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2. Trauma MCQs

Practice Set 273 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 5441

Topic: 2. Trauma

A 65-year-old woman landed on her nondominant left shoulder in a fall. An AP radiograph is shown in Figure 39. Management should consist of

Upper Extremity Board Review 2005: High-Yield MCQs (Set 4) - Figure 12

. closed reduction and immobilization.
. closed reduction and percutaneous pinning.
. open reduction and internal fixation.
. humeral hemiarthroplasty with tuberosity repair.
. total shoulder arthroplasty.

Correct Answer & Explanation

. humeral hemiarthroplasty with tuberosity repair.

Explanation

The radiograph reveals a four-part fracture-dislocation of the proximal humerus. Humeral hemiarthroplasty and tuberosity repair is the treatment of choice because the risk of osteonecrosis is high after attempted repair of this injury. Glenoid resurfacing is reserved for acute fractures in which there is significant preexisting glenoid arthrosis, such as in patients with rheumatoid arthritis. Neer CS II: Displaced proximal humeral fractures: II. Treatment of three- and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103.

Question 5442

Topic: 2. Trauma

Figure 6a shows the radiograph of a 50-year-old man who sustained an anterior dislocation of the shoulder. He undergoes closed reduction, and the postreduction radiograph is shown in Figure 6b. Management should now consist of

. continued use of a sling for 3 to 4 weeks, followed by repeat radiographs.
. open reduction and internal fixation of the greater tuberosity fracture.
. repeat reduction and placement of an abduction orthosis.
. hemiarthroplasty.
. percutaneous pinning.

Correct Answer & Explanation

. open reduction and internal fixation of the greater tuberosity fracture.

Explanation

Displaced greater tuberosity fractures often will block abduction and/or external rotation by impinging on the underside of the acromion or posterior glenoid. The indications for open reduction and internal fixation are 1 cm of displacement or 45 degrees of rotation of the tuberosity fracture. Surgical treatment has recently been recommended for 0.5 cm of tuberosity displacement. Neer CS II: Displaced proximal humeral fractures: II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103.

Question 5443

Topic: 2. Trauma

The fracture shown in Figure 50 is most reliably treated with what form of fixation?

Trauma Board Review 2006: High-Yield MCQs (Set 4) - Figure 22

. Compression screws only
. Tension band wires and Kirschner wires
. Posterior plate
. Medial plate
. Flexible intramedullary rod

Correct Answer & Explanation

. Posterior plate

Explanation

The radiograph shows a comminuted proximal ulnar fracture. The most reliable fixation is a posterior plate, acting as a tension band plate. The fracture involves the proximal shaft of the ulna; therefore, a 3.5-mm compression plate or one of similar size should be used to provide adequate stability. Kirschner wires and tension band wires do not provide axial stability of the comminution of the ulna. Compression screws alone will most likely fail and will not provide axial rotational stability to the construct. A medial plate will not resist the distraction forces across this fracture. McKee MD, Seiler JG, Jupiter JB: The application of the limited contact dynamic compression plate in the upper extremity: An analysis of 114 consecutive cases. Injury 1995;26:661-666.

Question 5444

Topic: Upper Extremity Trauma

Figure 17 shows the radiograph of a 25-year-old professional football player who has superior shoulder pain that prevents him from sports participation. History reveals that he sustained a shoulder injury that was treated with closed reduction and temporary pinning 3 years ago. The best course of action should be

Shoulder Board Review 2002: High-Yield MCQs (Set 2) - Figure 4

. no further participation in contact sports.
. open reduction of the acromioclavicular joint and coracoclavicular screw stabilization.
. open repair of the coracoclavicular ligaments.
. Weaver-Dunn reconstruction and coracoclavicular reconstruction.
. excision of the distal clavicle.

Correct Answer & Explanation

. Weaver-Dunn reconstruction and coracoclavicular reconstruction.

