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2. Trauma MCQs

Practice Set 274 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 5461

Topic: 2. Trauma

Figure 1 shows the radiograph of an 11-year-old boy who stubbed his great toe while playing soccer barefoot. He is able to walk home despite a small amount of bleeding at the nail fold. Management should consist of

Trauma 2006 Practice Questions: Set 1 (Solved) - Figure 3

. a hard-soled shoe for 4 to 6 weeks.
. closed reduction and percutaneous pinning.
. burning a hole in the nail for relief of the impending hematoma.
. digital block and irrigation and debridement of the wound.
. repair of the extensor hallucis longus tendon injury and use of a hard-soled shoe.

Correct Answer & Explanation

. digital block and irrigation and debridement of the wound.

Explanation

Great toe fractures through the physis should be considered open fractures if there is bleeding at the nail fold. Treatment should include irrigation and debridement and appropriate antibiotics. Immobilization with a cast is usually sufficient for treatment of the fracture. Noonan KJ, Saltzman CL, Dietz FR: Open physeal fractures of the distal phalanx of the great toe: A case report. J Bone Joint Surg Am 1994;76:122-125.

Question 5462

Topic: 2. Trauma
A 26-year-old professional rodeo bull rider sustained a grade III midshaft femoral fracture after being thrown from his bull. He underwent closed interlocking intermedullary nailing with a titanium rod, and his recovery was uneventful. Prior to returning to competition, the patient must
. be able to run and walk without pain.
. refrain from vigorous activity for 6 months.
. achieve full hip and knee range of motion.
. achieve symmetric lower extremity strength.
. have radiographic evidence of a circumferential external bridging callus.

Correct Answer & Explanation

. have radiographic evidence of a circumferential external bridging callus.

Explanation

While it is recommended that a patient gain full range of motion, pain-free function, and symmetric strength prior to returning to vigorous activities, it is absolutely essential that radiographs of the fracture site reveal a circumferential external bridging callus to prevent refracture. This is particularly important for comminuted femoral fractures with various sized fragments. It is also recommended that a return to rodeo riding be postponed for at least 1 year.

Question 5463

Topic: 2. Trauma
A 12-year-old boy with hemophilia A and no known inhibitors sustains a tibia fracture and has pain with passive motion of the deep toe flexors. Appropriate management should consist of
. emergency fasciotomy, followed by factor VIII replacement.
. cryoprecipitate, followed by assessment of compartment pressures.
. factor VIII replacement, followed by assessment of compartment pressures.
. physical therapy to prevent contractures.
. splinting, ice, and elevation.

Correct Answer & Explanation

. factor VIII replacement, followed by assessment of compartment pressures.

Explanation

In a patient with hemophilia, factor replacement followed by assessment of compartment pressures is essential. If the patient has inhibitors, the problem is more difficult. Porcine factor has been helpful in patients with inhibitory antibodies. Recent evidence points to using activated factor VII and bypassing the intrinsic pathway. Desmopressin is an adjunct to therapy but is not as effective as factor VII. Dumontier C, Sautet A, Man M, Bennani M, Apoil A: Entrapment and compartment syndromes of the upper limb in haemophilia. J Hand Surg Br 1994;19:427-429. Carr ME Jr, Loughran TP, Cardea JA, Smith WK, Kuhn JG, Dottore MV: Successful use of recombinant factor VIIa for hemostasis during total knee replacement in a severe hemophiliac with high-titer factor VIII inhibitor. Int J Hematol 2002;75:95-99.

Question 5464

Topic: 2. Trauma

An 8-year-old boy sustained an isolated distal radial fracture that was reduced and immobilized with 10 degrees of residual dorsal tilt. What is the next step in management?

Trauma 2006 Practice Questions: Set 1 (Solved) - Figure 10

. Percutaneous pinning
. Open reduction and pin fixation
. Follow-up in 6 weeks for conversion to a splint
. A short arm cast and follow-up in 4 weeks
. A long arm cast and follow-up in 1 week

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 degrees 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. The potential for increased fracture displacement and subsequent malunion may exist in up to one third of patients with displaced fractures with less than anatomic reduction. Therefore, early follow-up is recommended and remanipulation is indicated should loss in reduction occur. Consideration for percutaneous pinning of isolated distal radial fracture is reasonable in patients with little growth remaining. In these patients, higher rates of redisplacement exist with little chance for remodeling. Gibbons CL, Woods DA, Pailthorpe C, et al: The management of isolated distal radius fractures in children. J Pediatr Orthop 1994;14:207-210. McLauchlan GJ, Cowan B, Annan IH, et al: Management of completely displaced metaphyseal fractures of the distal radius in children. J Bone Joint Surg Br 2002;84:413-417. Proctor MT, Moore DJ, Patterson JH: Redisplacement after manipulation of distal radial fractures in children. J Bone Joint Surg Br 1993;75:453-454.

