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2. Trauma MCQs

Practice Set 327 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 6521

Topic: Upper Extremity Trauma

During evaluation of a severe shoulder injury, a radiograph

shows superior displacement of the clavicle by 150% relative to the acromion. Which of the following best describes the pathoanatomy of this Rockwood Type V acromioclavicular injury?

. Sprain of AC ligaments, intact CC ligaments
. Torn AC ligaments, sprained CC ligaments
. Torn AC and CC ligaments, intact deltotrapezius fascia
. Torn AC and CC ligaments, stripped deltotrapezius fascia
. Inferior dislocation of the clavicle under the coracoid

Correct Answer & Explanation

. Torn AC and CC ligaments, stripped deltotrapezius fascia

Explanation

A Rockwood Type V injury involves tearing of the acromioclavicular (AC) and coracoclavicular (CC) ligaments, along with extensive stripping of the deltotrapezius fascia, leading to severe superior displacement of the distal clavicle.

Question 6522

Topic: 2. Trauma

Which of the following factors is most predictive of avascular necrosis following a proximal humerus fracture?

. Displacement of the surgical neck
. Calcar length <8 mm attached to the articular segment
. Shortening of the humerus
. Intact medial hinge
. Fracture of the greater tuberosity

Correct Answer & Explanation

. Calcar length <8 mm attached to the articular segment

Explanation

According to the Hertel criteria, a calcar length of less than 8 mm attached to the articular segment is a strong predictor of ischemia and subsequent avascular necrosis. Other predictors include disruption of the medial hinge and anatomic neck fractures.

Question 6523

Topic: 2. Trauma

Which of the following is considered an absolute indication for operative treatment of an acute midshaft clavicle fracture?

. 1.5 cm of shortening
. 100% displacement
. Open fracture
. Z-type comminution
. Female gender

Correct Answer & Explanation

. Open fracture

Explanation

Absolute indications for open reduction and internal fixation of a clavicle fracture include open fractures, skin tenting threatening to progress to an open fracture, and associated subclavian vessel or brachial plexus injuries.

Question 6524

Topic: 2. Trauma

A 32-year-old male sustains a closed, distal-third spiral humeral shaft fracture (Holstein-Lewis) and presents with an inability to extend his wrist and fingers. What is the most appropriate initial management?

. Immediate surgical exploration of the radial nerve and ORIF
. Placement in a coaptation splint with clinical observation
. EMG and nerve conduction studies
. Closed reduction and functional bracing
. Primary nerve grafting

Correct Answer & Explanation

. Closed reduction and functional bracing

Explanation

Primary radial nerve palsies associated with closed humeral shaft fractures are typically managed expectantly with splinting or functional bracing and observation. Most cases resolve spontaneously within 3 to 4 months.

Question 6525

Topic: Upper Extremity Trauma

A 25-year-old rugby player sustains an acromioclavicular (AC) joint injury. Radiographs reveal 150% superior displacement of the clavicle relative to the acromion. Which of the following ligaments are disrupted in this Rockwood Type V injury?

. Acromioclavicular ligaments only
. Coracoclavicular ligaments only
. Acromioclavicular and coracoclavicular ligaments, with stripping of the deltotrapezial fascia
. Acromioclavicular ligaments and coracoacromial ligaments
. Coracohumeral ligaments

Correct Answer & Explanation

. Acromioclavicular and coracoclavicular ligaments, with stripping of the deltotrapezial fascia

Explanation

Rockwood Type V injuries involve severe superior displacement of the clavicle (100-300%). This requires disruption of the AC ligaments, CC ligaments, and significant stripping or detachment of the deltotrapezial fascia.

Question 6526

Topic: 2. Trauma
A 6-year-old child presents after a fall with a fracture of the proximal third of the ulna and an anterior dislocation of the radial head. What is the Bado classification of this injury?
. Bado Type I
. Bado Type II
. Bado Type III
. Bado Type IV
. Bado Type V

Correct Answer & Explanation

. Bado Type I

Explanation

Bado Type I Monteggia fracture-dislocation is characterized by a fracture of the proximal or middle third of the ulna with an anterior dislocation of the radial head. It is the most common Bado type in pediatric patients.

Question 6527

Topic: 2. Trauma

When utilizing tension band wiring for a transverse olecranon fracture, what is the primary biomechanical principle by which this fixation method promotes bone healing?

. Conversion of distraction forces into compression forces at the articular surface
. Splinting of the fracture to prevent varus collapse
. Rigid absolute stability through direct screw compression
. Maintenance of length through dynamic bridging
. Callus formation through relative stability

Correct Answer & Explanation

. Conversion of distraction forces into compression forces at the articular surface

Explanation

The tension band principle converts the tensile forces generated on the dorsal cortex by the triceps muscle into compressive forces at the articular surface during elbow flexion. This dynamic compression promotes primary bone healing.

