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2. Trauma MCQs

Practice Set 275 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 5481

Topic: 2. Trauma

Figures 32a and 32b show the radiographs of a 13-year-old right hand-dominant boy who sustained a closed Salter-Harris type II fracture of the proximal humerus during a hockey game. The shoulder has significant swelling, but is neurovascularly intact. What treatment offers the best chance of reestablishing normal shoulder motion?

. Closed reduction and application of a shoulder spica cast in the outpatient setting
. Closed reduction under fluoroscopy and application of a shoulder spica cast in the operating room
. No active reduction and placement of the upper extremity in a shoulder immobilizer
. Closed or open reduction and percutaneous pin stabilization
. Open reduction and internal fixation

Correct Answer & Explanation

. Closed or open reduction and percutaneous pin stabilization

Explanation

The patient has a significantly angulated proximal humerus fracture with a high degree of varus angulation, and rotational malalignment is likely. Failure to correct the varus angulation will result in permanent loss of shoulder abduction because the patient's age limits bony remodeling. These fractures are inherently unstable due to the inability to control the proximal fracture alignment. Shoulder spica casts have a high rate of redisplacement after treatment. Adequate open or closed reduction and pin fixation in the operating room optimizes alignment and all but eliminates the chance of redisplacement. Dobbs MB, Luhmann SJ, Gordon JE, et al: Severely displaced proximal humerus epiphyseal fractures. J Pediatr Orthop 2003;23:208-215. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, p 701.

Question 5482

Topic: 2. Trauma
A 19-year-old man was struck by a car and is seen in the emergency department with a grade IIIC open distal tibia and fibula fracture. Examination reveals that the toes are cool and dusky with a sluggish capillary refill. Angiography reveals a lesion in the posterior tibial artery amenable to repair. There is no sensation on the plantar aspect of the foot, and he is unable to flex his toes. A clinical photograph and radiograph are shown in Figures 2a and 2b. What is the next most appropriate step in management?
. Irrigation and debridement with immediate intramedullary fixation, vascular repair, and primary closure
. Irrigation and debridement with external fixation, vascular repair, and delayed closure
. Irrigation and debridement with external fixation, vascular repair, exploration of the tibial nerve, and delayed closure
. Guillotine amputation at the fracture site with delayed closure
. Immediate below-knee amputation

Correct Answer & Explanation

. Irrigation and debridement with external fixation, vascular repair, and delayed closure

Explanation

In the past, loss of plantar sensation in this grade IIIC tibial fracture would have been an indication for below-knee amputation regardless of the potential for vascular repair. However, the 2002 LEAP study divided 55 patients with loss of plantar sensation into two groups, the insensate amputation group and the insensate limb salvage group, with 55% of patients in the insensate salvage group regaining normal sensation 2 years after injury. Furthermore, those in the salvage group who remained insensate after 2 years had equivalent outcomes to those in the amputation group. Because of these findings, limb salvage with vascular repair and external stabilization with delayed closure is deemed appropriate treatment. Immediate intramedullary fixation is not indicated. Because ischemia, contusion, and stretch can adversely affect the tibial nerve, the additional insult of exploration of the nerve is also not advisable given the soft-tissue compromise.

Question 5483

Topic: Pelvic & Acetabular Trauma

Which of the following conditions is associated with palmoplantar pustulosis?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 2) - Figure 6

. Condensing osteitis
. Sternoclavicular hyperostosis
. Friedreich's disease
. Scleroderma
. Reiter syndrome

Correct Answer & Explanation

. Sternoclavicular hyperostosis

Explanation

Sternoclavicular hyperotosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis. Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA, WB Saunders, 2004, vol 2, pp 608-609.

Question 5484

Topic: 2. Trauma

Figure 42 shows the radiograph of a 70-year-old woman who has had a painful near ankylosis of her dominant elbow for 1 year. Treatment should consist of

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

. total elbow replacement.
. hardware removal and joint release.
. medial and lateral column humerus plating and a bone graft.
. distal humerus replacement.
. resection arthroplasty.

Correct Answer & Explanation

. total elbow replacement.

