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2. Trauma MCQs

Practice Set 212 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 4221

Topic: Upper Extremity Trauma

A 46-year-old woman fell from her bicycle and sustained the injury shown in Figure 24. Which of the following ligaments has been disrupted? Review Topic

. Acromioclavicular
. Acromioclavicular and coracoclavicular
. Coracoclavicular
. Coracoacromial and sternoclavicular
. Sternoclavicular

Correct Answer & Explanation

. Acromioclavicular and coracoclavicular

Explanation

The radiograph shows a type V acromioclavicular joint injury. Type V injuries involve disruption of the acromioclavicular and coracoclavicular ligaments. Type I injuries involve a sprain of the acromioclavicular joint ligaments. Type II injuries involve disruption of the acromioclavicular joint ligaments; the coracoclavicular ligaments are partially injured. Sternoclavicular ligaments stabilize the medial clavicle and the sternum; they are not damaged with acromioclavicular joint dislocations.

Question 4222

Topic: 2. Trauma
A 24-year-old man was thrown from a car and is seen in the emergency department with a Glasgow Coma Scale (GCS) score of 8. A CT scan of the head shows no significant bleeding. The patient is hemodynamically stable. The left femur has the closed injury shown on the radiographs in Figures 53a and 53b. What is the best treatment for this patient?
. Skin traction for the femur, with a follow-up CT scan of the head in the morning
. Distal femur skeletal traction, with a follow-up CT scan of the head in the morning
. External fixation of the femur with delayed intramedullary nailing
. Intramedullary nailing of the femur
. Ventriculostomy and external fixation of the femur

Correct Answer & Explanation

. Intramedullary nailing of the femur

Explanation

DISCUSSION: Treatment of patients with a closed head injury and a femoral fracture remains controversial but recent data suggest that intramedullary nails done acutely with avoidance of intraoperative hypotension did not compromise the outcome related to the head injury. This was especially true for high-level GCS scores. A GCS score of lower than 8 and intraoperative hypotension have been associated with worsening outcomes following acute intramedullary nailing of the femur. Skin traction and distal femur skeletal traction in a young adult man with a femoral fracture is not well tolerated secondary to spasm and pain. External fixation is an option but an unnecessary step in the treatment of this patient. Ventriculostomy is not necessary in stable patients with no significant bleeding on a CT scan of the head. REFERENCES: Starr AJ, Hunt JL, Chason DP, et al: Treatment of femur fracture with associated head injury. J Orthop Trauma 1998;12:38-45. Nau T, Kutscha-Lissberg F, Muellner T, et al: Effects of a femoral shaft fracture on multiply injured patients with a head injury. World J Surg 2003;27:365-369. McKee MD, Schemitsch EH, Vincent LO, et al: The effect of a femoral fracture on concomitant closed head injury in patients with multiple injuries. J Trauma 1997;42:1041-1045. Brundage SI, McGhan R, Jurkovich GJ, et al: Timing of femur fracture fixation: Effect on outcome in patients with thoracic and head injuries. J Trauma 2002;52:299-307.

Question 4223

Topic: 2. Trauma
The patient is at highest risk for which complication?
. Postoperative infection
. Heterotopic ossification
. Malunion
. Nonunion

Correct Answer & Explanation

. Nonunion

Explanation

DISCUSSION: The quality of femoral neck fracture reduction was the key outcome factor in a number of studies. Capsulotomy is performed when achieving open reduction of the femoral neck. In rare cases in which acceptable closed reduction is achieved, capsulotomy has been advocated, but poor anatomic reduction is more likely to negatively influence the outcome. Failure to achieve anatomic reduction of the femoral neck frequently leads to nonunion and varus collapse. Postoperative infection and/or heterotopic ossification are not typically seen in closed reduction and percutaneous stabilization of femoral neck fractures. Nonunion is more common than malunion of displaced femoral neck fractures.

