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2. Trauma MCQs

Practice Set 276 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 5501

Topic: 2. Trauma

A 42-year-old man sustained the periprosthetic fracture shown in Figures 19a and 19b. The femoral component is well fixed. What is the next most appropriate step in management?

. Closed reduction and bracing
. Retrograde femoral intramedullary nailing
. Open reduction and internal fixation of the fracture, leaving the femoral stem in place
. Open reduction and internal fixation of the fracture and insertion of a proximally porous-coated stem
. Open reduction and internal fixation of fracture fragments and insertion of a fully porous-coated femoral stem with diaphyseal fixation distal to the fracture

Correct Answer & Explanation

. Open reduction and internal fixation of the fracture, leaving the femoral stem in place

Explanation

The patient has a periprosthetic fracture below the femoral stem. The component is porous coated and well fixed. Open reduction and internal fixation, leaving the stem in place, can be performed when bone quality is good. Plating with or without allograft struts and supplemental cerclage fixation generally is acceptable. If the component is loose, revision to a longer device is recommended with appropriate stabilization of the fracture using the aforementioned methods. If bone loss has occurred, allograft supplementation or a tumor prosthesis may be indicated. Fractures located well below the stem tip can be treated without regard for the prosthesis. Closed reduction and bracing is not associated with good results for periprosthetic femoral fractures. Retrograde intramedullary nailing is not appropriate for this fracture. Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304.

Question 5502

Topic: Upper Extremity Trauma
The use of a screw between the clavicle and the coracoid process to maintain the clavicle and acromioclavicular (AC) joint in a reduced position is a treatment option for AC joint separations. Screw removal is generally recommended after soft-tissue healing. What effect does this rigid coracoclavicular fixation have on shoulder kinematics?
. Significant limitation of humeral elevation
. Significant limitation of shoulder abduction
. Significant loss of motion in all directions
. Little to no limitation of shoulder range of motion
. Limitation of humeral rotation

Correct Answer & Explanation

. Little to no limitation of shoulder range of motion

Explanation

This issue has been debated since Inman published his classic study on clavicular rotation in 1944. Subsequently, it has been shown by several authors that the clinical evaluation of patients with either coracoclavicular screws in place or with arthrodesis of the coracoclavicular reveals little to no loss of shoulder motion. This is most likely the result of synchronous motion of the scapula and clavicle in shoulder movements.

Question 5503

Topic: 2. Trauma

A 6-year-old girl is referred for the elbow injury seen in Figure 2. What is the most appropriate treatment?

Pediatrics 2007 Practice Questions: Set 1 (Solved) - Figure 7

. Immobilization in a long arm cast for 3 weeks
. Immobilization in a long arm cast for 8 weeks
. Open reduction and immobilization in a long-arm cast for 3 weeks
. Open reduction and internal fixation with smooth pins
. Open reduction and internal fixation with a screw

Correct Answer & Explanation

. Open reduction and internal fixation with smooth pins

Explanation

The patient has a displaced lateral condyle fracture; therefore, simple immobilization for 3 to 8 weeks is likely to result in malunion or nonunion. Closed reduction of such injuries is rarely successful. The fracture is unstable, so fixation is required after open reduction. Because the fixation must cross the physis, smooth pins are indicated for the skeletally immature elbow. Open reduction with fixation has been shown to reduce the risk of delayed union and malunion. Beaty JH, Kasser JR: The elbow: Physeal fractures, apophyseal injuries of the distal humerus, avascular necrosis of the trochlea, and T-condylar fractures, in Beaty JH, Kasser JR (eds): Fractures in Children, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 625-703. Rutherford A: Fractures of the lateral humeral condyle in children. J Bone Joint Surg Am 1985;67:851-856.