Explanation

The patient has arthritis and supracondylar nonunion of the elbow. Total elbow replacement has been shown to give almost immediate return of function as it can be performed while leaving the triceps intact and resecting the distal humerus fragment. Attempts at osteosynthesis are indicated in younger individuals with good joint surface. Resection arthroplasty yields poor function and is reserved as a salvage procedure. Ramsey ML, Morrey BF: Total elbow arthroplasty for nonunion and dysfunctional instability, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 655-661.

Question 5485

Topic: 2. Trauma

Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of

Sports Medicine 2007 Practice Questions: Set 1 (Solved) - Figure 27

. cast immobilization for 6 weeks.
. brief immobilization followed by rest for 6 weeks.
. internal fixation with a compression screw.
. internal fixation with a tension band wire.
. bone stimulation.

Correct Answer & Explanation

. cast immobilization for 6 weeks.

Explanation

The CT scan shows a stress fracture of the olecranon. This injury is the result of repetitive abutment of the olecranon into the olecranon fossa, traction from triceps activity during the deceleration phase of the throwing motion, and impaction of the medial olecranon onto the olecranon fossa from valgus forces. Fractures may be either transverse or oblique in orientation. Initial treatment consists of rest and temporary splinting. Electrical bone stimulation may also be considered. Open fixation with a large compression screw is recommended when nonsurgical management has failed to provide relief. Ahmad CS, ElAttrache NS: Valgus extension overload syndrome and stress injury of the olecranon. Clin Sports Med 2004;23:665-676.

Question 5486

Topic: 2. Trauma

A 64-year-old man with a history of diabetes mellitus underwent open reduction and internal fixation of a displaced ankle fracture 8 weeks ago. Examination now reveals recent onset erythema, warmth, and swelling of the midfoot. Radiographs are shown in Figures 23a through 23d. What is the most likely reason for the swelling of the foot?

. Infection
. Charcot arthropathy
. Delayed compartment syndrome
. Deep venous thrombosis
. Gout

Correct Answer & Explanation

. Charcot arthropathy

Explanation

A Charcot flare in adjacent joints is not uncommon in patients with neuropathy who undergo surgery or other trauma. Venous thrombosis would present with swelling of the entire leg, while infection would present earlier in the postoperative period. The radiographs are pathognomonic of Charcot arthropathy, not an unrecognized fracture or gout. A compartment syndrome this late after injury is extremely rare, and there would be no bony distraction associated with compartment syndrome.

Question 5487

Topic: 2. Trauma

A 30-year-old man falls off a 7-foot ladder and sustains the injury seen in the radiograph and the CT scan shown in Figures 39a and 39b. Medical history is negative. Management of this injury should include which of the following?

. Closed treatment and casting
. Open reduction and internal fixation
. Primary subtalar arthrodesis
. Percutaneous fixation
. External fixation

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

A Sanders type 2 intra-articular calcaneus fracture in a young healthy nonsmoker is best treated with open reduction and internal fixation. Whereas nonsurgical management is an option, Buckley and associates have shown that these fractures have a better outcome with surgical care. Percutaneous fixation is reserved for tongue-type fractures and subtalar arthrodesis is used in some type 4 fractures. External fixation has not been shown to be advantageous in closed fractures. Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744. Sanders R: Displaced intraarticular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.

Question 5488

Topic: 2. Trauma

A 24-year-old man sustains an injury to his right elbow after falling 10 feet. Radiographs are shown in Figures 41a and 41b. Treatment should consist of

. open reduction and internal fixation, followed by casting.
. open reduction and internal fixation, followed by early range of motion.
. open reduction and internal fixation, medial collateral ligament repair, and early range of motion.
. open reduction and internal fixation of the ulna, application of a hinged external fixator, and early range of motion.
. closed reduction and splinting, followed by early range of motion.

Correct Answer & Explanation

. open reduction and internal fixation, followed by early range of motion.

Explanation

Transolecranon fracture-dislocations are most effectively managed with open reduction and internal fixation, followed by early aggressive range of motion. Concomitant injury to the collateral ligament is rare, and stability is achieved by anatomic reconstruction of the olecranon fracture with rigid fixation. The need for collateral ligament repair or a hinged external fixator is uncommon in this fracture pattern.

