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 4341
Topic: 2. Trauma
A 40-year-old male who sustained an open pilon fracture 2 weeks ago is scheduled for a below-the-knee amputation (BKA). What laboratory value is the best predictor for wound healing?
Correct Answer & Explanation
. serum albumin level
Explanation
DISCUSSION: Albumin is the best measure of nutrition that is vital for wound healing. Total protein is a valuable measure as well, however it is not as sensitive as albumin levels. Calcium levels and ESR/C-reactive protein levels play no role.
Question 4342
Topic: 2. Trauma
Figure 35 shows a postoperative radiograph of a femur fracture proximal to a total knee prosthesis that was treated by open reduction and blade plate fixation 9 months ago. What is the most likely reason the previously well seated screw has backed out of the central portion of the plate?
Correct Answer & Explanation
. Infection
Explanation
[Radiograph: An A-P view of the distal femur. There is patchy increased radiodensity in the mid-plate region at the level of the fracture, which was just distal to the middle-distal third junction. The screw in the middle hole of the plate has backed out approximately 1 cm. There is no obvious fracture line at this time. The lateral cortex is not intact.]The referenced article clearly states that the major cause of failure of fractures to heal is nonunion. From the radiograph it appears the screw at one time was long enough. While the distal fragment perhaps has some disuse osteopenia there is no focal area of what could be considered osteonecrosis. We are not given any history of possible infection even though this could be the case.
Question 4343
Topic: 2. Trauma
Figures 78a and 78b are the emergency department radiographs of an 83-year-old woman who tripped and braced herself against a wall; this was followed by shoulder pain. Which intervention would provide optimal treatment for this patient?
Correct Answer & Explanation
. Nonsurgical treatment with closed reduction and immobilization
Explanation
Low-energy fractures in elderly patients typically are treated with nonsurgical care that involves early immobilization followed by early rehabilitation/therapy, especially when proximal humerus and distal humerus fractures are involved. Physical therapy should be initiated within the first 2 weeks. If surgery is needed, ORIF is preferred for most fractures, but replacement may improve outcomes for unreconstructable fractures.
Question 4344
Topic: 2. Trauma
An 8-year-old boy sustained an isolated distal radial fracture that was reduced and immobilized with 10° of residual dorsal tilt. What is the next step in management?
Correct Answer & Explanation
. A long arm cast and follow-up in 1 week
Explanation
Distal radial fractures in children are common, and a large amount of displacement is acceptable. In general, 20° of dorsal displacement and complete bayonet apposition in girls to age 12 years and in boys to age 14 years can be expected to remodel with an excellent outcome. Therefore, early follow-up is recommended and remanipulation is indicated should loss in reduction occur.
Question 4345
Topic: 2. Trauma
A 55-year-old woman has T-score -2.0 at the femoral neck. According to the World Health Organization Fracture Risk Assessment Tool (FRAX), she has a ten-year probability of sustaining a hip fracture of 1.5% and a ten-year probability of sustaining a major osteoporotic fracture of 8.9%. Which of the following statements is true regarding her antiresorptive therapy management?
Correct Answer & Explanation
. Antiresorptive therapy should not be started
Explanation
This patient has osteopenia. Assessment by FRAX shows that ten-year risk of hip fracture is less than 3% and her ten-year risk of major osteoporosis-related fracture is less than 20%. Therefore, antiresorptive therapy is not indicated at this time. According to the 2008 National Osteoporosis Foundation guidelines, pharmacologic treatment for osteoporosis should be considered if patients are postmenopausal women or men greater than 50 years old AND meet one of the following criteria: (1) they have a prior hip or vertebral fracture, (2) they have a T score -2.5 or less at the femoral neck or spine, (3) they have a T score between -1.0 and -2.5 at the femoral neck or spine AND a 10-year risk of hip fracture greater than 3% or 10-year risk of major osteoporosis-related fracture greater than 20%.
Question 4346
Topic: 2. Trauma
A 45-year-old male presented to the trauma department 10 hours after sustaining a fracture-dislocation of his ankle. The patient underwent an attempted closed reduction of his ankle which can be seen in Figures A and B. The splint was removed, and the appearance of the leg is shown in Figure C. Regarding the best next step in management and the intended goals, which of the following is most accurate?
