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2. Trauma MCQs

Practice Set 328 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 6541

Topic: 2. Trauma

A 68-year-old woman sustains a displaced 4-part proximal humerus fracture. According to Hertel's radiographic criteria, which of the following findings is the strongest predictor for the subsequent development of humeral head avascular necrosis (AVN)?

. Displacement of the greater tuberosity > 5 mm
. Angulation of the humeral head > 45 degrees
. Disruption of the medial periosteal hinge with a calcar segment < 8 mm
. Involvement of the bicipital groove
. Comminution of the surgical neck

Correct Answer & Explanation

. Disruption of the medial periosteal hinge with a calcar segment < 8 mm

Explanation

Hertel identified specific risk factors for ischemia of the humeral head following proximal humerus fractures. A posteromedial metaphyseal head extension (calcar length) of less than 8 mm and disruption of the medial hinge are the strongest predictors of subsequent AVN.

Question 6542

Topic: Upper Extremity Trauma

A 32-year-old motorcyclist is involved in a high-speed collision.

Chest radiographs demonstrate marked lateral displacement of the left scapula. The patient's left upper extremity is flaccid. What is the most critical next step in management?

. Immediate open reduction of the acromioclavicular joint
. CT angiography of the chest and upper extremity
. EMG and nerve conduction studies
. Application of a shoulder spica cast
. MRI of the brachial plexus

Correct Answer & Explanation

. CT angiography of the chest and upper extremity

Explanation

Scapulothoracic dissociation is a high-energy injury characterized by lateral scapular displacement and is highly associated with catastrophic neurovascular injuries. CT angiography is the most critical initial step to evaluate for a limb- or life-threatening subclavian or axillary artery disruption.

Question 6543

Topic: 2. Trauma

A 40-year-old woman presents with severe wrist pain and elbow stiffness 3 months after undergoing an isolated radial head excision for a comminuted radial head fracture. She did not receive a radial head arthroplasty. Radiographs of the wrist now show positive ulnar variance. Which of the following undetected injuries was most likely present at the time of her initial trauma?

. Ulnar collateral ligament tear
. Triangular fibrocartilage complex tear
. Distal radioulnar joint (DRUJ) capsular rupture and interosseous membrane tear
. Coronoid process fracture
. Scapholunate ligament dissociation

Correct Answer & Explanation

. Distal radioulnar joint (DRUJ) capsular rupture and interosseous membrane tear

Explanation

The patient's presentation of proximal radial migration and ulnocarpal impingement following radial head excision is diagnostic of an Essex-Lopresti injury. This injury involves a longitudinal radioulnar dissociation caused by a radial head fracture combined with an interosseous membrane tear and DRUJ disruption.

Question 6544

Topic: 2. Trauma

A 34-year-old man sustains an oblique fracture of the distal third of the humeral shaft (Holstein-Lewis fracture).

He demonstrates an inability to extend his wrist and fingers. The injured nerve is most susceptible to tethering and injury at which specific anatomical site?

. Where it passes through the quadrilateral space
. Where it pierces the lateral intermuscular septum to enter the anterior compartment
. At the arcade of Frohse
. Where it enters the spiral groove of the posterior humerus
. At the ligament of Struthers

Correct Answer & Explanation

. Where it pierces the lateral intermuscular septum to enter the anterior compartment

Explanation

In a Holstein-Lewis distal third humeral shaft fracture, the radial nerve is particularly vulnerable to entrapment or laceration. This occurs precisely where the nerve is tethered as it pierces the lateral intermuscular septum, passing from the posterior to the anterior compartment of the arm.

Question 6545

Topic: 2. Trauma

A 7-year-old boy sustains a Bado Type I Monteggia fracture-dislocation.

Intraoperatively, after open reduction and internal fixation of the ulnar shaft fracture, the surgeon notes that the radial head remains anteriorly dislocated. What is the most appropriate next step in management?