Question 5489

Topic: 2. Trauma

A 55-year-old man sustained an isolated closed fracture of the humerus. Initial neurologic examination reveals no active wrist or finger extension. Radiographs are shown in Figures 28a and 28b. Management should consist of

. closed treatment and observation for return of nerve function.
. closed treatment and immediate tendon transfer.
. open nerve exploration without internal fixation of the fracture.
. open nerve exploration with plating of the fracture.
. open nerve exploration with intramedullary rodding of the fracture.

Correct Answer & Explanation

. closed treatment and observation for return of nerve function.

Explanation

The patient has an isolated closed injury involving the humeral diaphysis. The lack of wrist and finger extension indicates injury to the radial nerve. Based on these findings, ongoing observation of the nerve is warranted with delayed exploration after 3 to 4 months if there are no signs of progressive return of nerve function. Treatment of the fracture should include external immobilization and fracture bracing. An indication for nerve exploration and surgical stabilization would be an open fracture. Zuckerman JD, Kovil KJ: Fractures of the shaft of the humerus, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green's Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 1025-1053.

Question 5490

Topic: 2. Trauma

A 30-year-old woman sustained a nondisplaced unilateral facet fracture of C5 in a motor vehicle accident. She is neurologically intact and has no other injuries. Management should consist of

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 33

. skeletal tong traction for 6 weeks.
. halo application.
. immobilization in a rigid collar for 6 weeks.
. open reduction posteriorly with interspinous wiring and bone grafting.
. open reduction anteriorly with diskectomy, interbody grafting, and plating.

Correct Answer & Explanation

. immobilization in a rigid collar for 6 weeks.

Explanation

The patient has a stable bony fracture that will heal with immobilization in a rigid collar. Flexion-extension radiographs may be obtained at 6 weeks to verify that there is no instability; mobilization may then be begun.

Question 5491

Topic: 2. Trauma

A 46-year-old man fell 20 feet and sustained the injury shown in Figure 3. The injury is closed; however, the soft tissues are swollen and ecchymotic with blisters. The most appropriate initial management should consist of

Trauma 2006 Practice Questions: Set 1 (Solved) - Figure 6

. a long leg cast.
. a short leg cast.
. immediate open reduction and internal fixation.
. a temporizing spanning external fixator.
. primary ankle fusion.

Correct Answer & Explanation

. a temporizing spanning external fixator.

Explanation

Although this is a fracture of the medial and lateral malleoli, the degree of displacement and comminution of the medial dome indicate that this injury is similar to a pilon fracture. Initial management should consistent of stabilization to allow for soft-tissue healing. The use of temporizing spanning external fixation should be the initial step, followed by limited or more extensive open reduction and internal fixation when the soft-tissue status will allow. Initial placement in either a short or long leg cast does not provide the needed stability and does not allow for care and monitoring of soft tissues. In addition, maintaining reduction of the talus may be very difficult. Immediate open reduction and internal fixation through an injured soft-tissue envelope adds the risk of difficulties with incision healing and a higher risk of deep infection. In the acute setting, a primary ankle fusion through this soft-tissue envelope is not indicated. Marsh JL, Bonar S, Nepola JV, et al: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509. Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am 1996;78:1646-1657.

Question 5492

Topic: 2. Trauma

A 25-year-old patient who sustained multiple bilateral rib fractures, a pulmonary contusion, a left nondisplaced transtectal acetabular fracture, and a closed humerus fracture in a motor vehicle accident 2 weeks ago is transferred from another hospital. The humerus fracture has been surgically treated. There are no signs of infection, and the trauma surgeon wants to mobilize the patient as soon as possible. Radiographs are shown in Figures 15a and 15b. Management of the humerus fracture should consist of

. open reduction and plate fixation.
. a humeral fracture brace.
. a locking intramedullary nail.
. insertion of at least two additional pins.
. removal of the pins and a long arm hanging cast.

Correct Answer & Explanation

. open reduction and plate fixation.

Explanation

The radiographs show a distal third humerus fracture that is angulated, rotated, and not rigidly fixed. Rigid fixation is needed because mobilization is highly desirable to improve pulmonary function. The acetabular fracture is through the weight-bearing dome but is nondisplaced. Nonsurgical management of the acetabular fracture requires at least 6 weeks of touchdown weight bearing to minimize the forces across the hip joint. Open reduction and plate fixation would achieve anatomic reduction and immediate mobilization. A single posterolateral 4.5-mm plate or two 3.5-mm plates at 90 degrees are possible alternatives. Immediate weight bearing on a plated humerus fracture with the use of crutches or a walker has been shown to be safe and would allow touchdown weight bearing, protecting the hip. None of the other options would achieve this goal for this distal fracture.

