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2. Trauma MCQs

Practice Set 354 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 7061

Topic: 2. Trauma

A 25-year-old cyclist sustains a displaced fracture of the distal third of the clavicle. Radiographs show superior displacement of the medial fragment, while the coracoclavicular (CC) ligaments remain attached to the distal fragment. What is the recommended management?

. Figure-of-eight brace for 6 weeks
. Sling immobilization and early passive motion
. Open reduction and internal fixation
. Closed reduction and percutaneous pinning
. Distal clavicle excision

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

Neer Type II distal clavicle fractures involve detachment of the medial segment from the CC ligaments. Because of the high nonunion rate (up to 50%) with nonoperative management, operative fixation is indicated.

Question 7062

Topic: 2. Trauma

A 65-year-old patient presents with a highly comminuted olecranon fracture that exits distal to the coronoid process (trans-olecranon fracture-dislocation pattern). What is the most appropriate method of internal fixation?

. Tension band wiring
. Plate and screw fixation
. Fragment excision and triceps advancement
. Intramedullary nailing
. Closed reduction and casting

Correct Answer & Explanation

. Plate and screw fixation

Explanation

Tension band wiring relies on anterior cortical contact to convert tensile forces to compressive forces; it is contraindicated in comminuted fractures or fractures distal to the coronoid. Plate and screw fixation is required to maintain the dimensions of the greater sigmoid notch.

Question 7063

Topic: 2. Trauma
A 28-year-old cyclist sustains a mid-shaft clavicle fracture after going over the handlebars. According to established orthopedic guidelines, which of the following is considered an absolute indication for acute operative fixation of a clavicle fracture?
. Displacement greater than 100%
. Shortening greater than 2 cm
. Open fracture
. Comminution with a Z-fragment
. Patient occupation as an overhead athlete

Correct Answer & Explanation

. Open fracture

Explanation

Absolute indications for operative fixation of a clavicle fracture include an open fracture, associated neurovascular injury, or skin tenting with progressive ischemia. Displacement and shortening > 2 cm are relative indications.

Question 7064

Topic: 2. Trauma

A 68-year-old osteoporotic woman sustains a displaced 3-part proximal humerus fracture. Open reduction and internal fixation with a locking plate is planned. To maximize biomechanical stability and prevent postoperative varus collapse of the humeral head, which of the following must be achieved intraoperatively?

. Reattachment of the lesser tuberosity with heavy nonabsorbable suture
. Placement of the plate 2 cm distal to the greater tuberosity
. Restoration of the medial calcar hinge and/or use of a calcar screw
. Routine use of structural fibular allograft
. Excision of the long head of the biceps tendon

Correct Answer & Explanation

. Restoration of the medial calcar hinge and/or use of a calcar screw

Explanation

Restoration of the medial hinge (calcar) and the insertion of inferomedial calcar screws are critical steps in locking plate fixation of proximal humerus fractures to prevent varus collapse and secondary screw cutout.

Question 7065

Topic: Upper Extremity Trauma

A 38-year-old bicyclist falls directly onto his shoulder. Clinical examination and standing X-rays demonstrate a Type V acromioclavicular (AC) joint separation, with the distal clavicle elevated 150% above the acromion. Which ligaments are completely disrupted in this injury pattern?

. Acromioclavicular ligaments only
. Coracoclavicular ligaments only
. Acromioclavicular and coracoclavicular ligaments
. Acromioclavicular, coracoclavicular, and coracoacromial ligaments
. Sternoclavicular and acromioclavicular ligaments

Correct Answer & Explanation

. Acromioclavicular and coracoclavicular ligaments

Explanation

A Type V AC joint separation involves severe superior displacement of the clavicle due to complete disruption of both the acromioclavicular (AC) and coracoclavicular (conoid and trapezoid) ligaments, along with disruption of the deltotrapezial fascia.

Question 7066

Topic: Upper Extremity Trauma
A 30-year-old right-hand-dominant construction worker sustains a Type III acromioclavicular (AC) joint separation following a direct blow to the shoulder. What is the most widely accepted initial management for this patient?
. Open reduction and hook plate fixation
. Coracoclavicular ligament reconstruction
. Weaver-Dunn procedure
. Nonoperative management with a sling and early range of motion
. Distal clavicle excision

Correct Answer & Explanation

. Nonoperative management with a sling and early range of motion

Explanation

Acute Type III AC joint separations (complete tear of the AC and CC ligaments) are generally treated nonoperatively with a sling and early rehabilitation. Multiple studies have shown that clinical outcomes of nonoperative management are comparable to surgery, with lower complication rates.

Question 7067

Topic: 2. Trauma
A 34-year-old cyclist falls directly onto his shoulder. Radiographs show a displaced distal third clavicle fracture with the fracture line located medial to the intact coracoclavicular ligaments. The proximal fragment is displaced superiorly. This injury is best classified as:
. Neer Type I
. Neer Type II
. Neer Type III
. Neer Type IV
. Neer Type V

Correct Answer & Explanation

. Neer Type II

Explanation

Neer Type II distal clavicle fractures occur when the fracture is medial to the coracoclavicular ligaments, and the proximal fragment is displaced superiorly by the pull of the trapezius. They have a high rate of nonunion with conservative management and typically require surgical fixation.

