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2. Trauma MCQs

Practice Set 412 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 8221

Topic: 2. Trauma

A 21-year-old cross-country runner complains of bilateral anterolateral leg pain that reliably begins 15 minutes into a run and resolves within 30 minutes of rest. She occasionally experiences mild weakness in ankle dorsiflexion immediately following a run. Which of the following post-exercise intracompartmental pressure readings is definitively diagnostic for chronic exertional compartment syndrome (CECS) according to the modified Pedowitz criteria?

. Resting pressure > 5 mmHg
. 1-minute post-exercise pressure > 30 mmHg
. 5-minute post-exercise pressure > 15 mmHg
. 15-minute post-exercise pressure > 10 mmHg
. Resting pressure > 10 mmHg

Correct Answer & Explanation

. 1-minute post-exercise pressure > 30 mmHg

Explanation

The Pedowitz criteria for the diagnosis of chronic exertional compartment syndrome (CECS) include one or more of the following intracompartmental pressure measurements: a pre-exercise (resting) pressure ≥ 15 mmHg, a 1-minute post-exercise pressure ≥ 30 mmHg, or a 5-minute post-exercise pressure ≥ 20 mmHg.

Question 8222

Topic: Upper Extremity Trauma

A 28-year-old cyclist falls directly onto his right shoulder. Clinical examination reveals a prominent distal clavicle. Radiographs demonstrate an acromioclavicular (AC) joint separation with 150% superior displacement of the distal clavicle relative to the acromion. Which of the following ligamentous structures are completely disrupted in this injury?

. Acromioclavicular ligaments only
. Coracoclavicular ligaments only
. Acromioclavicular and coracoclavicular ligaments
. Coracoacromial ligament only
. Sternoclavicular ligaments

Correct Answer & Explanation

. Acromioclavicular and coracoclavicular ligaments

Explanation

Displacement of the distal clavicle superiorly by more than 100% relative to the acromion classifies the injury as at least a Rockwood Type III AC joint separation. Type III (and above) injuries involve the complete rupture of both the acromioclavicular (AC) ligaments and the coracoclavicular (CC) ligaments (conoid and trapezoid).

Question 8223

Topic: Upper Extremity Trauma

A 28-year-old male falls directly onto the point of his shoulder. Radiographs demonstrate a Rockwood Type V acromioclavicular (AC) joint separation, characterized by >100% superior displacement of the clavicle relative to the acromion. Operative stabilization is planned. Which of the following ligaments are primarily targeted for reconstruction to restore vertical stability to the distal clavicle?

. Acromioclavicular and coracoacromial ligaments
. Conoid and trapezoid ligaments
. Superior and inferior acromioclavicular ligaments
. Coracohumeral and superior glenohumeral ligaments
. Sternoclavicular ligaments

Correct Answer & Explanation

. Conoid and trapezoid ligaments

Explanation

Vertical stability of the distal clavicle is primarily provided by the coracoclavicular (CC) ligaments, which consist of the conoid (medial) and trapezoid (lateral) ligaments. The acromioclavicular (AC) ligaments primarily provide anteroposterior (horizontal) stability. Surgical reconstruction of high-grade AC joint separations (Types IV, V, VI) focuses on repairing or reconstructing the CC ligaments to reduce the distal clavicle back to the coracoid process.

Question 8224

Topic: 2. Trauma

A 21-year-old Division I basketball player sustains a fracture of the fifth metatarsal during a game. Radiographs reveal a transverse fracture located at the metaphyseal-diaphyseal junction (Zone 2). Given his athletic status and desire to return to play safely, what is the most appropriate management?

. Non-weight-bearing in a short leg cast for 6 to 8 weeks
. Weight-bearing as tolerated in a stiff-soled boot for 4 weeks
. Open reduction and crossed K-wire fixation
. Intramedullary screw fixation
. Excision of the proximal fragment and peroneus brevis advancement

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

A fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal is a Jones fracture (Zone 2). In high-level athletes, early intramedullary screw fixation is the treatment of choice. Nonoperative management in this demographic carries an unacceptably high rate of nonunion and a prolonged time to return to play compared to surgical fixation.

