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2. Trauma MCQs

Practice Set 204 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 4061

Topic: 2. Trauma

A 10-year-old boy presents to the emergency department after falling directly onto a flexed knee. Radiographs reveal a high-riding patella and a small bony avulsion at the inferior pole of the patella. What is the most appropriate management for this injury?

. Cylinder cast in extension for 4 weeks
. Excision of the inferior pole fragment and patellar tendon advancement
. Open reduction and internal fixation with repair of the extensor retinaculum
. Long leg cast in 45 degrees of flexion
. Hinged knee brace locked in extension

Correct Answer & Explanation

. Open reduction and internal fixation with repair of the extensor retinaculum

Explanation

The presentation is classic for a patellar sleeve fracture, a pediatric injury where a large cartilaginous cap is avulsed from the patella along with a small piece of bone. Because the cartilaginous fragment is large, there is a significant disruption of the articular surface and extensor mechanism. These fractures require open reduction and internal fixation.

Question 4062

Topic: Lower Extremity Trauma
A 7-year-old girl presents with snapping and lateral joint line pain in her right knee. MRI demonstrates a Wrisberg variant discoid lateral meniscus. According to the Watanabe classification, what anatomical feature defines this specific variant?
. Complete coverage of the lateral tibial plateau with normal posterior attachments
. Incomplete coverage of the lateral tibial plateau with normal posterior attachments
. Absence of the posterior meniscotibial (coronary) ligaments, with the meniscofemoral ligament of Wrisberg serving as the only posterior attachment
. A hypermobile medial meniscus
. An anteriorly displaced meniscus with intact posterior attachments

Correct Answer & Explanation

. Absence of the posterior meniscotibial (coronary) ligaments, with the meniscofemoral ligament of Wrisberg serving as the only posterior attachment

Explanation

The Watanabe classification describes three types of discoid meniscus: Complete (Type I), Incomplete (Type II), and Wrisberg variant (Type III). The Wrisberg variant lacks the normal posterior meniscotibial (coronary) attachments; its only posterior tether is the meniscofemoral ligament of Wrisberg, leading to hypermobility and the classic 'snapping knee' presentation.

Question 4063

Topic: 2. Trauma
A 14-year-old male jumping athlete presents with acute knee pain and inability to extend the knee against gravity. Radiographs reveal a fracture extending from the tibial tubercle proximally across the epiphyseal plate and into the articular surface. According to the Ogden classification of tibial tubercle fractures, which type is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type III

Explanation

According to the Ogden classification: Type I is a fracture of the secondary ossification center. Type II extends to the junction of the primary and secondary ossification centers. Type III extends through the primary ossification center (physis) into the knee joint (intra-articular). Type IV is an avulsion of the entire proximal tibial epiphysis.

Question 4064

Topic: 2. Trauma

A 22-year-old soccer player sustains an internal rotation injury to the knee resulting in an ACL tear. Radiographs show an avulsion fracture of the anterolateral proximal tibia (Segond fracture). Which of the following structures is most likely attached to this avulsed bony fragment?

. Iliotibial band
. Anterolateral ligament
. Biceps femoris tendon
. Popliteofibular ligament
. Lateral collateral ligament

Correct Answer & Explanation

. Anterolateral ligament

Explanation

The Segond fracture is a pathognomonic avulsion fracture of the proximal anterolateral tibia strongly associated with ACL tears. It represents the bony avulsion of the anterolateral ligament (ALL) and associated capsular structures.

Question 4065

Topic: 2. Trauma

A 26-year-old patient presents to the emergency department after a high-energy dashboard injury resulting in a knee dislocation. The knee is currently reduced. Distal pulses are palpable but slightly asymmetric, and the ankle-brachial index (ABI) is 0.85. What is the most appropriate next step in management?

