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2. Trauma MCQs

Practice Set 324 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 6461

Topic: 2. Trauma
A 45-year-old construction worker falls from a ladder and sustains a displaced, intra-articular calcaneus fracture (Sanders Type III). He undergoes open reduction and internal fixation via a classic extensile lateral approach. Which of the following represents the most frequent complication associated specifically with this surgical approach?
. Deep peroneal nerve neuropraxia
. Sural nerve transection
. Wound edge necrosis and dehiscence
. Post-operative compartment syndrome
. Tethering of the flexor hallucis longus

Correct Answer & Explanation

. Wound edge necrosis and dehiscence

Explanation

The extensile lateral approach to the calcaneus is notorious for wound healing complications, including edge necrosis and dehiscence, occurring in up to 10-25% of cases. Careful handling of the full-thickness flap and adherence to subperiosteal dissection principles are required to minimize this risk.

Question 6462

Topic: 2. Trauma

A 65-year-old female sustains a 4-part proximal humerus fracture. According to Hertel's criteria, which of the following radiographic findings is the most reliable predictor of humeral head ischemia?

. Metaphyseal head extension (calcar length) less than 8 mm
. Medial hinge displacement less than 2 mm
. Greater tuberosity displacement greater than 5 mm
. Head-shaft angle of 45 degrees of valgus
. Bicipital groove comminution

Correct Answer & Explanation

. Metaphyseal head extension (calcar length) less than 8 mm

Explanation

Hertel's criteria identify calcar length < 8 mm, disrupted medial hinge > 2 mm, and a basicervical fracture pattern as the strongest predictors of humeral head ischemia. Preserved medial soft tissue attachments are critical for perfusion.

Question 6463

Topic: 2. Trauma

In evaluating a 65-year-old female with a 4-part proximal humerus fracture, which of the following radiographic findings is the strongest predictor of humeral head ischemia?

. Metaphyseal extension of the head fragment < 8 mm
. Tuberosity displacement > 5 mm
. Intact medial hinge
. Head angulation > 45 degrees
. Lesser tuberosity fracture

Correct Answer & Explanation

. Metaphyseal extension of the head fragment < 8 mm

Explanation

According to Hertel's criteria, a metaphyseal head extension (calcar length) of < 8 mm, disrupted medial hinge, and an anatomic neck fracture pattern are the most reliable predictors of ischemia. Of these, a short calcar segment is highly indicative of vascular compromise to the articular fragment.

Question 6464

Topic: 2. Trauma

Which of the following parameters represents a generally accepted indication for operative fixation of a significantly displaced scapular body or neck fracture?

. Glenoid articular step-off of 2 mm
. Glenopolar angle of 20 degrees
. Medial/lateral translation of 15 mm
. Angulation of 25 degrees
. Ipsilateral nondisplaced clavicle fracture

Correct Answer & Explanation

. Glenopolar angle of 20 degrees

Explanation

Indications for operative intervention in scapula fractures include a glenopolar angle < 22 degrees, medial/lateral translation > 25 mm, and angulation > 45 degrees. A severely decreased glenopolar angle alters the mechanics of the rotator cuff and warrants fixation.

Question 6465

Topic: 2. Trauma

Which of the following is the strongest independent predictor of nonunion when treating a midshaft clavicle fracture nonoperatively?

. Female gender
. Initial shortening of 10 mm
. Complete fracture displacement (lack of cortical apposition)
. Location in the medial third
. Early initiation of pendulum exercises

Correct Answer & Explanation

. Complete fracture displacement (lack of cortical apposition)

Explanation

Complete displacement with no cortical apposition is the most significant risk factor for nonunion in midshaft clavicle fractures. Other associated risk factors include advancing age, smoking, and severe initial shortening.

Question 6466

Topic: 2. Trauma

In an independent 75-year-old female with a highly comminuted, intra-articular distal humerus fracture, what is the primary advantage of total elbow arthroplasty (TEA) compared to open reduction internal fixation (ORIF)?

. Higher lifelong lifting capacity
. Lower lifetime reoperation rate
. Improved terminal extension strength
. More predictable early functional outcomes and avoidance of fixation failure
. Lower incidence of postoperative ulnar neuropathy

Correct Answer & Explanation

. More predictable early functional outcomes and avoidance of fixation failure

Explanation

In elderly patients with severe comminution or osteopenia, TEA allows for immediate mobilization and yields more predictable early functional outcomes compared to ORIF. However, TEA imposes a lifelong 5-pound lifting restriction and carries a higher long-term complication rate.

Question 6467

Topic: 2. Trauma
Which nerve injury is most commonly associated with a Bado Type I (anterior) Monteggia fracture-dislocation?
. Anterior interosseous nerve
. Posterior interosseous nerve
. Ulnar nerve
. Musculocutaneous nerve
. Superficial sensory radial nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The posterior interosseous nerve (PIN) is the most commonly injured nerve in Bado Type I (anterior) and Type III (lateral) Monteggia fractures. The injury is typically a neuropraxia that resolves spontaneously with conservative management.