Question 5465

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. Pelvic binders are used only acutely and should not be used for definitive management. Iliosacral screws usually are not necessary in the acute management of AP II injuries. Matta JM: Indications for anterior fixation of pelvic fractures. Clin Orthop Relat Res 1996;329:88-96. Templeman DC, Schmidt AH, Sems AS, et al: Diastasis of the symphysis pubis: Open reduction internal fixation, in Wiss D (ed): Masters Techniques in Orthopaedic Surgery-Fractures, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 639-648.

Question 5466

Topic: 2. Trauma

A patient who was involved in a motor vehicle accident 2 days ago now reports neck pain. He denies any other symptoms. Radiographs reveal a type II odontoid fracture that is 2 mm anteriorly displaced. Management consists of halo vest immobilization in extension, and repeat radiographs reveal that the fracture is completely reduced. The patient is discharged to home, but later that evening he notes difficulty swallowing while trying to eat dinner. What is the most likely cause of this difficulty?

Spine Surgery Board Review 2000: High-Yield MCQs (Set 2) - Figure 7

. Injury to the recurrent laryngeal nerve
. Injury to the superior laryngeal nerve
. Esophageal trauma at the time of the fracture or at the time of the reduction
. Retropharyngeal edema or hematoma from the fracture
. Halo vest placement

Correct Answer & Explanation

. Halo vest placement

Explanation

If the neck is immobilized in excessive extension, it can be difficult for the patient to swallow. If the patient had injured the recurrent or superior laryngeal nerve at the time of the accident, it is likely to have manifested itself earlier on. Esophageal trauma or retropharyngeal edema or hematoma from the fracture also should have manifested itself earlier. Because the fracture was completely reduced, it is unlikely that moving the small fragment posteriorly would have injured the esophagus. Garfin SR, Botte MJ, Waters RL, Nickel VL: Complications in the use of halo fixation device. J Bone Joint Surg Am 1986;68:320-325.

Question 5467

Topic: 2. Trauma

A 32-year-old man sustained a closed injury after falling 25 feet from a roof. His ankle and foot are severely swollen. Radiographs and CT scans are shown in Figures 29a through 29d. Initial management should consist of

. closed reduction and application of a long leg cast.
. open reduction and internal fixation with plate and screw fixation.
. percutaneous plate fixation.
. spanning external fixation with delayed limited open reduction and internal fixation.
. primary ankle arthrodesis.

Correct Answer & Explanation

. spanning external fixation with delayed limited open reduction and internal fixation.

Explanation

The patient has a severe high-energy injury from axial loading to the left ankle and distal tibia. This is a closed injury, but the soft tissues are injured and severely swollen. Initial treatment should focus on skeletal stabilization, and incisions directly over the fracture area should be avoided until soft-tissue stabilization has occurred. Immediate spanning external fixation with plans for a delayed reconstruction as needed for the joint surface is the treatment of choice. Closed reduction and application of a constrictive long leg cast may lead to increased risk of tissue necrosis. Immediate open procedures to internally fix the fracture add the risks of soft-tissue necrosis and are to be avoided. Percutaneous plating may be one of the delayed fixation options but should not be used immediately. Primary ankle arthrodesis is not indicated. Thordarson DB: Complications after treatment of tibial pilon fractures: Prevention and management strategies. J Am Acad Orthop Surg 2000;8:253-265. Marsh JL, Bonar S, Nepola JV, DeCoster TA, Hurwitz SR: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509.

Question 5468

Topic: 2. Trauma

Figures 31a and 31b show the T1- and T2-weighted MRI scans of a patient's knee joint. What is the most likely diagnosis?

. Torn anterior cruciate ligament
. Torn medial meniscus
. Staphylococcus infection
. Rheumatoid arthritis
. Tibial plateau fracture

Correct Answer & Explanation

. Tibial plateau fracture

Explanation

The scans show a lipohemarthrosis. There is the characteristic layering of a superior zone containing fat (high signal intensity), a central zone containing serum (low signal intensity), and an inferior zone that contains red blood cells (low signal intensity). The most common cause of a lipohemarthrosis is an intra-articular fracture with leakage of marrow fat into the joint. Resnick D, Kang HS: Synovial joints, in Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 49-53.