. Immediate surgical exploration of the popliteal artery
. Observation and serial physical examinations
. CT angiography of the lower extremity
. Duplex ultrasonography of the popliteal vein
. Fasciotomy of the lower leg compartments

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An ABI of less than 0.9 in the setting of a knee dislocation is highly suspicious for a vascular injury, even if pulses remain palpable. CT angiography (or conventional arteriography) is the gold standard next step to evaluate for a popliteal artery intimal tear or occlusion.

Question 4066

Topic: Lower Extremity Trauma

A 19-year-old female hears a "pop" while pivoting during basketball. Based on the classic MRI findings of a noncontact ACL rupture, what associated bone bruise pattern is most commonly seen?

. Medial femoral condyle and medial tibial plateau
. Lateral femoral condyle and posterolateral tibial plateau
. Anterior lateral femoral condyle and anterior medial tibial plateau
. Trochlear groove and patella
. Posterior medial femoral condyle and anterior lateral tibial plateau

Correct Answer & Explanation

. Medial femoral condyle and medial tibial plateau

Explanation

Noncontact ACL injuries (pivot-shift mechanism) characteristically produce bone bruises involving the lateral femoral condyle (terminal sulcus) and the posterolateral tibial plateau due to anterior subluxation and impaction.

Question 4067

Topic: 2. Trauma
What inflammatory mediator has been most closely associated with the magnitude of the systemic inflammatory response to trauma and with the development of multiple organ dysfunction syndrome (MODS)?
. IL-1
. IL-6
. TNF
. TGF-beta
. CRP

Correct Answer & Explanation

. IL-6

Explanation

Multiple cytokines (inflammatory mediators) are released following trauma, and their levels can be measured in serum. Persistent elevated levels of IL-6 (> 800 pg/mL) indicate an exaggerated systemic inflammatory response to trauma and have been associated with the development of MODS. Recent work has shown that extensive surgical procedures should be avoided when IL-6 levels remain elevated to prevent the precipitation of MODS. In the future, it is likely that this mediator and possibly others will be used to determine timing and techniques of future treatment.

Question 4068

Topic: 2. Trauma

Figure 23 is the radiograph of a 22-year-old woman who was involved in a motor vehicle collision. She reports isolated pain in her left shoulder. She is hemodynamically stable, respiring comfortably, and neurovascularly intact. Based on these findings, which of the following statements regarding treatment is most appropriate?

. Union rates are in excess of 95% if treated nonsurgically.
. A figure-of-8 brace is superior to a sling for nonsurgical management.
. Open reduction and internal fixation increases the likelihood of a nonunion.
. Open reduction and internal fixation results in improved functional outcomes.
. Open reduction and internal fixation and nonsurgical management have equivalent outcomes at 1 year.

Correct Answer & Explanation

. Union rates are in excess of 95% if treated nonsurgically.

Explanation

The patient has sustained an isolated, closed, transverse fracture of the middle third of the clavicle with greater than 100% displacement and greater than 2 cm of shortening. Whereas the traditional treatment of clavicle fractures has been overwhelmingly conservative, recent reports suggest that surgical fixation should be considered for certain injury patterns. The union rates of displaced clavicle fractures are more recently noted to be approximately 85%, which is lower than the traditional literature. In a prospective randomized trial of clavicle fractures with greater than 100% displacement, union rates were higher and functional outcomes were better at all time points up to 1 year after injury in the surgical group when compared with nonsurgical management.

Question 4069

Topic: 2. Trauma
The injury shown in Figure 24 was most likely caused by what mechanism of injury?
. Anterior posterior compression
. Lateral compression
. Vertical shear
. Combined mechanism
. Flexion-rotation

Correct Answer & Explanation

. Lateral compression

Explanation

The CT cut shows a fracture through the posterior portion of the iliac wing or a crescent fracture. This occurs after a laterally directed force is applied to the anterior part of the involved iliac wing.

Question 4070

Topic: Lower Extremity Trauma
During a posterior cruciate ligament-sacrificing total knee arthroplasty with anterior referencing, 8 mm of distal femur is resected. It is noted that the flexion gap is tight and the extension gap appears stable. What is the next most appropriate step in management?
. Cut more proximal tibia.
. Cut more distal femur.
. Cut both the proximal tibia and distal femur.
. Decrease the size of the femoral component.
. Decrease the tibial polyethylene insert thickness.

