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2. Trauma MCQs

Practice Set 231 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 4601

Topic: 2. Trauma

A 45-year-old polytrauma patient presents with an ipsilateral midshaft clavicle fracture and a displaced scapular neck fracture (floating shoulder). The surgeon considers operative fixation of the scapula rather than the clavicle alone. Which of the following radiographic findings is a primary indication for surgical fixation of the scapular fracture in this scenario?

. Medial displacement of the glenoid by 3 mm
. Disruption of the coracoacromial ligament
. A glenopolar angle of 18 degrees
. Associated minimally displaced rib fractures
. An acromiohumeral interval of 8 mm

Correct Answer & Explanation

. A glenopolar angle of 18 degrees

Explanation

A glenopolar angle (GPA) of less than 20 to 22 degrees indicates significant rotational malalignment of the glenoid and is associated with poor functional outcomes. In the setting of a floating shoulder, a decreased GPA is a primary indication for surgical fixation of the scapula, as fixing the clavicle alone may not adequately correct the glenoid version and tilt.

Question 4602

Topic: 2. Trauma

A 26-year-old male sustains an elbow dislocation that is reduced in the emergency department.

A subsequent CT scan reveals an isolated fracture of the anteromedial facet of the coronoid process. What specific mechanism of injury and associated ligamentous disruption is most characteristic of this particular fracture pattern?

. Valgus and hyperextension force; medial collateral ligament tear
. Varus and posteromedial rotatory force; lateral collateral ligament complex tear
. Axial load and supination force; isolated lateral ulnar collateral ligament tear
. Direct posterior blow to the olecranon; triceps tendon avulsion
. Hyperextension and valgus force; radiocapitellar impaction injury

Correct Answer & Explanation

. Varus and posteromedial rotatory force; lateral collateral ligament complex tear

Explanation

Fractures of the anteromedial facet of the coronoid process are pathognomonic for a varus posteromedial rotatory instability (VPMRI) mechanism. This injury pattern typically involves a varus force that causes failure of the lateral collateral ligament (LCL) complex, followed by impaction of the anteromedial coronoid facet against the medial trochlea, often sparing the medial collateral ligament.

Question 4603

Topic: 2. Trauma

A 19-year-old collegiate football player sustains a direct blow to the anteromedial aspect of his shoulder. He presents to the trauma bay with severe pain, a feeling of fullness in his neck, dysphagia, and mild stridor. Imaging confirms a posterior sternoclavicular (SC) joint dislocation. A closed reduction in the operating room under general anesthesia is planned. Which surgical specialist must be immediately available on standby during the reduction?

. Vascular surgeon
. Neurosurgeon
. Cardiothoracic surgeon
. Otolaryngologist
. General surgeon

Correct Answer & Explanation

. Cardiothoracic surgeon

Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies due to the proximity of the displaced medial clavicle to vital mediastinal structures, including the trachea, esophagus, and great vessels (e.g., brachiocephalic veins and artery). Because of the high risk of catastrophic vascular injury either from the initial trauma or during the reduction maneuver, a cardiothoracic surgeon should be available on standby.

Question 4604

Topic: Upper Extremity Trauma

A 48-year-old male presents with acute weakness in elbow extension after attempting a heavy overhead triceps extension. MRI confirms a complete avulsion of the distal triceps tendon from the olecranon. During surgical repair using a transosseous cruciate technique, understanding the anatomic footprint is crucial. What is the most accurate description of the triceps tendon insertion on the olecranon to guide anatomic repair?