Question 5504

Topic: 2. Trauma

An 11-year-old girl sustained an injury to her right foot when a 500-lb headstone fell on it. The headstone was removed after 3 minutes. Radiographs show multiple midfoot fractures. Examination reveals severe pain that is worse with passive toe motion. Clinical photographs are shown in Figure 28. Management should consist of

Foot & Ankle 2006 Practice Questions: Set 3 (Solved) - Figure 11

. a short leg cast and elevation of the foot.
. fasciotomies of the foot.
. MRI.
. CT.
. stress radiographs.

Correct Answer & Explanation

. fasciotomies of the foot.

Explanation

The patient has a classic history and examination for an acute compartment syndrome of the foot. CT, MRI, or stress radiographs are not necessary prior to emergent fasciotomies of the foot. These studies can be performed after the initial fasciotomies to determine the best long-term management of the fractures. There are nine compartments in the foot. These are decompressed through three incisions (two on the dorsal foot and one medially). A short leg cast does not address the compartment syndrome and could be limb threatening with excessive swelling in a circumferential cast. It is preferable to splint severe crush injuries rather than apply a cast. Fulkerson E, Razi A, Tejwani N: Review: Acute compartment syndrome of the foot. Foot Ankle Int 2003;24:180-187.

Question 5505

Topic: 2. Trauma

The management of a complex multifragmentary diaphyseal fracture of either the tibia or femur has changed during the last decade. Which of the following principles of treatment is now considered less important?

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 23

. Anatomic alignment
. Indirect reduction
. Anatomic reduction of the fragments
. Relatively stable fixation
. Functional aftercare

Correct Answer & Explanation

. Anatomic alignment

Explanation

Although the original concept of internal fixation was one of anatomic reduction and stable fixation, over the past 10 to 15 years there has been a change based on the advent of intramedullary nailing and bridge plating. It is now appreciated that in a multifragmentary diaphyseal fracture, particularly of the lower extremity, the achievement of axis alignment (mechanical and anatomic axis) is all that is required. Healing will occur by callus. Relatively stable fixation is achieved through intramedullary nailing or bridge plating, providing adequate pain relief for functional aftercare. Perren SM, Claes L: Biology and mechanics of fracture management, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 7-32. deBoer P: Diaphyseal fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 93-104.

Question 5506

Topic: 2. Trauma

A 24-year-old female soccer player has had lateral joint line pain and a recurrent effusion in the left knee after sustaining a twisting injury 6 weeks ago. She reports that symptoms worsen with athletic activities. MRI scans are shown in Figures 2a through 2c. What is the most likely diagnosis?

. Osteochondral fracture of the lateral femoral condyle
. Trabecular injury of the lateral tibial plateau
. Lateral meniscal tear with a parameniscal cyst
. Fibular collateral ligament tear
. Discoid lateral meniscal tear

Correct Answer & Explanation

. Discoid lateral meniscal tear

Explanation

The MRI scans show the typical findings of a torn discoid lateral meniscus. The average transverse diameter of the lateral meniscus is 11 or 12 mm. A discoid lateral meniscus is suggested when three or more contiguous 5-mm sagittal sections on the MRI scan show continuity of the menicus between the anterior and posterior horns, or when two adjacent peripheral sagittal 5-mm sections show equal meniscal height. Normally the black "bow tie" would be seen on two contiguous sagittal sections. The presence of a discoid meniscus can be further confirmed if coronal views reveal increased width. Jordan MR: Lateral meniscal variants: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:191-200.

Question 5507

Topic: 2. Trauma

A 7-year-old girl has pain and swelling of the right elbow after falling off her bicycle. Radiographs are shown in Figure 31. What is the most appropriate initial step in management?