Explanation

The radiograph shows a complete acromioclavicular separation. Because the patient is a professional athlete who is unable to participate, surgery is indicated. Chronic separations, especially those with previous trauma from joint pinning, should be treated with resection of the distal clavicle and stabilization to the coracoid. Some type of biologic reconstruction of the coracoclavicular ligaments is generally recommended. Open repair of the ligaments is generally not possible in such a delayed fashion. Screw fixation alone will not provide a lasting solution as the screws usually need to be removed, leaving no fixation in place. Reconstruction using the coracoacromial ligament is generally recommended with coracoclavicular fixation to protect the repair while it heals. Nuber GW, Bowen MK: Disorders of the acromioclavicular joint: Pathophysiology, diagnosis and management, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999.

Question 5445

Topic: Pelvic & Acetabular Trauma
Figure 2a shows the radiograph of a 48-year-old man who was involved in a motorcycle accident. A CT scan is shown in Figure 2b. The patient underwent pelvic angiography for persistent hypotension despite resuscitation. What vessel is most likely to be injured?
. Internal iliac
. External iliac
. Pudendal
. Superior rectal
. Superior gluteal

Correct Answer & Explanation

. Superior gluteal

Explanation

The pelvic injury is a severe anterior-posterior compression III or Tile C injury. The vessel most likely injured is the superior gluteal artery, but several arterial bleeding sources are likely. Vertical shear injuries can also injure this vessel, but it is much less common.

Question 5446

Topic: 2. Trauma

An otherwise healthy 13-year-old boy sustains the fracture shown in Figure 40 while throwing a fastball. Management should consist of

Upper Extremity Board Review 2005: High-Yield MCQs (Set 4) - Figure 13

. an arm sling.
. functional bracing supporting the humerus and arm.
. closed reduction and a shoulder spica cast.
. open reduction and internal fixation with retrograde rods.
. open reduction and internal fixation with a rigid plate and screws.

Correct Answer & Explanation

. functional bracing supporting the humerus and arm.

Explanation

Nonsurgical management such as a functional brace, hanging arm cast, or sugar tong splint is the treatment of choice for a fracture of the humeral shaft that is the result of throwing. The fracture surface typically is wide and the degree of displacement is not large; therefore, surgery is not indicated in most patients. Ogawa K, Yoshida A: Throwing fracture of the humeral shaft: An analysis of 90 patients. Am J Sports Med 1998;26:242-246.

Question 5447

Topic: Pelvic & Acetabular Trauma

Figures 28a through 28c show the MRI scans of a 30-year-old woman who weighs 290 lb and has low back and left leg pain. She also reports frequent urinary dribbling, which her gynecologist has advised her may be related to obesity. Examination will most likely reveal

. ipsilateral weakness of the tibialis anterior.
. ipsilateral weakness of the peroneus longus and brevis.
. ipsilateral weakness of the extensor hallucis longus.
. a positive Beevor's sign.
. a positive ipsilateral Gaenslen's sign.

Correct Answer & Explanation

. ipsilateral weakness of the tibialis anterior.

Explanation

The patient will most likely exhibit ipsilateral weakness of the tibialis anterior. Gaenslen's test is designed to detect sacroiliac inflammation as a source of low back pain. Beevor's sign tests the innervation of the rectus abdominus and paraspinal musculature (L1 innervation). The extensor hallucis longus is predominantly innervated by L5. The peroneals are predominantly innervated by S1. Hoppenfeld S: Physical Examination of the Spine and Extremities. Appleton, WI, Century-Crofts, 1976.

Question 5448

Topic: 2. Trauma

A type 2A hangman's fracture, which has the potential to overdistract with traction, has which of the following hallmark findings?

. Anterior translation of greater than 3 mm
. Severe angulation with minimal translation
. Extension at the fracture site
. Associated C1 ring fracture
. Associated C2-3 facet dislocation

Correct Answer & Explanation

. Anterior translation of greater than 3 mm

Explanation

Type 2A hangman's fractures are thought to have a flexion mechanism rather than extension and axial loading. This allows them to rotate around the anterior longitudinal ligament into flexion. Anterior translation of greater than 3 mm and angulation distinguish type 2 fractures from type 1 fractures. Although there is an association between C1 ring fractures and C2 fractures, this does not factor into the classification. If a C2-3 facet dislocation exists in combination with a C2 pars fracture, it is considered a type 3 fracture. Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-217.

