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2. Trauma MCQs

Practice Set 229 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 4561

Topic: 2. Trauma

A 30-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft. Initial examination reveals an intact neurologic profile. Following a closed reduction and application of a coaptation splint, the patient demonstrates an inability to extend his wrist and fingers. What is the most appropriate next step in management?

. Reassure the patient and observe for 3 months
. Obtain an EMG/NCS immediately
. Immediate surgical exploration and nerve decompression
. Perform a targeted steroid injection into the radial tunnel
. Loosen the splint and re-evaluate in 48 hours

Correct Answer & Explanation

. Immediate surgical exploration and nerve decompression

Explanation

While primary radial nerve palsy in a Holstein-Lewis fracture is typically observed, a secondary radial nerve palsy that develops AFTER a closed reduction attempt indicates possible entrapment of the nerve in the fracture site. Immediate surgical exploration is indicated.

Question 4562

Topic: 2. Trauma

A 25-year-old male sustains a severe crush injury to the forearm. Several hours later, he develops excruciating pain out of proportion to the injury. Which of the following clinical findings is generally considered the most reliable early indicator of evolving forearm compartment syndrome?

. Absence of a palpable radial pulse
. Pain with passive extension of the fingers
. Decreased capillary refill time
. Pallor of the hand and digits
. Complete paralysis of the intrinsic hand muscles

Correct Answer & Explanation

. Pain with passive extension of the fingers

Explanation

Pain with passive stretch of the muscles in the involved compartment (e.g., passive finger extension for the deep volar forearm compartment) is the most reliable and earliest clinical sign of compartment syndrome. Pulselessness and pallor are very late and unreliable signs.

Question 4563

Topic: 2. Trauma

According to current literature, which of the following is a widely accepted absolute indication for Open Reduction and Internal Fixation (ORIF) of a scapular fracture?

. Scapular body fracture with 5 mm of translation
. Glenohumeral joint instability due to an anterior glenoid rim fracture involving 30% of the articular surface
. Glenoid neck fracture with 10 degrees of angular deformity
. Coracoid process fracture with 5 mm displacement
. Non-displaced acromion fracture

Correct Answer & Explanation

. Glenohumeral joint instability due to an anterior glenoid rim fracture involving 30% of the articular surface

Explanation

Intra-articular glenoid fractures resulting in glenohumeral instability or those involving greater than 25% of the articular surface with displacement are absolute indications for ORIF. Most body and neck fractures are managed non-operatively unless highly displaced or angulated.

Question 4564

Topic: 2. Trauma

A 35-year-old cyclist sustains a midshaft clavicle fracture. Which of the following radiographic parameters is most strongly associated with an increased risk of symptomatic nonunion if treated nonoperatively?

. Comminution with fracture shortening greater than 2 cm
. Superior displacement of 5 mm without shortening
. Inferior displacement of the medial fragment
. Presence of a butterfly fragment with 1 cm of shortening
. Angulation of 10 degrees

Correct Answer & Explanation

. Comminution with fracture shortening greater than 2 cm

Explanation

Significant fracture shortening (greater than 2 cm) and comminution are the strongest predictive risk factors for nonunion and poor functional outcomes in midshaft clavicle fractures managed conservatively.

Question 4565

Topic: 2. Trauma

A 45-year-old male presents with a closed, isolated scapula fracture following a high-energy fall. Which of the following radiographic parameters is a widely accepted indication for operative fixation?

. Medialization of the glenoid by 15 mm
. Glenopolar angle of 45 degrees
. Angulation of the scapular body of 25 degrees
. Glenopolar angle of 20 degrees
. Intra-articular step-off of 2 mm

Correct Answer & Explanation

. Glenopolar angle of 20 degrees

Explanation

A glenopolar angle (GPA) of less than 22 degrees is a recognized indication for open reduction and internal fixation of scapular neck fractures. Medialization greater than 20 mm, angulation greater than 45 degrees, and intra-articular step-off greater than 4 mm are also typical operative indications.

Question 4566

Topic: 2. Trauma

A 6-year-old boy presents with an anterior dislocation of the radial head and a fracture of the ulnar diaphysis. What is the most commonly injured nerve associated with this specific injury pattern?