Trauma 2006 Practice Questions: Set 3 (Solved) - Figure 9

. Cast immobilization in the current position for 6 weeks
. Closed reduction and cast immobilization for 6 weeks
. Reduction and internal fixation with Kirschner wires
. Arthrography to assess articular surface congruity
. MRI to assess articular congruity

Correct Answer & Explanation

. Cast immobilization in the current position for 6 weeks

Explanation

Lateral condylar fractures are challenging to treat because of late displacement and development of a nonunion that may lead to valgus instability, pain, or tardy ulnar nerve palsy. Fractures such as this one with more than 2 mm of displacement on any radiographic view are prone to nonunion and should be stabilized. Fractures with less than 2 mm of displacement usually are stable and may be treated nonsurgically. In these patients, careful follow-up is recommended within several days of casting to check for fracture displacement. Arthrography or MRI may be helpful in these minimally displaced fractures. Fractures with an intact articular cartilage surface, such as noted on these studies, are unlikely to displace further. Finnbogason T, Karlsson G, Lindberg L, et al: Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: A prospective radiographic investigation of fracture stability. J Pediatr Orthop 1995;15:422-425. Attarian DE: Lateral condyle fractures: Missed diagnoses in pediatric elbow injuries. Mil Med 1990;155:433-434. Flynn JC: Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-696.

Question 5508

Topic: 2. Trauma

A 21-year-old collegiate wrestler sustains a blow to his right eye during a match. Examination reveals anisocoria with a dilated right pupil. The globe is properly formed, and extra-occular movements and the visual field are grossly intact. What is the most likely diagnosis?

Sports Medicine 2004 Practice Questions: Set 1 (Solved) - Figure 1

. Traumatic mydriasis
. Detached retina
. Dislocated lens
. Corneal abrasion
. Traumatic hyphema

Correct Answer & Explanation

. Traumatic mydriasis

Explanation

Traumatic mydriasis occurs from a contusion to the iris sphincter. This is a transient phenomenon during which the iris fails to constrict properly, resulting in a dilated pupil. More severe trauma can result in a tear of the sphincter and permanent pupillary deformity. In association with head injury, traumatic anisocoria would be a concerning indicator of the severity of injury. Retinal detachment, lens dislocation, corneal abrasion, and traumatic hyphema are all potential results of eye injury but are not reflected by this clinical description. Brucker AJ, Kozart DM, Nichols CW, Irving MR: Diagnosis and management of injuries to the eye and orbit, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face, ed 2. St Louis, MO, Mosby Year Book, 1991, pp 650-670.

Question 5509

Topic: 2. Trauma

A 17-year-old man sustained a 5-mm laceration on the lateral aspect of the hindfoot while working on a farm. Examination in the emergency department revealed no fractures. Twenty-four hours later, he returns to the emergency department with increasing foot pain. Thin brown drainage is seen emanating from the wound. He has a temperature of 102.0 degrees F (38.9 degrees C), a pulse rate of 120, and a blood pressure of 80/40 mm Hg. Examination of the foot reveals diffuse swelling, ecchymosis, tenderness, and crepitus with palpation. Current radiographs are shown in Figures 40a and 40b. Management should now consist of

. intravenous antibiotics.
. hyperbaric oxygen therapy and intravenous antibiotics.
. surgical debridement, primary wound closure, and intravenous antibiotics.
. surgical debridement, closure of the wound over drains, and intravenous antibiotics.
. surgical debridement, leaving the wound open, and intravenous antibiotics.

Correct Answer & Explanation

. surgical debridement, leaving the wound open, and intravenous antibiotics.

Explanation

The mechanism and environment in which the injury occurred, the clinical picture, and the radiographic findings of gas in the tissues suggest an anaerobic Gram-positive bacterial infection. This can be a life- and limb-threatening infection. Treatment should consist of wide debridement of all devitalized tissue, and intravenous antibiotics should be started. Wounds should be left open to allow bacterial effluent and increase oxygen tension in the wound. Hyperbaric oxygen may be used as an adjuvant but is no substitute for debridement. Pellegrini VD, Reid JS, Evarts CM: Complications, in Rockwood CA, Green DP, Bucholz RW, et al (eds): Rockwood and Green's Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 1, pp 458-463.

