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2. Trauma MCQs

Practice Set 287 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 5721

Topic: 2. Trauma
A 32-year-old male sustains a vertically oriented femoral neck fracture (Pauwels type III). Open reduction and internal fixation is performed. Which of the following fixation constructs provides the greatest biomechanical stability for this specific fracture pattern?
. Three parallel cannulated cancellous screws
. Two parallel cannulated screws
. Sliding hip screw (SHS) with a derotational screw
. Cephalomedullary nail
. Fully threaded cortical screws placed in a divergent pattern

Correct Answer & Explanation

. Sliding hip screw (SHS) with a derotational screw

Explanation

Vertical femoral neck fractures (Pauwels III) experience extreme shear forces and varus instability. Biomechanical studies show that a fixed-angle sliding hip screw supplemented with an anti-rotation screw provides superior resistance to shear and varus collapse compared to parallel cannulated screws.

Question 5722

Topic: 2. Trauma

A 45-year-old male is involved in a severe motor vehicle collision. Pelvic radiographs demonstrate an acetabular fracture with a positive 'gull sign' on the AP view. What does this specific radiographic finding indicate?

. Posterior wall comminution
. Superomedial dome impaction
. Quadrilateral plate displacement
. Anterior column disruption
. Intra-articular loose body

Correct Answer & Explanation

. Superomedial dome impaction

Explanation

The 'gull sign' represents superomedial dome impaction of the acetabulum, frequently seen in elderly patients with osteopenic bone or after high-energy trauma. It is a critical finding because failure to appropriately elevate and graft this impacted fragment leads to rapid post-traumatic osteoarthritis.

Question 5723

Topic: 2. Trauma

A 35-year-old male sustains an isolated, closed, mid-diaphyseal femur fracture. He is optimized and scheduled for an antegrade intramedullary nailing utilizing a trochanteric entry portal. To minimize the risk of a varus malalignment during nail insertion, where should the optimal starting point be located on the AP radiograph?

. Lateral to the tip of the greater trochanter
. Slightly medial to the tip of the greater trochanter
. At the center of the piriformis fossa
. Directly anterior to the greater trochanteric tip
. Posterior to the lesser trochanter

Correct Answer & Explanation

. Slightly medial to the tip of the greater trochanter

Explanation

For antegrade intramedullary nailing via the trochanteric entry portal, a starting point slightly medial to the tip of the greater trochanter is ideal. A starting point that is too lateral inherently forces the proximal fracture segment into a varus malalignment as the rigid nail traverses down the diaphysis.

Question 5724

Topic: Upper Extremity Trauma
A 45-year-old male sustains a fall directly onto the tip of his right shoulder. He presents with severe pain, a visible deformity, and tenderness over the acromioclavicular (AC) joint. On examination, there is a prominent distal clavicle and positive cross-body adduction test. Radiographs show complete disruption of both the AC and coracoclavicular (CC) ligaments, with significant superior displacement of the clavicle relative to the acromion. Which Rockwood classification type BEST describes this injury?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type V

Explanation

This patient's injury, with complete disruption of both AC and CC ligaments and significant superior displacement of the clavicle, fits the description of a Rockwood Type V AC joint injury. Type I involves a sprain of the AC ligaments with intact CC ligaments. Type II involves disruption of the AC ligaments with intact CC ligaments. Type III involves complete disruption of AC and CC ligaments, with clavicle displacement of 25-100% of the acromion width. Type IV involves posterior displacement of the clavicle into the trapezius muscle. Type V involves severe superior displacement of the clavicle, often 100-300% of the acromion width, through the deltotrapezial fascia. Type VI involves inferior displacement of the clavicle, which is rare.

Question 5725

Topic: 2. Trauma

A 12-year-old boy falls off his bicycle, landing on an outstretched arm. He presents with elbow pain, swelling, and an inability to fully extend the elbow. Radiographs show a displaced supracondylar fracture of the humerus. On examination, the radial pulse is diminished, and he has pain with passive extension of the fingers. Which of the following is the MOST appropriate immediate next step in management?