Question 5469

Topic: 2. Trauma

A 9-year-old boy falls from a scooter and sustains the injury shown in the radiographs in Figure 26. After closed reduction and cast immobilization, what is the most likely complication that can result?

General Orthopedics 2026 Practice Questions: Set 13 (Solved) - Figure 24

. Growth arrest of the distal ulna
. Growth arrest of the distal radius
. Compartment syndrome
. Radioulnar synostosis
. Entrapment of the extensor pollicis longus (EPL) tendon

Correct Answer & Explanation

. Growth arrest of the distal ulna

Explanation

The radiographs show a fracture of the distal radius and ulna physis. The most likely complication is growth arrest of the distal ulna. In contradistinction to physis fractures of the radius (growth arrest incidence of less than 5%), the incidence of growth arrest in the ulna is between 30% and 40%. Entrapment of the EPL tendon and cross union between the two bones is extremely rare. Vanheest A: Wrist deformities after fracture. Hand Clin 2006;22:113-120. Cannata G, De Maio F, Mancini F, et al: Physeal fractures of the distal radius and ulna: Long-term prognosis. J Orthop Trauma 2003;17:172-179. Ray TD, Tessler RH, Dell PC: Traumatic ulnar physeal arrest after distal forearm fractures in children. J Pediatr Orthop 1996;16:195-200.

Question 5470

Topic: 2. Trauma
A 36-year-old woman was injured in a train derailment. She has a significant open depressed skull fracture with active bleeding, a hemopneumothorax, and blood in the left upper quadrant and colic gutter by Focused Assessment with Sonography for Trauma (FAST) examination. Additionally, she has the pelvic injury seen on the CT scans in Figures 18a and 18b. The mortality rate for this patient approaches
. less than 10%.
. 30%.
. 50%.
. 70%.
. greater than 90%.

Correct Answer & Explanation

. greater than 90%.

Explanation

Mortality following trauma that requires surgical intervention for head, chest, and abdominal injury exceeds 90%. The type of pelvic fracture is a predictor of associated injury, blood requirements, and overall mortality. AP III pelvic fractures require the most blood, and are associated with significant abdominal trauma and shock. Lateral compression pelvic fractures are more associated with head, chest, and occasionally abdominal trauma, and mortality often occurs from associated injuries. Dalal SA, Burgess AR, Siegel JH, et al: Pelvic fracture in multiple trauma: Classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. J Trauma 1989;29:981-1000. Eastridge BJ, Burgess AR: Pedestrian pelvic fractures: 5-year experience of a major urban trauma center. J Trauma 1997;42:695-700.

Question 5471

Topic: 2. Trauma

A 9-year-old child has right groin pain after falling from a tree. Examination reveals that the right leg is held in external rotation, and there is significant pain with attempts at passive range of motion. Radiographs are shown in Figures 43a and 43b. Management should consist of

. closed reduction and a double spica cast.
. skeletal traction for 3 weeks, followed by a double spica cast.
. reduction and internal fixation crossing the physis if necessary.
. reduction and internal fixation with primary bone grafting.
. skin traction.

Correct Answer & Explanation

. reduction and internal fixation crossing the physis if necessary.

Explanation

The complications of femoral neck fractures in children include osteonecrosis, malunion, nonunion, and premature physeal closure. It is presumed that the risk of osteonecrosis is directly related to the amount of displacement at the time of injury and is not affected by the type of treatment. The risk of the other complications can be decreased depending on the type of treatment. Anatomic reduction by either closed or open methods can reduce the risk of malunion. The addition of internal fixation allows for maintenance of the reduction. In young children who cannot comply with a partial or non-weight-bearing status, the addition of a spica cast gives added protection. Canale ST: Fractures of the hip in children and adolescents. Orthop Clin North Am 1990;21:341-352.

Question 5472

Topic: 2. Trauma

Figure 21 shows the AP radiograph of a 41-year-old patient who sustained a closed bicolumnar fracture of the distal humerus that resulted in a painful nonunion. What is the best initial construct for rigid stabilization of this fracture pattern?