Question 5510

Topic: Pelvic & Acetabular Trauma

A 30-year-old male is involved in a motorcycle collision. Radiographs demonstrate a displaced symphysis pubis (3.5 cm) and widening of the left sacroiliac joint. He remains hypotensive despite 2 liters of crystalloid and 2 units of packed RBCs. A pelvic binder was properly placed in the field. What is the most appropriate next step in management?

. CT scan of the abdomen and pelvis
. Open reduction and internal fixation of the symphysis pubis
. Pre-peritoneal pelvic packing and/or angioembolization
. Application of an external fixator
. Exploratory laparotomy

Correct Answer & Explanation

. Pre-peritoneal pelvic packing and/or angioembolization

Explanation

In a hemodynamically unstable patient with a pelvic ring injury, despite initial resuscitation and mechanical stabilization (pelvic binder), the immediate priority is hemorrhage control. This is best achieved via pre-peritoneal pelvic packing or angioembolization, depending on institutional protocol. CT is contraindicated in hemodynamically unstable patients.

Question 5511

Topic: 2. Trauma

An 82-year-old female presents after a fall at home. Imaging is shown:

She is diagnosed with an unstable intertrochanteric femur fracture. Which of the following anatomic patterns defines an unstable intertrochanteric fracture?

. Two-part fracture with a non-displaced lesser trochanter
. Intact posteromedial calcar cortex
. Reverse obliquity pattern
. Fracture line extending proximal to the vastus ridge
. Non-displaced transcervical extension

Correct Answer & Explanation

. Intact posteromedial calcar cortex

Explanation

Unstable intertrochanteric fracture patterns inherently resist stable reduction and include: reverse obliquity fractures, subtrochanteric extension, large posteromedial comminution (loss of the calcar support), and lateral wall blowout. An intact posteromedial cortex or simple two-part fractures are generally considered stable.

Question 5512

Topic: Pelvic & Acetabular Trauma
A 45-year-old male presents after a high-speed crush injury to the pelvis. Imaging demonstrates an Anteroposterior Compression Type III (APC-III) pelvic ring disruption with severe pubic symphysis diastasis and bilateral sacroiliac joint disruption. Severe hemodynamic instability in this specific fracture pattern is most frequently due to disruption of which of the following structures?
. Superior gluteal artery
. Internal pudendal artery
. External iliac artery
. Posterior venous plexus
. Corona mortis

Correct Answer & Explanation

. Posterior venous plexus

Explanation

The vast majority (80-90%) of major hemorrhage in pelvic ring injuries is venous in origin, particularly from the pre-sacral (posterior) venous plexus. If an arterial source is present, Anteroposterior Compression (APC) patterns classically injure branches of the anterior division of the internal iliac artery (such as the pudendal or obturator arteries), whereas Lateral Compression (LC) injuries more commonly injure the posterior division branches, specifically the superior gluteal artery.

Question 5513

Topic: 2. Trauma

A 30-year-old male is evaluated in the emergency department for a severe crush injury to his lower leg. He has pain out of proportion to exam and paresthesias in the first dorsal web space. Continuous compartment pressure monitoring is initiated. His absolute anterior compartment pressure is 45 mmHg. His mean arterial pressure (MAP) is 75 mmHg, and his diastolic blood pressure is 60 mmHg. According to current evidence-based guidelines, which of the following criteria is the strongest physiological indication for emergent four-compartment fasciotomy?

. Absolute compartment pressure > 30 mmHg
. Delta pressure (Diastolic BP - Compartment Pressure) < 30 mmHg
. Delta pressure (MAP - Compartment Pressure) < 40 mmHg
. Presence of subjective paresthesias in the deep peroneal nerve distribution
. Pain with passive stretch of the extensor hallucis longus

Correct Answer & Explanation

. Delta pressure (Diastolic BP - Compartment Pressure) < 30 mmHg

Explanation

While clinical exam is critical, in patients requiring objective pressure monitoring, the 'Delta pressure' is the most reliable threshold for diagnosing acute compartment syndrome. A Delta pressure (calculated as Diastolic Blood Pressure minus the Compartment Pressure) of less than 30 mmHg represents critical hypoperfusion to the tissue capillary beds and is an absolute indication for emergent fasciotomy. Absolute pressure alone >30 mmHg has a high false-positive rate and can lead to unnecessary surgeries.

