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2. Trauma MCQs

Practice Set 230 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 4581

Topic: 2. Trauma

A 65-year-old female sustains a comminuted fracture of the olecranon extending distal to the coronoid process. What is the most appropriate fixation construct?

. Tension band wiring
. Intramedullary screw fixation
. Fragment excision and triceps advancement
. Posterior plating
. Anterior plating

Correct Answer & Explanation

. Tension band wiring

Explanation

Tension band wiring relies on an intact anterior cortex to convert tensile forces into compressive forces; therefore, it is contraindicated in comminuted fractures or those exiting distal to the center of rotation (coronoid level) due to the risk of shortening and joint subluxation. Posterior plate osteosynthesis is the standard of care for comminuted olecranon fractures.

Question 4582

Topic: 2. Trauma

A patient develops severe heterotopic ossification (HO) following a distal humerus fracture, resulting in profound elbow stiffness. What is the most appropriate timing for surgical excision of the HO?

. Immediately upon detection to prevent further progression
. After 4 to 6 months when the bone appears radiographically mature with well-defined trabecular markings
. Only after alkaline phosphatase levels normalize completely
. After 2 years to ensure zero recurrence risk
. Concurrent with manipulation under anesthesia 4 weeks post-injury

Correct Answer & Explanation

. Immediately upon detection to prevent further progression

Explanation

Historically, surgical excision of HO was delayed until bone scans cooled or alkaline phosphatase normalized (12-18 months). Modern evidence indicates that excision is safe and effective when the HO appears radiographically mature (distinct cortical margins and trabecular patterns), typically at 4 to 6 months. Waiting too long increases the risk of irreversible joint contracture.

Question 4583

Topic: 2. Trauma

A 35-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). He presents with an isolated radial nerve palsy noted immediately after the injury. What is the most appropriate initial management?

. Immediate open reduction internal fixation and nerve exploration
. Functional bracing and observation
. External fixation
. Intramedullary nailing
. Immediate primary nerve grafting

Correct Answer & Explanation

. Immediate open reduction internal fixation and nerve exploration

Explanation

A primary radial nerve palsy in the setting of a closed humeral shaft fracture (including Holstein-Lewis patterns) is not an absolute indication for immediate surgical exploration. Up to 90% of these palsies represent neuropraxia or axonotmesis and will recover spontaneously. Functional bracing and close observation (often followed by EMG at 3-4 weeks if no recovery) is the initial standard of care.

Question 4584

Topic: 2. Trauma
A 'floating shoulder' is typically defined as a double disruption of the superior shoulder suspensory complex (SSSC). Which of the following injury combinations classically constitutes a floating shoulder?
. Ipsilateral clavicle and proximal humerus fractures
. Ipsilateral clavicle and scapular neck fractures
. Ipsilateral scapular neck and glenoid fractures
. Ipsilateral acromion and coracoid fractures
. Ipsilateral sternoclavicular and acromioclavicular dislocations

Correct Answer & Explanation

. Ipsilateral clavicle and scapular neck fractures

Explanation

A floating shoulder results from simultaneous fractures of the clavicle and the scapular neck, creating a mechanically unstable segment connecting the upper extremity to the axial skeleton. It often requires operative fixation of at least the clavicle to restore stability to the SSSC.

Question 4585

Topic: 2. Trauma

When treating an intra-articular distal humerus fracture, an olecranon osteotomy approach provides excellent visualization of the articular surface. Which of the following osteotomies is preferred to facilitate subsequent reduction and promote reliable bone healing?

. Transverse osteotomy of the proximal ulna
. Chevron osteotomy with the apex pointing distal
. Chevron osteotomy with the apex pointing proximal
. Oblique osteotomy from medial to lateral
. Coronal osteotomy of the olecranon tip

Correct Answer & Explanation

. Transverse osteotomy of the proximal ulna

Explanation

A chevron osteotomy with the apex pointing distal provides a highly stable, self-centering construct when repaired (usually with tension band wiring or plating). This geometry dramatically increases the contact surface area and rotational stability, minimizing the risk of nonunion compared to a simple transverse osteotomy.

