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2. Trauma MCQs

Practice Set 28 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 541

Topic: 2. Trauma

A 15-year-old boy has a Salter type-2 fracture of the distal tibia. His foot is in valgus and external rotation. Recommended treatment is:

. Obtaining computed tomograms of the fracture
. Obtaining a magnetic resonance imaging study of the ankle
. C losed reduction and immobilization in a long leg cast
. C losed reduction and percutaneous fixation of the fracture
. Open reduction and internal fixation

Correct Answer & Explanation

. C losed reduction and immobilization in a long leg cast

Explanation

There is a good chance that a satisfactory closed reduction may be achieved by correcting the valgus and external rotation. The fracture should first be reduced. There is a good chance of a satisfactory reduction. The patient is old enough that a significant physeal growth disorder is not likely. Magnetic resonance imaging is not indicated unless there is a question of physeal disorder after healing or an entrapped fragment.

Question 542

Topic: 2. Trauma

Secondary ossification of the elbow

. Occurs over a two-year period
. Occurs more rapidly in males
. Proceeds in a predictable fashion through skeletal maturity
. Is not important for the orthopedist to understand
. Is complete by age 10

Correct Answer & Explanation

. Proceeds in a predictable fashion through skeletal maturity

Explanation

Secondary ossification is very imprtant in managing fractures. It begins at age 1-2 and is complete by 14 years girls and 16 years in boys.

Question 543

Topic: Lower Extremity Trauma

Osteochondral defects occur bilaterally in the distal femur in approximately:

. 10% to 20% of patients.
. 20% to 30% of patients.
. 30% to 40% of patients.
. 60% to 70% of patients.
. 80% to 90% of patients

Correct Answer & Explanation

. 20% to 30% of patients.

Explanation

Osteochondral defects occur bilaterally in the distal femur for approximately 20% to 30% of patients. The fact that 20% to 30% of patients with an osteochondral lesion in the distal femur have bilateral involvement suggests that there is a predisposition to the development of a lesion at this location, either genetic or secondary to repetitive microtrauma.

Question 544

Topic: 2. Trauma

A 35-year-old man sustains a displaced midshaft clavicle fracture. Which of the following is considered an absolute indication for operative fixation?

. Shortening greater than 2 cm
. Z-type comminution
. Open fracture
. Floating shoulder variant
. Transient brachial plexus neurapraxia

Correct Answer & Explanation

. Open fracture

Explanation

Absolute indications for operative fixation of clavicle fractures include open fractures, vascular compromise, and progressive neurologic deficits. Severe shortening and floating shoulder are generally considered relative indications depending on patient factors.

Question 545

Topic: 2. Trauma
A 25-year-old male sustains a vertically oriented (Pauwels type III) displaced femoral neck fracture in a motor vehicle accident. What is the biomechanical advantage of using a sliding hip screw with a derotation screw compared to three parallel cancellous screws?
. Superior resistance to varus collapse and vertical shear forces
. Decreased risk of developing avascular necrosis
. Shorter operative time and less blood loss
. Increased preservation of the fracture hematoma
. Complete elimination of rotational instability

Correct Answer & Explanation

. Superior resistance to varus collapse and vertical shear forces

Explanation

Pauwels type III fractures are highly unstable due to significant vertical shear forces along the fracture line. A fixed-angle device such as a sliding hip screw provides superior biomechanical resistance to varus collapse compared to multiple cancellous screws in these vertical fracture patterns.

Question 546

Topic: 2. Trauma

A 35-year-old male is admitted with a highly comminuted tibial shaft fracture and severe closed head trauma. He is obtunded, with a blood pressure of 110/70 mmHg. Intracompartmental pressure monitoring is performed. Which of the following values is most definitively diagnostic of acute compartment syndrome requiring urgent fasciotomy?

. Absolute compartment pressure of 25 mmHg
. Absolute compartment pressure of 28 mmHg
. Delta pressure (Diastolic BP minus compartment pressure) of 20 mmHg
. Delta pressure (Mean arterial BP minus compartment pressure) of 45 mmHg
. Delta pressure (Systolic BP minus compartment pressure) of 50 mmHg

Correct Answer & Explanation

. Delta pressure (Diastolic BP minus compartment pressure) of 20 mmHg

Explanation

Acute compartment syndrome is definitively diagnosed when the delta pressure (diastolic blood pressure minus absolute compartment pressure) falls below 30 mmHg. A delta pressure of 20 mmHg indicates severely impaired local tissue perfusion necessitating an immediate four-compartment fasciotomy.