Question 4224

Topic: 2. Trauma
Figure 1 is the radiograph and Figure 2 is the CT image of a 45-year-old woman who fell about 20 feet off her balcony. These images show an isolated, open injury with a 3-cm open medial wound. The best delayed definitive surgical fixation plan would include
. lateral plating of the fibula and a percutaneous medial column plate.
. intramedullary fixation of the fibula and an anterolateral tibial plate.
. open medial column plating, percutaneous screw fixation of the joint, and lateral fibular plating.
. screw fixation of the medial column with an anterolateral tibial plate and lateral fibular plating

Correct Answer & Explanation

. open medial column plating, percutaneous screw fixation of the joint, and lateral fibular plating.

Explanation

DISCUSSION: The timely administration of antibiotics has been shown to be the best initial treatment to reduce the incidence of infection following an open fracture. Life-threatening injuries must first be addressed. In this isolated open pilon fracture, antibiotics should be initiated early along with tetanus prophylaxis. Reduction and splinting would stabilize the fracture, but these interventions should follow antibiotic coverage. Emergency department irrigation is controversial. Closed reduction and splinting, external fixation, CT scan, and delayed open reduction internal fixation would be the preferred sequence of management. External fixation to provide provisional limb stabilization would be indicated in this length-unstable C-type injury to provide soft tissue stabilization and prevent further chondral injury. Splinting alone would not prevent shortening and would not allow soft tissue recovery. CT scans prior to limb stabilization are not warranted because the patterns make more sense after the restoration of gross length, rotation, and alignment in the external fixator. Initial fibular fixation is also not recommended in this case because the location of incisions could affect the definitive surgical tactic. In this multi-fragmentary fibular injury, anatomic reduction would be challenging and malreduction could occur and influence subsequent reconstructions. Delayed open reduction internal fixation is ideal after the resolution of soft tissue swelling.

Question 4225

Topic: 2. Trauma
A patient with an intertrochanteric hip fracture undergoes reduction and dynamic hip screw application. The post-operative radiographs demonstrate that the lag screw is superior in the femoral head with a tip-apex distance of 40 millimeters. This patient is at increased risk of what complication?
. lag screw cutout
. osteonecrosis
. osteoarthritis
. peri-prosthetic fracture
. lag screw breakage

Correct Answer & Explanation

. lag screw cutout

Explanation

DISCUSSION: Baumgaertner et al in their classic study in 1995 determined that the position of the lag screw in the femoral head influenced the risk of cutout of a dynamic hip screw construct in treatment of intertrochanteric fractures. They had no cutouts if the tip-apex distance on the combined AP and lateral radiographs was less than 25 millimeters. Subsequent studies demonstrated a decreased cutout rate once people were aware of the tip-apex distance importance.

Question 4226

Topic: 2. Trauma
Each of the following are guidelines for management of a domestic violence victim EXCEPT:
. Socioeconomic status should not preclude evaluation for domestic violence
. Interview the patient outside the presence of others
. Federal law mandates photographs be taken of injuries (regardless of patient’s consent)
. Document your opinion if the patient’s injuries are not consistent with the offered explanation
. Physicians should check requirements to see if there is mandatory reporting statute in their state

Correct Answer & Explanation

. Federal law mandates photographs be taken of injuries (regardless of patient’s consent)

Explanation

DISCUSSION: It is important to fully document the abuse as it has been described to you, however there is no federal law mandating photographic documentation of domestic violence injuries. Photographs may be taken but only with the patient's permission. Disclosure of a diagnosis of abuse to any third party and reporting it to the authorities should be done only with the abused patient’s knowledge and consent, unless there is a mandatory reporting statute in the particular state of practice. Being a female, age 19-29, pregnant, or of a low socioeconomic status (<$10,000 per/yr) increases one's risk for domestic abuse. Pregnancy is the highest risk factor for abuse with 40% to 60% of battered women reporting that they were abused during pregnancy. Interviewing should be done outside the presence of others to minimize potential interference by the abusive spouse/partner. The review article by Zillmer outlines that as many as 35% of women presenting to ERs for trauma care have injuries that are a result of domestic violence.