. Anterior interosseous nerve
. Posterior interosseous nerve
. Ulnar nerve
. Superficial radial nerve
. Median nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

This patient has a Bado Type I Monteggia fracture-dislocation. The posterior interosseous nerve (PIN) is the most commonly injured nerve in this fracture pattern due to traction or direct trauma from the anteriorly displaced radial head.

Question 4567

Topic: Upper Extremity Trauma

Recent quantitative perfusion studies have redefined the vascularity of the proximal humerus. According to these studies, which artery provides the predominant blood supply to the humeral head?

. Anterior humeral circumflex artery
. Posterior humeral circumflex artery
. Thoracoacromial artery
. Profunda brachii artery
. Suprascapular artery

Correct Answer & Explanation

. Posterior humeral circumflex artery

Explanation

Historically, the anterior humeral circumflex artery (via the arcuate artery) was thought to provide the main blood supply to the humeral head. However, recent studies (e.g., Hettrich et al.) demonstrate that the posterior humeral circumflex artery supplies approximately 64% of the humeral head.

Question 4568

Topic: 2. Trauma

A 28-year-old cyclist sustains a closed midshaft clavicle fracture. If managed nonoperatively, which of the following fracture characteristics is most strongly associated with an increased risk of nonunion?

. Age less than 30 years
. Fracture shortening greater than 2 cm
. Medial third location
. Male sex
. Presence of a single, small inferior butterfly fragment

Correct Answer & Explanation

. Fracture shortening greater than 2 cm

Explanation

Fracture shortening greater than 2 cm is a well-established risk factor for nonunion and symptomatic malunion in completely displaced midshaft clavicle fractures. Other risk factors include advancing age, comminution, and female sex.

Question 4569

Topic: 2. Trauma

When utilizing an olecranon osteotomy for open reduction and internal fixation of a multi-fragmentary distal humerus fracture (AO/OTA 13C3), which osteotomy type is biomechanically superior for minimizing nonunion?

. Transverse osteotomy at the bare area
. Chevron osteotomy with the apex pointing distally
. Chevron osteotomy with the apex pointing proximally
. Step-cut osteotomy
. Oblique osteotomy from dorsal-proximal to volar-distal

Correct Answer & Explanation

. Chevron osteotomy with the apex pointing proximally

Explanation

A distally pointing chevron osteotomy created at the bare area of the sigmoid notch provides maximum articular surface contact area and superior rotational stability compared to a transverse osteotomy, thereby minimizing the risk of nonunion.

Question 4570

Topic: 2. Trauma

A 19-year-old male presents to the trauma bay with a posterior sternoclavicular joint dislocation following a rugby tackle. He has mild dysphagia but stable vitals. What is the most appropriate initial management?

. Immediate open reduction in the emergency department
. Closed reduction in the emergency department with procedural sedation
. Closed reduction in the operating room with a cardiothoracic surgeon available
. Sling immobilization and delayed reconstruction
. CT angiogram followed by conservative management

Correct Answer & Explanation

. Closed reduction in the operating room with a cardiothoracic surgeon available

Explanation

Posterior sternoclavicular dislocations can compress critical mediastinal structures. Closed reduction should be attempted but must be performed in the operating room under general anesthesia with a cardiothoracic surgeon available due to the risk of catastrophic retrosternal vascular injury during reduction.

Question 4571

Topic: 2. Trauma

In the evaluation of a proximal humerus fracture, which of the following radiographic findings is the most reliable predictor of subsequent avascular necrosis of the humeral head?

. Greater tuberosity displacement >1 cm
. Disruption of the medial hinge >2 mm
. Diaphyseal extension of the fracture
. Shortening of the anatomic neck <5 mm
. Posteromedial impaction of the head

Correct Answer & Explanation

. Disruption of the medial hinge >2 mm

Explanation

Hertel et al. identified key predictors of ischemia in proximal humerus fractures. The most significant predictors include disruption of the medial hinge >2 mm, an anatomic neck fracture (rather than surgical neck), and a short calcar length (<8 mm). Medial hinge disruption indicates tearing of the medial periosteal vessels (branches of the anterior circumflex humeral artery and posterior circumflex humeral artery).