Correct Answer & Explanation

. Decrease the size of the femoral component.

Explanation

If the flexion gap is tight and the extension gap is correct, it is preferable to change only the flexion gap and leave the extension gap unchanged; therefore, the treatment of choice is to decrease the size of the femoral component. The smaller component will be smaller in both medial-lateral as well as anterior-posterior dimensions. A smaller anterior-posterior size will allow more space for the flexion gap without significantly affecting the extension gap. Decreasing the size of the tibial polyethylene insert thickness or cutting more proximal tibia will affect both the flexion and extension gaps. Cutting more distal femur will increase the extension gap and not change the flexion gap, making the described situation worse. Cutting both the proximal tibia and distal femur will increase both the flexion and extension gaps.

Question 4071

Topic: 2. Trauma
  • A 50 year old man who has insulin-dependent diabetes mellitus with associated neuropathy has a stress fracture of the fourth metatarsal. Examination of the foot reveals acute swelling, warmth, and erythema; however, the patient reports very little pain. Treatment should include
. a total contact cast.
. electrical stimulation.
. an off the shelf fracture brace.
. an elastic compression bandage and crutches.
. a hard soled shoe until the patient is asymptomatic.

Correct Answer & Explanation

. a total contact cast.

Explanation

The approach to the diabetic foot is a challenging problem. The team approach has taken various forms and venues with the basic principles being the same: education, prevention, follow up and aggressive care. Custom shoes, custom-molded inserts, and increased depth shoes are being used in treatment as well as prevention. Brand documented that repeated low-energy trauma is the cause of most skin breakdown with impaired sensation. Responses 3 and 5 can be eliminated since they are not custom. Compression bandage can cause minor trauma and ischemic problems if sensation is altered. Electrical stimulation is not used for acute fractures. A total contact cast will relieve pressure areas. This should be monitored closely since swelling will decrease and with movement in the cast, minor trauma may occur.

Question 4072

Topic: 2. Trauma
  • A 17-year old boy who sustained a closed clavicle fracture after he was ejected from an all-terrain vehicle was treated with a figure-of-8 brace 1 year ago. He now reports continuous pain at the site of the fracture and is unable to actively raise his arm above his head. A radiograph is shown in Figure 1. Management should now include
. an onlay bone graft
. electrical stimulation
. resection of the distal clavicle
. plate fixation and a bone graft
. smooth Kirschner wire fixation and a bone graft

Correct Answer & Explanation

. an onlay bone graft

Explanation

The radiograph illustrates a middle third clavicular fracture with bone loss. According to Jupiter and associates, the biomechanics of the clavicle predisposes the middle third to be prone for fracture secondary to both moments of tension and bending and also torsional forces. In their study, fixation was best accomplish with plate fixation and a bone graft.[JBJS 1987, 69-A pg. 753-759]Selection (1) would not provide adequate fixation to promote healing. (2) Electrical stimulation would not be sufficient for the above reasons. (3) Resection of the distal clavicle would not be indicate for this case because it promote further instability of the clavicle and increasing the affected forces to the clavicle.(5) Kirschner wire fixation with bone graft, the author stated would provide fixation, but they achieved better results with plate fixation and bone graft Question 6 -A 75-year-old woman sustains a fracture below the level of a total hip prosthesis. Radiographs demonstrate loosening of the prosthetic component. Treatment should consist ofa cast bracea spica castplate fixationallograft strut fixationlong stem revisionThe key to this question lies in the radiographic evidence of loosening of the prosthetic component. The long stem revision is clearly indicated in this case because of various factors, one decreases impingement of the loose stem against the lateral femoral cortex. A non-surgical approach in the elderly patient will only increase the many risk factors such as atelectasis, pneumonia, and thromboembolic disease.[Instructional Course 44 pg. 293-303]