. It inserts exclusively on the sharp proximal tip of the olecranon
. It inserts over a broad area on the proximal olecranon dome, beginning slightly distal to the tip and extending 1 to 2 cm distally
. It inserts predominantly on the medial aspect of the proximal ulna, blending with the sublime tubercle
. It inserts as a narrow, pencil-like footprint 3 cm distal to the olecranon tip
. It inserts bilaterally on the epicondyles with a central aponeurosis over the olecranon

Correct Answer & Explanation

. It inserts over a broad area on the proximal olecranon dome, beginning slightly distal to the tip and extending 1 to 2 cm distally

Explanation

The anatomic footprint of the distal triceps tendon is broad and covers the proximal portion of the olecranon (the dome). It typically begins a few millimeters distal to the articular tip of the olecranon and extends distally for approximately 1 to 2 cm. Reattaching the tendon specifically to the tip without covering the dome can lead to altered biomechanics and an extension lag.

Question 4605

Topic: 2. Trauma

A 45-year-old female who smokes 1 pack of cigarettes a day presents 9 months after sustaining a midshaft humerus fracture that was treated non-operatively in a functional brace. She reports persistent pain and gross motion at the fracture site. Radiographs demonstrate smooth, sclerotic fracture ends with no bridging callus. Which of the following represents the gold standard surgical management for this condition?

. Exchange to a customized functional brace for an additional 3 months
. Open reduction, internal fixation with dynamic compression plating, and autologous bone grafting
. Closed reamed intramedullary nailing without bone grafting
. Application of a circular fine-wire external fixator
. Non-invasive low-intensity pulsed ultrasound (LIPUS) therapy

Correct Answer & Explanation

. Open reduction, internal fixation with dynamic compression plating, and autologous bone grafting

Explanation

The patient has an atrophic nonunion of the humeral shaft (indicated by motion at 9 months and sclerotic ends with no callus). The gold standard treatment for atrophic humeral shaft nonunions is open reduction and internal fixation (ORIF) with rigid compression plating combined with autologous bone grafting (typically from the iliac crest) to provide both mechanical stability and biological stimulation.

Question 4606

Topic: 2. Trauma

A 65-year-old female sustains an AO/OTA 13-C3 comminuted intra-articular fracture of the distal humerus. The surgeon elects to perform an olecranon osteotomy for optimal articular visualization during open reduction and internal fixation. To maximize stability and minimize the risk of subsequent osteotomy nonunion, what is the preferred geometry and location of the osteotomy?

. A transverse osteotomy precisely at the tip of the olecranon
. A chevron (V-shaped) osteotomy with the apex directed distally, located at the bare area of the greater sigmoid notch
. A chevron osteotomy with the apex directed proximally, located at the base of the coronoid
. An oblique osteotomy exiting medially at the sublime tubercle
. A step-cut osteotomy through the triceps insertion footprint

Correct Answer & Explanation

. A chevron (V-shaped) osteotomy with the apex directed distally, located at the bare area of the greater sigmoid notch

Explanation

A chevron-shaped (V-shaped) osteotomy with the apex pointing distally is preferred over a transverse cut because it provides greater surface area for healing and inherent rotational stability, aiding in anatomic reduction. It should be performed at the 'bare area' (the non-articular groove in the center of the greater sigmoid notch) to minimize damage to the articular cartilage.

Question 4607

Topic: 2. Trauma

A 55-year-old man presents with a complex elbow injury following a fall from a height. Radiographs demonstrate a comminuted fracture of the olecranon. The distal radius and ulna, along with the radial head and coronoid, are displaced anteriorly relative to the distal humerus. However, the proximal radioulnar joint (PRUJ) remains anatomically congruent. What is the key pathomechanical feature of this 'trans-olecranon fracture-dislocation' that distinguishes it from an anterior Monteggia fracture-dislocation?

. The lateral collateral ligament complex is completely avulsed from the humerus
. The proximal radioulnar joint is disrupted with a concurrent interosseous membrane tear
. The collateral ligaments and the proximal radioulnar joint are generally preserved, and the forearm bones translate together
. The radial head is invariably fractured and requires excision
. The medial collateral ligament is always ruptured mid-substance

Correct Answer & Explanation

. The collateral ligaments and the proximal radioulnar joint are generally preserved, and the forearm bones translate together

Explanation

In a true trans-olecranon fracture-dislocation, the injury energy is dissipated through the bone (the olecranon fracture) rather than the ligaments. Consequently, the proximal radioulnar joint (PRUJ) and the collateral ligament complexes usually remain intact. The radius and ulna dislocate as a single unit anteriorly relative to the humerus. This contrasts with a Monteggia fracture, where the PRUJ is disrupted as the radial head dislocates independently of the proximal ulna.