. Apply a splint and discharge with follow-up in orthopaedic clinic
. Attempt closed reduction and percutaneous pinning immediately
. Obtain an urgent CT angiogram to assess vascular compromise
. Observe for 6 hours to see if pulse returns spontaneously
. Perform a forearm fasciotomy

Correct Answer & Explanation

. Attempt closed reduction and percutaneous pinning immediately

Explanation

The diminished radial pulse and pain with passive finger extension are red flags for potential impending compartment syndrome or vascular compromise (Volkmann's ischaemia), which are serious complications of supracondylar humerus fractures. Immediate closed reduction and percutaneous pinning (CRPP) is indicated for displaced fractures, especially with neurovascular compromise, to restore alignment and relieve pressure on neurovascular structures. Waiting for observation is inappropriate. A CT angiogram is too time-consuming and unnecessary; clinical assessment and immediate reduction are paramount. Fasciotomy is reserved for confirmed compartment syndrome after reduction and observation, not as an initial step. Applying a splint and discharge is completely inappropriate given the vascular compromise.

Question 5726

Topic: 2. Trauma

A 70-year-old female presents with a new onset of severe right elbow pain after a fall onto her outstretched hand. She has significant swelling and ecchymosis around the elbow. Radiographs reveal a comminuted fracture of the radial head involving more than one-third of the articular surface, with associated ulnohumeral dislocation and a coronoid fracture. Which of the following describes this complex injury pattern?

. Essex-Lopresti lesion
. Terrible triad of the elbow
. Monteggia fracture-dislocation
. Galeazzi fracture-dislocation
. Maissoneuve fracture

Correct Answer & Explanation

. Terrible triad of the elbow

Explanation

The described injury pattern – comminuted radial head fracture, ulnohumeral dislocation, and coronoid fracture – is classically known as the 'terrible triad of the elbow'. This is a highly unstable injury with a high risk of chronic instability and stiffness. An Essex-Lopresti lesion involves a radial head fracture with disruption of the interosseous membrane and distal radioulnar joint subluxation/dislocation. Monteggia involves a proximal ulna fracture with radial head dislocation. Galeazzi involves a radial shaft fracture with distal radioulnar joint dislocation. Maissoneuve involves a proximal fibula fracture with distal tibiofibular syndesmosis disruption and medial ankle injury.

Question 5727

Topic: 2. Trauma

A 35-year-old male sustains a fall onto his elbow, resulting in an olecranon fracture. Radiographs show a displaced, comminuted intra-articular fracture involving the articular surface, with significant displacement. On examination, he is unable to actively extend his elbow. Which of the following is the MOST appropriate surgical management?

. Non-operative treatment with long arm cast
. Tension band wiring
. Plate and screw fixation
. Excision of the olecranon fragment
. Radial head replacement

Correct Answer & Explanation

. Tension band wiring

Explanation

Displaced olecranon fractures that disrupt the extensor mechanism (inability to extend the elbow) are surgical indications. While plate and screw fixation is also a viable option, especially for comminuted fractures or those extending into the shaft, tension band wiring is a commonly used and highly effective technique for displaced transverse or oblique olecranon fractures, as it converts the distractive forces of the triceps into compressive forces across the fracture site, promoting healing and allowing early motion. Non-operative treatment is for non-displaced fractures. Excision of the olecranon fragment is typically for small, non-articular fragments or in rare cases of severe comminution with severe osteoporosis in elderly patients where stable fixation is not possible. Radial head replacement is for radial head fractures.

Question 5728

Topic: 2. Trauma

A 60-year-old female presents with persistent shoulder pain and limited abduction following a proximal humerus fracture treated non-operatively 6 months ago. Radiographs show a malunited fracture with significant varus angulation and superior migration of the humeral head. Her active abduction is 60 degrees, and passive abduction is 80 degrees. She has significant crepitus with movement. What is the MOST appropriate next step in management?

. Continued physical therapy for another 3 months
. Repeat radiographs and consider CT for detailed assessment of malunion
. Reverse total shoulder arthroplasty
. Shoulder hemiarthroplasty
. Osteotomy to correct the varus malunion

Correct Answer & Explanation

. Repeat radiographs and consider CT for detailed assessment of malunion

Explanation

The patient presents with symptomatic malunion of a proximal humerus fracture, leading to pain and reduced range of motion. Given the varus angulation and superior migration, the glenohumeral mechanics are likely significantly altered, leading to impingement and possibly early arthrosis. A CT scan is crucial at this stage to fully characterize the extent of the malunion, assess the articular surface, and rule out avascular necrosis, which is vital for surgical planning. While arthroplasty (hemi or reverse) is a definitive treatment for pain and dysfunction, especially if glenohumeral arthritis has developed, understanding the precise bony anatomy of the malunion is the critical next step before deciding on an irreversible procedure. Continued physical therapy is unlikely to overcome a significant mechanical block from malunion. An osteotomy is a complex procedure, and arthroplasty is often preferred in older patients with significant deformity.