Question 4073

Topic: 2. Trauma
Figures 1 and 2 are the radiographs of a 35-year-old man who is brought into the emergency department after a motor vehicle collision. He is complaining of isolated knee pain. Examination reveals swelling, blood-filled blisters, popliteal ecchymosis, joint line pain, and limited knee joint motion. His pulses and sensation are normal. Initial surgical management should consist of:
. closed reduction and percutaneous screw placement.
. open reduction internal fixation through an anterior midline approach.
. spanning external fixation and closed manipulative realignment.
. ring fixation.

Correct Answer & Explanation

. spanning external fixation and closed manipulative realignment.

Explanation

DISCUSSION: Posterior partial articular tibial plateau fractures are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the lateral radiograph include maintenance of continuity between the anterior articular surface and tibial shaft along with subluxation of the knee joint with excessively anterior tibial station. Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally stabilized in reduced station.

Question 4074

Topic: 2. Trauma
In which scenario is application of negative pressure wound therapy (NPWT) contraindicated?
. Fasciotomy wound after compartment syndrome
. Exposed bone after debridement
. Surgical wound that cannot be closed because of tension
. Surgical tumor bed after excision while awaiting final pathology and definitive closure

Correct Answer & Explanation

. Surgical tumor bed after excision while awaiting final pathology and definitive closure

Explanation

NPWT is contraindicated in the setting of neoplasm because its effect on tumors is unknown. There is potential for increased angiogenesis in residual tumor cells, which could lead to recurrence or even metastasis. NPWT has been used safely and effectively for coverage of open fractures between initial debridement and definitive coverage. Fasciotomy wounds are frequently covered with NPWT dressings on a temporary basis with excellent results. NPWT has been used to temporize wounds with exposed bone before flap coverage. Wounds with excessive tension frequently can be closed after short-term coverage with NPWT dressings.

Question 4075

Topic: Pelvic & Acetabular Trauma
In patients with Crowe types III and IV developmental dysplasia of the hip with high hip centers, acetabular reconstruction often requires lowering the acetabular component into the native acetabulum. In doing so, considerable risk for limb lengthening beyond 4 cm exists, making the hip difficult to reduce and raising the risk for nerve injury. Which technique is used to overcome this problem?
. Subtrochanteric osteotomy with femoral shortening
. An offset femoral component
. A lateralized liner
. Extended trochanteric osteotomy

Correct Answer & Explanation

. Subtrochanteric osteotomy with femoral shortening

Explanation

DISCUSSION: When substantial lengthening of a dysplastic hip will occur because a high dislocation is relocated into a considerably lower acetabulum, a femoral shortening may be necessary to reduce the hip and avoid a stretch injury to the sciatic nerve. No other choice specifically addresses the need for femoral shortening, and high offset stems and lateralized liners may exacerbate the problem if used alone and without femoral shortening.

Question 4076

Topic: 2. Trauma
Which of the following statements regarding conus medullaris syndrome is most accurate?
. Conus medullaris syndrome most commonly accompanies injuries at the T12-L2 region.
. Conus medullaris injury is a lower motor neuron injury, resulting in an excellent prognosis for recovery of bowel and bladder dysfunction.
. The conus medullaris houses the motor cell bodies for the lumbar roots.
. Lower extremity weakness is a common sign of conus medullaris syndrome.
. Autonomic dysreflexia is common.

Correct Answer & Explanation

. Conus medullaris syndrome most commonly accompanies injuries at the T12-L2 region.