Question 6468

Topic: 2. Trauma

According to the Hertel criteria, which of the following radiographic findings is the most reliable predictor of humeral head ischemia following a proximal humerus fracture?

. Greater tuberosity displacement greater than 5 mm
. Anatomical neck fracture with calcar length less than 8 mm
. Surgical neck fracture with greater than 45 degrees of angulation
. Lesser tuberosity comminution
. Head-split fracture with an intact medial periosteal hinge

Correct Answer & Explanation

. Anatomical neck fracture with calcar length less than 8 mm

Explanation

Hertel criteria predicting humeral head ischemia include a short metaphyseal head extension (calcar length < 8 mm), disruption of the medial periosteal hinge, and an anatomical neck fracture. The combination of these factors significantly increases the risk of avascular necrosis.

Question 6469

Topic: 2. Trauma

A 30-year-old cyclist sustains a midshaft clavicle fracture. Which of the following is considered an absolute indication for open reduction and internal fixation?

. Displacement greater than 100%
. Shortening of 1.5 cm
. Z-type deformity with severe comminution
. Skin tenting with threatened skin breakdown
. Patient preference for earlier return to sports

Correct Answer & Explanation

. Skin tenting with threatened skin breakdown

Explanation

Absolute indications for operative fixation of clavicle fractures include open fractures, neurovascular compromise, and threatened skin breakdown. Displacement, shortening, and comminution are considered strong relative indications.

Question 6470

Topic: 2. Trauma

During open reduction and internal fixation of a 3-part proximal humerus fracture with a locked plate, the surgeon places inferomedial calcar screws. What is the primary biomechanical purpose of these specific screws?

. To prevent screw penetration into the glenohumeral joint
. To minimize the risk of osteonecrosis of the humeral head
. To prevent varus collapse of the humeral head
. To prevent subacromial impingement by the plate
. To compress the greater tuberosity fragment to the shaft

Correct Answer & Explanation

. To prevent varus collapse of the humeral head

Explanation

Inferomedial calcar screws provide critical structural support to the inferomedial humeral head, acting as a buttress. This significantly reduces the risk of postoperative varus collapse, particularly when the medial hinge is comminuted.

Question 6471

Topic: 2. Trauma

Understanding the vascular anatomy of the scaphoid is essential for managing acute fractures and nonunions. Which of the following best describes the primary arterial supply to the scaphoid?

. Volar branches of the ulnar artery entering distally
. Volar branches of the radial artery entering proximally
. Dorsal carpal branch of the radial artery entering distally and flowing retrograde
. Dorsal carpal branch of the ulnar artery entering proximally
. Nutrient artery from the anterior interosseous artery entering centrally

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery entering distally and flowing retrograde

Explanation

The scaphoid receives 70-80% of its blood supply from the dorsal carpal branch of the radial artery, which enters at the distal pole and flows in a retrograde fashion to the proximal pole. This retrograde flow is why proximal pole fractures are at high risk for avascular necrosis.

Question 6472

Topic: Upper Extremity Trauma

During an anatomic reconstruction of the coracoclavicular (CC) ligaments for a chronic Type V acromioclavicular dislocation, accurate footprint placement is crucial. Which of the following describes the normal anatomic orientation of the CC ligaments on the clavicle?

. The conoid is posteromedial, and the trapezoid is anterolateral.
. The conoid is anterolateral, and the trapezoid is posteromedial.
. Both insert centrally along the mechanical axis of the clavicle.
. The conoid inserts 3.0 cm from the distal end, and the trapezoid inserts 4.5 cm from the distal end.
. The trapezoid inserts on the acromion, and the conoid inserts on the clavicle.

Correct Answer & Explanation

. The conoid is posteromedial, and the trapezoid is anterolateral.

Explanation

The conoid ligament inserts posteromedially on the conoid tubercle (roughly 4.5 cm from the distal clavicle). The trapezoid ligament inserts anterolaterally (roughly 3.0 cm from the distal clavicle).

Question 6473

Topic: 2. Trauma

A 55-year-old presents with a Bado Type II Monteggia fracture (posterior apex ulnar fracture with posterior radial head dislocation). What associated injury is most frequently seen with this specific fracture pattern in adults?

. Ulnar nerve palsy
. Radial head or neck fracture
. Distal radioulnar joint (DRUJ) dislocation
. Anterior interosseous nerve palsy
. Coronoid process fracture

Correct Answer & Explanation

. Radial head or neck fracture

Explanation

Bado Type II (posterior Monteggia) lesions are the most common Monteggia variant in adults. They are highly associated with concomitant radial head or neck fractures, which can complicate the management of radiocapitellar stability.

Question 6474

Topic: 2. Trauma

Hertel's radiographic criteria are utilized to predict ischemia of the humeral head following a proximal humerus fracture. Which combination of findings carries the highest positive predictive value for avascular necrosis?