Question 4572

Topic: 2. Trauma

A 78-year-old female with severe rheumatoid arthritis sustains a comminuted intra-articular distal humerus fracture (OTA type 13-C3). Which of the following is an established advantage of performing a total elbow arthroplasty (TEA) compared to open reduction and internal fixation (ORIF) in this specific patient population?

. Lower lifetime risk of revision surgery
. Allows for immediate weight-bearing through the upper extremity
. More predictable postoperative range of motion and functional recovery
. Elimination of the permanent 5-lb lifting restriction
. Decreased risk of postoperative ulnar neuropathy

Correct Answer & Explanation

. More predictable postoperative range of motion and functional recovery

Explanation

In elderly patients, particularly those with poor bone quality or pre-existing joint disease like rheumatoid arthritis, TEA provides a more predictable and often superior return of functional range of motion and reliable pain relief compared to ORIF for complex, comminuted distal humerus fractures. However, TEA does carry a permanent lifting restriction (typically 5-10 lbs) and a higher lifetime risk of implant failure or loosening requiring revision.

Question 4573

Topic: 2. Trauma

A 25-year-old competitive cyclist sustains a Type IIB distal clavicle fracture (Neer classification). Which of the following best describes the pathomechanics and optimal treatment of this injury?

. The coracoclavicular ligaments remain attached to the proximal fragment; nonoperative treatment is preferred.
. The coracoclavicular ligaments are detached from the proximal fragment; operative fixation is generally recommended due to high nonunion rates.
. The fracture involves the articular surface of the AC joint; distal clavicle excision is the primary treatment.
. The conoid ligament is intact while the trapezoid is torn; sling immobilization for 6 weeks is the standard of care.
. The coracoacromial ligament is avulsed; reconstruction with a semitendinosus allograft is indicated.

Correct Answer & Explanation

. The coracoclavicular ligaments are detached from the proximal fragment; operative fixation is generally recommended due to high nonunion rates.

Explanation

Neer Type II distal clavicle fractures occur medial to the AC joint ligaments. In Type IIA, the conoid and trapezoid remain attached to the distal fragment. In Type IIB, the conoid is torn while the trapezoid remains attached to the distal fragment, or both are detached from the proximal fragment, leading to superior displacement of the medial fragment by the trapezius. Because of the high nonunion rate (>30%) with nonoperative management, operative fixation is frequently recommended in active individuals.

Question 4574

Topic: 2. Trauma

A 32-year-old male sustains a closed, spiral fracture of the distal third of the humerus (Holstein-Lewis fracture). On examination in the emergency department, he is noted to have a dense radial nerve palsy. What is the most appropriate initial management?

. Immediate open reduction and internal fixation with nerve exploration
. Closed reduction and functional bracing with clinical observation of the nerve
. Immediate EMG/NCS to determine the extent of nerve injury
. Application of a hanging arm cast and immediate nerve grafting
. External fixation and primary nerve repair

Correct Answer & Explanation

. Closed reduction and functional bracing with clinical observation of the nerve

Explanation

The presence of a radial nerve palsy with a closed humeral shaft fracture (including Holstein-Lewis types) is not an absolute indication for immediate surgical exploration. Most of these represent neuropraxia or axonotmesis and will recover spontaneously (over 70-80% recovery rate). The initial management is closed reduction, application of a coaptation splint or functional brace, and clinical observation. If there is no clinical or EMG evidence of recovery by 3-4 months, or if the palsy occursafterclosed reduction, exploration is indicated.

Question 4575

Topic: 2. Trauma
In the management of extra-articular scapular body and neck fractures, which of the following is generally accepted as an absolute indication for open reduction and internal fixation (ORIF)?
. Medial/lateral displacement of 10 mm
. Glenopolar angle (GPA) of 35 degrees
. Medialization of the glenoid fragment by 25 mm
. Angulation of the scapular body of 20 degrees
. Presence of an ipsilateral clavicle fracture (floating shoulder) with 5 mm displacement

Correct Answer & Explanation

. Medialization of the glenoid fragment by 25 mm

Explanation

While most scapular body and neck fractures are treated nonoperatively, indications for ORIF of the scapular neck include severe displacement. Generally accepted indications for surgery include: medial/lateral displacement > 20 mm, angulation > 45 degrees, glenopolar angle (GPA) < 22 degrees, or a double disruption of the superior shoulder suspensory complex (SSSC) with significant displacement (>10 mm). Option 2 (medialization by 25 mm) exceeds the surgical threshold of 20 mm. Option 4 (floating shoulder) is not an absolute indication unless severely displaced.