Shoulder Board Review 2002: High-Yield MCQs (Set 2) - Figure 18

. Posterior "Y" plate fixation
. Dual one third tubular plate fixation with a hinged external fixator
. Dual one third tubular plate fixation
. Dual 3.5-mm reconstruction plate fixation
. Single lateral plate fixation with transcortical screw fixation

Correct Answer & Explanation

. Dual 3.5-mm reconstruction plate fixation

Explanation

The dual plate fixation construct is significantly stronger than single plate or "Y" plate fixation. Two-plate constructs at right angles, the ulnar plate medially and the lateral plate posteriorly, would appear to be biomechanically optimal. This approach usually is feasible at the time of surgery. Clinically, dual 3.5-mm reconstruction or dynamic compression plates are superior to one third tubular plate fixation. Supplementary external fixation is not considered a better treatment option. Failure of fixation and nonunion are often the result of inadequate fixation and osteoporosis. Helfet DL, Hotchkiss RN: Internal fixation of the distal humerus: A biomechanical comparison of methods. J Orthop Trauma 1990;4:260-264.

Question 5473

Topic: 2. Trauma

An 18-year-old football player sustains a contact injury to his right lower leg, and radiographs show a closed transverse fracture of the middle third of the tibia. Based on the clinical examination, a compartment syndrome is suspected. When measuring compartment pressures, the highest tissue pressure is recorded how many centimeters proximal or distal to the fracture site?

. 0 cm to 5 cm
. 5 cm to 10 cm
. 10 cm to 15 cm
. 15 cm to 20 cm
. Greater than 20 cm

Correct Answer & Explanation

. 5 cm to 10 cm

Explanation

Measurements of compartment pressures in patients with tibial fractures and compartment syndrome reveal that the highest tissue pressures are recorded at the level of the fracture or within 5 cm of the fracture. Tissue pressures show a statistically significant decrease when they are recorded at increasing distances proximal and distal to the site of the highest pressure recorded. To reliably determine the location of the highest tissue pressure in patients with tibial fractures, measurements should be obtained, at a minimum, in both the anterior and deep posterior compartments at the level of the fracture, as well as at locations proximal and distal. The highest tissue pressure recorded should serve as a basis for determining the need for fasciotomy. Heckman MM, Whitesides TE Jr, Grewe SR, Rooks MD: Compartment pressure in association with closed tibial fractures: The relationship between tissue pressure, compartment, and the distance from the site of the fracture. J Bone Joint Surg Am 1994;76:1285-1292.

Question 5474

Topic: 2. Trauma

A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?

. Chronic osteomyelitis
. Planovalgus hindfoot
. Plantar nerve entrapment
. Wound dehiscence
. Painful hardware

Correct Answer & Explanation

. Wound dehiscence

Explanation

The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence. Sanders R: Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.

Question 5475

Topic: 2. Trauma

Figures 4a and 4b show the radiographs of a 53-year-old woman who was injured in a fall. After initial closed reduction, what is the preferred treatment for this fracture?

. Open reduction and internal fixation of the radial head and immobilization
. Medial collateral ligament repair
. Radial head replacement, ulnar nerve transposition, and external fixation
. Coronoid repair, radial head replacement, and lateral ligamentous repair
. Nonsurgical management in a hinged elbow brace

Correct Answer & Explanation

. Coronoid repair, radial head replacement, and lateral ligamentous repair

Explanation

This elbow fracture-dislocation involves a radial head fracture, coronoid fracture, and ulnohumeral dislocation (terrible triad). Several algorithms exist for treatment; surgical treatment is indicated. The treatment should address the radial head. Studies have shown replacement to be superior to repair in comminuted fractures. The coronoid may be addressed in unstable cases at the time of radial head excision and replacement. Lateral ligamentous repair is carried out during closure of the lateral elbow capsule. Medial ligamentous repair also may be undertaken but usually in concert with bony repair. Hinged external fixation remains an option when instability exists following bony and soft-tissue repair. Acute ulnar nerve transposition is rarely indicated. Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551.

Question 5476

Topic: 2. Trauma

A 40 year-old-man was involved in a motor vehicle accident and sustained the pelvic injury seen in Figures 24a and 24b. Definitive management of the injury should consist of reduction by

. skeletal traction and bed rest.
. anterior external fixation.
. internal fixation of the symphysis pubis.
. internal fixation of the symphysis pubis with supplemental external fixation.
. internal fixation of the symphysis pubis and sacral fracture.

Correct Answer & Explanation

. internal fixation of the symphysis pubis and sacral fracture.

Explanation

The radiograph reveals disruption of the symphysis pubis and a displaced left sacral fracture. A posterior injury with displacement of greater than 1 cm is unstable, and a sacral fracture is particularly unstable. Surgical stabilization is required for these unstable anterior and posterior injuries. External fixation provides little stability to an unstable posterior pelvic injury. Reduction and internal fixation of the symphysis pubis and sacral fracture will provide the most stable pelvis with the least resultant deformity and allow patient mobilization. Tile M: Management of pelvic ring injuries, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 168-202.