Question 5729

Topic: 2. Trauma

A 25-year-old male sustains a direct blow to his right clavicle during a rugby match. He presents with pain, swelling, and a visible deformity in the middle third of his clavicle. Radiographs confirm a displaced midshaft clavicle fracture. Which of the following is an indication for operative management in this acute setting?

. Shortening of less than 1 cm
. Superior displacement of less than 50% of clavicle width
. Open fracture
. Non-dominant arm injury
. Minimal comminution

Correct Answer & Explanation

. Open fracture

Explanation

While most midshaft clavicle fractures can be treated non-operatively, an open fracture is a clear indication for surgical management due to the risk of infection and to ensure proper wound care and reduction. Other relative indications for surgery include significant displacement (>100% cortical apposition loss), significant shortening (>2cm), tenting of skin, associated neurovascular injury, impending skin compromise, and floating shoulder. Shortening of less than 1 cm or displacement less than 50% are typically managed non-operatively. Non-dominant arm injury doesn't contraindicate surgery if other indications exist. Minimal comminution doesn't automatically mean surgical management.

Question 5730

Topic: 2. Trauma

A 30-year-old male presents with a fall onto an outstretched hand, resulting in a radial shaft fracture and distal radioulnar joint (DRUJ) dislocation. Which of the following describes this specific injury pattern?

. Monteggia fracture-dislocation
. Galeazzi fracture-dislocation
. Essex-Lopresti lesion
. Colles fracture
. Smith fracture

Correct Answer & Explanation

. Galeazzi fracture-dislocation

Explanation

A radial shaft fracture with associated distal radioulnar joint (DRUJ) dislocation is classically known as a Galeazzi fracture-dislocation. Monteggia fracture-dislocation involves an ulnar shaft fracture and radial head dislocation. Essex-Lopresti lesion involves a radial head fracture with disruption of the interosseous membrane and DRUJ instability. Colles and Smith fractures are distal radius fractures. Understanding these eponyms is crucial for the FRCS exam.

Question 5731

Topic: 2. Trauma

A 40-year-old male sustains a direct fall onto his shoulder, resulting in a displaced fracture of the midshaft of the clavicle. He also has a fracture of the glenoid neck and a significant tear of the rotator cuff. This combination of injuries is referred to as:

. Floating elbow
. Floating shoulder
. Terrible triad of the shoulder
. Pelligrini-Stieda syndrome
. Monteggia equivalent

Correct Answer & Explanation

. Floating shoulder

Explanation

A 'floating shoulder' injury is characterized by ipsilateral fractures of the clavicle (usually midshaft) and the scapula neck or glenoid (often involving the body). This results in loss of both superior (clavicle) and inferior (scapula) support of the shoulder girdle, making the glenoid 'float'. The associated rotator cuff tear indicates additional soft tissue damage but the bony components define the floating shoulder. Floating elbow is a distal humerus and forearm fracture. Terrible triad of the shoulder is not a recognized eponym. Pellegrini-Stieda syndrome is heterotopic ossification near the medial collateral ligament of the knee. Monteggia equivalent is a variation of Monteggia fracture-dislocation.

Question 5732

Topic: 2. Trauma

A 10-year-old boy presents with right elbow pain and limited range of motion following a fall. Radiographs show a minimally displaced Salter-Harris Type II fracture of the distal humerus, with the fracture line extending through the metaphysis and physis. There are no signs of neurovascular compromise. What is the MOST appropriate management?

. Open reduction and internal fixation
. Closed reduction and long arm cast immobilization
. Percutaneous pinning without reduction
. Sling immobilization with early range of motion
. Observation and serial radiographs

Correct Answer & Explanation

. Closed reduction and long arm cast immobilization

Explanation

Salter-Harris Type II fractures of the distal humerus, even if minimally displaced, need careful attention. If truly minimally displaced with no neurovascular compromise, closed reduction and long arm cast immobilization is often appropriate. Open reduction and internal fixation is typically reserved for irreducible or significantly displaced fractures, or when neurovascular compromise is present after failed closed reduction. Percutaneous pinning is usually done after closed reduction for unstable fractures. Sling immobilization with early range of motion is for very stable or non-displaced injuries, but not for a true fracture in this age group. Observation alone is risky for growth plate fractures.