Question 6528

Topic: 2. Trauma

A 75-year-old woman sustains a severely displaced 4-part proximal humerus fracture. You are considering whether to perform open reduction internal fixation (ORIF) or arthroplasty. Which of the following radiographic factors is the most reliable predictor of humeral head ischemia?

. Calcar length less than 8 mm and medial hinge disruption greater than 2 mm
. Greater tuberosity displacement greater than 1 cm
. Varus angulation greater than 20 degrees
. Surgical neck translation greater than 50%
. Head-split fracture with 1 mm step-off

Correct Answer & Explanation

. Calcar length less than 8 mm and medial hinge disruption greater than 2 mm

Explanation

Hertel's criteria identify predictors of humeral head ischemia in proximal humerus fractures. The most significant predictors include a posteromedial hinge disruption > 2 mm, a metaphyseal head extension (calcar length) < 8 mm, and an anatomic neck fracture.

Question 6529

Topic: 2. Trauma
A 24-year-old cyclist falls and sustains a midshaft clavicle fracture. Which of the following is considered an absolute indication for operative fixation?
. Displacement greater than 100%
. Shortening greater than 2 cm
. Open fracture
. Comminution with a Z-deformity
. Bilateral clavicle fractures

Correct Answer & Explanation

. Open fracture

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, fractures with associated neurovascular injury, and severe skin tenting threatening to progress to an open injury. Shortening and displacement are relative indications.

Question 6530

Topic: 2. Trauma
A 40-year-old male sustains a high-energy trauma resulting in a scapula fracture. Radiographs demonstrate a transverse fracture line originating at the glenoid fossa and exiting the lateral border of the scapula. According to the Ideberg classification of intra-articular glenoid fractures, which type is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

In the Ideberg classification, Type II is a transverse fracture exiting the lateral scapular border. Type I involves the anterior rim, Type III exits superiorly involving the coracoid, and Type IV exits the medial border.

Question 6531

Topic: 2. Trauma
A 55-year-old female presents with an isolated ulnar shaft fracture combined with a dislocation of the radial head. Radiographs show the radial head is dislocated posteriorly. According to the Bado classification of Monteggia fractures, which type does this represent?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

Bado Type II Monteggia fractures involve posterior dislocation of the radial head with posterior angulation of the ulnar fracture. This pattern is the most common Monteggia lesion seen in adults.

Question 6532

Topic: 2. Trauma

During open reduction and internal fixation of a complex intra-articular distal humerus fracture, a transolecranon approach is selected. To minimize damage to the articular cartilage of the proximal ulna, the chevron osteotomy should be directed towards which anatomic landmark?

. The coronoid process
. The bare area of the sigmoid notch
. The sublime tubercle
. The radial notch
. The supinator crest

Correct Answer & Explanation

. The bare area of the sigmoid notch

Explanation

An olecranon osteotomy for distal humerus exposure should be directed to exit through the 'bare area' (non-articular portion) of the greater sigmoid notch. This minimizes damage to the articular cartilage of the ulna.

Question 6533

Topic: Upper Extremity Trauma
A 28-year-old rugby player sustains a Type III acromioclavicular (AC) joint separation. Which ligaments are structurally disrupted in this specific injury pattern?
. The acromioclavicular ligaments only
. The coracoclavicular ligaments only
. Both the acromioclavicular and coracoclavicular ligaments
. The coracoacromial and acromioclavicular ligaments
. The sternoclavicular and coracoclavicular ligaments

Correct Answer & Explanation

. Both the acromioclavicular and coracoclavicular ligaments

Explanation

A Rockwood Type III AC joint separation involves complete tearing of both the acromioclavicular ligaments and the coracoclavicular (conoid and trapezoid) ligaments. The clavicle is typically elevated 25-100% relative to the acromion.

Question 6534

Topic: 2. Trauma

A 68-year-old female sustains a displaced proximal humerus fracture. According to the Hertel criteria, which of the following is the most significant radiographic predictor for the development of humeral head avascular necrosis (AVN)?

. Length of the posteromedial metaphyseal extension less than 8 mm
. Intact medial periosteal hinge
. Valgus impaction of the humeral head
. Greater tuberosity displacement greater than 10 mm
. Diaphyseal extension of the fracture line

Correct Answer & Explanation

. Length of the posteromedial metaphyseal extension less than 8 mm

Explanation

Hertel et al. identified key predictors for humeral head ischemia following proximal humerus fractures. The most reliable predictors include a posteromedial metaphyseal head extension (calcar length) of less than 8 mm, disruption of the medial hinge greater than 2 mm, and an anatomic neck fracture pattern.

Question 6535

Topic: 2. Trauma

A 17-year-old high school football player reports wrist pain 5 months after the conclusion of the football season. A radiograph and MRI scan are shown in Figures 29a and 29b. What is the recommended intervention?