Question 5449

Topic: 2. Trauma

A 35-year-old man who snowboards sustained the injury shown in Figures 4a through 4c. What is the mechanism of injury?

. Inversion and external rotation
. Axial loading and internal rotation
. Plantar flexion, axial loading, and inversion
. Dorsiflexion and axial loading
. Dorsiflexion, axial loading, inversion, and external rotation

Correct Answer & Explanation

. Dorsiflexion, axial loading, inversion, and external rotation

Explanation

Fractures of the lateral process of the talus in snowboarders have been thought to result from pure dorsiflexion, inversion, and axial loading. In a cadaveric study, 10 cadavers were placed in fixed dorsiflexion and inversion with an axial load. This was combined with or without external rotation. No fractures occurred after axial loading in the dorsiflexed-inverted position. Fractures of the lateral process of the talus occurred in 75% of the specimens with the addition of external rotation. Boon AJ, Smith J, Zobitz ME, et al: Snowboarder's talus fracture: Mechanism of injury. Am J Sports Med 2001;29:333-338.

Question 5450

Topic: Lower Extremity Trauma

Figure 43 shows an arthroscopic view of the posteromedial compartment of a patient's left knee using a 70-degree arthroscope placed through the intercondylar notch. The arrow is pointing to what structure?

Anatomy Board Review 2005: High-Yield MCQs (Set 4) - Figure 1

. Posterior horn of the medial meniscus
. Semimembranosus tendon
. Medial tibial plateau
. Medial head of the gastrocnemius tendon
. Medial plica

Correct Answer & Explanation

. Posterior horn of the medial meniscus

Explanation

Passing the 70-degree arthroscope through the intercondylar notch provides excellent visualization of the posteromedial corner of the knee. This view should be part of every knee arthroscopy because these structures are often not well visualized from the anterior portals. If this view is omitted, tears of the peripheral posterior horn of the medial meniscus can be overlooked. The arrow points to the peripheral aspect of the posterior horn of the medial meniscus. With an intact medial meniscus, the medial tibial plateau should not be seen from this view. The semimembranosus and gastrocnemius tendons are extra-articular and not visualized. Miller MD: Basic arthroscopic principles, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, Saunders, 2003, pp 224-237.

Question 5451

Topic: 2. Trauma

Figures 43a and 43b show the AP and lateral radiographs of the radius and ulna of a 9-year-old patient. The fracture is manipulated and placed in a long arm cast with the elbow flexed to 90 degrees and the forearm to neutral rotation. Figures 43c and 43d show the alignment of the fracture after the manipulation. What is the next most appropriate step in management?

. Stabilize the present reduction internally with intramedullary pins.
. Accept the present reduction and obtain follow-up radiographs in 1 week.
. Remanipulate the fracture and place the forearm in pronation.
. Remanipulate the fracture and place the forearm in supination.
. Stabilize the present reduction with plates and screws.

Correct Answer & Explanation

. Remanipulate the fracture and place the forearm in supination.

Explanation

By placing the forearm at neutral rotation, as shown in Figures 43c and 43d, the distal fragment has become malrotated by 90 degrees. This is evident by the fact that the bicipital tuberosity is rotated 90 degrees to the radial styloid. Normally, it should be directly opposite (180 degrees) to the radial styloid. The correct alignment was present in the original radiographs shown in Figures 43a and 43b. Another clue to the malrotation in the postreduction radiographs is the difference in the diameters of the opposing radial shafts. To correct this rotational malalignment, the distal fragment needs to be remanipulated into supination so that it is correctly aligned with the supinated proximal radius. Evans EM: Fractures of the radius and ulna. J Bone Joint Surg Br 1951;33:548-561.