Question 4586

Topic: 2. Trauma

A 78-year-old female with severe rheumatoid arthritis sustains a comminuted intra-articular distal humerus fracture. She is managed with a Total Elbow Arthroplasty (TEA). Which implant design is most appropriate for this patient?

. Unlinked
. Linked (semi-constrained)
. Resurfacing
. Radial head replacement only
. Hemiarthroplasty

Correct Answer & Explanation

. Unlinked

Explanation

Linked (semi-constrained) TEA is indicated for trauma and for patients with inflammatory arthritis where the collateral ligaments are compromised or absent. Unlinked designs require intact collateral ligaments to provide joint stability.

Question 4587

Topic: 2. Trauma

Which of the following factors is most strongly predictive of nonunion in nonoperatively managed midshaft clavicle fractures?

. Age > 40
. Male gender
. Fracture displacement with > 2 cm shortening
. Associated rib fractures
. Proximal third location

Correct Answer & Explanation

. Fracture displacement with > 2 cm shortening

Explanation

Fracture shortening greater than 2 cm and 100% displacement are the strongest predictors of nonunion in midshaft clavicle fractures treated nonoperatively. These morphological factors often warrant primary surgical fixation to optimize outcomes.

Question 4588

Topic: 2. Trauma

After open reduction and internal fixation of a proximal humerus fracture using a fixed-angle locking plate, what is the most common cause of late intra-articular screw penetration?

. Humeral head settling and varus collapse
. Incorrect initial screw length selection
. Primary osteonecrosis of the humeral head
. Hardware failure or plate breakage
. Nonunion of the surgical neck

Correct Answer & Explanation

. Humeral head settling and varus collapse

Explanation

The most common cause of late intra-articular screw penetration is secondary settling or varus collapse of the osteoporotic humeral head over the fixed locking screws. It is rarely due to initially placing screws that are too long.

Question 4589

Topic: 2. Trauma

Which of the following is considered an absolute indication for operative fixation of a scapular fracture?

. Medial/lateral displacement of 10 mm of the scapular body
. Angular deformity of 15 degrees in the sagittal plane
. Associated non-displaced midshaft clavicle fracture
. Intrathoracic penetration of a scapular spike
. Ipsilateral rib fractures without flail chest

Correct Answer & Explanation

. Intrathoracic penetration of a scapular spike

Explanation

Most scapular body fractures are treated nonoperatively and heal well. However, absolute indications for surgery include intrathoracic penetration of a bone spike, open fractures, and severe glenohumeral instability due to massive glenoid involvement.

Question 4590

Topic: 2. Trauma

A 6-year-old child sustains a Bado Type I Monteggia fracture equivalent. Closed reduction normalizes the ulnar alignment, but the radial head remains anteriorly dislocated. What is the most likely interposing structure preventing reduction?

. Biceps tendon
. Median nerve
. Annular ligament
. Brachioradialis muscle
. Anterior joint capsule

Correct Answer & Explanation

. Annular ligament

Explanation

In pediatric Monteggia fractures where the radial head fails to reduce despite anatomic restoration of the ulnar bow, the annular ligament is the most common interposed structure. Open reduction is required to extract the ligament and allow the radial head to seat properly.

Question 4591

Topic: 2. Trauma

During tension band wiring of a transverse olecranon fracture, what is the biomechanical principle achieved by the figure-of-eight wire?

. It converts tensile forces at the dorsal cortex into compressive forces at the articular surface during flexion
. It converts compressive forces at the articular surface into tensile forces
. It acts purely as a static block to fragment migration
. It neutralizes rotational forces across the joint line during pronation
. It provides static direct compression along the longitudinal axis of the ulna independently of joint motion

Correct Answer & Explanation

. It converts tensile forces at the dorsal cortex into compressive forces at the articular surface during flexion

Explanation

The tension band principle relies on converting the tensile forces generated by the triceps pull on the dorsal cortex into dynamic compressive forces across the articular surface. This dynamic compression occurs during active elbow flexion.

Question 4592

Topic: 2. Trauma

A 25-year-old male sustains a closed transverse fracture of the middle third of the humeral shaft resulting from a high-energy fall. He presents with a complete radial nerve palsy. What is the most appropriate initial management?

