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2. Trauma MCQs

Practice Set 203 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 4041

Topic: 2. Trauma
Figure 10 shows the radiograph of a 9-year-old girl who injured her left lower leg after being thrown from a horse. Examination reveals no other injuries. Which of the following forms of management will provide the lowest rate of complications and the earliest return to function?
. Distal femoral pin and 90-90 traction for 3 weeks, followed by a spica cast
. Closed reduction and stabilization with an external fixator
. Closed reduction and stabilization with an interlocking nail
. Closed reduction and stabilization with multiple flexible intramedullary nails
. Open reduction and stabilization with a plate and screws

Correct Answer & Explanation

. Closed reduction and stabilization with multiple flexible intramedullary nails

Explanation

Because the patient has a transverse midshaft fracture with no evidence of comminution, the treatment of choice is closed reduction and stabilization with flexible intramedullary nails.

Question 4042

Topic: 2. Trauma
Which treatment option will most reliably achieve long-term success?
. Dwyer osteotomy
. Surgical fixation with a solid screw
. Surgical fixation with a cannulated screw
. Iliac crest bone graft with plate fixation

Correct Answer & Explanation

. Surgical fixation with a solid screw

Explanation

Jones fractures are associated with a 15% to 20% nonunion rate with nonsurgical care. Surgical intervention is preferred in athletic patients. Fixation with a solid screw is mechanically stronger than fixation with a cannulated screw.

Question 4043

Topic: 2. Trauma
A patient has a lactate level of 0 mmol/L (normal < 2.5), 1 hour postinjury it was 3.5 mmol/L, and it is now 5 mmol/L. His core temperature is 93°F (34°C). What is the most appropriate management for the femoral shaft fracture at this point?
. Reamed intramedullary nailing
. Traction
. External fixation
. Open plating
. Mast suit

Correct Answer & Explanation

. External fixation

Explanation

The patient has several indications that he is not ready for definitive fixation of the femoral shaft fracture at this point. He is cold with a core temperature of 93°F, and hypothermia of less than 95°F (35°C) has been shown to be associated with an increased mortality rate in trauma patients. The patient has also not been resuscitated based on his increasing lactate levels and although controversial, it has been shown that temporary external fixation leads to a lower incidence of multiple organ failure and acute respiratory distress syndrome.

Question 4044

Topic: Pelvic & Acetabular Trauma
During percutaneous iliosacral screw placement for an unstable pelvic ring injury, use of the lateral sacral fluoroscopic image is critical to help avoid iatrogenic injury to what structure?
. L4 nerve root
. L5 nerve root
. S1 nerve root
. Sacroiliac joint cartilage
. External iliac artery

Correct Answer & Explanation

. L5 nerve root

Explanation

Unstable anterior and posterior pelvic ring injuries are amenable to percutaneous treatment if reduction is able to be obtained in a closed manner and appropriate radiographic visualization is able to be achieved. Proper SI screw placement is described using pelvic inlet, outlet, and lateral sacral images. The iliac cortical density seen adjacent to the SI joint is the anterior edge of the insertion safe zone, and is only able to be seen on the lateral image. Failure to place the screw behind this radiographic line would lead to an "in-out-in" screw (in the ilium, and then exiting anterior to the sacral ala, only to re-enter in the sacral body), which would cause direct injury to the L5 nerve root. Safe SI screw insertion in the S1 body should be underneath the sacral ala line to minimize risk of an "in-out-in" screw that would come out in the area of the ala and injure the L5 nerve root that sits directly on top of this structure.

Question 4045

Topic: 2. Trauma
Which of the following provides the most stable fixation for comminuted fractures of the posterior acetabular wall?
. Cable
. Buttress plate
. Methylmethacrylate
. Multiple lag screws
. Multiple Kirschner wires

Correct Answer & Explanation

. Buttress plate

Explanation

Comminuted fractures so close to the posterior rim are amenable only to stabilization with a plate; a buttress plate enhances stability of fixation for comminuted fractures of the posterior wall of the acetabulum. Fixation requires rigid fixation to prevent loss of fixation resulting in incongruity and instability. The other four distracters (cable, methylmethacrylate, multiple lag screws, and multiple K-wires) may achieve initial stability, but reduction will not be maintained.

Question 4046

Topic: 2. Trauma
The iliopectineal fascia runs between which of the following structures?
. Iliopsoas muscle and the iliac vessels/femoral nerve
. Lateral femoral cutaneous nerve and the iliac vessels
. Iliopsoas muscle/femoral nerve and the iliac vessels
. Iliac wing and the iliopsoas muscle
. Pubic symphysis and the iliac vessels

Correct Answer & Explanation

. Iliopsoas muscle/femoral nerve and the iliac vessels

Explanation

The sheath of the psoas muscle or the iliopectineal fascia separates the more lateral iliopsoas muscle and the femoral nerve from the more medially located iliac vessels. This fascia has to be taken down to enter the true pelvis.