Question 4608

Topic: 2. Trauma

A 42-year-old male sustains a closed, isolated scapula fracture in an MVC. Non-operative management is generally indicated for most scapula fractures; however, surgical fixation is recommended when certain criteria are met. Which of the following radiographic parameters is a widely accepted indication for open reduction and internal fixation of the scapula?

. Glenopolar angle of 18 degrees
. Medialization of the lateral border by 10 mm
. Angulation of the scapular body of 30 degrees
. Glenoid articular step-off of 2 mm
. Inferior displacement of the glenoid by 5 mm

Correct Answer & Explanation

. Glenopolar angle of 18 degrees

Explanation

A glenopolar angle of less than 22 degrees indicates severe angular deformity of the scapular neck and is a widely accepted indication for surgery. Other operative indications include medialization greater than 20 mm, angulation greater than 45 degrees, and an intra-articular glenoid step-off greater than 4 mm.

Question 4609

Topic: 2. Trauma

A 55-year-old female sustains a completely displaced, comminuted midshaft clavicle fracture. She opts for non-operative management. Which of the following radiographic or demographic factors is most strongly predictive of nonunion in this patient?

. Shortening of less than 1 cm
. Inferior displacement of the lateral fragment
. Shortening greater than 2 cm
. Presence of a butterfly fragment strictly on the inferior border
. Medial clavicle involvement

Correct Answer & Explanation

. Shortening greater than 2 cm

Explanation

Risk factors for nonunion of midshaft clavicle fractures include advanced age, female gender, complete displacement (100%), comminution, and fracture shortening of greater than 2 cm. Shortening > 2 cm is a strong relative indication for operative fixation.

Question 4610

Topic: 2. Trauma

A 40-year-old patient sustains a severely comminuted fracture of the scapular body after falling from a roof. Measurement of the glenopolar angle (GPA) is obtained to evaluate the need for surgical intervention. What is the normal range of the GPA, and at what threshold is surgical fixation generally recommended?

. Normal 10-20 degrees; Surgery if < 10 degrees
. Normal 20-30 degrees; Surgery if > 40 degrees
. Normal 30-45 degrees; Surgery if < 22 degrees
. Normal 50-60 degrees; Surgery if < 30 degrees
. Normal 60-75 degrees; Surgery if < 45 degrees

Correct Answer & Explanation

. Normal 30-45 degrees; Surgery if < 22 degrees

Explanation

The normal glenopolar angle is between 30 and 45 degrees. A GPA of less than 22 degrees indicates severe rotational malalignment of the glenoid and is a widely accepted indication for open reduction and internal fixation.

Question 4611

Topic: Upper Extremity Trauma
A 28-year-old manual laborer requires surgical reconstruction for a chronic Type III acromioclavicular (AC) joint separation. The reconstruction will target the coracoclavicular (CC) ligaments. Which of the following best describes the anatomical orientation of the native CC ligaments?
. The conoid is medial and posterior; the trapezoid is lateral and anterior.
. The conoid is lateral and anterior; the trapezoid is medial and posterior.
. The conoid is medial and anterior; the trapezoid is lateral and posterior.
. The conoid is lateral and posterior; the trapezoid is medial and anterior.
. Both ligaments run parallel with no distinct anteroposterior separation.

Correct Answer & Explanation

. The conoid is medial and posterior; the trapezoid is lateral and anterior.

Explanation

The coracoclavicular ligament complex consists of the conoid and trapezoid ligaments. The conoid is situated medial and posterior, while the trapezoid is lateral and anterior. Anatomic reconstruction techniques aim to reproduce this specific footprint.

