When the initial pain has subsided in a coaptation splint, the patient is converted to a functional brace and allowed to use the arm for activities. The fracture should heal within 6 weeks to 12 weeks with acceptable results. Surgery is indicated if there is vascular injury, open injury, floating elbow, chest injury, bilateral humeral fractures, or if a reduction cannot be obtained or maintained. The surgical treatment of choice is either antegrade reamed locked intramedullary nailing or plate osteosynthesis. Plate osteosynthesis appears to offer better results with respect to union, function, and risk of complications.

Question 4002

Topic: 2. Trauma
The management of a complex multifragmentary diaphyseal fracture of either the tibia or femur has changed during the last decade. Which of the following principles of treatment is now considered less important?
. Anatomic alignment
. Indirect reduction
. Anatomic reduction of the fragments
. Relatively stable fixation
. Functional aftercare

Correct Answer & Explanation

. Anatomic reduction of the fragments

Explanation

Although the original concept of internal fixation was one of anatomic reduction and stable fixation, over the past 10 to 15 years there has been a change based on the advent of intramedullary nailing and bridge plating. It is now appreciated that in a multifragmentary diaphyseal fracture, particularly of the lower extremity, the achievement of axis alignment (mechanical and anatomic axis) is all that is required. Healing will occur by callus. Relatively stable fixation is achieved through intramedullary nailing or bridge plating, providing adequate pain relief for functional aftercare.

Question 4003

Topic: 2. Trauma
A 47-year-old woman falls and sustains a direct blow to her middle finger. She notes pain and swelling and is unable to move the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints. Radiographs are shown in Figures 8a through 8c. Proper management should consist of
. closed reduction and splinting in metacarpophalangeal (MCP) and PIP joint extension.
. closed reduction and splinting in MCP joint flexion and PIP joint extension.
. reduction and percutaneous intramedullary Kirschner wire fixation.
. reduction and lag screw fixation.
. buddy taping and early range of motion.

Correct Answer & Explanation

. reduction and lag screw fixation.

Explanation

The oblique nature of the fracture and extension of the fracture to the condyles implies an unstable fracture. Lag screw fixation provides an excellent chance of union, and the ability to start early range of motion.

Question 4004

Topic: 2. Trauma
A 25-year-old male polytrauma patient undergoes initial temporary external fixation for a femoral shaft fracture. He is converted to a femoral nail at 7 days. This management can be expected to result in
. higher infection rates.
. higher nonunion rates.
. equal union and infection rates.
. higher rate of ARDS.
. higher mortality rate.

Correct Answer & Explanation

. equal union and infection rates.

Explanation

DISCUSSION: Recently Harwood and associates investigated the principles of damage control orthopaedics (DCO) as they apply to patients with femoral shaft fractures. When they compared those who underwent initial external fixation of femoral shaft fractures with conversion to an intramedullary nail to those who underwent intramedullary nailing as their initial treatment, they found the following: overall infection rates were comparable in patients receiving DCO versus primary intramedullary fixation; open fracture was an independent risk factor for infection regardless of the treatment method; contamination rates in external fixator pin sites rose considerably when left in place more than 2 weeks and logistic regression analysis suggests that infection rates may increase when conversion to an intramedullary nail occurs after 2 weeks following external fixation; and there was no significant difference in time to union among treatment groups. REFERENCES: Harwood PJ, Giannoudis PV, Probst C, et al: The risk of local infective complications after damage control procedures for femoral shaft fracture. J Orthop Trauma 2006;20:181-189. Roberts CS, Pape HC, Jones AL, et al: Damage control orthopaedics: Evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect 2005;54:447-462.

Question 4005

Topic: 2. Trauma
A 33-year-old male patient presents with a comminuted open tibia fracture after involvement in a motor vehicle crash. He has a history of smoking but is otherwise healthy. He is given antibiotics, and taken immediately for irrigation and debridement, followed by an un-reamed stainless steel intramedullary nail. Due to bone loss there is a non-circumferential cortical defect measuring 12 mm at the fracture site. All of the following factors in this patient's history and presentation increase his risk for adverse outcome EXCEPT:
. High-energy mechanism of injury
. Use of un-reamed nail
. Implant material
. Fracture gap
. History of smoking