Question 4047

Topic: 2. Trauma
Figure 37 shows the radiograph of a 21-year-old collegiate basketball player who has had mild midfoot aching for the past 4 months. What is the best course of action?
. Functional bracing
. Cast immobilization with weight bearing permitted
. Cast immobilization with no weight bearing
. Open reduction and internal fixation
. Midfoot arthrodesis

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

A stress fracture of the navicular is considered a high-risk injury because of the incidence of nonunion. If identified early, cast immobilization with no weight bearing is appropriate. However, this patient is a high-caliber athlete who has had symptoms for 4 months. Therefore, surgery is recommended to expedite recovery and optimize the chance of healing.

Question 4048

Topic: 2. Trauma
A 15-year-old boy with mild type I osteogenesis imperfecta (OI) has a midshaft radius/ulna fracture that is in bayonet apposition with loss of the radial bow and 40-degree apex volar and ulnar angulation. Closed reduction improves the angulation to 20 degrees; the bayonet apposition and loss of radial bow remains. His contralateral forearm has a normal appearance upon examination. What is the best treatment for this fracture?
. Open reduction and plate fixation
. Open reduction and intramedullary rod fixation with casting
. Cast immobilization with expected remodeling of the fracture and near-full motion
. Cast immobilization, accepting malunion and some dysfunction because surgical treatment has a high rate of nonunion in OI

Correct Answer & Explanation

. Open reduction and intramedullary rod fixation with casting

Explanation

DISCUSSION: Teenagers with displaced midshaft forearm fractures do not remodel fully if the angulation is beyond 10 degrees after reduction. Load sharing with intramedullary rodding is preferred in surgical management of fractures whenever possible. This patient is 15 years old with unacceptable reduction, so remodeling of this fracture would not be expected with closed management.

Question 4049

Topic: 2. Trauma

A 34-year-old male presents with elbow pain after sustaining a ground level fall 2 weeks ago. An injury radiograph is shown in Figure

. Which of the following provocative maneuvers will most likely be positive?
. Lateral pivot shift test
. Milking maneuver
. Chair rise test
. Posterior drawer test
. Gravity-assisted varus stress testCorrent answer: 5Figure A demonstrates a fracture of the anteromedial coronoid. Patients with this injury pattern will have feelings of instability with the gravity-assisted varus stress test.Varus posteromedial rotatory instability (VPMRI) of the elbow is caused by a varus and posteromedial rotation force, resulting in rupture of the lateral collateral ligament (LCL) from its humeral origin. The medial coronoid process is subsequently forced against the medial trochlea, which results in fracture of the anteromedial portion. The most sensitive test is the gravity-assisted varus stress test. The arm is abducted to 90° and the patient is asked to flex and extend the elbow. The test is positive for pain, grinding, or instability during range of motion, as the ulnohumeral joint is closed medially by the lack of the buttress from the anteromedial coronoid. Treatment involves surgically addressing the anteromedial facet of the coronoid and repairing the LCL.Steinmann performed a review of coronoid process fractures. He reports that with an anteromedial coronoid fracture, the anteroposterior (AP) radiograph of the elbow will demonstrate progressive narrowing of the joint space from lateral to medial. They conclude that an important determinant of stability is the involvement of the sublime tubercle (insertion point of the MCL). When the sublime tubercle is involved, medial elbow instability is likely.Doornberg et al. performed a retrospective review of coronoid fracture patterns. They found that large fractures of the coronoid were involved with anterior and posterior olecranon fracture/dislocations, small transverse fractures were involved with terrible triad injuries, and anteromedial facet fractures were associated with VPMRI.Doornberg et al. performed a retrospective review of patients with fracture of the anteromedial facet of the coronoid. They report that if the fracture is not specifically treated, patients ultimately developed arthrosis. They report that the coronoid fracture may be secured with a plate, screw, or sutures. They conclude that secure fixation of the coronoid usually restores good elbow function.Figure A is an AP radiograph of the elbow demonstrating a fracture of the anteromedial facet of the coronoid. Illustration A is a fluoroscopic stress view demonstrating ulnohumeral instability due to an associated LCL injury.Illustration B is an AP radiograph demonstrating plate and screw fixation of the coronoid and suture anchor repair of the LCL.Incorrect Answers:

Correct Answer & Explanation

. Which of the following provocative maneuvers will most likely be positive?