Question 4612

Topic: 2. Trauma

A 28-year-old sustains a closed, isolated midshaft transverse humerus fracture after a direct blow. On initial examination in the emergency department, he is noted to have a complete absence of wrist extension, finger extension, and decreased sensation over the dorsal first web space. What is the most appropriate initial management for this neurologic finding?

. Immediate surgical exploration of the radial nerve
. Electromyography (EMG) and nerve conduction studies
. Closed reduction and coaptation splinting with clinical observation
. Urgent MRI of the arm
. Surgical exploration with open reduction and internal fixation of the humerus

Correct Answer & Explanation

. Closed reduction and coaptation splinting with clinical observation

Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture is typically a neuropraxia and should be managed with closed reduction, splinting, and observation. Surgical exploration is generally indicated only if the palsy occurs after a closed reduction attempt or in open fractures.

Question 4613

Topic: 2. Trauma

A 24-year-old cyclist sustains a highly displaced midshaft clavicle fracture. Which of the following is considered an absolute indication for acute open reduction and internal fixation?

. Displacement greater than 2 cm
. Z-type fracture configuration
. Skin tenting with impending necrosis
. Concomitant non-displaced scapular body fracture
. Patient preference for early return to sport

Correct Answer & Explanation

. Skin tenting with impending necrosis

Explanation

Absolute indications for operative treatment of clavicle fractures include open fractures, vascular injury, and severe skin tenting with impending necrosis. Displacement and shortening >2 cm are relative indications based on the increased risk of symptomatic nonunion.

Question 4614

Topic: 2. Trauma
Figure 12 shows the radiograph of an 80-year-old woman who has had an 8-month history of back pain after a fall. What is the most likely diagnosis based on the radiographic findings at the fractured vertebrae?
. A healing osteoporotic compression fracture
. A pathologic fracture that is the result of an underlying neoplasm
. Nonunion of the fracture with osteonecrosis
. Vertebral osteomyelitis
. Degeneration of the adjacent intervertebral disk

Correct Answer & Explanation

. Nonunion of the fracture with osteonecrosis

Explanation

An intravertebral vacuum cleft suggests nonunion of the vertebral fracture with osteonecrosis and is not seen in routine healing fractures. MRI characteristically shows a high T2 signal in the cleft. The cleft is not indicative of an infectious or neoplastic lesion.

Question 4615

Topic: 2. Trauma
A 22-year-old cheerleader who fell from the top of a pyramid now reports anterior and posterior pelvic pain. A radiograph and CT scans are shown in Figures 43a through 43c. What is the best treatment for this injury?
. Nonsurgical management with weight bearing as tolerated
. Nonsurgical management with no weight bearing on the left side
. Nonsurgical management with use of a pelvic binder
. Open reduction and internal fixation of the anterior pelvis
. Open reduction and internal fixation of the anterior pelvis with placement of a left-sided percutaneous posterior screw

Correct Answer & Explanation

. Open reduction and internal fixation of the anterior pelvis

Explanation

Symphyseal widening of greater than 2.5 cm and less than 5 cm denotes an AP II injury and a rotationally unstable pelvis. An AP II pelvic ring injury is best treated with anterior open reduction and internal fixation. Nonsurgical management is reserved for AP I injuries.

Question 4616

Topic: 2. Trauma

A 25-year-old male sustains a closed transverse fracture of the middle third of the humeral shaft. Examination reveals an inability to extend the wrist and fingers, as well as loss of sensation in the first dorsal web space. What is the most appropriate initial management?

. Immediate surgical exploration of the radial nerve and fracture fixation
. Closed reduction and functional bracing, with nerve exploration if there is no clinical or EMG recovery by 3 to 4 months
. Immediate EMG/NCS to determine the extent of nerve injury
. Fracture fixation with an intramedullary nail and no nerve exploration
. External fixation and primary nerve grafting

Correct Answer & Explanation

. Closed reduction and functional bracing, with nerve exploration if there is no clinical or EMG recovery by 3 to 4 months

Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture is typically a neuropraxia or axonotmesis (up to 90% recover spontaneously). The standard of care is nonoperative management of the fracture (e.g., functional brace) and observation of the nerve. If there is no clinical or electromyographic (EMG) evidence of recovery by 3 to 4 months, surgical exploration of the nerve is indicated.