. Perform an annular ligament reconstruction using a fascial slip
. Excise the radial head
. Assess and revise the ulnar reduction to ensure anatomic length and alignment
. Immobilize the elbow in full extension and pronation
. Pin the radiocapitellar joint in its current dislocated position

Correct Answer & Explanation

. Assess and revise the ulnar reduction to ensure anatomic length and alignment

Explanation

In acute Monteggia fracture-dislocations, persistent dislocation of the radial head following ulnar fixation is almost exclusively due to malreduction (especially shortening or angular deformity) of the ulna. The immediate next step must be to critically assess and revise the ulnar reduction.

Question 6546

Topic: 2. Trauma

A 22-year-old cyclist falls directly onto his shoulder, sustaining a completely displaced, midshaft clavicle fracture with 2.5 cm of shortening. Compared to nonoperative management with a sling, operative plate fixation of this specific injury pattern is proven to significantly decrease the risk of which complication?

. Infection
. Adhesive capsulitis
. Nonunion
. Need for future hardware removal
. Subclavian vein thrombosis

Correct Answer & Explanation

. Need for future hardware removal

Explanation

In completely displaced and shortened (>2 cm) midshaft clavicle fractures, operative fixation has been shown to significantly decrease the rate of nonunion and symptomatic malunion compared to nonoperative management. However, operative fixation increases the risks of infection and need for hardware removal.

Question 6547

Topic: 2. Trauma

A 25-year-old cyclist falls, sustaining a midshaft clavicle fracture with 100% displacement and 2 cm of shortening. Compared to nonoperative management, open reduction and internal fixation (ORIF) of this fracture is associated with which of the following outcomes?

. Higher rate of nonunion
. Decreased risk of symptomatic malunion
. Lower rate of hardware removal
. Decreased shoulder strength
. Increased risk of brachial plexus injury

Correct Answer & Explanation

. Lower rate of hardware removal

Explanation

ORIF of severely displaced and shortened midshaft clavicle fractures decreases the risk of nonunion and symptomatic malunion compared to nonoperative treatment. However, it carries surgical risks, including a higher likelihood of requiring subsequent hardware removal.

Question 6548

Topic: 2. Trauma

A 35-year-old man presents with a stiff elbow 6 months after a complex fracture-dislocation. His range of motion is 30 to 90 degrees, and radiographs show heterotopic ossification (HO). When considering surgical release and HO excision, what is the most important factor dictating the timing of surgery?

. Normalization of serum alkaline phosphatase
. Evidence of a mature trabecular pattern on radiographs
. A minimum of 12 months since the initial injury
. Negative triphasic bone scan
. Failure of 6 weeks of dynamic splinting

Correct Answer & Explanation

. Evidence of a mature trabecular pattern on radiographs

Explanation

The presence of a well-defined, mature trabecular pattern on plain radiographs indicates mature heterotopic ossification. Historical markers like normal alkaline phosphatase or a cold bone scan are no longer considered reliable prerequisites for excision.

Question 6549

Topic: 2. Trauma



A 24-year-old woman falls on her outstretched hand. Radiographs demonstrate a coronal shear fracture of the capitellum extending medially to involve the lateral trochlear ridge (Type IV or McKee modification). What is the preferred surgical approach and fixation strategy?

. Medial approach with tension band wiring
. Lateral (extended Kocher) approach with anterior-to-posterior headless compression screws
. Posterior approach with olecranon osteotomy and posterior-to-anterior lag screws
. Arthroscopic excision of the fracture fragment
. Lateral approach with lateral column bridge plating

Correct Answer & Explanation

. Lateral (extended Kocher) approach with anterior-to-posterior headless compression screws

Explanation

Coronal shear fractures of the capitellum, especially those involving the trochlea, are best managed via an extended lateral approach. Fixation is optimally achieved with anterior-to-posterior headless compression screws buried beneath the articular cartilage.