Explanation

positive finding and is seen in valgus posterolateral rotatory instability of the elbow.OrthoCash 2020

Question 4050

Topic: 2. Trauma
Examination of a hand with compartment syndrome is most likely to reveal which of the following?
. Clenched fist
. Intrinsic minus posturing
. Pain with passive stretch
. Compression of the superficial arch
. Pallor

Correct Answer & Explanation

. Intrinsic minus posturing

Explanation

DISCUSSION: The typical posture of the hand in compartment syndrome is an intrinsic minus posture of metacarpophalangeal joint extension and flexion of the proximal and distal interphalangeal joints.

Question 4051

Topic: 2. Trauma
A 9-year-old boy falls from a scooter and sustains the injury shown in the radiographs in Figure 26. After closed reduction and cast immobilization, what is the most likely complication that can result?
. Growth arrest of the distal ulna
. Growth arrest of the distal radius
. Compartment syndrome
. Radioulnar synostosis
. Entrapment of the extensor pollicis longus (EPL) tendon

Correct Answer & Explanation

. Growth arrest of the distal ulna

Explanation

DISCUSSION: The radiographs show a fracture of the distal radius and ulna physis. The most likely complication is growth arrest of the distal ulna. In contradistinction to physis fractures of the radius (growth arrest incidence of less than 5%), the incidence of growth arrest in the ulna is between 30% and 40%. Entrapment of the EPL tendon and cross union between the two bones is extremely rare.

Question 4052

Topic: Lower Extremity Trauma

Figure 1 is the MRI scan of a 35-year-old female soccer player who injured her knee during a game. Given the findings of the scan, physical examination is most likely to reveal

. grade 2 pivot shift.
. positive Thessaly test.
. positive quadriceps active test.
. positive dial test at 30°.

Correct Answer & Explanation

. grade 2 pivot shift.

Explanation

The MRI scan clearly reveals bone bruises in the mid lateral femoral condyle and posterior tibial plateau. These MRI findings are commonly associated with acute anterior cruciate ligament injuries. Therefore, the preferred answer would be a positive pivot shift examination. A positive posterior drawer and positive quad active test are associated with posterior cruciate ligament injuries. A positive dial test would be suggestive of a posterolateral instability of the knee.

Question 4053

Topic: 2. Trauma

A 75-year-old female undergoes fixation of an unstable, reverse obliquity intertrochanteric femur fracture with a standard sliding hip screw (dynamic hip screw). Six weeks later, radiographs show catastrophic cut-out of the lag screw and medialization of the femoral shaft. What is the primary biomechanical reason a sliding hip screw is relatively contraindicated for this specific fracture pattern?

. It cannot provide adequate rotational stability to the femoral head.
. The fracture line is parallel to the sliding vector, driving medialization of the shaft and lateral translation of the proximal fragment.
. The side plate inherently pulls off the lateral femoral cortex due to immense bending forces.
. It causes excessive impaction and avascular necrosis of the cancellous bone in the femoral head.
. The device inherently prevents the use of a supplementary derotation screw.

Correct Answer & Explanation

. It cannot provide adequate rotational stability to the femoral head.

Explanation

In reverse obliquity intertrochanteric fractures, the fracture line runs from proximal-medial to distal-lateral. A sliding hip screw allows controlled collapse along the axis of the lag screw. Because the sliding vector is nearly parallel to the fracture line, it causes the femoral shaft to medialize and the head/neck fragment to translate laterally, leading to nonunion and fixation failure. Cephalomedullary nails are biomechanically superior for this pattern.

Question 4054

Topic: 2. Trauma
A 30-year-old male sustains a vertically oriented, highly displaced femoral neck fracture (Pauwels type III). Which of the following internal fixation constructs provides the most biomechanical stability against the extreme shear forces present in this specific fracture pattern?
. Three parallel partially threaded cancellous screws placed in an inverted triangle
. A sliding hip screw (DHS) supplemented with an anti-rotation cancellous screw
. Two parallel fully threaded cancellous screws
. A standard trochanteric entry cephalomedullary nail
. A unipolar hemiarthroplasty

Correct Answer & Explanation

. A sliding hip screw (DHS) supplemented with an anti-rotation cancellous screw

Explanation

Pauwels type III femoral neck fractures are highly vertically oriented, resulting in massive shear forces across the fracture site rather than compressive forces. Biomechanical studies demonstrate that a fixed-angle construct, such as a sliding hip screw (DHS) often supplemented with a derotational screw, provides superior biomechanical stability and higher load-to-failure against these shear forces compared to multiple parallel cancellous screws.

Question 4055

Topic: 2. Trauma

A 70-year-old female sustains a supracondylar femur fracture 2 cm above the flange of her primary total knee arthroplasty. The femoral component is a posterior-stabilized, closed-box design and appears well-fixed. Which of the following is the most appropriate fixation strategy?