Question 7068

Topic: 2. Trauma

A 25-year-old cyclist falls and 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
. Shortening of 1.5 cm
. Open fracture
. Z-deformity on radiographs
. Presence of a butterfly fragment

Correct Answer & Explanation

. Open fracture

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, neurovascular compromise, and severe skin tenting predicting imminent skin breakdown. Shortening and severe displacement are relative indications depending on patient activity level.

Question 7069

Topic: Upper Extremity Trauma
A 28-year-old recreational hockey player falls onto the point of his shoulder. Radiographs show a 100% superior displacement of the distal clavicle relative to the acromion. The coracoclavicular distance is increased by 50% compared to the contralateral side. What is the most appropriate initial management?
. Coracoclavicular ligament reconstruction
. Hook plate fixation
. Weaver-Dunn procedure
. Nonoperative management with a sling
. Distal clavicle excision

Correct Answer & Explanation

. Nonoperative management with a sling

Explanation

This is a Type III acromioclavicular (AC) joint separation. Initial management for acute Type III AC separations is generally nonoperative with a short period of sling immobilization, followed by early range of motion.

Question 7070

Topic: 2. Trauma

A 25-year-old man sustains a closed, transverse midshaft humerus fracture. Upon examination in the emergency department, he is unable to extend his wrist or fingers, though he had normal function immediately after the injury prior to closed reduction. What is the most appropriate management of this neurologic deficit?

. Observation and functional bracing
. Immediate ORIF with radial nerve exploration
. External fixation of the humerus
. Electromyography (EMG) testing in the emergency department
. Closed reduction under general anesthesia

Correct Answer & Explanation

. Immediate ORIF with radial nerve exploration

Explanation

A secondary radial nerve palsy (occurring after manipulation or closed reduction) is a classic indication for immediate surgical exploration and fracture fixation, as the nerve may be entrapped in the fracture site. Primary radial nerve palsies are usually observed.

Question 7071

Topic: 2. Trauma

A scaphoid waist fracture is at high risk of nonunion and avascular necrosis due to its tenuous retrograde blood supply. Which vessel provides the dominant blood supply to the proximal pole of the scaphoid?

. Superficial palmar arch
. Volar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery
. Ulnar artery
. Anterior interosseous artery

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The dorsal carpal branch of the radial artery provides approximately 80% of the blood supply to the scaphoid. It enters the bone distally and provides retrograde flow to the proximal pole, explaining the high risk of avascular necrosis in proximal pole fractures.

Question 7072

Topic: 2. Trauma

A 30-year-old man requires tension band wiring for a displaced, non-comminuted transverse olecranon fracture. What is the primary biomechanical principle underlying tension band wiring in this setting?

. Converts tensile forces on the articular surface into compressive forces
. Converts tensile forces on the dorsal cortex into compressive forces at the articular surface
. Provides rigid absolute stability via direct interfragmentary lag screw compression
. Acts as a neutralization device for shear forces across the joint
. Bypasses the fracture site entirely to allow secondary bone healing

Correct Answer & Explanation

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

Explanation

Tension band wiring operates on the principle of converting tensile forces (from the pull of the triceps on the dorsal cortex) into dynamic compressive forces at the articular surface during active elbow flexion.

Question 7073

Topic: 2. Trauma

A 28-year-old male presents with a closed midshaft humeral fracture after a direct blow. On examination, he is unable to extend his wrist or fingers, and he has decreased sensation over the dorsal web space of the hand. Which of the following is the most appropriate initial management?

. Immediate exploration of the radial nerve and open reduction internal fixation (ORIF)
. Placement of a coaptation splint and close clinical observation
. Immediate external fixation to restore length and alignment
. Electromyography (EMG) and nerve conduction studies
. ORIF of the humerus without nerve exploration

Correct Answer & Explanation

. Placement of a coaptation splint and close clinical observation

Explanation

Immediate closed reduction and application of a coaptation splint is the standard of care for a closed humeral shaft fracture with an acute radial nerve palsy. Most of these palsies are neuropraxias that will recover spontaneously.

Question 7074

Topic: 2. Trauma

While operative fixation of acute midshaft clavicle fractures is increasingly common in active individuals, certain findings mandate surgical intervention. Which of the following is an absolute indication for operative fixation of an acute clavicle fracture?

. 2 cm of shortening
. 100% fracture displacement
. Impending skin necrosis due to severe tenting
. Concomitant ipsilateral rib fractures
. A Z-type deformity on the anteroposterior radiograph

Correct Answer & Explanation

. Impending skin necrosis due to severe tenting

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, acute neurovascular compromise, and severe skin tenting causing impending skin necrosis. Displacement and shortening are considered relative indications.