Question 4576

Topic: 2. Trauma

A 35-year-old female falls on an outstretched hand and sustains a shear fracture of the capitellum that includes a large portion of the trochlea (McKee modification of Bryan and Morrey Type 4). Which of the following surgical approaches provides the most optimal exposure for fixation of this specific fracture pattern?

. Posterior approach with olecranon osteotomy
. Kocher (lateral) approach
. Extended lateral approach (extensile lateral)
. Medial approach over the medial epicondyle
. Anterior Henry approach

Correct Answer & Explanation

. Extended lateral approach (extensile lateral)

Explanation

A Type 4 capitellum fracture (McKee) is a coronal shear fracture involving the capitellum and extending medially to include most or all of the trochlea. The standard Kocher lateral approach often does not provide adequate exposure for the medial (trochlear) extent of the fracture. An extended lateral approach (e.g., Kaplan or an extensile lateral approach elevating the common extensor origin and anterior capsule) is required to visualize and fix the articular surface adequately. A posterior approach with olecranon osteotomy is typically reserved for complex, comminuted bi-columnar distal humerus fractures, not isolated coronal shear fractures.

Question 4577

Topic: 2. Trauma

When performing open reduction and internal fixation (ORIF) of a valgus-impacted 4-part proximal humerus fracture, which structural element is critical to maintain or repair to prevent postoperative varus collapse?

. The lateral periosteal sleeve
. The medial calcar hinge
. The greater tuberosity attachment
. The long head of the biceps tendon
. The coracoacromial ligament

Correct Answer & Explanation

. The medial calcar hinge

Explanation

In proximal humerus fractures, particularly those treated with ORIF using a locking plate, restoration and support of the medial calcar (the medial hinge) is the most critical factor in preventing postoperative varus collapse and screw cut-out. If the medial cortex is comminuted and lacks structural support, adjuncts such as an intramedullary fibular strut allograft or inferior calcar screws (kickstand screws) must be used to provide medial support and prevent failure.

Question 4578

Topic: 2. Trauma



Which of the following radiographic findings in a proximal humerus fracture is the strongest predictor for the development of avascular necrosis (AVN) of the humeral head according to the Hertel criteria?

. Greater tuberosity displacement > 5 mm
. Metaphyseal head extension (calcar length) < 8 mm
. Medial hinge displacement of 1 mm
. Shaft displacement > 50%
. Angulation of the head > 20 degrees

Correct Answer & Explanation

. Metaphyseal head extension (calcar length) < 8 mm

Explanation

Hertel et al. identified key predictors for humeral head ischemia. The most reliable predictors are a short metaphyseal head extension (calcar length) of < 8 mm, disruption of the medial hinge (> 2 mm), and an anatomic neck fracture pattern. These findings indicate severe disruption of the critical intraosseous and ascending branch of the anterior humeral circumflex artery blood supply.

Question 4579

Topic: 2. Trauma

A 25-year-old cyclist sustains a midshaft clavicle fracture. Which of the following is considered an absolute indication for operative fixation?

. 1.5 cm of shortening
. 100% displacement without skin tenting
. Open fracture
. Comminution with a butterfly fragment
. Concomitant non-displaced scapular body fracture

Correct Answer & Explanation

. Open fracture

Explanation

Absolute indications for open reduction and internal fixation (ORIF) of a clavicle fracture include open fractures, impending skin compromise (severe tenting causing ischemia), neurovascular compromise, and symptomatic nonunion. Relative indications include shortening > 2 cm, severe displacement, and a 'floating shoulder'.

Question 4580

Topic: 2. Trauma
Operative management of a scapular body and neck fracture is typically indicated if the glenoid medialization exceeds which of the following thresholds?
. 5 mm
. 10 mm
. 15 mm
. 20 mm
. 30 mm

Correct Answer & Explanation

. 20 mm

Explanation

Surgical indications for extra-articular scapular neck/body fractures include glenoid medialization greater than 20 mm, angular deformity greater than 40 degrees, or a double disruption of the superior shoulder suspensory complex (SSSC) with significant displacement.

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