Question 5733

Topic: 2. Trauma

A 68-year-old female presents with a fall onto her elbow. Radiographs show an intra-articular comminuted fracture of the distal humerus (C-type according to AO classification). The fracture extends into the articular surface and the metaphysis. Which of the following principles is MOST critical for achieving a successful outcome with surgical management?

. Early range of motion to prevent stiffness
. Stable fixation allowing for early motion and anatomical reduction of the articular surface
. Non-operative management with extended immobilization
. Radial head replacement to improve stability
. Shortening the humerus to achieve union

Correct Answer & Explanation

. Stable fixation allowing for early motion and anatomical reduction of the articular surface

Explanation

Distal humerus fractures, especially complex intra-articular ones (AO C-type), require meticulous anatomical reduction of the articular surface and stable internal fixation to allow for early range of motion. Stable fixation is paramount to prevent loss of reduction and allow early motion to minimize post-traumatic stiffness, which is a common and debilitating complication of these injuries. Non-operative management leads to poor outcomes for displaced articular fractures. Radial head replacement is for radial head fractures. Shortening the humerus is not a goal of distal humerus fracture management and would compromise function.

Question 5734

Topic: 2. Trauma

A 30-year-old male develops numbness and weakness in his intrinsic hand muscles 3 days after undergoing surgery for a complex elbow fracture. He now complains of severe, throbbing pain in his forearm, exacerbated by passive extension of his fingers. His forearm is tense to palpation. What is the MOST appropriate immediate management?

. Remove the cast and observe for 24 hours
. Administer higher doses of opioid analgesia
. Obtain an urgent MRI of the forearm
. Perform emergency forearm fasciotomy
. Elevate the arm above the heart

Correct Answer & Explanation

. Perform emergency forearm fasciotomy

Explanation

The constellation of severe, throbbing pain out of proportion to the injury, pain with passive stretching of muscles (finger extension), paresthesia/numbness, and tense compartment to palpation are the cardinal signs and symptoms of acute forearm compartment syndrome. This is a surgical emergency. The MOST appropriate immediate management is emergency forearm fasciotomy to decompress the compartments and prevent irreversible ischemic damage to muscles and nerves (Volkmann's contracture). Removing the cast and observing is dangerous. Opioids mask symptoms. MRI is too slow and not indicated. Elevating the arm can reduce perfusion and worsen ischemia.

Question 5735

Topic: 2. Trauma

A 28-year-old male sustains a fall onto his elbow. Radiographs show a fracture of the ulnar shaft and an associated anterior dislocation of the radial head. What is the appropriate eponymous classification for this injury?

. Galeazzi fracture
. Monteggia fracture
. Essex-Lopresti fracture
. Barton's fracture
. Colles fracture

Correct Answer & Explanation

. Monteggia fracture

Explanation

A Monteggia fracture-dislocation is defined by a fracture of the ulnar shaft associated with a dislocation of the radial head. The dislocation can be anterior, posterior, or lateral. Galeazzi fracture is a radial shaft fracture with DRUJ dislocation. Essex-Lopresti lesion is a radial head fracture with interosseous membrane disruption and DRUJ dislocation. Barton's and Colles fractures are types of distal radius fractures.

Question 5736

Topic: 2. Trauma

A 70-year-old female presents with severe pain and limited motion of her right shoulder after a fall. Radiographs show a severely comminuted fracture of the humeral head involving the articular surface, with four distinct fragments. Which of the following classifications is MOST commonly used for proximal humerus fractures?

. Gustilo-Anderson classification
. Neer classification
. AO/OTA classification
. Salter-Harris classification
. Rockwood classification

Correct Answer & Explanation

. Neer classification

Explanation

The Neer classification is the most commonly used system for classifying proximal humerus fractures, particularly in the English-speaking world. It categorizes fractures based on the number of 'parts' (humeral head, greater tuberosity, lesser tuberosity, shaft) that are displaced by >1cm or >45 degrees angulation. Gustilo-Anderson is for open fractures. AO/OTA is a comprehensive alphanumeric system. Salter-Harris is for physeal fractures in children. Rockwood classification is for AC joint injuries.