Explanation

DISCUSSION: Conus medullaris syndrome most frequently occurs as a result of trauma or with a disk herniation at L1, resulting in a lower motor neuron syndrome but with a poor prognosis for recovery of bowel and bladder dysfunction. The conus region, as the termination of the spinal cord, contains the motor cell bodies of the sacral roots. The syndrome is usually a sacral level neural injury; therefore, lower extremity weakness is uncommon. REFERENCES: Haher TR, Felmly WT, O’Brien M: Thoracic and lumbar fractures: Diagnosis and management, in Bridwell KH, Dewald RL, Hammerberg KW, et al (eds): The Textbook of Spinal Surgery, ed 2. New York, NY, Lippincott Williams & Wilkins, 1977, pp 1773-1778. Reitman CA (ed): Management of Thoracolumbar Fractures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 35-45.

Question 4077

Topic: 2. Trauma
A 28-year-old cowgirl was injured while herding cattle 1 week ago. A radiograph and CT scans are shown in Figures 13a through 13c. What is the most appropriate management for this injury?
. Nonsurgical management and gradual weight bearing as tolerated
. Nonsurgical management and restricted weight bearing
. Placement of a pelvic binder
. Open reduction and internal fixation of the symphysis
. Open reduction and internal fixation of the symphysis and iliosacral screws

Correct Answer & Explanation

. Nonsurgical management and gradual weight bearing as tolerated

Explanation

DISCUSSION: The patient has an AP I pelvic ring disruption with minimal symphyseal widening. The best treatment is nonsurgical management and weight bearing as tolerated. This will help close the anterior pelvic ring during the healing process. Pelvic binders are excellent for acute treatment of widely displaced pelvic fractures but are not recommended for long-term use. Open reduction and internal fixation is not indicated for this injury and furthermore, the posterior ring is not injured.

Question 4078

Topic: Pelvic & Acetabular Trauma
Of all the pelvic ring injury types, anteroposterior compression type III pelvic ring injuries have the highest rate of which of the following?
. Head injury
. Pulmonary injury
. Traumatic amputation
. Need for transfusion
. Upper extremity fractures

Correct Answer & Explanation

. Need for transfusion

Explanation

DISCUSSION: Of the pelvic ring injuries, APC type III have the highest rate of mortality, blood loss, and need for transfusion. They also have a high rate of urogenital injury and abdominal organ injury. Lateral compression injuries (especially type III) have the highest rate of head injury.

Question 4079

Topic: 2. Trauma
A 68-year-old man fell off a 20-foot mountain cliff and was seen in the emergency department the following morning. A radiograph is shown in Figure 12. He is a nonsmoker with medical comorbidities of hypertension and hypercholesterolemia that is well controlled with medicine and diet. Capillary refill and sensation are intact distally and the patient is able to move his toes with mild discomfort. Serosanguinous fracture blisters are present laterally, and the foot is swollen and red. What is the most appropriate management?
. Short leg cast for 6 weeks
. Splinting with early range of motion at 3 weeks
. Immediate open reduction and internal fixation through a medial approach
. Delayed open reduction and internal fixation
. Fusion

Correct Answer & Explanation

. Delayed open reduction and internal fixation

Explanation

DISCUSSION: Surgical treatment of Sanders II and III displaced intra-articular calcaneal fractures with initial Bohler angles of > 15 degrees results in better outcomes as compared to nonsurgical management. Indications for primary fusion might include Sanders IV fractures in which articular congruity or Bohler angles cannot be restored. Given the condition of the soft tissues at presentation, delayed fixation is recommended.

Question 4080

Topic: 2. Trauma
Intramedullary nailing of proximal tibial shaft fractures is technically demanding, and use of an extended medial parapatellar incision with a semiextended technique can prevent what common deformity at the fracture site?
. Valgus
. Varus
. Recurvatum
. Procurvatum
. Rotational deformity

Correct Answer & Explanation

. Procurvatum

Explanation

DISCUSSION: Valgus and flexion is the most common deformity seen after intramedullary nailing of proximal tibia fractures. The semi-extended nailing position helps overcome the procurvatum or flexion deformity of the fracture. Tornetta advocates use of extended medial parapatellar incision with the leg in a semiextended position to allow for a more proximal and lateral starting point. This modified starting point forces the nail to overcome the tendency of the fracture to flex (apex anterior) and go into valgus.

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