Question 5493

Topic: 2. Trauma

Figures 20a through 20c show the radiographs of a 69-year-old woman who has severe pain in her dominant right arm after falling on the ice. History includes arthritis, hypertension, and heart disease. She is neurovascularly intact. Management should consist of

. a long arm cast.
. immediate functional bracing.
. closed reduction and percutaneous pin fixation.
. percutaneous olecranon pin traction.
. total elbow arthroplasty.

Correct Answer & Explanation

. total elbow arthroplasty.

Explanation

The radiographs reveal a severely comminuted distal humerus fracture. A long arm cast, functional bracing, and closed reduction and percutaneous pin fixation all have a poor outcome and could result in a nonunion that will be very difficult to treat. Open reduction and internal fixation is indicated in most supracondylar humerus fractures, but total elbow arthroplasty is a good alternative in elderly patients who have multiple medical problems and when the fracture pattern may preclude stable enough internal fixation to allow postoperative motion. Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997;79:826-832.

Question 5494

Topic: 2. Trauma

Figure 23 shows the radiograph of an elderly man who fell on his right arm. What is the most important determinate of a good outcome following this injury?

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 26

. Early open reduction and internal fixation
. Initiation of physical therapy and passive motion within 2 weeks of the injury
. Fracture involvement of the greater tuberosity
. Immobilization with a sling and swathe for 4 weeks
. Age of younger than 70 years

Correct Answer & Explanation

. Initiation of physical therapy and passive motion within 2 weeks of the injury

Explanation

Minimally displaced fractures of the proximal humerus have a good outcome if physical therapy is initiated within 2 weeks of the injury. Results are not affected by age, open reduction and internal fixation, or involvement of the greater tuberosity. Immobilization for longer than 3 weeks will often result in stiffness. Koval KJ, Gallagher MA, Marsicano JG, et al: Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am 1997;79:203-207.

Question 5495

Topic: 2. Trauma
Figure 7 shows the radiograph of an otherwise healthy 65-year-old man who injured his right dominant shoulder while skiing 18 months ago. He did not seek treatment at the time of the injury. He now reports intermittent soreness when playing golf but has no other limitations. Examination reveals full range of motion and no tenderness, but he has slight pain with a crossed arm adduction stress test. He is neurologically intact. Initial management should consist of
. excision of the distal clavicle.
. open reduction and internal fixation with intramedullary partial threaded pins.
. open reduction and internal fixation with a reconstruction plate, screws, and bone grafting.
. bone grafting and use of heavy sutures to secure the clavicle to the coracoid.
. observation and nonsteroidal anti-inflammatory drugs.

Correct Answer & Explanation

. observation and nonsteroidal anti-inflammatory drugs.

Explanation

The radiograph shows a displaced type II distal clavicle fracture with nonunion. Because the patient's symptoms are minimal, the injury can be treated like a grade III acromioclavicular separation. Present management should consist of ice, anti-inflammatory drugs, activity modification, and perhaps physical therapy. If nonsurgical management fails to provide relief, the surgical options are varied with no uniformity in the literature regarding surgical treatment of this injury.

Question 5496

Topic: Upper Extremity Trauma

Figure 35 shows the radiograph of a 35-year-old weightlifter who has had pain with overhead lifts for the past 7 months. Cortisone injections in the acromioclavicular joint provided only temporary relief. A bone scan reveals increased activity of the acromioclavicular joint. Treatment should now consist of

Sports Medicine Board Review 2004: High-Yield MCQs (Set 4) - Figure 5

. rotator cuff interval closure.
. distal clavicle excision.
. superior labrum anterior and posterior repair.
. biceps tenodesis.
. thermal capsulorrhaphy.

Correct Answer & Explanation

. distal clavicle excision.