Question 5452

Topic: 2. Trauma

A 47-year-old woman falls and sustains a direct blow to her middle finger. She notes pain and swelling and is unable to move the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints. Radiographs are shown in Figures 8a through 8c. Proper management should consist of

. closed reduction and splinting in metacarpophalangeal (MCP) and PIP joint extension.
. closed reduction and splinting in MCP joint flexion and PIP joint extension.
. reduction and percutaneous intramedullary Kirschner wire fixation.
. reduction and lag screw fixation.
. buddy taping and early range of motion.

Correct Answer & Explanation

. reduction and lag screw fixation.

Explanation

The oblique nature of the fracture and extension of the fracture to the condyles implies an unstable fracture. Lag screw fixation provides an excellent chance of union, and the ability to start early range of motion. Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green's Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.

Question 5453

Topic: 2. Trauma

A 26-year-old man sustains a displaced bimalleolar fracture by sliding into second base while playing baseball. Following initial closed reduction and splinting of the fracture, moderate swelling is noted. What is the safest time to perform surgery?

. Immediately
. When skin wrinkles are present and abrasions are epithelialized
. Five days after injury
. Following analysis of laser Doppler skin measurements
. Following measurement of transcutaneous oxygen tension

Correct Answer & Explanation

. When skin wrinkles are present and abrasions are epithelialized

Explanation

Following any closed fracture, the most important determinant for the timing of surgery is the condition of the soft tissues and especially the skin. The best determinant of appropriate soft-tissue condition is the presence of wrinkling of the skin (wrinkle sign) at the site of the incision. A wrinkle sign is present when all the interstitial edema has left the skin; this may take up to 14 to 21 days of elevation. Any abrasion must be epithelialized so that there are no bacteria left at the site. To date, no other method of soft-tissue viability measurement has been shown to be of any clinical benefit. Stover MD, Kellam JF: Articular fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 105-119. Hahn DM, Colton CL, Malleolar fractures, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 559-581.

Question 5454

Topic: 2. Trauma
A 52-year-old woman underwent open reduction and internal fixation for radial and ulnar shaft fractures 2 months ago. In a second fall she refractured her forearm and required revision surgery with bone grafting. One month after the second operation she notes erythema, swelling, and drainage from the volar radial incision. In addition to antibiotic treatment, management should consist of
. observation and splinting.
. local wound drainage under local anesthesia.
. incision and drainage, deep wound cultures, removal of the plates and screws, and cast application.
. incision and drainage, deep wound cultures, and removal of the fixation only if it is loose.
. incision and drainage, deep wound cultures, and bone grafting.

Correct Answer & Explanation

. incision and drainage, deep wound cultures, removal of the plates and screws, and cast application.

Explanation

Deep infections after plating of closed fractures of the forearm are unusual. However, the risk increases with repeat surgeries. Debridement of all infected, nonviable tissue is the initial step in management. The fixation may be retained if it is stable, but if the plate and screws are loose, they should be removed and revision performed after removal of nonviable bone. Either external fixation or repeat plating may be performed. Late infections after fracture union may be treated with plate and screw removal, debridement, and IV antibiotics.

Question 5455

Topic: 2. Trauma

Figures 29a and 29b show a clinical photograph and radiographs of a patient who sustained an open calcaneus fracture in a motor vehicle accident. The patient received immediate IV antibiotics and an emergent irrigation and debridement. The swelling has subsided by 3 weeks and the medial wound is clean. What do you tell the patient about the likelihood of infection if a formal open reduction and internal fixation via a lateral approach is performed?

. There is no significant difference between the infection rate for this fracture and a similar closed fracture.
. Due to the risk of infection, open reduction and internal fixation is not recommended for this fracture.
. The infection rate is three to five times more likely with this fracture.
. Due to the risk of infection from a lateral approach, treatment is confined to limited internal fixation or an external fixator.
. The patient will need to undergo 3 weeks of IV antibiotics at home.

Correct Answer & Explanation

. There is no significant difference between the infection rate for this fracture and a similar closed fracture.