Question 5737

Topic: 2. Trauma

A 6-year-old boy presents with a displaced supracondylar humerus fracture. After successful closed reduction and percutaneous pinning, he develops a palpable mass in the antecubital fossa which gradually ossifies over several weeks. He now has a severe elbow flexion contracture. What is the MOST likely complication?

. Non-union of the fracture
. Compartment syndrome
. Volkmann's ischemic contracture
. Myositis ossificans
. Ulnar nerve entrapment

Correct Answer & Explanation

. Myositis ossificans

Explanation

Myositis ossificans is the most likely complication. It is the heterotopic formation of bone in soft tissues, commonly seen after trauma around the elbow, especially supracondylar fractures. Risk factors include repeated trauma, vigorous manipulation, and head injuries. It presents as a palpable mass and progressive loss of motion, leading to a flexion contracture. Non-union is a different issue. Compartment syndrome is an acute ischemic event. Volkmann's ischemic contracture is a severe ischemic contracture resulting from unaddressed compartment syndrome. Ulnar nerve entrapment might occur but wouldn't typically present with a palpable ossified mass and a severe flexion contracture as the primary problem.

Question 5738

Topic: Upper Extremity Trauma
A 70-year-old female presents with persistent pain, limited range of motion, and a visible step-off deformity at her right acromioclavicular (AC) joint following a fall 3 months ago. Radiographs show a Rockwood Type III AC joint injury. She has significant discomfort with overhead activities and reaching across her body. What is the MOST appropriate management?
. Continued non-operative management with physical therapy
. Corticosteroid injection into the AC joint
. AC joint arthrodesis
. Surgical reconstruction of the coracoclavicular ligaments
. Distal clavicle excision (Mumford procedure)

Correct Answer & Explanation

. Surgical reconstruction of the coracoclavicular ligaments

Explanation

For symptomatic chronic Rockwood Type III AC joint injuries that have failed conservative management, surgical reconstruction of the coracoclavicular ligaments (often combined with AC ligament repair or reconstruction) is the most appropriate treatment to restore stability and reduce pain. This aims to restore the anatomical relationship and kinematics. Continued non-operative management is unlikely to resolve chronic symptoms in this active patient. Corticosteroid injections are temporary. AC joint arthrodesis is an option but less common than reconstruction. Distal clavicle excision (Mumford procedure) addresses AC joint pain from arthritis or impingement but does not restore stability to a Type III injury.

Question 5739

Topic: 2. Trauma

A 25-year-old male sustains a direct blow to the lateral aspect of his elbow, resulting in a displaced fracture of the radial head. He also presents with severe wrist pain and instability of the distal radioulnar joint (DRUJ). Which of the following describes this complex injury pattern?

. Monteggia fracture
. Galeazzi fracture
. Essex-Lopresti lesion
. Terrible triad of the elbow
. Barton's fracture

Correct Answer & Explanation

. Essex-Lopresti lesion

Explanation

An Essex-Lopresti lesion is a triad of radial head fracture, rupture of the interosseous membrane (connecting radius and ulna), and dislocation or subluxation of the distal radioulnar joint (DRUJ). This injury typically occurs from a fall onto an outstretched hand with a pronated forearm. Monteggia is ulnar fracture with radial head dislocation. Galeazzi is radial shaft fracture with DRUJ dislocation. Terrible triad is elbow dislocation + radial head fracture + coronoid fracture. Barton's is a distal radius fracture.

Question 5740

Topic: Upper Extremity Trauma

A 32-year-old competitive weightlifter feels a sudden 'pop' in his anterior chest while performing a bench press. He presents with bruising and weakness in shoulder internal rotation. If a complete pectoralis major rupture is present, which anatomical location is most commonly involved?

. Muscle belly of the clavicular head
. Musculotendinous junction of the clavicular head
. Avulsion of the sternal head tendon from the humerus
. Origin of the sternal head at the sternum
. Coracoid process avulsion

Correct Answer & Explanation

. Avulsion of the sternal head tendon from the humerus

Explanation

Pectoralis major ruptures most frequently occur at the tendinous insertion of the sternal head onto the proximal humerus, particularly during eccentric loading exercises like the bench press.

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