Question 6550

Topic: Upper Extremity Trauma

A 29-year-old weightlifter feels a tearing sensation in his chest while performing a heavy bench press. Examination reveals bruising and loss of the normal anterior axillary fold contour. What is the most common anatomic location for a pectoralis major rupture?

. Muscle belly
. Musculotendinous junction
. Clavicular head origin
. Sternal head origin
. Tendinous insertion onto the proximal humerus

Correct Answer & Explanation

. Tendinous insertion onto the proximal humerus

Explanation

Pectoralis major ruptures most frequently occur in weightlifters (especially during the bench press) at the tendinous insertion onto the lateral lip of the bicipital groove of the proximal humerus.

Question 6551

Topic: 2. Trauma

A 60-year-old woman sustains a highly comminuted intra-articular distal humerus fracture (AO type 13-C). The surgeon plans an open reduction and internal fixation via a posterior approach with an olecranon osteotomy. Which osteotomy technique is associated with the highest intrinsic stability and lowest rate of hardware complications?

. Transverse osteotomy with plate fixation
. Chevron (V-shaped) osteotomy repaired with tension band wiring or a plate
. Oblique osteotomy with independent lag screws
. Step-cut osteotomy
. Base of coronoid osteotomy

Correct Answer & Explanation

. Chevron (V-shaped) osteotomy repaired with tension band wiring or a plate

Explanation

A chevron (V-shaped) osteotomy directed toward the bare area of the greater sigmoid notch provides excellent intrinsic bony stability due to its interdigitating geometry, facilitating high union rates when repaired with a tension band or plate.

Question 6552

Topic: 2. Trauma

Which of the following radiographic findings is the most reliable predictor of future avascular necrosis (AVN) following a displaced proximal humerus fracture?

. Displacement of the greater tuberosity > 1 cm
. Angulation of the surgical neck > 45 degrees
. Short calcar segment (< 8 mm) attached to the articular surface
. Presence of a split head (head-splitting) component
. Disruption of the lateral periosteal hinge

Correct Answer & Explanation

. Short calcar segment (< 8 mm) attached to the articular surface

Explanation

Hertel criteria for predicting ischemia and AVN of the humeral head include a short medial calcar segment (<8 mm attached to the articular segment), disrupted medial hinge, and an anatomic neck fracture pattern. A short calcar segment is highly predictive of AVN because it implies disruption of the ascending branch of the anterior humeral circumflex artery and intraosseous vessels.

Question 6553

Topic: 2. Trauma

A 78-year-old woman with severe osteoporosis falls and sustains a highly comminuted, displaced intra-articular fracture of the distal humerus. The articular fragments are too small for rigid fixation. What is the most appropriate surgical treatment that allows early mobilization?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with dual orthogonal plates
. Total elbow arthroplasty
. Hemiarthroplasty of the distal humerus
. External fixation across the elbow joint

Correct Answer & Explanation

. Total elbow arthroplasty

Explanation

Total elbow arthroplasty (TEA) is the treatment of choice for highly comminuted, unsalvageable intra-articular distal humerus fractures in elderly, osteoporotic patients. It allows for immediate postoperative range of motion and has reliable outcomes for pain control and function in low-demand individuals.

Question 6554

Topic: 2. Trauma

A 24-year-old male cyclist sustains a midshaft clavicle fracture. Which of the following is considered an absolute indication for open reduction and internal fixation?

. Displacement greater than 2 cm
. Z-type comminution
. Skin tenting with threatened overlying skin integrity
. Shortening of 1.5 cm
. Patient occupation as an overhead athlete

Correct Answer & Explanation

. Skin tenting with threatened overlying skin integrity

Explanation

Absolute indications for operative treatment of clavicle fractures include open fractures, neurovascular compromise, and severe skin tenting that threatens skin integrity (impending open fracture). Displacement and shortening are relative indications, considered primarily to decrease nonunion rates in active individuals.