Explanation

Multiple authors have shown similar infection rates for grade 1 and 2 open medial fractures and closed fractures that have been treated with an extensile lateral approach and open reduction and internal fixation. Patients only need IV antibiotics for 2 to 3 days after surgery. Formal open reduction and internal fixation is not recommended for grade 3 medial wounds and most lateral wounds. Heier KA, Infante AF, Walling AK, et al: Open fractures of the calcaneus: Soft-tissue injury determines outcome. J Bone Joint Surg Am 2003;85:2276-2282.

Question 5456

Topic: 2. Trauma

A 16-year-old high school football player who sustained an acute forceful dorsiflexion ankle injury reported that he felt a pop and then noted immediate swelling over the lateral malleolus. Examination 24 hours later reveals moderate swelling and tenderness along the lateral malleolus. The external rotation, squeeze, anterior drawer, and talar tilt tests are negative. Subluxation of the peroneal tendons is palpable over the peroneal groove of the fibula. Radiographs reveal a small cortical avulsion off the distal rim of the fibula. The stress views show no instability. Initial management for this injury should include

. a lace-up ankle splint and progressive activities.
. anatomic repair of the anterior talofibular and calcaneofibular ligaments.
. Kirschner wire and tension band fixation of the cortical avulsion fracture off the fibula.
. local ligament transfer and reconstruction of the lateral ankle ligaments.
. protected weight bearing and a short leg cast for 6 weeks.

Correct Answer & Explanation

. protected weight bearing and a short leg cast for 6 weeks.

Explanation

The patient has an acute peroneal tendon dislocation. The evaluation for syndesmotic injury and lateral ankle instability is negative. The cortical avulsion off the distal tip of the lateral malleolus, a rim fracture, is characteristic of peroneal tendon dislocations. The sensation of apprehension or frank subluxation of the peroneal tendons with active dorsiflexion of the foot while the foot is held in plantar flexion confirms the diagnosis. Based on these findings, initial management should consist of cast immobilization and protected weight bearing. If a recurrent or chronic condition develops, surgery is the most reliable treatment option. Arrowsmith SR, Fleming LL, Allman FL: Traumatic dislocations of the peroneal tendons. Am J Sports Med 1983;11:142-146.

Question 5457

Topic: 2. Trauma

Figures 43a and 43b show the T1- and T2-weighted MRI scans of a 78-year-old woman who reports the sudden atraumatic onset of well-localized medial knee pain. Pain is worse at night and also occurs with weight-bearing activity. What is the most likely diagnosis?

. Complex regional pain syndrome
. Osteoarthritis
. Osteosarcoma
. Osteonecrosis
. Inflammatory arthritis

Correct Answer & Explanation

. Osteonecrosis

Explanation

Osteonecrosis of the tibial plateau occurs infrequently. The symptoms are similar to those of idiopathic osteonecrosis of the medial femoral condyle and include pain and tenderness of the medial aspect of the knee and a slight synovitis. The range of motion of the knee remains within normal limits, and no gross deformity is present. Osteonecrosis of the tibial plateau is easily misdiagnosed as degenerative meniscus or osteoarthritis of the compartment of the knee. Review of lateral radiographs may reveal an osteopenic area in the subchondral bone of the medial tibial plateau. The diagnosis is more easily established with a bone scan where increased uptake of radionucleides is shown over the medial tibial plateau. In osteoarthritic involvement of the medial compartment, uptake is over both the medial femoral condyle and the medial tibial plateau, whereas if osteoarthritis involves the entire knee, uptake is diffuse over the entire joint. Radiographic findings in complex regional pain syndrome are normal as opposed to the findings for osteonecrosis or osteoarthritis. Osteosarcoma has a characteristic radiographic appearance of a bone-forming tumor. Loose bodies can derive from osteochondral fractures; a history of trauma is usually elicited. Osteoarthritis usually presents with joint space narrowing accompanying the weight-bearing pain. Soucacos PN, Berris AE, Xenakis TH, et al: Knee osteonecrosis: Distinguishing features in differential diagnosis, in Urbanik JR, Jones JD (eds): Osteonecrosis. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 413-424.