Correct Answer & Explanation
. Repeat closed reduction and splinting under anesthesia to achieve absolute stability
Explanation
The patient has hemorrhagic fracture blisters overlying the expected locations of incisions for definitive fixation of his ankle fracture, and therefore the next best step in treatment is external fixation. An external fixator will reduce the joint and provide relative stability during appropriate blister care until definitive open reduction internal fixation (ORIF).Patients with high-energy periarticular fractures in the lower extremity are at risk for surgical wound complications due to compromised soft tissues. As in this case, joint dislocations can place harmful tension on the skin that leads to blistering and/or skin necrosis. An urgent reduction is indicated, and if it cannot be obtained with a closed manipulation alone, percutaneous or open treatment is indicated. Staged joint-spanning external fixation can both hold a reduction and allow access for skin or wound care prior to a definitive open reduction of an articular fracture. Fracture healing during external fixation occurs by enchondral ossification by way of the relative stability.Strauss et al. developed a treatment protocol for the treatment of fracture blisters. They used silver sulfadine to minimize soft tissue complications by promoting re-epithelialization. After providone-iodine prep, each blister was unroofed by removing the overlying epithelium of the fracture. Once the blister was unroofed, silver sulfadiazine was applied and covered with dry gauze. They would then perform bid dressing changes. Extremities were deemed operable when skin wrinkles were visible on the overlying skin of the injured extremity.Anglen et al. in a review of external fixation, report that fractures of the lower extremity are frequently associated with soft tissue trauma that precludes safe surgical treatment in the early period. They present a technique of temporary joint-spanning external fixation which allows stabilization of length and alignment while awaiting resolution of soft tissue swelling. They report no differences between patients who had a temporary external fixator and those who did not with respect to healing time, time to partial or full weight bearing, or clinical score.Figures A and B demonstrate a pronation-external rotation type fracture with disruption of the syndesmosis. Figure C demonstrates fracture blisters.Illustration A demonstrates an ankle-spanning external fixator. Illustration B demonstrates skin wrinkling to indicate that the skin is safe to incise.Incorrect Answers:OrthoCash 2020
Question 4347
Topic: Lower Extremity Trauma
A 25 year-old-male sustains a closed injury shown in Figure A. If a tibial intramedullary nail is placed with the starting points shown (arrows), what subsequent alignment will occur?
Correct Answer & Explanation
. Neutral
Explanation
In proximal third tibial shaft fractures, due to the deforming forces of the pes anserine and the extensor mechanism, utilizing standard starting points during intramedullary nailing (IMN) will result in a valgus and apex anterior deformity.There are several tips and tricks to avoid subsequent deformity following tibial IMN of a proximal third fracture. One way to avoid deformity is to use a more lateral starting point than normal to ensure nail placement in the true center of the canal, which is more lateral when compared to the tibial plateau.Walker et al. studied 12 cadaveric tibias and inserted a Kirschner wire depending on rotated views of the knee. In order obtain a perfect starting point, a perfect anteroposterior as well as lateral of the knee must be obtained; otherwise, the authors noted that malrotation is bound to occur. With a perfect view, a more lateral starting point correlated with the center of the tibial canal.McConnell et al. studied cadaveric and subsequent radiographic correlation on a lateral knee x-ray to determine the ideal 'safe zone' for the starting point of a tibial nail. This safe zone is more lateral and posterior, when looking at the axial cut of the plateau.Figure A exhibits a proximal third tibia fracture with starting points that are not lateral enough, and too distal (on the lateral view), which will result in apex anterior and valgus deformity.Incorrect answers:
Question 4348
Topic: 2. Trauma
A 45-year-old male is brought to the trauma bay in hemorrhagic shock following a motorcycle collision. Radiographs demonstrate an AP Compression Type III (APC-III) pelvic ring injury. A resident rapidly applies a pelvic binder and positions it firmly over the iliac crests. What is the most appropriate next step in management regarding the placement of this binder?
Correct Answer & Explanation
. Reposition the binder down to the level of the greater trochanters
Explanation
Pelvic binders provide the most effective mechanical advantage for reducing pelvic volume and controlling hemorrhage when centered over the greater trochanters. Placement over the iliac crests is less effective and can paradoxically widen the true pelvis, worsening hemorrhage in certain fracture patterns.