. Pedicled vascularized bone graft
. Long arm thumb spica cast
. Percutaneous screw fixation
. Corticocancellous bone grating via a volar approach (Matti-Russe)
. Open reduction and differential pitch screw placement via a dorsal approach

Correct Answer & Explanation

. Pedicled vascularized bone graft

Explanation

The patient has a nonunion of the proximal pole of the scaphoid. Acutely, this can be repaired with a screw alone, but as a nonunion the proximal pole has very poor healing potential. Vacularized bone grafts have been successful for these challenging nonunions, particularly in adolescents. A cast can be used for nondisplaced acute waist fractures, and corticocancellous grafts can be used for nonunions of the waist. Waters PM, Stewart SL: Surgical treatment of nonunion and avascular necrosis of the proximal part of the scaphoid in adolescents. J Bone Joint Surg Am 2002;84:915-920.

Question 6536

Topic: 2. Trauma

According to the Hertel criteria for proximal humerus fractures, which of the following radiographic findings is most strongly associated with subsequent humeral head ischemia?

. Calcar length greater than 15 mm
. Disruption of the medial hinge greater than 2 mm
. Greater tuberosity displacement less than 5 mm
. Intact posteromedial periosteal hinge
. Varus angulation of 10 degrees

Correct Answer & Explanation

. Disruption of the medial hinge greater than 2 mm

Explanation

The Hertel criteria identify predictors for high risk of avascular necrosis, which include a metaphyseal head extension (calcar length) of less than 8 mm and disruption of the medial hinge greater than 2 mm. An intact medial hinge suggests preserved vascularity.

Question 6537

Topic: 2. Trauma

A 75-year-old female sustains a highly comminuted, osteoporotic intra-articular distal humerus fracture.

What is the primary advantage of total elbow arthroplasty (TEA) over open reduction and internal fixation (ORIF) in this specific patient population?

. Higher postoperative weight-bearing limits
. Decreased risk of postoperative ulnar neuropathy
. Avoidance of hardware failure and fracture nonunion
. Better suitability for high-demand physical labor
. Restoration of normal elbow kinematics

Correct Answer & Explanation

. Avoidance of hardware failure and fracture nonunion

Explanation

In elderly patients with poor bone quality, TEA allows for immediate postoperative motion and reliable pain relief, avoiding the high risks of nonunion, malunion, and hardware failure seen with ORIF. However, TEA imposes permanent weight-bearing restrictions.

Question 6538

Topic: 2. Trauma

A 28-year-old male falls onto his shoulder while snowboarding. Radiographs reveal a completely displaced midshaft clavicle fracture with 2.5 cm of shortening.

Compared to nonoperative management, surgical fixation of this injury is associated with:

. A higher rate of neurovascular injury
. A lower rate of nonunion and symptomatic malunion
. Increased rates of delayed union
. Decreased patient satisfaction at 1 year
. Higher risk of ipsilateral shoulder adhesive capsulitis

Correct Answer & Explanation

. A lower rate of nonunion and symptomatic malunion

Explanation

Surgical fixation of completely displaced, significantly shortened (>2 cm) midshaft clavicle fractures in active adults reduces the rate of nonunion and symptomatic malunion compared to nonoperative management. It also typically results in earlier functional return.

Question 6539

Topic: 2. Trauma

A 28-year-old man sustains a closed midshaft humeral fracture

. On initial emergency department presentation, he is unable to extend his wrist or fingers. What is the most appropriate initial management of this patient's neurologic deficit?

. Immediate surgical exploration of the radial nerve
. Electromyography (EMG) and nerve conduction studies
. Application of a coaptation splint and clinical observation
. Open reduction and internal fixation with nerve grafting
. Skeletal traction with frequent neurologic checks

Correct Answer & Explanation

. Application of a coaptation splint and clinical observation

Explanation

Primary radial nerve palsies associated with closed humeral shaft fractures should be managed observationally with a functional brace or coaptation splint. Most palsies are neurapraxias or axonotmeses that spontaneously recover; surgical exploration is only indicated for open fractures, severe vascular injuries, or secondary palsies appearing after closed reduction.

Question 6540

Topic: 2. Trauma

A lateral elbow radiograph of a 28-year-old woman who fell on an outstretched arm demonstrates a 'double arc' sign.

What does this radiographic finding indicate?

. An isolated Hahn-Steinthal capitellar fracture
. A radial head fracture combined with a coronoid fracture
. A coronal shear fracture of the capitellum with extension into the trochlea
. A posterolateral rotatory subluxation of the radiocapitellar joint
. An Essex-Lopresti injury

Correct Answer & Explanation

. A coronal shear fracture of the capitellum with extension into the trochlea

Explanation

The 'double arc' sign on a lateral elbow radiograph pathognomonically represents a type IV coronal shear fracture (McKee modification). The two arcs correspond to the subchondral bone of the capitellum and the lateral ridge of the trochlea, indicating trochlear extension.

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