. Calcar length <8 mm, disrupted medial hinge, and anatomic neck fracture pattern
. Calcar length >8 mm, intact medial hinge, and surgical neck fracture pattern
. Tuberosity displacement >1 cm, head-split fracture, and surgical neck fracture
. Valgus impaction, calcar length >8 mm, and intact medial hinge
. Varus displacement, intact medial hinge, and greater tuberosity comminution

Correct Answer & Explanation

. Calcar length <8 mm, disrupted medial hinge, and anatomic neck fracture pattern

Explanation

Hertel identified that the combination of an anatomic neck fracture, a short calcar segment attached to the articular fragment (<8 mm), and a disrupted medial hinge (>2 mm displacement) carries a 97% positive predictive value for humeral head ischemia.

Question 6475

Topic: 2. Trauma

A 25-year-old male presents with a 2-mm displaced fracture of the scaphoid waist following a fall. Surgical fixation is planned. Which of the following is the primary advantage of a volar percutaneous or mini-open approach over a dorsal approach for this specific fracture?

. Avoidance of the superficial branch of the radial nerve
. Preservation of the primary dorsal blood supply to the proximal pole
. Direct visualization of the scapholunate ligament
. Lower risk of flexor pollicis longus rupture
. Easier access to the proximal pole for screw insertion

Correct Answer & Explanation

. Preservation of the primary dorsal blood supply to the proximal pole

Explanation

The primary blood supply to the scaphoid enters dorsally at the wrist and supplies the proximal pole in a retrograde fashion. A volar approach is preferred for waist fractures to avoid disrupting this critical dorsal vascularity.

Question 6476

Topic: 2. Trauma

A 30-year-old male cyclist presents with a midshaft clavicle fracture. Which of the following is considered an absolute indication for operative fixation?

. Fracture shortening of 2.5 cm
. Skin tenting without blanching
. Z-type comminution with a butterfly fragment
. Progressive neurologic deficit of the brachial plexus
. Concomitant non-displaced scapular body fracture

Correct Answer & Explanation

. Progressive neurologic deficit of the brachial plexus

Explanation

Absolute indications for ORIF of a clavicle fracture include open fractures, vascular compromise, and progressive neurologic deficits. Displacement, shortening, and skin tenting are generally considered relative indications.

Question 6477

Topic: 2. Trauma

A 65-year-old female sustains a 4-part proximal humerus fracture. According to Hertel's criteria, which of the following radiographic findings is the most reliable predictor of ischemia to the humeral head?

. Greater tuberosity displacement > 5mm
. Disrupted medial periosteal hinge with metaphyseal extension < 8 mm
. Valgus impaction of the head
. Lesser tuberosity comminution
. Anatomic neck fracture without tuberosity involvement

Correct Answer & Explanation

. Disrupted medial periosteal hinge with metaphyseal extension < 8 mm

Explanation

Hertel identified that a calcar length (metaphyseal extension) of less than 8 mm and disruption of the medial periosteal hinge are the strongest predictors of humeral head ischemia and subsequent avascular necrosis.

Question 6478

Topic: 2. Trauma

A 40-year-old male sustains a severe Essex-Lopresti injury. If the comminuted radial head is primarily excised without replacement, what is the most likely long-term biomechanical complication?

. Proximal migration of the radius leading to ulnocarpal impingement
. Varus instability of the elbow
. Posterior interosseous nerve palsy
. Heterotopic ossification of the proximal radioulnar joint
. Nonunion of the interosseous membrane

Correct Answer & Explanation

. Proximal migration of the radius leading to ulnocarpal impingement

Explanation

An Essex-Lopresti injury involves a radial head fracture, tear of the interosseous membrane, and DRUJ disruption. Excision of the radial head without replacement removes the proximal longitudinal stabilizer, leading to proximal radial migration and ulnocarpal impingement.

Question 6479

Topic: 2. Trauma

A pediatric patient sustains a Bado Type I Monteggia fracture (anterior dislocation of the radial head with anterior bowing/fracture of the ulna). Following ulnar reduction and plating, the radial head remains persistently dislocated anteriorly. What is the most common cause of this failure of reduction?

. Interposition of the annular ligament
. Inadequate restoration of the anatomic ulnar bow and length
. Concomitant radial head fracture
. Entrapment of the radial nerve
. Subluxation of the biceps tendon

Correct Answer & Explanation

. Inadequate restoration of the anatomic ulnar bow and length

Explanation

The most common reason for failure of the radial head to reduce in a Monteggia fracture is incomplete restoration of ulnar length or failure to recreate the anatomic posterior bow of the proximal ulna.

Question 6480

Topic: 2. Trauma

A 25-year-old male undergoes tension band wiring for a simple transverse olecranon fracture. Which of the following is the most frequently reported complication associated with this specific fixation technique?

. Ulnar nerve neuropathy
. Symptomatic hardware requiring removal
. Permanent loss of elbow extension
. Nonunion of the fracture site
. Deep surgical site infection

Correct Answer & Explanation

. Symptomatic hardware requiring removal

Explanation

Symptomatic hardware is the most common complication of tension band wiring for olecranon fractures, occurring in up to 40-80% of cases and frequently necessitating a second surgery for hardware removal.

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