Question 8225

Topic: 2. Trauma

A 9-year-old boy sustains a type III tibial spine eminence fracture after a bicycle accident. Radiographs show complete displacement of the avulsed fragment. What is the primary risk of nonoperative management (casting without reduction) for this specific fracture pattern?

. Premature physeal closure
. Anterior cruciate ligament laxity and knee instability
. Patellofemoral osteoarthritis
. Meniscal tear
. Deep vein thrombosis

Correct Answer & Explanation

. Anterior cruciate ligament laxity and knee instability

Explanation

A Meyers and McKeever type III tibial spine fracture is completely displaced. Failure to anatomically reduce and stabilize the fragment can result in nonunion or malunion, leading to anterior cruciate ligament (ACL) laxity, anterior knee instability, and a potential block to knee extension. Operative reduction and internal fixation is indicated for type III fractures.

Question 8226

Topic: 2. Trauma

A 3-year-old girl is brought to the emergency department after falling from a slide. Radiographs reveal a closed, isolated, spiral fracture of the middle third of the left femoral shaft. She has no neurovascular deficits and no other injuries. What is the most appropriate definitive management for this patient?

. Elastic stable intramedullary nailing (ESIN)
. Rigid locked intramedullary nailing
. Early spica casting
. Open reduction and internal fixation with a compression plate
. Skeletal traction for 3 weeks followed by a cast

Correct Answer & Explanation

. Early spica casting

Explanation

Early spica casting is the treatment of choice for isolated, closed femoral shaft fractures in young children aged 6 months to 5 years (with less than 2 cm of shortening). ESIN is generally indicated for children aged 5 to 11 years (or younger children with multiple trauma/open fractures). Rigid nailing is contraindicated in this age group due to the risk of avascular necrosis and physeal injury.

Question 8227

Topic: 2. Trauma

An 11-year-old boy weighing 65 kg (143 lbs) sustains a length-unstable spiral fracture of the femoral shaft following a fall from a tree.

Which of the following surgical interventions is most appropriate for this patient, optimizing biomechanical stability while minimizing the risk of iatrogenic avascular necrosis (AVN) of the femoral head?

. Titanium elastic nails (TENs)
. Solid rigid intramedullary nail via piriformis fossa entry
. Solid rigid intramedullary nail via lateral trochanteric entry
. Immediate hip spica cast application
. Skeletal traction for 3 weeks followed by a cast

Correct Answer & Explanation

. Solid rigid intramedullary nail via lateral trochanteric entry

Explanation

In older and heavier pediatric patients (typically >11 years old or weighing >50 kg/110 lbs), Titanium Elastic Nails (TENs) have unacceptably high rates of failure, malunion, and loss of reduction, particularly in length-unstable fractures. Rigid locked intramedullary nailing is the standard of care. To prevent iatrogenic avascular necrosis of the femoral head due to injury of the medial femoral circumflex artery branches, a lateral greater trochanteric entry point is strictly utilized in the pediatric population, completely avoiding the piriformis fossa.

Question 8228

Topic: Lower Extremity Trauma

An 8-year-old boy complains of a painless snapping sensation and intermittent lateral pain in his right knee. Radiographs reveal widening of the lateral joint space, squaring of the lateral femoral condyle, and a cupped appearance of the lateral tibial plateau. MRI demonstrates a complete, intact discoid lateral meniscus with no evidence of a tear. Given his symptomatic presentation, what is the recommended surgical management?

. Observation and aggressive physical therapy
. Total lateral meniscectomy
. Subtotal meniscectomy (saucerization) with preservation of a stable peripheral rim
. Meniscal repair utilizing an inside-out suturing technique without resection
. Anterior horn meniscectomy leaving the posterior horn intact

Correct Answer & Explanation

. Subtotal meniscectomy (saucerization) with preservation of a stable peripheral rim

Explanation

The patient has a symptomatic complete discoid lateral meniscus. While asymptomatic discoid menisci should be observed, symptomatic ones (snapping, pain, locking) warrant surgical intervention. The modern standard of care is subtotal meniscectomy (saucerization) to reshape the meniscus into a normal crescent, while preserving a stable 6 to 8 mm peripheral rim to maintain meniscal function and prevent early osteoarthritis. Total meniscectomy is avoided due to the high risk of rapid, severe degenerative joint disease.