. Immediate surgical exploration of the radial nerve and ORIF
. Coaptation splinting and observation of the nerve palsy
. External fixation and early nerve grafting
. Open reduction and internal fixation without nerve exploration
. Immediate baseline EMG/NCS

Correct Answer & Explanation

. Coaptation splinting and observation of the nerve palsy

Explanation

Primary radial nerve palsy associated with closed humeral shaft fractures is typically a neuropraxia. The standard of care is nonoperative fracture management (e.g., functional bracing or coaptation splint) and observation, as the vast majority recover spontaneously.

Question 4593

Topic: Upper Extremity Trauma

In the Rockwood classification of acromioclavicular (AC) joint injuries, what defines a Type V injury?

. Disruption of the AC ligaments with intact coracoclavicular (CC) ligaments
. Disruption of AC and CC ligaments with 100% to 300% superior displacement of the clavicle
. Posterior displacement of the clavicle into the trapezius muscle
. Inferior displacement of the clavicle under the coracoid process
. Disruption of AC and CC ligaments with less than 25% displacement

Correct Answer & Explanation

. Disruption of AC and CC ligaments with 100% to 300% superior displacement of the clavicle

Explanation

A Rockwood Type V injury involves complete disruption of both the AC and CC ligaments along with the deltotrapezial fascia. This extensive soft tissue failure leads to severe superior displacement (100% to 300%) of the distal clavicle relative to the acromion.

Question 4594

Topic: 2. Trauma

A 72-year-old female sustains a minimally displaced 3-part proximal humerus fracture involving the greater tuberosity. She elects for non-operative management. What is the most common complication she should be counseled about?

. Avascular necrosis of the humeral head
. Adhesive capsulitis and shoulder stiffness
. Nonunion of the surgical neck
. Axillary nerve palsy
. Malunion of the lesser tuberosity

Correct Answer & Explanation

. Avascular necrosis of the humeral head

Explanation

The most common complication following non-operative management of proximal humerus fractures is significant shoulder stiffness (adhesive capsulitis). Early, supervised passive range of motion is critical to mitigate this debilitating risk.

Question 4595

Topic: 2. Trauma

A 68-year-old osteoporotic female undergoes open reduction and internal fixation of a 3-part proximal humerus fracture using a locked plate construct. Postoperative follow-up at 6 weeks reveals varus collapse of the humeral head and superior screw cut-out into the glenohumeral joint. To minimize the risk of this specific complication, which of the following surgical maneuvers is most critical during the index procedure?

. Placement of medial calcar screws into the inferomedial quadrant of the humeral head
. Utilization of polyaxial screws exclusively throughout the construct
. Ensuring the plate is placed at least 3 cm distal to the tip of the greater tuberosity
. Over-drilling the near cortex for all humeral head screws
. Placement of the plate exactly 5 mm posterior to the bicipital groove

Correct Answer & Explanation

. Placement of medial calcar screws into the inferomedial quadrant of the humeral head

Explanation

Varus collapse is a common mode of failure in proximal humerus fracture fixation. The placement of medial calcar screws (screws directed into the inferomedial quadrant of the humeral head) provides crucial mechanical support to the medial column, significantly reducing the risk of varus displacement and subsequent secondary screw cut-out into the joint.

Question 4596

Topic: 2. Trauma

A 25-year-old male sustains a midshaft clavicle fracture from a bicycle crash. He prefers non-operative management. Which of the following radiographic fracture characteristics is most strongly associated with a higher risk of nonunion if treated non-operatively?

. Oblique fracture pattern
. 10 mm of initial shortening
. Presence of a butterfly fragment
. 100% displacement with no cortical contact
. Distal third diaphyseal location

Correct Answer & Explanation

. Oblique fracture pattern

Explanation

Risk factors for nonunion of midshaft clavicle fractures treated non-operatively include 100% displacement (lack of cortical contact), shortening greater than 2 cm (20 mm), advanced age, female sex, and comminution. Complete displacement with no cortical contact is a strong independent predictor of nonunion.