Question 547

Topic: 2. Trauma

A 55-year-old patient with poorly controlled diabetes presents with a swollen, erythematous, and warm right foot. There are no open ulcers, and systemic vital signs are normal. Radiographs show soft tissue swelling but no fractures or dislocations. What is the initial treatment of choice?

. Intravenous antibiotics and surgical incision and drainage
. Total contact casting and strict non-weight bearing
. Immediate primary arthrodesis of the midfoot
. Custom orthotic shoe wear and unrestricted activity
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing

Explanation

This clinical presentation is characteristic of an acute stage 0 or early stage I Charcot neuroarthropathy. The gold standard for initial management is immediate immobilization with a total contact cast and strict non-weight bearing to prevent progressive bone destruction and midfoot collapse.

Question 548

Topic: 2. Trauma

A 28-year-old man presents with a 6-month-old scaphoid waist fracture nonunion. MRI confirms avascular necrosis of the proximal pole, but radiographs show no carpal collapse or degenerative changes. What is the most appropriate surgical management?

. Proximal row carpectomy
. Scaphoid excision and four-corner fusion
. Vascularized bone grafting and rigid internal fixation
. Non-vascularized corticocancellous bone graft from the iliac crest
. Radial styloidectomy alone

Correct Answer & Explanation

. Vascularized bone grafting and rigid internal fixation

Explanation

For a scaphoid nonunion complicated by avascular necrosis of the proximal pole without significant radioscaphoid arthritis or carpal collapse, a vascularized bone graft (e.g., 1,2-ICSRA graft) combined with rigid internal fixation provides the highest rate of bony union.

Question 549

Topic: Pelvic & Acetabular Trauma

A 25-year-old man is brought to the emergency department after a motorcycle collision. Radiographs demonstrate symphyseal widening of 3.5 cm and widening of the anterior sacroiliac joints bilaterally. The posterior sacroiliac ligaments are intact. According to the Young-Burgess classification, which of the following ligaments is ruptured?

. Anterior sacroiliac, sacrospinous, and sacrotuberous ligaments
. Posterior sacroiliac and sacrotuberous ligaments
. Iliolumbar and posterior sacroiliac ligaments
. Anterior sacroiliac ligament only
. Sacrotuberous and sacrospinous ligaments only

Correct Answer & Explanation

. Anterior sacroiliac, sacrospinous, and sacrotuberous ligaments

Explanation

This is an APC-II pelvic ring injury (symphyseal widening greater than 2.5 cm with anterior SI joint widening). It is characterized by rupture of the symphyseal, anterior sacroiliac, sacrospinous, and sacrotuberous ligaments, while the strong posterior sacroiliac ligaments remain intact.

Question 550

Topic: Upper Extremity Trauma

A 14-year-old left-handed boy suffers an avulsion of the medial epicondyle of the distal humerus when landing from a fall. The epicondyle is displaced 7 mm. His physical demands include swimming and lifting boxes. The recommended treatment for this injury is:

. Open reduction and internal fixation
. Manipulation and percutaneous fixation
. Percutaneous fixation in situ
. Splint for 1 week
. Excision of the fragment with reattachment of muscle to bone

Correct Answer & Explanation

. Splint for 1 week

Explanation

Unless the fragment is entrapped or significant valgus loading is anticipated, nonoperative treatment is indicated. Range of motion should be started within 1 week. Open reduction is only indicated, if the epicondyle was entrapped in the joint, or if significant valgus loading was anticipated. The results of nonoperative treatment are just as good as any invasive treatment. Excision of the fragment is only indicated, if operative treatment is indicated, and the epicondyle is fragmented.

Question 551

Topic: Upper Extremity Trauma

Which of the following statements is true about the medial humeral epicondyle:

. The medial humeral epicondyle is the first center to ossify in the distal humerus.
. The medial humeral epicondyle usually fuses to the distal humerus at age twelve.
. The medial humeral epicondyle is located anteromedially on the distal humerus.
. The medial humeral epicondyle is the origin of the wrist extensor muscles.
. The medial humeral epicondyle may ossify from several centers.

Correct Answer & Explanation

. The medial humeral epicondyle may ossify from several centers.

Explanation

The medial epicondyle may have several ossification centers. The medial epicondyle is the third center to ossify, beginning at age 4 to 6 years old. The medial epicondyle usually fuses near skeletal maturity, at approximately age 15. The medial epicondyle is located posteromedially. The medial epicondyle is the origin of the flexor-pronator muscles.