Question 5458

Topic: 2. Trauma

Figure 2 shows the lateral radiograph of an 8-year-old boy who sustained an acute injury to the elbow after falling down the stairs. Management should consist of

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 4

. closed reduction, followed by a long arm cast in 120 degrees of flexion.
. closed reduction, followed by percutaneous cross pin fixation.
. open reduction and internal fixation using an oblique screw combined with an absorbable suture as a tension band.
. a large intramedullary screw.
. a long arm cast in full extension.

Correct Answer & Explanation

. open reduction and internal fixation using an oblique screw combined with an absorbable suture as a tension band.

Explanation

The patient has a flexion-type olecranon fracture, and the integrity of the extensor mechanism is disrupted. With this degree of displacement, closed reduction and extension casting would not be adequate. The strongest construct is an oblique screw across the fracture site, with a tension band. Healing is rapid in this age group; therefore one of the heavy absorbable sutures can be used as the tension band. Two parallel pins with the stainless steel tension band wire (AO technique) can be used but requires wire dissection for removal. Once the fracture is healed, the single screw can be removed easily with only a small incision. The presence of the screw, across the apophysis, has not been shown to produce any significant growth disturbance. Use of a large intramedullary screw would not be advisable because of the small size of the proximal fragment. Murphy DF, Greene WB, Gilbert JA, Dameron TB Jr: Displaced olecranon fractures in adults: Biomechanical analysis of fixation methods. Clin Orthop 1987;224:210-214.

Question 5459

Topic: 2. Trauma
Figure 35 shows the lateral radiograph of a 15-year-old basketball player who felt a dramatic pop in his knee when landing after a lay-up. The patient reports that he cannot bear weight on the injured extremity. Management should consist of
. closed reduction and casting in extension.
. open reduction with suture fixation of the proximal fragment.
. closed reduction, followed by functional bracing.
. open reduction and internal fixation with screws and complete proximal tibial epiphysiodesis.
. open reduction and internal fixation with screws.

Correct Answer & Explanation

. open reduction and internal fixation with screws.

Explanation

Tibial tubercle avulsion is an injury of the adolescent knee that most often occurs just before the end of growth. The fracture usually occurs with jumping, either at push-off or landing. This patient has a type III injury. In type III injuries, the articular surface is disrupted, and meniscal injury and compartment syndrome can occur. Open reduction is the treatment of choice, and anterior fasciotomy should be considered prophylactically at the time of surgery. Although the fracture heals with an anterior epiphysiodesis of the proximal tibia, little growth remains in this patient and no special handling of the physis is warranted.

Question 5460

Topic: 2. Trauma

A 5-year-old boy has a deformity of his right arm after falling from a jungle gym. A radiograph is shown in Figure 37. Management should consist of

Trauma 2006 Practice Questions: Set 3 (Solved) - Figure 18

. closed reduction of the ulna and transcapitellar pinning of the radial head.
. closed reduction of the ulna and radial head dislocation.
. closed reduction of the ulna and annular ligament repair.
. open reduction of the radius and plating of the ulna.
. open reduction of the ulna and immobilization in an extension cast.

Correct Answer & Explanation

. closed reduction of the ulna and radial head dislocation.

Explanation

Monteggia fractures in children must be recognized. Early appropriate treatment is much easier than delayed reconstruction for a missed radial head dislocation. In younger children, attempts should be made to reduce the ulna fracture and radial head dislocation with traction and manual manipulation. Anterior Monteggia fractures are the most common, and in this variety the radius is much better stabilized in elbow flexion. Posterior Monteggia fractures are less common and may be managed in elbow extension. Closed reduction is much more successful in younger children; ulnar fixation with a rod or plate may be needed in older patients with unstable fractures. Annular ligament repair is rarely needed in the acute fracture. Wilkins KE: Changes in the management of Monteggia fractures. J Pediatr Orthop 2002;22:548-554. Kay RM, Skaggs DL: The pediatric Monteggia fracture. Am J Orthop 1998;27:606-609.

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