Question 4597

Topic: 2. Trauma

A 40-year-old male is involved in a high-speed motor vehicle collision and sustains multiple injuries, including an isolated fracture of the scapula. Which of the following isolated fracture patterns is an absolute indication for open reduction and internal fixation?

. Scapular body fracture with 15 mm of medial translation
. Extra-articular glenoid neck fracture with 20 degrees of angulation
. Intra-articular anterior glenoid rim fracture involving 30% of the articular surface
. Coracoid process fracture with 5 mm of displacement
. Scapular spine fracture with 5 mm of displacement

Correct Answer & Explanation

. Scapular body fracture with 15 mm of medial translation

Explanation

Indications for operative fixation of the scapula include intra-articular glenoid fractures with >4-5 mm of step-off or involving >20-25% of the anterior/posterior articular rim (which causes glenohumeral instability). Other relative indications include glenoid neck fractures with >40 degrees angulation or >1 cm translation, or a significantly decreased glenopolar angle (< 22 degrees).

Question 4598

Topic: 2. Trauma

An 82-year-old low-demand nursing home resident sustains an isolated, displaced, transverse olecranon fracture after a ground-level fall. Due to severe medical comorbidities, non-operative management with early mobilization is chosen. Based on current literature, what is the most likely functional outcome and complication profile for this patient?

. High rate of symptomatic nonunion requiring delayed complex reconstruction
. Good functional range of motion and high satisfaction despite a high rate of radiographic nonunion
. Severe elbow stiffness with an arc of motion less than 60 degrees
. Progressive rapidly destructive ulnohumeral arthritis leading to severe pain
. High risk of early delayed-onset ulnar neuropathy

Correct Answer & Explanation

. High rate of symptomatic nonunion requiring delayed complex reconstruction

Explanation

Studies evaluating the non-operative treatment of displaced olecranon fractures in elderly, low-demand patients (e.g., Duckworth et al.) have consistently shown that while the radiographic nonunion rate is very high (often >70%), clinical outcomes are excellent. Patients typically achieve a functional range of motion, experience minimal pain, and report high satisfaction without the risks associated with surgery in frail patients.

Question 4599

Topic: 2. Trauma

A 35-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture) following an arm-wrestling match. On initial examination in the emergency department, he exhibits an inability to extend his wrist and fingers, with loss of sensation over the dorsal first web space. What is the most appropriate initial management?

. Immediate surgical exploration of the radial nerve and ORIF of the fracture
. Closed reduction and application of a coaptation splint or functional brace
. Immediate electromyography (EMG) to establish a baseline
. Application of a hanging arm cast to optimize gravity traction
. Placement of a spanning external fixator

Correct Answer & Explanation

. Immediate surgical exploration of the radial nerve and ORIF of the fracture

Explanation

A primary radial nerve palsy associated with a closed humeral shaft fracture, even a Holstein-Lewis type (distal third spiral fracture), is initially managed conservatively (non-operatively) with a coaptation splint or functional brace. The vast majority of these injuries are neuropraxias that will spontaneously recover. Indications for immediate exploration include open fractures, penetrating trauma, or a secondary nerve palsy that develops after a closed reduction attempt.

Question 4600

Topic: Upper Extremity Trauma
A 28-year-old male cyclist falls directly onto his right shoulder. Clinical examination and radiographs confirm a Type III acromioclavicular (AC) joint dislocation. He is counseled on operative versus non-operative treatment. According to the current orthopedic literature, what is the expected outcome if he chooses non-operative management compared to surgical reconstruction?
. Higher rate of returning to his pre-injury level of sport
. Lower risk of chronic cosmetic deformity
. No significant difference in long-term shoulder functional outcome scores
. Significantly decreased shoulder strength in internal rotation
. Higher rate of delayed neurologic deficit

Correct Answer & Explanation

. No significant difference in long-term shoulder functional outcome scores

Explanation

For Type III AC joint dislocations, the literature generally demonstrates no significant difference in long-term functional outcome scores (e.g., DASH, Constant scores) between operative and non-operative management. Non-operative management avoids surgical complications and allows an earlier return to work and sports, though it is associated with a higher likelihood of persistent cosmetic deformity. Internal rotation strength is generally not significantly affected.

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