Question 7075

Topic: Upper Extremity Trauma

A 22-year-old rugby player falls directly onto the point of his shoulder and presents with severe pain. Radiographs demonstrate a superiorly displaced distal clavicle. The superior translation is measured at 250% of the normal coracoclavicular (CC) distance. Which of the following accurately describes the ligamentous and fascial pathology in this Type V acromioclavicular (AC) joint injury?

. Intact AC ligaments, torn CC ligaments
. Torn AC ligaments, torn CC ligaments, intact deltotrapezial fascia
. Torn AC ligaments, torn CC ligaments, disrupted deltotrapezial fascia
. Torn AC ligaments, intact CC ligaments, intact deltotrapezial fascia
. Torn CC ligaments, intact AC ligaments, disrupted deltotrapezial fascia

Correct Answer & Explanation

. Torn AC ligaments, torn CC ligaments, disrupted deltotrapezial fascia

Explanation

A Type V acromioclavicular joint injury is characterized by severe superior displacement (>100%). This requires rupture of both the AC and CC ligaments, accompanied by disruption of the stabilizing deltotrapezial fascial envelope.

Question 7076

Topic: Upper Extremity Trauma

A 32-year-old bodybuilder felt a sudden tear in his anterior chest wall while performing a heavy bench press. Examination reveals loss of the anterior axillary fold and extensive ecchymosis over the anterior arm. If surgical repair is planned, where is the most common site of failure requiring anatomic reattachment in this specific injury?

. The sternal head origin on the rib cage
. Within the muscle belly itself
. At the musculotendinous junction
. The tendinous insertion onto the proximal humerus
. The clavicular head origin

Correct Answer & Explanation

. The tendinous insertion onto the proximal humerus

Explanation

Pectoralis major ruptures almost exclusively involve the sternal head, typically tearing at the tendinous insertion onto the proximal humerus or the musculotendinous junction. Tears at the tendinous insertion are most amenable to direct surgical repair.

Question 7077

Topic: 2. Trauma

A 25-year-old cyclist sustains a midshaft clavicle fracture. Which of the following radiographic or clinical findings is the strongest predictor of nonunion if this injury is managed nonoperatively?

. Superior displacement of 5 mm
. Shortening greater than 2 cm
. Undisplaced butterfly fragment
. Middle-third location of the fracture
. Age younger than 30 years

Correct Answer & Explanation

. Superior displacement of 5 mm

Explanation

Shortening greater than 2 cm, 100% displacement, and severe comminution are major predictors of nonunion in midshaft clavicle fractures. Operative fixation is generally indicated to prevent symptomatic nonunion in these patients.

Question 7078

Topic: 2. Trauma

A 65-year-old woman sustains a 4-part proximal humerus fracture. According to the Hertel criteria, which radiographic feature is the strongest predictor of subsequent humeral head ischemia?

. Greater tuberosity displacement > 1 cm
. Calcar length < 8 mm attached to the articular segment
. Head-shaft angle > 130 degrees
. Intact medial hinge
. Varus angulation < 20 degrees

Correct Answer & Explanation

. Greater tuberosity displacement > 1 cm

Explanation

According to the Hertel criteria, a short posteromedial calcar length (< 8 mm), disruption of the medial hinge, and an anatomic neck fracture pattern are the most accurate predictors of humeral head ischemia.

Question 7079

Topic: 2. Trauma

A 30-year-old man presents with a closed distal-third spiral humeral shaft fracture (Holstein-Lewis type). Initial examination shows normal nerve function, and he is placed in a coaptation splint. At his 1-week clinic follow-up, he demonstrates a complete radial nerve palsy. What is the next most appropriate step in management?

. Observation and EMG at 6 weeks
. Immediate surgical exploration and fracture fixation
. Change to a functional fracture brace
. Corticosteroid injection at the spiral groove
. MRI of the humerus

Correct Answer & Explanation

. Observation and EMG at 6 weeks

Explanation

A secondary radial nerve palsy that develops after a closed reduction or splinting of a humeral shaft fracture is a classic indication for immediate surgical exploration to rule out nerve entrapment in the fracture site.

Question 7080

Topic: Upper Extremity Trauma
A 28-year-old man falls directly onto the point of his shoulder. Radiographs demonstrate 150% superior displacement of the distal clavicle relative to the acromion. Which ligaments are completely disrupted in this injury?
. Acromioclavicular ligaments only
. Coracoclavicular ligaments only
. Both acromioclavicular and coracoclavicular ligaments
. Coracoacromial ligaments only
. Both acromioclavicular and coracoacromial ligaments

Correct Answer & Explanation

. Both acromioclavicular and coracoclavicular ligaments

Explanation

A Type III or higher acromioclavicular (AC) joint separation, characterized by 100% to 300% superior displacement, involves the complete disruption of both the AC ligaments and the coracoclavicular (conoid and trapezoid) ligaments.

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