Explanation

Osteolysis of the distal clavicle is common in weightlifters; therefore, distal clavicle excision is the treatment of choice. A subacromial decompression alone would not alleviate the acromioclavicular joint symptoms. Interval closure, biceps degeneration, and superior labrum anterior and posterior repair would limit superior migration but would not explain the abnormal bone scan. Thermal capsular shrinkage does not have a role here. Flatow EL, Cordasco FA, McCluskey GM, Bigliani LU: Arthroscopic resection of the distal clavicle via a superior portal: A critical quantitative radiographic assessment of bone removal. Arthroscopy 1990;6:153-154.

Question 5497

Topic: Pelvic & Acetabular Trauma

A patient with severe rheumatoid arthritis reports progressive hip pain. Serial hip radiographs will most likely show which of the following findings?

. Asymmetric joint space narrowing
. Sacroiliac joint ankylosis
. Progressive superior and lateral migration of the femoral head
. Periarticular osteopenia
. Hip synovitis

Correct Answer & Explanation

. Progressive superior and lateral migration of the femoral head

Explanation

Radiographic findings in patients with rheumatoid arthritis include symmetric joint space narrowing, periacetabular and femoral head erosions, and diffuse periarticular osteopenia. In advanced stages, protrusio acetabuli is a common finding. Ranawat and associates have shown a rate of superior femoral head migration of 4.5 mm per year and medial (axial) migration of 2.5 mm per year. Asymmetric joint space narrowing is a classic radiographic finding of degenerative arthrosis. Sacroiliac joint ankylosis commonly occurs in ankylosing spondylitis. Hip synovitis is a pathologic diagnosis, not a radiographic finding. Lachiewicz PF: Rheumatoid arthritis of the hip. J Am Acad Orthop Surg 1997;5:332-338.

Question 5498

Topic: 2. Trauma

A 32-year-old man has an open comminuted humeral shaft fracture. Examination reveals absence of sensation in the first web space and he is unable to fully extend the thumb, fingers, and wrist. What is the recommended treatment following irrigation and debridement of the fracture?

General Orthopedics Board Review 2026: High-Yield MCQs (Set 20) - Figure 23

. Functional bracing
. Hanging long arm cast immobilization
. Intramedullary nailing
. Open reduction and internal fixation, radial nerve exploration
. External bone stimulator

Correct Answer & Explanation

. Open reduction and internal fixation, radial nerve exploration

Explanation

There is a high incidence of partial or complete laceration of the radial nerve with high-energy open fractures of the humeral shaft. The recommended treatment is irrigation and debridement of the fracture followed by open reduction and internal fixation and exploration of the radial nerve. If the nerve is completely lacerated, primary repair may be performed but poor outcomes have been reported. If a large zone of nerve injury is identified, delayed nerve grafting is advocated. Ring D, Chin K, Jupiter JB: Radial nerve palsy associated with high energy humeral shaft fractures. J Hand Surg 2004;29:144-147. Foster RJ, Swiontkowski MR, Bach AW, et al: Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am 1993;18:121-124.

Question 5499

Topic: 2. Trauma

A 31-year-old man sustained a closed injury to his arm in a motor vehicle accident 16 months ago. Treatment of the fracture consisted of intramedullary nailing of the humerus. He now reports pain with minimal activities. Clinical examination and laboratory studies suggest no signs of infection. Radiographs are seen in Figures 12a through 12c. Treatment should now consist of

. open reduction and exchange humeral nailing.
. a custom orthosis and an external bone stimulator.
. removal of the humeral nail and external fixation.
. removal of the humeral nail and plate fixation with bone grafting.
. open bone grafting and an internal bone stimulator.

Correct Answer & Explanation

. removal of the humeral nail and plate fixation with bone grafting.

Explanation

The use of locked nailing for the treatment of established nonunion of the humerus has produced poor results. Since humeral nailing has already failed, exchange humeral nailing without bone grafting has an even less change of success. To increase the likelihood of achieving bony union, the treatment of choice is removal of the humeral nail, dynamic compression plating, and bone grafting. Zuckerman J, Giordanno C, Rosen H: Treatment of humeral shaft non-unions, in Bigliani L (ed): Complications of shoulder surgery. Baltimore, MD, William & Wilkins, 1993, pp 173-190.

Question 5500

Topic: 2. Trauma

A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?

. MRI scan
. Physical examination
. Workers' compensation status
. Surgeon availability
. Patient age

Correct Answer & Explanation

. Physical examination

Explanation

The most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.

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