Correct Answer & Explanation

. Use of un-reamed nail

Explanation

Of the factors listed only the use of an un-reamed intramedullary nail for an open tibia fracture has not been shown to increase the risk of adverse outcome or need for reoperation. The treatment of open tibia fractures with intramedullary nailing can be complicated by many factors. High energy mechanism of injury, use of a stainless steel nail, residual fracture gap greater than 1 cm, and a history of smoking have all been shown to increase the risk of adverse outcome. The use of reamed and un-reamed nails for open tibia fractures have been studied, and no significant difference in outcome has been found. Schemitsch et al. present data from a prospective randomized trial of tibia fractures treated with reamed or unreamed intramedullary nails. They found no difference in risk of adverse outcome between reamed and un-reamed nails in open tibia fractures. They did, however, find an increased risk of adverse outcomes in high-energy mechanisms, use of stainless steel (versus titanium) rods, and a residual fracture gap of greater than 1 cm. They comment that their data did not show a significant increase in risk due to history of smoking, but cite other studies that have demonstrated such a relationship. Bhandari et al. present data from a prospective randomized study of patients with tibia fractures randomized to reamed or un-reamed tibial nails. For closed fractures they found a lower rate of primary events (most commonly need for dynamization) in the reamed group. However, they found no difference in outcomes for either technique in open fractures.

Question 4006

Topic: 2. Trauma
  • Examination of a 45 year old construction worker who was crushed by falling dirt and buried to midchest level reveals hemodynamic instability; however, radiographs of the chest are normal, and results of a diagnostic peritoneal lavage are negative. Despite the administration of a fluid bolus and packed red blood cells, hemodynamic instability persists. A radiograph of the pelvis is shown in Figure 4. The next step in the management should be

. Application of a pelvic external fixator
. A pelvic sling
. Angiography of the pelvis
. Open reduction and internal fixation
. Open packing of the pelvic hematoma

Correct Answer & Explanation

. Application of a pelvic external fixator

Explanation

In patients with pelvic fractures who are hemodynamic unstable upon presentation, the initial management starts with application of external pelvic fixation. If there is no response (stabilization of vital signs and decreased fluid requirements), pelvic angiography with possible embolization is the next course of treatment. Open reduction internal fixation can be performed following General surgical management of associated abdominal injuries. Pelvic fractures have a high association of retroperitoneal bleeding which may not be necessarily be picked up from diagnostic peritoneal lavage.

Question 4007

Topic: 2. Trauma
A 28-year-old man underwent open reduction and internal fixation of a closed, displaced, intra-articular calcaneal fracture 8 weeks ago. Examination now reveals that the lateral wound is red and draining purulent material. Cultures obtained from the wound grow out Staphylococcus aureus. Radiographs show early healing of the fracture. What is the next most appropriate step in management?
. Intravenous antibiotics
. Debridement of the wound without hardware removal
. Debridement of the wound with hardware removal
. Vacuum-assisted closure (VAC) and negative pressure therapy
. Total calcanectomy

Correct Answer & Explanation

. Debridement of the wound with hardware removal

Explanation

Intravenous antibiotics alone will not adequately treat this infection. At 8 weeks after surgery, the hardware must be removed because Staphylococcus aureus is a virulent microbe. VAC therapy alone is not adequate without debridement and hardware removal, but it may play a role in postoperative wound care. Calcanectomy is a salvage procedure for calcaneal osteomyelitis or recalcitrant heel ulceration.

Question 4008

Topic: 2. Trauma
What is the best surgical approach for the scapular fracture shown in Figure 46?
. Anterior
. Anterior and superior
. Posterior
. Percutaneous pinning
. Closed reduction

Correct Answer & Explanation

. Posterior

Explanation

Indications for open reduction of glenoid intra-articular fractures include those fractures with a 5-mm articular surface displacement or when the humeral head is subluxated with the fracture fragment. Kavanaugh and associates and Leung and Lam have shown that the posterior approach with plate fixation is best for most glenoid fractures, including the Ideberg type II fracture shown here. The anterior approach is best used for anterior rim and transverse fractures.

Question 4009

Topic: 2. Trauma
Which of the following is an advantage of using blocking screws for tibial nailing?
. Decrease risk of nail breakage
. Eliminate use of interlocking screws
. Allow for larger nail use
. Enhance construct stiffness
. Decrease torsional rigidity

Correct Answer & Explanation

. Enhance construct stiffness

Explanation

Blocking screws can be used to help obtain and maintain reductions, increase construct stiffness, and neutralize translational forces. Krettek found that medial and lateral blocking screws can increase the primary stability of distal and proximal metaphyseal fractures after nailing and can be an effective tool for selected cases that exhibit malalignment and/or instability by decreasing mechanically measured deformation.