Question 5477

Topic: 2. Trauma

A 26-year-old woman sustained a nondisplaced femoral neck fracture and treatment consisted of use of percutaneous cannulated screws. At her 3-month follow-up visit, she reports hip pain and is unable to ambulate. A radiograph is shown in Figure 1. What is the next most appropriate treatment?

Trauma 2009 Practice Questions: Set 1 (Solved) - Figure 1

. Bone grafting and revision open reduction and internal fixation
. Hemiarthroplasty
. Dynamic hip screw without angular correction
. Valgus intertrochanteric osteotomy
. Core decompression

Correct Answer & Explanation

. Valgus intertrochanteric osteotomy

Explanation

Femoral neck fracture nonunion is a challenging problem for orthopaedic surgeons. Vertical fractures are more prone to nonunion due to shear stress rather than compressive forces across the fracture site. Several authors have suggested these fractures are more common in young adults due to injury type and bone composition. It is widely regarded that an effort should be made to salvage the femoral head if vascularity remains. The most common method to treat this complication is valgus intertrochanteric osteotomy of the femur. This functionally makes a vertical fracture more horizontal, converting shear into compressive forces. It also helps correct the varus position of the fracture nonunion. Hartford JM, Patel A, Powell J: Intertrochanteric osteotomy using a dynamic hip screw for femoral neck nonunion. J Orthop Trauma 2005;19:329-333.

Question 5478

Topic: 2. Trauma

Figure 13a shows the radiograph of a 9-year-old girl who sustained complete transverse fractures of the radial and ulnar shafts while in-line skating. A manipulative closed reduction is performed, and the result is seen in Figure 13b. What is the next most appropriate step in management?

. Wedge the cast to correct angulation.
. Accept the present alignment and continue follow-up.
. Perform open reduction and internal fixation of both the radius and ulna with plates and screws.
. Perform open reduction and internal fixation of both the radius and ulna with intramedullary rods.
. Remanipulate both the radius and ulna and stabilize with an external fixator.

Correct Answer & Explanation

. Accept the present alignment and continue follow-up.

Explanation

Bayonet apposition of the radius and ulnar shafts is quite acceptable, as long as the angulation is less than 10 degrees. The rotation must be acceptable as well. This patient went on to full healing, with full supination and pronation of the forearm and no cosmetic deformity. Price CT, Scott DS, Kurzner ME, Flynn JC: Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-712.

Question 5479

Topic: Lower Extremity Trauma

A 28-year-old man reports knee stiffness, swelling, and a constant ache that is worse with activity. Examination reveals an effusion, global tenderness, and warmth to the touch. Flexion is limited to 110 degrees. Figures 48a through 48d show sagittal T1-weighted, sagittal T2-weighted, axial T1-weighted fat-saturated gadolinium, and axial gradient echo MRI scans. Based on these findings, what is the most likely diagnosis?

. Infection
. Arthritis
. Synovial chondromatosis
. Pigmented villonodular synovitis (PVNS)
. Reactive synovitis

Correct Answer & Explanation

. Pigmented villonodular synovitis (PVNS)

Explanation

The MRI scans show multiple low-signal intensity lesions scattered throughout the knee, extending posteriorly inferior to the tibial plateau. The low-signal intensity on both the T1- and T2-weighted images, the modest vascularity noted on the gadolinium image, and the "blooming" noted on the gradient echo image (ferrous-laden tissue) are all strongly suggestive of diffuse PVNS. Whereas synovial chondromatosis can present as diffuse masses in the knee, they present as nodule masses that have low T1- and high T2-weighted signal characteristics. Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 4241-4252.

Question 5480

Topic: 2. Trauma

A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals that the knee is held in 45 degrees of flexion, and any attempt to actively or passively extend the knee produces pain and muscle spasms. A lateral radiograph is shown in Figure 4. What is the most likely diagnosis?

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 9

. Patellar sleeve fracture
. Avulsion of the tibial tubercle
. Avulsion of the anterior tibial spine
. Osteochondral fracture of the femoral condyle
. Osteochondral fracture of the patella

Correct Answer & Explanation

. Patellar sleeve fracture

Explanation

This is a typical patellar sleeve fracture. The patellar tendon avulses a portion of the distal bony patella, along with the retinaculum and articular cartilage from the inferior pole of the patella. It is common in children between ages 8 and 10 years. Anatomic reduction and repair of the extensor mechanism are mandatory to reestablish full knee extension. Houghton GR, Ackroyd CE: Sleeve fractures of the patella in children: A report of three cases. J Bone Joint Surg Br 1979;61:165-168.

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