Question 4227

Topic: 2. Trauma

Figures 30a and 30b are the radiographs of a 61-year-old man with diabetes who fell from a ladder and sustained an isolated closed fracture. After realignment and splint application, what is the most appropriate next step in management?

. CT scan
. Hybrid external fixation
. Ankle-spanning external fixation
. Open reduction and internal fixation within 6 to 8 hours
. Open reduction and internal fixation within 2 to 3 days

Correct Answer & Explanation

. CT scan

Explanation

The patient has sustained a high-energy severely comminuted AO/OTA C2 fracture of the distal tibia. This injury is notably fraught with soft-tissue complications that can lead to disastrous clinical results. In general, a staged protocol is now preferred in an effort to avoid these complications and has shown substantial decreases in infection rates and wound healing problems. A CT scan is certainly appropriate for preoperative planning but should be obtained after frame application because the indirect reduction that is achieved improves one's ability to understand the fracture characteristics and morphology. Hybrid external fixation has fallen out of favor because of its limited biomechanic rigidity and clinical results. Open reduction andinternal fixation in the acute phase (6 to 8 hours) or sub-acute phase (2 to 3 days) is difficult.

Question 4228

Topic: 2. Trauma
Antegrade femoral nailing has an increased rate of which of the following when compared to retrograde femoral nailing?
. Varus malalignment
. Union rate
. Operative time
. Subsequent operative procedures
. Hip pain

Correct Answer & Explanation

. Hip pain

Explanation

DISCUSSION: In the referenced study by Ricci et al, antegrade femoral nailing was shown to have an increased rate of hip pain as compared to retrograde femoral nailing, while having a similar rate of union, time to union, rate of malalignment, and operative time. Hip pain was significantly higher in the antegrade nailing group, while knee pain was significantly greater in the retrograde group. The referenced study by Winquist et al noted a 99.1% union rate with intramedullary nailing. The referenced study by Moed et al noted a 6% nonunion rate in non-reamed retrograde femoral nailing with nail dynamization at 6-12 weeks and early weightbearing.

Question 4229

Topic: 2. Trauma
A 46-year-old male is involved in a motor vehicle accident and suffers a proximal humerus fracture. Operative treatment is recommended, and plate fixation is performed through an extended anterolateral acromial approach. Which of the following structures is at increased risk of injury using this surgical exposure compared to the deltopectoral approach?
. Musculocutaneous nerve
. Posterior humeral circumflex artery
. Axillary nerve
. Cephalic vein
. Anterior humeral circumflex artery

Correct Answer & Explanation

. Axillary nerve

Explanation

DISCUSSION: The anterolateral acromial approach was developed to allow less invasive treatment of proximal humerus fractures. The plane of the avascular anterior deltoid raphe is utilized, and the axillary nerve is at particular risk of injury and must be identified and protected. With this approach, anterior dissection near the critical blood supply is avoided, substantial muscle retraction is minimized, and the lateral plating zone is directly accessed.

Question 4230

Topic: 2. Trauma
What is the most commonly reported complication following elbow arthroscopy?
. Synovial cutaneous fistula
. Nerve transection
. Compartment syndrome
. Infection
. Transient neurapraxia

Correct Answer & Explanation

. Transient neurapraxia

Explanation

DISCUSSION: The complication rate following elbow arthroscopy is reported at 5%. The most commonly reported complication is transient neurapraxia, with nerve transection remaining an unfortunate and rare event. While infection remains the most common serious complication, it is uncommon (0.8%).