Question 4010

Topic: 2. Trauma

A football player who injured his right lower extremity during a game could not get up and reported extreme pain. The initial sideline evaluation showed a probable anterior cruciate, posterior cruciate, and lateral collateral ligament rupture with a very unstable knee. He also reports pain in his ankle and is unable to dorsiflex the ankle. He has limited sensation over the dorsum of his foot. Examination reveals no swelling of the ankle and no pain with passive range of motion of the ankle. What is the most likely diagnosis? Review Topic

. Tibial nerve injury
. Associated ankle fracture
. Acute compartment syndrome
. Injury to the common peroneal nerve
. Rupture of the tibialis anterior tendon

Correct Answer & Explanation

. Injury to the common peroneal nerve

Explanation

It is not uncommon to sustain a peroneal nerve injury in association with a knee dislocation or multi-ligament injury. There should always be a high index of suspicion for this injury, and the vascular status to the leg should be carefully evaluated. From the history and examination, there is no indication that the ankle was fractured. A compartment syndrome will not develop within a few minutes of the injury. It takes several hours for a compartment syndrome to develop and become symptomatic. The tibial nerve supplies the plantar aspect of the foot. An acute rupture of the tibialis anterior tendon in a young person is very uncommon, and it is associated with pain and localized swelling about the ankle. It is also unlikely that it would lead to sensory loss.

Question 4011

Topic: 2. Trauma
Figure 61 is the radiograph of a 42-year-old man who falls from a roof and sustains a right calcaneus fracture. His hindfoot is moderately swollen without skin wrinkling and the skin is intact and viable. Neurologic examination findings are normal and the dorsalis pedis pulse is strong and palpable. What is the best treatment plan at this time?
. Immediate open reduction and internal fixation (ORIF) via an extensile lateral approach
. Casting in a plantar-flexed position for 6 weeks
. Splinting with follow-up in 10 to 14 days to check for resolution of swelling
. Splinting with a repeat examination in 1 to 2 days

Correct Answer & Explanation

. Splinting with a repeat examination in 1 to 2 days

Explanation

DISCUSSION: This patient has a displaced tuberosity of the calcaneus. A high rate of posterior skin breakdown is associated with these fracture types. The skin should be checked within 10 to 14 days when these fractures occur. The skin is swollen and not acutely at risk, so an immediate ORIF via an extensile lateral approach is not warranted. Immobilizing the ankle in a plantar-flexed position can take some tension off the posterior skin with this fracture type but should not be definitive treatment. Splinting with repeat examination in 1 to 2 days is the preferred response because of the short follow-up for a repeat skin check. If the skin is at risk when a fracture of this type occurs, the ankle can be immobilized in plantar flexion to relieve tension on the skin. Immediate repair with either open or percutaneous techniques may be necessary if the skin remains at risk. RECOMMENDED READINGS: Gardner MJ, Nork SE, Barei DP, Kramer PA, Sangeorzan BJ, Benirschke SK. Secondary soft tissue compromise in tongue-type calcaneus fractures. J Orthop Trauma. 2008 Aug;22(7):439-45. PubMed PMID: 18670282. Schwartz AK, Brage ME, Laughlin RT, Stephen D. Foot injuries. In: Baumgartner MR, Tornetta P III, eds. Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:453-468.

Question 4012

Topic: 2. Trauma

A 22-year-old male cyclist was struck by a car. He complains of right knee pain and swelling, as well as reduced sensation and weakness in his right foot. His leg compartments are soft and not tender. Distal pulses in the extremity are palpable. Radiographs of the knee, as shown in Figures A and B, were taken after a closed reduction maneuver was performed. What would be the next best step in management of this patient?

. Non-operative managment, but arrange for early follow-up in clinic
. Intra-compartmental pressure measurements
. Ankle-brachial index measurements
. Knee spanning external fixation
. Open reduction internal fixation

Correct Answer & Explanation

. Non-operative managment, but arrange for early follow-up in clinic

Explanation

This patient presents with a Schatzker IV tibia plateau fracture with lower extremity neurologic deficits. The next best step would be to investigate for an acute vascular injury with ankle-brachial index measurements.Fracture-dislocations of the knee must be suspected with all Schatzker type IV injuries as this fracture pattern is usually associated with high energy trauma. Identifying this injury should prompt a thorough assessment of the neurovascular structures across the knee. After closed reduction and emergent immobilization of the knee, ankle brachial indices (ABI) must be immediately performed. If <0.9, further vascular testing is warranted, such as MR or CT angiography.Berkson et al. reviewed high energy tibia fractures. They state that Schatzker Type IV fractures typically requires more energy than corresponding lateral plateau fractures, due to denser bone on the medial side.Chang et al. described an anatomic sub-classification of Schatzker IV fractures. They describe Group 1fractures as classic medial unicondylar fractures. Group 2fractures are complicated variants characterized by medial condyle fractures with lateral plateau extension. Usually these have articular impaction of the centroposterior lateral plateau.Figures A and B show AP and lateral radiographs of the knee demonstrating a classic medial unicondylar Schatzker IV fracture. Note the anterior subluxation of the tibia in relation to the femur. Illustration A shows the multiple CT images of this fracture pattern.Incorrect Answers:

Question 4013

Topic: 2. Trauma
Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision. On examination, she has well-healed scars and a well-healed flap on the medial aspect at the level of the fracture. She reports having an infection after the initial surgery, which resulted in debridement of the soft tissue and need for the local rotational flap. There are no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is healthy and has no comorbidities. What is the best next step in the patient’s evaluation?
. Complete metabolic workup
. Advanced imaging with a CT scan
. Laboratory studies for CBC, ESR and CRP
. Nuclear medicine studies

Correct Answer & Explanation

. Laboratory studies for CBC, ESR and CRP

Explanation

DISCUSSION: The patient had an open fracture that was initially treated with what appears to be appropriate irrigation and debridement and intramedullary nail placement. The post-operative infection and need for rotational flap is worrisome, but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone non-union, especially in the femur.

Question 4014

Topic: 2. Trauma
Figure 83 is the CT scan of a 36-year-old man who fell from a roof. Eight hours later at the emergency department he describes low-back pain with numbness and weakness in his bilateral lower extremity. A neurologic examination reveals 2/5 strength in his quadriceps and iliopsoas bilaterally, 2/5 strength in his right anterior tibialis and gastrocsoleus, and 1/5 strength in his left anterior tibialis and gastrocsoleus. Two hours later, strength in his lower extremities has diminished markedly. What is the best next step?
. Emergent open reduction/decompression
. Intravenous (IV) methylprednisolone with a 30-mg/kg loading dose followed by continuous infusion of 5.4 mg/kg/hour for 24 hours
. Immediate awake traction reduction
. Admission to the intensive care unit for fluid resuscitation followed by reduction/decompression when stable

Correct Answer & Explanation

. Emergent open reduction/decompression

Explanation

DISCUSSION: Any progressive neurologic deficit requires emergent surgical intervention. Lumbar injuries cannot be reliably reduced with traction. Although IV steroids and management of mean arterial blood pressure are appropriate interventions for injuries in the region of the conus medullaris, steroids are only indicated when given within 8 hours of injury and are not appropriate as a sole means of management for progressive neurologic deficit.

Question 4015

Topic: 2. Trauma

When planning pin placement for external fixation of the tibia, what is the maximum extent of the knee capsular reflection from the subchondral joint line?

. 4 mm
. 6 mm
. 10 mm
. 14 mm
. 20 mm

Correct Answer & Explanation

. 4 mm

Explanation

Intracapsular pin placement is a concern for septic arthritis. Reid and associates and DeCoster and associates have demonstrated that the maximum distal extent of the knee capsule is 14 mm from the subchondral line and occurs in the posterolateral region. The recommended placement of external fixation pins is greater than 14 mm from the subchondral line of the proximal tibia.

Question 4016

Topic: 2. Trauma

Figures 39a and 39b are the radiographs of a 45-year-old man with diabetes who fell 12 feet from a ladder and sustained an isolated closed injury to his left leg. Examination revealed that he was neurovascularly intact and compartments were soft. A damage control knee spanning external fixator was applied and after 2 weeks in the frame, his blisters have resolved and his skin now wrinkles. What is the most appropriate treatment?

. Conversion to a periarticular 'hybrid' frame
. Open reduction and internal fixation with a lateral nonlocking plate
. Open reduction and internal fixation with a lateral locking plate
. Open reduction and internal fixation with medial and lateral plates
. Open reduction and internal fixation with posteromedial and lateral plates

Correct Answer & Explanation

. Conversion to a periarticular 'hybrid' frame

Explanation

The patient has sustained a severely comminuted bicondylar fracture of the tibial plateau. The mechanism and radiographs highlight the high-energy mechanism of the injury and should warrant aggressive monitoring for compartment syndrome which is relatively common in this scenario. A staged surgical approach is warranted with application of a spanning damage control external fixator to maintain length andalignment while the soft-tissue injury recovers and to allow for surveillance and examination of the limb. The radiographs reveal a comminuted bicondylar pattern with significant depression of the lateral articular surface and a split fracture with condylar widening. This element of the fracture will require direct elevation of the joint surface and reduction/buttress of the lateral condyle. This is best achieved with a lateral plate with subchondral rafting screws. The medial articular surface is coronally split and the posteromedial fragment is displaced. This fragment requires direct reduction and buttress via a separate posteromedial approach which is frequently performed prior to the lateral approach and fixation. A lateral buttress plate or a lateral locking plate alone does not reliably capture or adequately support the displaced posteromedial fragment. A medial and lateral plate construct is less soft-tissue friendly, particularly if inserted through a single incision. A medial plate would also fail to give direct buttress to the posteromedial fragment.