Question 4617

Topic: 2. Trauma

A 22-year-old cyclist falls onto his left shoulder and sustains a midshaft clavicle fracture. Which of the following clinical or radiographic findings is a widely accepted relative indication for operative fixation over nonoperative management?

. 5 mm of superior displacement
. 100% displacement with 2 cm of shortening
. An undisplaced inferior butterfly fragment
. Location in the medial third of the clavicle
. Presence of a concomitant type I acromioclavicular sprain

Correct Answer & Explanation

. 100% displacement with 2 cm of shortening

Explanation

Indications for operative fixation of midshaft clavicle fractures include completely displaced fractures with > 2 cm of shortening, severe comminution (Z-deformity), skin tenting posing a risk for open fracture, open fractures, and concomitant vascular or progressive neurologic deficits. Undisplaced or minimally displaced fractures have a very high union rate with nonoperative care.

Question 4618

Topic: 2. Trauma

A 40-year-old male is involved in a high-speed motor vehicle collision. Radiographs and CT show an extra-articular scapular body fracture. Which of the following is the most commonly accepted indication for open reduction and internal fixation (ORIF) of an isolated extra-articular scapular fracture?

. Medial/lateral displacement > 5 mm
. Medial/lateral displacement > 20 mm or angular deformity > 45 degrees
. Any degree of medialization
. Concomitant non-displaced rib fractures
. Superior shoulder suspensory complex double disruption with < 5 mm displacement

Correct Answer & Explanation

. Medial/lateral displacement > 20 mm or angular deformity > 45 degrees

Explanation

Most extra-articular scapula body and neck fractures are treated nonoperatively with good results. However, indications for surgery include significant displacement, typically defined as medial/lateral displacement > 20 mm, angular deformity > 45 degrees, or a glenopolar angle < 22 degrees. These thresholds aim to prevent altered rotator cuff mechanics and impingement.

Question 4619

Topic: Upper Extremity Trauma

A 30-year-old male falls directly on his shoulder and is diagnosed with a Type V acromioclavicular (AC) joint separation. He undergoes an anatomic coracoclavicular (CC) ligament reconstruction. Which two ligaments are being reconstructed, and what is their normal anatomic orientation from medial to lateral?

. Conoid is medial, Trapezoid is lateral
. Trapezoid is medial, Conoid is lateral
. Coracoacromial is medial, Conoid is lateral
. Conoid is medial, Coracoacromial is lateral
. Trapezoid is medial, Coracoacromial is lateral

Correct Answer & Explanation

. Conoid is medial, Trapezoid is lateral

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and the trapezoid. Anatomically, the conoid ligament is medial and posterior, inserting on the conoid tubercle of the clavicle. The trapezoid ligament is lateral and anterior, inserting on the trapezoid line. Anatomic reconstruction aims to recreate these distinct structural bands.

Question 4620

Topic: 2. Trauma

A 55-year-old female sustains a transverse olecranon fracture and undergoes tension band wiring. The biomechanical principle of tension band wiring relies on converting which of the following forces at the articular surface into which other force during active elbow extension?

. Converts compressive forces into tensile forces
. Converts tensile forces into compressive forces
. Converts shear forces into compressive forces
. Converts torsional forces into tensile forces
. Converts bending forces into shear forces

Correct Answer & Explanation

. Converts compressive forces into tensile forces

Explanation

The tension band principle relies on placing the implant (wire or suture) on the tension side of a bone (the dorsal/posterior surface of the olecranon). As the triceps pulls and the elbow goes through its range of motion, the tensile forces at the posterior cortex are converted into dynamic compressive forces at the articular surface, promoting stability and healing.

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