Question 4231

Topic: Lower Extremity Trauma
Which of the following factors is responsible for causing the distal femur to pivot about a medial axis as the knee moves from full extension into early flexion?
. Differential forces generated from the vastus lateralis and vastus medialis
. Differential tension within the bundles of the posterior cruciate ligament
. Differential radius of curvature between the medial and lateral femoral condyles
. Asymmetry of the tibial tubercle on the anterior surface of the tibia
. Asymmetric forces generated from the uneven patellar facets

Correct Answer & Explanation

. Differential radius of curvature between the medial and lateral femoral condyles

Explanation

DISCUSSION: The radius of curvature of the distal femur is greater over the distal aspect of the lateral femoral condyle than the distal aspect of the medial femoral condyle. As the femur rolls posteriorly during early knee flexion, both condyles undergo similar angular changes equal to the amount of flexion. With a similar amount of angular rotation, the sphere with the larger radius experiences greater net rollback, producing a pivoting motion.

Question 4232

Topic: 2. Trauma
A polytrauma patient sustains a right bicondylar tibial plateau fracture and a right humeral shaft fracture both treated with open reduction, internal fixation. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. What is the appropriate weightbearing status?
. non-weight bearing bilateral lower extremities and right upper extremity
. weight bearing as tolerated bilateral lower extremities and right upper extremity
. non-weight bearing left lower extremity and weight bearing as tolerated right upper and right lower extremities
. non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities
. weight bearing as tolerated bilateral lower extremities and non-weight bearing right upper extremity

Correct Answer & Explanation

. non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities

Explanation

DISCUSSION: Tingstad et al found favorable results of immediate weightbearing on humeral shaft fractures treated with plating. Brumback et al evaluated the feasibility, safety and efficacy of immediate weightbearing after treatment of femoral shaft fractures with statically locked IM nail. The standard treatment for a bicondylar tibial plateau fracture is a period of post-operative non-weight bearing.

Question 4233

Topic: 2. Trauma
Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of
. cast immobilization for 6 weeks.
. brief immobilization followed by rest for 6 weeks.
. internal fixation with a compression screw.
. internal fixation with a tension band wire.
. bone stimulation.

Correct Answer & Explanation

. internal fixation with a compression screw.

Explanation

DISCUSSION: The CT scan shows a stress fracture of the olecranon. Initial treatment consists of rest and temporary splinting. Open fixation with a large compression screw is recommended when nonsurgical management has failed to provide relief.

Question 4234

Topic: Pelvic & Acetabular Trauma
A patient who had previously undergone a salvage pelvic (Chiari) osteotomy now requires a total hip arthroplasty. The most frequent complication of this procedure is
. fracture of the acetabulum
. protrusion of the acetabulum
. inadequate inferior coverage
. inadequate superior coverage
. inadequate anterior and posterior coverage

Correct Answer & Explanation

. inadequate anterior and posterior coverage

Explanation

The Chiari osteotomy is recommended for patients with inadequate femoral head coverage and an incongruous joint. The osteotomy shortens the affected leg. It also medializes the hip's center of rotation. The osteotomy involves cutting the ilium at a spot above the acetabulum, which in effect abducts the acetabulum into a more vertical and medial position. The iliac wing then serves as a superior buttress. The most frequent complication of subsequent total hip arthroplasty is inadequate anterior and posterior coverage.

Question 4235

Topic: 2. Trauma

Figure 53 is the radiograph obtained at the time of transfer to the trauma center of a 41-year-old man who was involved in a motor vehicle accident. What is the most appropriate initial management?

. MRI scan
. CT scan of the pelvis
. Application of skeletal traction
. Closed reduction of the right hip
. Open reduction and internal fixation

Correct Answer & Explanation

. MRI scan

Explanation

The radiograph reveals a displaced transverse posterior wall acetabular fracture, and the hip is dislocated. On recognition of a hip dislocation, the hip should be promptly reduced. A time to reduction of greater than 12 hours has been associated with adverse outcomes. Although skeletal traction and a CT scan are essential elements in this patient's care, the hip should be reduced prior to these actions. An MRI scan is not indicated in this patient, particularly with the hip dislocated. The ultimate surgical treatment for this injury will be open reduction and internal fixation, but the patient should be stabilized, the hip reduced, and appropriate imaging obtained before taking the patient to surgery.