Question 4017

Topic: 2. Trauma

A 41-year-old male underwent intramedullary nailing for a low-energy left femoral shaft fracture. At his follow-up appointment, he complains that his feet are pointing in opposite directions when walking. Using the imaging study shown in Figure A, which of the following represents this patient's left femur malalignment?

. Internal rotation malalignment of 44 degrees
. External rotation malalignment of 44 degrees
. Internal rotation malalignment of 21 degrees
. External rotation malalignment of 21 degrees
. Internal rotation malalignment of 63 degrees

Correct Answer & Explanation

. Internal rotation malalignment of 44 degrees

Explanation

Figure A shows axial CT scan slices of the pelvis and knee. On the operative left side, there is an internal rotation malalignment of 21° compared to the contralateral side (44°-23°=21°).Radiographic rotational malalignment after fixation of femoral shaft fractures may be measured by comparing the femoral anteversion of both femurs. This can be determined by measuring the angle between a line tangential to the dorsal bony contours of the femoral condyles and a line drawn through the axis of the femoral neck. Rotational differences of less than 10° are considered variations of normal.Jaarsma et al. reviewed rotational malalignment after intramedullary nailing of femoral fractures. They report that rotational measurements by CT are superior to clinical assessment. They note a high incidence of malrotation after IM nailing of fractures. This has shown to be in the range 15% to 30%.Figure A shows left femoral malrotation using CT-torsion measurements with axial cuts of the femoral neck and distal femoral condyles. Note the normal anteversion of the right femur (23 degrees; normal range 10-25).Incorrect Answers:

Question 4018

Topic: 2. Trauma
Which of the following complications occurs more commonly after antegrade femoral nail insertion when compared with retrograde insertion?
. Increased blood loss
. Decreased range of motion of the knee
. Infection
. Hip pain
. Muscle weakness

Correct Answer & Explanation

. Hip pain

Explanation

There is no difference between the rates of union, malunion, range of motion of the hip or knee, muscle weakness, or infection for the two types of femoral nail insertion. The only difference is the location of the morbidity, which is around the insertion point of the rod. The antegrade technique has more morbidity about the hip, and the retrograde insertion technique has more morbidity about the knee.

Question 4019

Topic: 2. Trauma
In the management of an open tibia fracture, what factor is considered most important in preventing deep infection?
. Size of the skin lesion
. Degree and the completeness of the debridement
. Amount of contamination
. Method of fixation
. Cultures of the wound

Correct Answer & Explanation

. Degree and the completeness of the debridement

Explanation

The most important aspect of management of any open fracture, and in particular the tibia, is the degree and the completeness of the debridement of the soft tissue and most importantly, the muscle. The ultimate function is determined by the amount of muscle left, as well as the ability to heal. The amount of necrotic muscle left in the wound also determines the predisposition to infection. The method of fixation, the size of the wound, and the amount of contamination are controlled by the surgeon or the injury and have little to do with the long-term outcome. Initial wound cultures have little predictive value.

Question 4020

Topic: 2. Trauma
Figure 31 shows the radiograph of an 8-year-old boy who has a swollen forearm after falling out of a tree. Examination reveals that all three nerves are functionally intact, and there is no evidence of circulatory embarrassment. Management should consist of
. open reduction of both the radius and ulna with plate and screw fixation.
. closed reduction and a long arm cast, with the elbow in 90 degrees of flexion and the forearm in neutral rotation.
. closed reduction and a long arm cast, with the elbow in 120 degrees of flexion and the forearm in full supination.
. closed reduction and a long arm cast, with the elbow extended and the forearm pronated.
. closed reduction and intramedullary pin fixation of both the radius and ulna.

Correct Answer & Explanation

. closed reduction and intramedullary pin fixation of both the radius and ulna.

Explanation

The patient has a Bado type IV Monteggia lesion. It involves dislocation of the radial head and fractures of both the radial and ulnar shafts. These fractures are very difficult to manage by closed reduction alone. The radial and ulnar shafts first have to be stabilized surgically to give a lever arm to reduce the radial head. In this age group, intramedullary pins are easy to insert percutaneously and cause less tissue trauma than plates and screws.

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