Question 8229

Topic: 2. Trauma

A 2-year-old girl is evaluated for a painless limp. Examination demonstrates a positive Galeazzi sign and asymmetric thigh folds. Radiographs reveal a dislocated right hip with a false acetabulum. The surgeon is considering closed reduction and spica casting versus open reduction. Which of the following is an absolute contraindication to closed reduction in this clinical scenario?

. Patient age greater than 18 months
. Inverted limbus mechanically blocking reduction
. Acetabular index of 35 degrees
. Intact, elongated ligamentum teres
. Hypertrophied pulvinar

Correct Answer & Explanation

. Inverted limbus mechanically blocking reduction

Explanation

An inverted limbus (or any dense fibrofatty tissue that interposes and prevents concentric seating of the femoral head) acts as a mechanical block. Forcing a closed reduction against this block will dramatically increase joint contact pressures and the risk of avascular necrosis (AVN). This is an absolute contraindication to closed reduction; an open reduction is required to excise or evert the limbus and clear the joint.

Question 8230

Topic: 2. Trauma

An 11-year-old boy weighing 65 kg (143 lbs) sustains an isolated, closed, transverse midshaft femur fracture during a football game. What is the most appropriate definitive surgical management to minimize complications while maximizing functional outcome?

. Titanium elastic nailing (TENs) via distal medial and lateral entry points
. Rigid intramedullary nailing via a piriformis fossa entry point
. Rigid intramedullary nailing via a lateral trochanteric entry point
. Closed reduction and early spica casting
. External fixation

Correct Answer & Explanation

. Rigid intramedullary nailing via a lateral trochanteric entry point

Explanation

For pediatric femoral shaft fractures, patient weight and age dictate the optimal implant. Children weighing over 50 kg (110 lbs) or older than 11 years have unacceptably high rates of loss of fixation, malunion, and hardware prominence when treated with flexible titanium elastic nails (TENs). Rigid intramedullary nailing is indicated; however, the piriformis fossa entry point is strictly avoided in children due to the high risk of iatrogenic avascular necrosis of the femoral head. A lateral trochanteric entry point rigid nail avoids the vascular supply to the femoral head and is the standard of care for this demographic.

Question 8231

Topic: 2. Trauma

A 5-year-old boy falls off monkey bars and sustains a laterally displaced pediatric elbow fracture.

Radiographs demonstrate a fracture of the lateral condyle with 4 mm of displacement. What is the most appropriate management?

. Long-arm cast with forearm in supination
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation
. Excision of the fracture fragment
. Elastic intramedullary nailing

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

Lateral condyle fractures of the humerus with > 2 mm of displacement are generally treated with open reduction and internal fixation (ORIF) to ensure anatomic restoration of the articular surface and physis, minimizing the risk of nonunion, malunion, and late tardy ulnar nerve palsy. Closed reduction and pinning can be attempted for less displaced fractures, but 4 mm requires direct visualization to ensure the articular surface is congruent.

Question 8232

Topic: 2. Trauma

A 3-year-old boy weighing 15 kg sustains an isolated, closed, transverse fracture of the middle third of the right femur after a fall from a trampoline. Radiographs show 1.5 cm of shortening and 10 degrees of varus angulation. What is the most appropriate definitive management for this patient?

. Pavlik harness
. Early spica casting
. Titanium elastic nails
. Submuscular plating
. External fixation

Correct Answer & Explanation

. Early spica casting

Explanation

The treatment of pediatric femoral shaft fractures is age and weight dependent. In children aged 6 months to 5 years with isolated femur fractures and less than 2 cm of shortening, early spica casting is the standard of care and provides excellent outcomes. The Pavlik harness is indicated for infants 0-6 months old. Titanium elastic nails are indicated for children 5-11 years old (or heavier children). Rigid intramedullary nails are used in adolescents near skeletal maturity.