Question 6555

Topic: 2. Trauma

A 24-year-old cyclist falls directly onto his left shoulder, sustaining a closed midshaft clavicle fracture. Which of the following radiographic or clinical findings is the strongest indication for open reduction and internal fixation (ORIF) to decrease the rate of symptomatic malunion?

. Fracture comminution with less than 5 mm of displacement
. Superior displacement of the lateral fragment
. Fracture shortening of greater than 2 cm
. Presence of an associated nondisplaced acromion fracture
. Inferior displacement of the medial fragment

Correct Answer & Explanation

. Fracture shortening of greater than 2 cm

Explanation

Significant shortening (greater than 2 cm) and 100% displacement of midshaft clavicle fractures are strong indications for ORIF in active adults. Surgical fixation in these cases significantly reduces the rates of nonunion and symptomatic malunion compared to nonoperative management.

Question 6556

Topic: 2. Trauma

A 78-year-old woman with severe rheumatoid arthritis sustains a comminuted intra-articular distal humerus fracture. Radiographs show osteopenic bone and extensive articular fragmentation. What is the most appropriate surgical treatment?

. Closed reduction and casting
. External fixation
. Total elbow arthroplasty
. Orthogonal double plating
. Parallel double plating

Correct Answer & Explanation

. Total elbow arthroplasty

Explanation

Total elbow arthroplasty is the treatment of choice for highly comminuted, intra-articular distal humerus fractures in elderly patients. It allows for early mobilization in patients with poor bone quality or pre-existing inflammatory arthritis.

Question 6557

Topic: 2. Trauma

Which of the following is a widely accepted relative indication for open reduction and internal fixation of a midshaft clavicle fracture?

. Displacement greater than 1 cm
. Shortening greater than 2 cm
. Associated nondisplaced scapular body fracture
. Age greater than 65 years
. Presence of a butterfly fragment

Correct Answer & Explanation

. Shortening greater than 2 cm

Explanation

Shortening >2 cm, complete displacement, and severe Z-deformity are relative indications for operative fixation of midshaft clavicle fractures. Surgery decreases the risk of nonunion and symptomatic malunion.

Question 6558

Topic: 2. Trauma
A 6-year-old boy falls off monkey bars and sustains a diaphyseal fracture of the proximal third of the ulna with an associated anterior dislocation of the radial head. What Bado classification does this represent?
. Bado Type I
. Bado Type II
. Bado Type III
. Bado Type IV
. Bado Type V

Correct Answer & Explanation

. Bado Type I

Explanation

A Bado Type I Monteggia fracture 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 Monteggia type in children.

Question 6559

Topic: 2. Trauma

A 50-year-old man sustains a transverse, non-comminuted fracture of the olecranon. He undergoes tension band wiring. What is the primary biomechanical principle of this fixation construct?

. Converts compressive forces at the articular surface into tensile forces
. Converts tensile forces at the dorsal cortex into compressive forces at the articular surface
. Provides rigid absolute stability through compression screws
. Relies on splinting forces of the triceps tendon
. Acts as a neutralization plate

Correct Answer & Explanation

. Converts tensile forces at the dorsal cortex into compressive forces at the articular surface

Explanation

Tension band wiring converts the tensile forces on the dorsal cortex caused by the pull of the triceps into compressive forces at the articular surface. This promotes primary bone healing in transverse fractures.

Question 6560

Topic: 2. Trauma
A 25-year-old cyclist sustains a completely displaced, shortened (>2 cm) midshaft clavicle fracture. Compared to nonoperative management, operative fixation with plate and screws is primarily associated with a lower incidence of which of the following?
. Infection
. Need for subsequent surgery
. Symptomatic nonunion
. Brachial plexus injury
. Adhesive capsulitis

Correct Answer & Explanation

. Symptomatic nonunion

Explanation

Operative fixation of completely displaced, shortened midshaft clavicle fractures significantly reduces the rate of symptomatic nonunion and symptomatic malunion compared to nonoperative treatment. However, operative management does carry risks of infection and hardware irritation requiring subsequent removal.

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