Question 4349
Topic: 2. Trauma
A 78-year-old low-demand female sustains a closed distal femur fracture after a mechanical fall. Radiographs demonstrate severe, non-reconstructible intra-articular comminution (AO/OTA 33-C3) with severe osteopenia. Which of the following is considered the strongest indication for distal femoral replacement (megaprosthesis) rather than open reduction and internal fixation in this setting?
Correct Answer & Explanation
. Open Gustilo Type II fracture
Explanation
Distal femoral replacement is indicated for highly comminuted, non-reconstructible intra-articular distal femur fractures in elderly, severely osteopenic, or low-demand patients where internal fixation is likely to fail. It allows for immediate weight-bearing and early mobilization, reducing complications associated with prolonged bed rest.
Question 4350
Topic: 2. Trauma
A 30-year-old construction worker falls from scaffolding and sustains an L1 burst fracture. Axial CT imaging shows a vertical split (greenstick) fracture of the lamina. The presence of this specific posterior element fracture pattern most strongly increases the likelihood of which of the following?
Correct Answer & Explanation
. Conus medullaris avulsion
Explanation
In the setting of a thoracolumbar burst fracture, a vertical split or greenstick fracture of the lamina is highly associated with a dural tear and subsequent entrapment of the neural elements (nerve roots of the cauda equina) within the fracture site. Surgeons must be cautious of dural tears when performing posterior decompression or stabilization in these patients.
Question 4351
Topic: 2. Trauma
A 42-year-old male sustains a severe Schatzker VI tibial plateau fracture. On examination, the leg is tense with extensive hemorrhagic fracture blisters over the proximal tibia. A spanning external fixator is immediately placed. What clinical sign indicates the optimal timing to proceed with definitive open reduction and internal fixation?
Correct Answer & Explanation
. Rupture and crusting of all fracture blisters
Explanation
Definitive internal fixation of severe, high-energy tibial plateau fractures must be delayed until the soft tissue envelope has adequately recovered to minimize the risk of devastating wound complications and infection. The classic 'wrinkle sign' indicates that swelling has subsided enough to safely allow surgical incisions and primary wound closure.
Question 4352
Topic: 2. Trauma
An 84-year-old female with severe osteoporosis and multiple medical comorbidities presents with an isolated, minimally displaced Anderson-D'Alonzo Type II odontoid fracture after a fall from a standing height. Given her frailty and high surgical risk, which of the following treatments is associated with the lowest treatment-related morbidity and mortality, despite a recognized high rate of nonunion?
Correct Answer & Explanation
. Halo vest immobilization
Explanation
In frail elderly patients, halo vest immobilization is poorly tolerated and associated with high complication rates, including respiratory failure and significant mortality. While surgical fusion (posterior C1-C2) provides definitive stability, the surgical risk is often prohibitive. Rigid cervical collar immobilization provides an acceptable risk-to-benefit profile; although the nonunion rate is high, a stable fibrous nonunion is a common, well-tolerated outcome in this population.
Question 4353
Topic: 2. Trauma
A 28-year-old male develops severe leg pain out of proportion to his injury following a closed tibia shaft fracture. A four-compartment lower extremity fasciotomy via a two-incision technique is planned. If the medial incision is made incorrectly and the fascial release is superficial, which compartment is most frequently missed or inadequately decompressed?
Correct Answer & Explanation
. Anterior compartment
Explanation
The deep posterior compartment is the most commonly missed or inadequately decompressed compartment during leg fasciotomies. Access requires releasing the soleus bridge from the posteromedial aspect of the tibia to expose and incise the deep posterior fascia.
Question 4354
Topic: 2. Trauma
A 35-year-old male sustains a closed, isolated midshaft humerus fracture (Holstein-Lewis type). Upon presentation in the emergency department, he exhibits a complete inability to extend his wrist and fingers, alongside dorsal first web space numbness. Which of the following is the most appropriate initial management?