Question 5514

Topic: Lower Extremity Trauma

A 45-year-old male sustains a high-energy posterior bicondylar tibial plateau fracture (Schatzker VI). The surgeon plans a posteromedial approach to directly buttress the posteromedial shear fragment. During the superficial dissection of this approach, the internervous/intermuscular plane is typically developed between which two anatomical structures?

. Semitendinosus and semimembranosus
. Medial head of the gastrocnemius and the pes anserinus tendons
. Lateral head of the gastrocnemius and the soleus
. Tibialis posterior and the flexor digitorum longus
. Sartorius and gracilis

Correct Answer & Explanation

. Medial head of the gastrocnemius and the pes anserinus tendons

Explanation

The posteromedial approach to the tibial plateau is indicated for addressing posteromedial shear fragments. The surgical interval is developed between the pes anserinus tendons (sartorius, gracilis, semitendinosus) anteriorly and the medial head of the gastrocnemius posteriorly. Retracting the pes anteriorly and the medial gastrocnemius posteriorly protects the neurovascular structures in the popliteal fossa and provides direct access to the posteromedial corner of the proximal tibia.

Question 5515

Topic: Pelvic & Acetabular Trauma
An 18-year-old pedestrian is struck by a motor vehicle and sustains a severe pelvic ring injury. AP, inlet, and outlet radiographs suggest an anteroposterior compression (APC) mechanism. According to the Young-Burgess classification system, an APC Type III injury is fundamentally distinguished from an APC Type II injury by the complete disruption of which of the following specific structures?
. Symphysis pubis
. Anterior sacroiliac ligaments
. Posterior sacroiliac ligaments
. Sacrotuberous ligament
. Sacrospinous ligament

Correct Answer & Explanation

. Posterior sacroiliac ligaments

Explanation

In the Young-Burgess classification, anteroposterior compression (APC) injuries follow a progressive pattern of ligamentous disruption. APC I features symphyseal widening <2.5 cm with intact posterior ligaments. APC II features symphyseal widening >2.5 cm, complete disruption of the anterior sacroiliac, sacrospinous, and sacrotuberous ligaments, but crucially, the strong posterior sacroiliac ligaments remain intact, allowing the hemipelvis to open like a book (rotationally unstable but vertically stable). APC III involves complete disruption of both the anterior and posterior sacroiliac ligaments, completely dissociating the hemipelvis from the sacrum (both rotationally and vertically unstable).

Question 5516

Topic: 2. Trauma

To decrease construct stiffness and promote secondary bone healing via callus formation in a comminuted diaphyseal fracture managed with a locking plate, which of the following modifications should be made?

. Decrease the working length
. Use bicortical screws exclusively near the fracture
. Leave screw holes empty adjacent to the fracture site
. Use larger diameter screws
. Place the plate closer to the bone surface

Correct Answer & Explanation

. Leave screw holes empty adjacent to the fracture site

Explanation

Leaving screw holes empty adjacent to the fracture site increases the 'working length' of the plate. Working length is the distance between the closest fixation points on either side of the fracture. A longer working length decreases the stiffness of the construct, allowing for interfragmentary micro-motion, which is necessary to promote robust callus formation (secondary bone healing).

Question 5517

Topic: 2. Trauma

A 65-year-old male sustains a subtrochanteric femur fracture. Due to the deforming muscle forces on the proximal fragment, what is the typical anatomical position of the proximal fragment prior to reduction?