. Retrograde intramedullary nailing
. Anterolateral locked plating
. Lateral locked plating
. Revision to a distal femoral replacement
. Conservative management in a hinged knee brace

Correct Answer & Explanation

. Retrograde intramedullary nailing

Explanation

A closed-box design of a posterior-stabilized femoral component physically blocks the insertion of a retrograde intramedullary nail. Consequently, lateral locked plating is the preferred fixation method for a periprosthetic fracture above a well-fixed, closed-box component.

Question 4056

Topic: 2. Trauma

An 82-year-old male sustains a closed supracondylar femur fracture just proximal to his total knee arthroplasty (Lewis-Rorabeck Type II). The femoral component is well-fixed, and there is no evidence of osteolysis. Which of the following is the most appropriate surgical treatment?

. Nonoperative management in a hinged knee brace
. Revision to a distal femoral replacement
. Retrograde intramedullary nailing or lateral locked plating
. External fixation
. Amputation

Correct Answer & Explanation

. Nonoperative management in a hinged knee brace

Explanation

A Lewis-Rorabeck Type II periprosthetic distal femur fracture features a displaced fracture with a well-fixed femoral component. The gold standard treatment is internal fixation, typically achieved using lateral locked plating or a retrograde intramedullary nail (if the femoral component box allows).

Question 4057

Topic: 2. Trauma
A 52-year-old woman who is right hand-dominant sustains an injury to her elbow in a fall. A radiograph is shown in Figure 60. The preferred treatment of this injury pattern should include
. lateral plating of the proximal ulna and fixation of the radial head.
. Kirschner wire/tension band fixation of the proximal ulna alone.
. closed reduction and casting.
. dorsal plating of the proximal ulna and radial head replacement.
. total elbow arthroplasty.

Correct Answer & Explanation

. dorsal plating of the proximal ulna and radial head replacement.

Explanation

The patient has a Bado type 2 variant Monteggia fracture with a radial head fracture. The type 2 variant is associated with a higher nonunion rate and poorer outcomes compared to other Bado-type Monteggia fractures. While it is potentially acceptable to repair the radial head, factors such as higher degrees of comminution and older age lead toward replacement as the treatment of choice. Plate and screw fixation is favored over Kirschner wire/tension band fixation because this is not a simple olecranon fracture. Plate placement in a type 2 fracture is dorsal to counteract very high tensile forces associated with fixation failure.

Question 4058

Topic: 2. Trauma
A healthy, active, independent 74-year-old woman fell and sustained the elbow injury shown in Figures 41a and 41b. Management should consist of
. a sling and early elbow range-of-motion exercises.
. a long arm cast for 6 weeks.
. open reduction and internal fixation.
. total elbow arthroplasty.
. elbow arthrodesis.

Correct Answer & Explanation

. total elbow arthroplasty.

Explanation

Open reduction and internal fixation of distal humeral fractures in elderly patients often fails. These fractures characteristically have a very small distal segment and poor bone quality, resulting in failure of fixation and nonunion. Total elbow arthroplasty provides good results when used for distal humeral fractures in elderly patients with osteopenic bone and fracture patterns thought to be irreconstructable.

Question 4059

Topic: 2. Trauma
During a dual incision fasciotomy of the leg, the soleus is elevated from the tibia to allow access to which of the following compartments?
. Superficial posterior
. Deep posterior
. Lateral
. Anterior
. Mobile wad

Correct Answer & Explanation

. Deep posterior

Explanation

DISCUSSION: The soleus is elevated/released from the posterior tibia during the medial approach to allow access to the deep posterior compartment. Release of this compartment cannot be done without proper elevation of the soleus. The superficial posterior compartment mass is primarily located in the proximal half of the leg, while the deep posterior musculature is located in the distal 2/3 of the leg.

Question 4060

Topic: 2. Trauma
A 55-year-old male is involved in a motorcycle crash and sustains a closed, right-sided, midshaft femur fracture. This is an isolated injury. He is treated with retrograde femoral nailing, and postoperatively is noted to have 30 degrees of internal rotation of the operative extremity, when compared with his nonsurgical side. Which of the following is the most likely cause of this malrotation deformity?
. External rotation of the distal femoral segment relative to the proximal femoral segment during nailing
. Internal rotation of the proximal femoral segment relative to the distal femoral segment during nailing
. Iatrogenic decrease in femoral anteversion on the operative leg during nailing
. Increased contralateral femoral retroversion during surgery
. Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing

Correct Answer & Explanation

. Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing

Explanation

DISCUSSION: Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing can cause a malrotation deformity. Postsurgical internal malrotation after treatment for a diaphyseal femur fracture typically occurs either via internal rotation of the distal segment relative to the proximal or external rotation of the proximal segment relative to the distal.

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