Correct Answer & Explanation
. Immediate surgical exploration of the radial nerve and open reduction internal fixation
Explanation
A primary radial nerve palsy in the setting of a closed humerus shaft fracture is overwhelmingly a neurapraxia that resolves spontaneously in 70-90% of cases. The standard of care is conservative management with observation and functional bracing. Immediate surgical exploration is generally reserved for open fractures, associated vascular injuries, or secondary nerve palsies that develop after closed reduction.
Question 4355
Topic: Pelvic & Acetabular Trauma
Proper placement of a pelvic binder for a hemodynamically unstable patient with an anteroposterior compression (APC) type pelvic ring injury is centered at the level of the:
Correct Answer & Explanation
. Anterior superior iliac spines
Explanation
For effective reduction and stabilization of the pelvic ring, a pelvic binder or sheet should be centered directly over the greater trochanters. Placement over the iliac crests or ASIS can paradoxically open the pelvic ring further in certain fracture patterns and provides less effective mechanical advantage.
Question 4356
Topic: 2. Trauma
A 28-year-old male sustains a displaced, intracapsular femoral neck fracture. He is scheduled for urgent closed reduction and internal fixation. According to the literature, which of the following factors is most strongly associated with the subsequent development of avascular necrosis (AVN) of the femoral head in this patient?
Correct Answer & Explanation
. Time from injury to surgery being greater than 24 hours
Explanation
The most significant predictive factor for the development of avascular necrosis (AVN) following a femoral neck fracture in a young adult is the initial degree of fracture displacement, which dictates the extent of injury to the medial femoral circumflex artery. While time to surgery and capsulotomy are heavily debated, the initial displacement remains the strongest independent risk factor.
Question 4357
Topic: 2. Trauma
A 22-year-old female is involved in a high-speed motor vehicle collision while wearing a lap belt. She sustains a flexion-distraction (Chance) injury of L2. What associated concomitant injury must be most carefully evaluated and ruled out?
Correct Answer & Explanation
. Aortic transection
Explanation
Chance fractures (flexion-distraction injuries) are frequently caused by lap seatbelts during rapid deceleration. They have a high association with intra-abdominal visceral injuries, specifically hollow viscus injuries (e.g., bowel perforation), which occur in up to 40-50% of cases and require careful general surgical evaluation.
Question 4358
Topic: 2. Trauma
The Sanders classification for intra-articular calcaneal fractures is based on the number and location of primary fracture lines seen on which of the following radiographic imaging views?
Correct Answer & Explanation
. Coronal CT reconstruction
Explanation
The Sanders classification system is based on coronal CT images. Specifically, it assesses the number of fracture lines through the posterior facet of the calcaneus at its widest point. Type I is non-displaced, Type II has one fracture line (two fragments), Type III has two lines (three fragments), and Type IV is highly comminuted (four or more fragments).
Question 4359
Topic: 2. Trauma
A 32-year-old male presents with a severely comminuted midshaft tibia fracture. Clinical concern for acute compartment syndrome arises due to pain out of proportion to the injury. Which of the following intracompartmental pressure measurements represents the most widely accepted threshold indicating the need for immediate fasciotomy?
Correct Answer & Explanation
. Delta pressure (diastolic blood pressure minus compartment pressure) less than 30 mm Hg
Explanation
The most reliable indicator for diagnosing acute compartment syndrome in an objective manner is the delta pressure (ΔP), defined as the diastolic blood pressure minus the absolute compartment pressure. A delta pressure of less than 30 mm Hg is the widely accepted threshold for surgical decompression (fasciotomy) because it accounts for individual variations in perfusion pressure.
Question 4360
Topic: 2. Trauma
A 24-year-old male sustains a closed, distal-third spiral fracture of the humeral shaft (Holstein-Lewis fracture) following an arm-wrestling match. On physical examination, he is unable to extend his wrist or fingers. What is the most appropriate initial management of this patient?
Correct Answer & Explanation
. Immediate open reduction and internal fixation with radial nerve exploration
Explanation
A primary radial nerve palsy in the setting of a closed humeral shaft fracture (including Holstein-Lewis patterns) is typically a neuropraxia. The standard of care is non-operative management initially, using a coaptation splint or functional brace, with clinical observation. Spontaneous recovery occurs in over 70-90% of cases. Immediate exploration is generally reserved for open fractures, penetrating trauma, or palsies that develop after closed reduction.
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