. Flexed, adducted, and internally rotated
. Extended, abducted, and externally rotated
. Flexed, abducted, and externally rotated
. Extended, adducted, and internally rotated
. Flexed, abducted, and internally rotated

Correct Answer & Explanation

. Flexed, abducted, and externally rotated

Explanation

In a subtrochanteric fracture, the proximal fragment is acted upon by three primary muscle groups: the iliopsoas (attaching to the lesser trochanter) pulls the fragment into flexion; the abductors (gluteus medius/minimus inserting on the greater trochanter) pull it into abduction; and the short external rotators pull it into external rotation.

Question 5518

Topic: 2. Trauma

A 72-year-old female on prolonged bisphosphonate therapy presents with thigh pain.

Radiographs show a fracture of the femoral shaft. Which of the following radiographic features is most characteristic of an atypical femur fracture associated with bisphosphonate use?

. Spiral fracture pattern with medial comminution
. Transverse or short oblique fracture line originating at the lateral cortex with localized periosteal thickening (beaking)
. High-energy comminuted fracture with extensive soft tissue damage
. Pathologic fracture through a geographic lytic lesion
. Subtrochanteric fracture with significant medial cortical thickening

Correct Answer & Explanation

. Transverse or short oblique fracture line originating at the lateral cortex with localized periosteal thickening (beaking)

Explanation

Atypical femur fractures (AFFs) associated with prolonged bisphosphonate therapy have specific major criteria defined by the ASBMR. These include a location anywhere from just distal to the lesser trochanter to just proximal to the supracondylar flare, transverse or short oblique orientation, non-comminuted (or minimally comminuted), and originating at the lateral cortex with localized periosteal or endosteal thickening ('beaking').

Question 5519

Topic: 2. Trauma

Which of the following describes the correct vascular anatomy and blood supply of the scaphoid, predisposing its proximal pole to avascular necrosis following fracture?

. The primary blood supply enters at the dorsal ridge and supplies the proximal pole via retrograde flow.
. The primary blood supply enters the proximal pole directly from the anterior interosseous artery.
. The primary blood supply enters the volar tubercle and supplies the bone via antegrade flow.
. The ulnar artery provides the dominant supply to the proximal pole via the deep palmar arch.
. The dorsal carpal branch of the radial artery enters the proximal pole directly.

Correct Answer & Explanation

. The primary blood supply enters at the dorsal ridge and supplies the proximal pole via retrograde flow.

Explanation

The major blood supply to the scaphoid (70-80%) comes from branches of the radial artery that enter the bone via the dorsal ridge (near the waist) and perfuse the proximal pole in a retrograde fashion. Because of this retrograde flow, fractures at the waist or proximal pole can disrupt the blood supply to the proximal fragment, greatly increasing the risk of avascular necrosis and nonunion.

Question 5520

Topic: Pelvic & Acetabular Trauma
In the Young-Burgess classification, an anteroposterior compression Type II (APC-II) pelvic ring injury is characterized by a symphyseal diastasis or longitudinal rami fractures and widening of the sacroiliac joint. Which of the following best describes the status of the posterior pelvic ligaments in an APC-II injury?
. Both anterior and posterior sacroiliac ligaments are ruptured
. Anterior sacroiliac ligaments are ruptured, while the posterior sacroiliac ligaments remain intact
. Both anterior and posterior sacroiliac ligaments are intact
. Sacrospinous ligaments are intact, but sacrotuberous ligaments are ruptured
. Posterior sacroiliac ligaments are ruptured, while the anterior sacroiliac ligaments remain intact

Correct Answer & Explanation

. Anterior sacroiliac ligaments are ruptured, while the posterior sacroiliac ligaments remain intact

Explanation

An APC-II injury involves disruption of the symphysis pubis (or vertical rami fractures) along with widening of the anterior sacroiliac joint. This anterior widening signifies rupture of the anterior sacroiliac ligaments and the sacrotuberous/sacrospinous ligaments, but the posterior sacroiliac ligaments remain intact. Because the strong posterior SI ligaments are intact, the pelvis is rotationally unstable but vertically stable. An APC-III injury occurs when the posterior SI ligaments also rupture, leading to global instability.

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