Question 4236

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? Review Topic

. 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

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 4237

Topic: 2. Trauma

After reduction and pinning, the radial pulse is absent by both palpation and Doppler. Capillary refill in the fingers appears normal. What is the most likely explanation?

. Laceration of the brachial artery during reduction
. Compression of the brachial artery by a pin
. Abnormal arterial supply
. Spasm in the brachial artery

Correct Answer & Explanation

. Laceration of the brachial artery during reduction

Explanation

DISCUSSIONThis is a classic extension-type supracondylar elbow fracture typically caused by a fall on an outstretched hand. The medial comminution of this fracture renders it predictably unstable and susceptible to varus malunion. Extra attention with fixation is required. In general, use of lateral-entry pins alone is effective for most supracondylar humeral fractures. The best technique for fixation with lateral-entry pins only involves maximization of pin separation at the fracture site, engaging sufficient bone in both the proximal segment and the distal fragment and using more than 2 lateral entry pins (if needed) for stability. In the presence of medial comminution, medial fixation also may be necessary.Brachial artery spasm is the usual cause of absence of radial pulse if capillary refill is normal. Close postsurgical monitoring is warranted after reduction and pinning.

Question 4238

Topic: 2. Trauma

When performing distraction osteogenesis for a post-traumatic tibial bone defect using an Ilizarov frame, what are the classic optimal latency period and rate of distraction to promote high-quality regenerate bone?

. Latency of 1-2 days; Rate of 2.0 mm/day
. Latency of 5-7 days; Rate of 1.0 mm/day
. Latency of 10-14 days; Rate of 1.5 mm/day
. Latency of 3-4 days; Rate of 0.5 mm/day
. Latency of 14-21 days; Rate of 0.25 mm/day

Correct Answer & Explanation

. Latency of 1-2 days; Rate of 2.0 mm/day

Explanation

Ilizarov established the biologic principles for distraction osteogenesis. The optimal latency period is typically 5 to 7 days to allow the initial phase of fracture healing (callus formation) before distraction begins. The ideal rate is 1.0 mm per day (usually divided into 4 increments of 0.25 mm) to optimize regenerate bone formation without causing premature consolidation or nonunion.

Question 4239

Topic: Upper Extremity Trauma

During anatomic reconstruction of a chronic type V acromioclavicular (AC) joint separation, the surgeon reconstructs the coracoclavicular (CC) ligaments. To accurately reproduce the biomechanics of the native joint, where should the conoid and trapezoid reconstruction tunnels be placed relative to the distal clavicle?

. Conoid 25 mm medial, Trapezoid 45 mm medial
. Conoid 45 mm medial, Trapezoid 25 mm medial
. Conoid 15 mm medial, Trapezoid 30 mm medial
. Conoid 30 mm medial, Trapezoid 15 mm medial
. Both at 35 mm medial

Correct Answer & Explanation

. Conoid 25 mm medial, Trapezoid 45 mm medial

Explanation

The trapezoid ligament is positioned more anteriorly and laterally, inserting approximately 2.5 cm (25 mm) medial to the distal clavicle. The conoid ligament is positioned more posteromedially, inserting on the conoid tubercle approximately 4.5 cm (45 mm) medial to the distal clavicle.

Question 4240

Topic: 2. Trauma

In evaluating a proximal humerus fracture for the risk of avascular necrosis (AVN), which of the following is considered the strongest predictor of ischemia to the articular segment according to Hertel's criteria?

. Valgus impaction of the head
. Medial hinge disruption > 2 mm
. Short posteromedial metaphyseal head extension (< 8 mm)
. Displacement of the greater tuberosity > 5 mm
. Bicipital groove fracture

Correct Answer & Explanation

. Valgus impaction of the head

Explanation

Hertel described radiographic predictors of ischemia in proximal humerus fractures. The strongest predictors include a short posteromedial metaphyseal head extension (<8 mm) attached to the articular segment, disruption of the medial hinge (>2 mm), and an anatomic neck fracture pattern. These indicate disruption of the arcuate artery, the terminal branch of the anterior humeral circumflex artery.

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