Question 552

Topic: 2. Trauma
A 6-year-old boy sustains a supracondylar fracture of the humerus. The 2 fragments are not completely displaced, but there is some overlap of the medial column and a gap on the lateral column of the distal humerus. Baumann's angle measures 85°-89°. The alignment on the lateral film shows no significant translation, but approximately 15° of increased extension. The recommended treatment is:
. Accept this and treat in a long arm cast
. Closed reduction with supination of the forearm and application of long arm cast
. Closed reduction with the elbow in extension to better monitor the angulation
. Closed reduction and percutaneous pin fixation
. Open reduction and medial and lateral plate fixation

Correct Answer & Explanation

. Closed reduction and percutaneous pin fixation

Explanation

Closed reduction should allow regain of alignment and percutaneous pin fixation will allow it to be maintained. The elbow is in 10°-15° of varus and this will be an objectionable appearance in the future. Supination will increase the varus. Extension will exacerbate the deformity seen on the lateral and will cause further loss of contact of the fracture fragments. Medial and lateral plate fixation is needed in adolescents and adults with intercondylar fractures to allow early range of movement but is excessive treatment for this fracture in young children.

Question 553

Topic: 2. Trauma

A 6-year-old girl presents with a fracture of the radial neck that is angulated 25° compared to the other side. No other abnormalities are seen. The recommended treatment is:

. Sling and early range of motion
. Reduction using an intramedullary K-wire introduced from a retrograde approach (Metaizeau technique)
. Reduction using a percutaneously placed K-wire with intraosseous fixation
. Open reduction without internal fixation
. Open reduction and internal fixation

Correct Answer & Explanation

. Sling and early range of motion

Explanation

Fractures with angulation <30° have an excellent chance of remodeling, and can be left as they are with early range of motion. Reduction using an intramedullary K-wire introduced from a retrograde approach (Metaizeau technique) is indicated mainly for fractures angulated >30°. Reduction using a percutaneously placed K-wire with intraosseous fixation, while effective, is not needed unless the fracture is angulated >30°. Open reduction and internal fixation are indicated only if the fracture is angulated >50° and does not reduce by one of the manipulative techniques.

Question 554

Topic: 2. Trauma

A 12-year-old boy sustains a Salter type II fracture of the proximal humerus during a fall. The fracture has an apex angulation of 40° anteriorly and laterally. The neurovascular examination is normal. The recommended treatment is:

. Longitudinal traction in abduction followed by slowly bringing the arm into an abduction (airplane) splint
. Closed reduction and percutaneous pin fixation
. Open reduction and plate fixation
. Skeletal traction in abduction with an olecranon pin
. No formal reduction attempt, rather placement of the arm in a sling

Correct Answer & Explanation

. No formal reduction attempt, rather placement of the arm in a sling

Explanation

Recommended treatment involves no formal reduction attempt, rather placement of the arm in a sling. This simple treatment is adequate for all patients with at least 2 years of growth remaining. This is due to the tendency to self-align, the remodeling potential, and the ability to tolerate some deformity in the region with no functional consequence. The abduction splint is cumbersome. It is not necessary because simpler means are effective due to the young age and remodeling potential. Closed reduction and pin fixation are not needed because adequate remodeling is expected. Any residual deformity is well tolerated in this region. The pins can sometimes cause significant soft tissue irritation in the bulky area of the shoulder. Plate fixation is not feasible because of the open physis. It is also not necessary because simpler means are available. Skeletal traction is not needed because the humerus will align itself better with time in a dependent position.

Question 555

Topic: 2. Trauma
A 6-year-old boy has a painful elbow, with swelling over the region of the olecranon. Radiographs reveal a thin sliver of bone that is displaced 4 mm from the proximal border of the olecranon. Treatment should consist of:
. Closed treatment in a cast in 90° of flexion
. Closed treatment in a cast in extension
. Open excision of the osseous fragment
. Open reduction and tension band fixation
. No immobilization; early range of motion

Correct Answer & Explanation

. Open reduction and tension band fixation

Explanation

Open reduction and tension band fixation is the best method to hold the proximal ulnar apophysis. The patient has a 'sleeve' fracture that should be reduced because it is attached to the olecranon apophysis. The osseous fragment is attached to the entire olecranon apophysis, which develops a secondary ossification center at age 9. With early range of motion, further displacement and/or nonunion may develop.

Question 556

Topic: 2. Trauma

A 14-year-old boy sustains an intercondylar fracture of the distal humerus. There is a single fracture line into the joint between the capitellum and the trochlea. The medial column of the distal humerus is comminuted, but the lateral column is not. All fragments are highly displaced. Neurovascular status is normal. The recommended treatment is:

. Olecranon pin traction overhead for 2 weeks and long arm cast
. Closed reduction and long arm cast
. Closed reduction and pin fixation
. Open reduction and dual plate fixation through an anterior incision
. Open reduction and dual plate fixation through a posterior approach

Correct Answer & Explanation

. Open reduction and dual plate fixation through a posterior approach

Explanation

A posterior approach (Bryan-Morrey or olecranon osteotomy) will facilitate anatomic reduction and rigid fixation sufficient for early range of motion. Prolonged traction and cast will result in an incomplete reduction and excessive stiffness. A cast alone will result in an incomplete reduction and excessive stiffness. Rigid fixation with plates, rather than pins, is required to maintain reduction of these fractures and allow early range of motion. An anterior approach will not allow adequate exposure of the distal humerus for articular fixation.

Question 557

Topic: 2. Trauma

In treating which of the following elbow fractures is it most important to begin early range of motion:

. Salter I physeal fracture of distal humerus
. Intercondylar (T-condylar) fracture of distal humerus
. Supracondylar fracture of distal humerus
. Lateral condyle fracture
. Lateral epicondyle fracture

Correct Answer & Explanation

. Intercondylar (T-condylar) fracture of distal humerus

Explanation

Intercondylar fractures have a significant risk of loss of motion because of the magnitude of injury, intra-articular extension, and older age of patient. Salter I physeal fractures typically occur in young children. They usually pose no difficulty with regaining motion after 4 to 6 weeks of immobilization. Supracondylar fractures usually are followed by regaining motion after healing despite immobilization of up to 6 weeks or more. Patients with this fracture usually regain their motion after healing. Because this is a nonarticular fracture, loss of motion is not a high risk.

Question 558

Topic: 2. Trauma
The following is the most common complication of lateral condyle fractures:
. Radial nerve palsy
. Compartment syndrome
. Heterotopic ossification
. Nonunion
. Posterior interosseous nerve injury

Correct Answer & Explanation

. Nonunion

Explanation

Nonunion occurs more commonly after lateral condyle fracture than following most children's fractures because the fracture line is predominantly intra-articular and not always adequately reduced and immobilized. Radial nerve injury, compartment syndrome, heterotopic ossification, and posterior interosseous nerve injury are uncommon with lateral condyle fractures.

Question 559

Topic: Lower Extremity Trauma

An 11-year-old girl is observed for legs that have been bowed for the past 5 years. She has a mechanical axis that is in 26° of varus, a medial tibial plateau slope of 8°, a tibial joint angle of 15° varus, and a femoral joint angle of 10° varus. Her physis appears open. Recommended treatment is:

. Tibial valgus osteotomy
. Femoral valgus osteotomy
. Tibial and femoral valgus osteotomy
. Medial tibial plateau elevation
. Brace treatment

Correct Answer & Explanation

. Tibial and femoral valgus osteotomy

Explanation

Both a tibial and a femoral valgus osteotomy are necessary to correct significant deformities in these areas. A tibial valgus osteotomy is necessary but not sufficient. The femoral joint angle is off by 13° from the normal angle. A femoral valgus osteotomy is necessary but not sufficient. The tibial joint angle is off by 15° of varus. A tibial plateau elevation is not necessary for this mild degree of plateau depression. Brace treatment is not recommended for patients older than 3 years of age.

Question 560

Topic: 2. Trauma
A 13-year-old boy sustains a Salter II fracture of the proximal humeral epiphysis. On radiograph, there is a 40° varus angulation and a 30° apex anterior angulation. Recommended treatment includes:
. Closed reduction and abduction cast
. Closed reduction and sling
. Closed reduction and percutaneous pin fixation
. Open reduction and percutaneous pin fixation
. Application of a sling and swathe

Correct Answer & Explanation

. Closed reduction and sling

Explanation

Spontaneous partial reduction will occur when the patient becomes upright, and there is good remodeling potential due to growth. Closed reduction and abduction cast is not necessary because of the patient's age, remodeling potential, and range of motion available in the joint. A formal attempt at closed reduction is not necessary because there is no way of holding it without internal fixation. This process will occur naturally to a large degree when the patient becomes upright. Open reduction and percutaneous pin fixation poses a risk of pin tract infection because of the large amount of muscle traversed. This procedure is not necessary because of the good results with conservative treatment.

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