Question 8233

Topic: 2. Trauma

A 6-year-old boy falls on an outstretched hand and sustains a lateral condyle fracture of the distal humerus that is displaced 3 mm. The fracture is managed non-operatively, but 6 months later, radiographs show a definitive nonunion. Which of the following is the most common long-term clinical consequence if this nonunion is left untreated?

. Progressive cubitus varus and tardy radial nerve palsy
. Progressive cubitus valgus and tardy ulnar nerve palsy
. Avascular necrosis of the trochlea
. Premature closure of the medial epicondyle physis
. Myositis ossificans of the brachialis muscle

Correct Answer & Explanation

. Progressive cubitus valgus and tardy ulnar nerve palsy

Explanation

Lateral condyle fractures are Salter-Harris IV equivalent injuries that are intra-articular. Because the fracture fragment is bathed in synovial fluid and has a tenuous blood supply, it is prone to nonunion if displaced > 2 mm and inadequately stabilized. An established nonunion leads to proximal migration of the lateral condyle, resulting in a progressive cubitus valgus deformity. This valgus deformity stretches the ulnar nerve behind the medial epicondyle, ultimately leading to tardy ulnar nerve palsy years later.

Question 8234

Topic: 2. Trauma

A 4-year-old boy who weighs 18 kg (40 lbs) sustains an isolated, closed, length-stable, spiral fracture of the mid-diaphyseal femur after a fall from a playground structure. What is the most appropriate definitive management?

. Pavlik harness
. Early spica casting
. Flexible intramedullary nailing
. Rigid reamed intramedullary nailing
. Submuscular plating

Correct Answer & Explanation

. Early spica casting

Explanation

For children aged 6 months to 5 years with isolated, closed femoral shaft fractures and acceptable shortening (<2 cm), early spica casting is the standard of care. Flexible intramedullary nailing is typically reserved for children aged 5-11 years or weighing more than 50 lbs (23 kg). Rigid nailing is contraindicated in this age group due to the risk of avascular necrosis of the femoral head and growth arrest from injury to the trochanteric apophysis.

Question 8235

Topic: 2. Trauma

A 9-year-old boy weighing 55 kg (121 lbs) sustains a closed, length-unstable, midshaft femur fracture. Among the following options, which surgical intervention carries the highest risk of complication, specifically loss of reduction and malunion, in this specific patient?

. Open reduction and internal fixation with a compression plate
. Titanium elastic nailing (TENs)
. Rigid lateral entry trochanteric intramedullary nailing
. Submuscular bridge plating
. External fixation

Correct Answer & Explanation

. Submuscular bridge plating

Explanation

Titanium elastic nails (TENs) are a standard of care for pediatric femur fractures in children aged 5 to 11 years. However, a patient weight exceeding 49 kg (approx 100-110 lbs) is a recognized relative contraindication due to a significantly higher risk of biomechanical failure, leading to loss of reduction, malunion, and prominent hardware. For this patient, submuscular plating or a rigid lateral-entry nail would be more appropriate.

Question 8236

Topic: 2. Trauma
A 14-year-old male basketball player presents after feeling a 'pop' in his right knee while jumping. Radiographs reveal a displaced Ogden Type III tibial tubercle avulsion fracture with intra-articular extension. He has significant tense swelling over the anterior aspect of the leg. Which of the following complications is most critically associated with this specific injury pattern?
. Popliteal artery transaction
. Acute anterior compartment syndrome
. Patellar tendon rupture
. Proximal tibiofibular joint dislocation
. Avascular necrosis of the patella

Correct Answer & Explanation

. Acute anterior compartment syndrome

Explanation

Tibial tubercle avulsion fractures, particularly when displaced (Ogden Type II or III), have a well-documented risk of tearing the anterior tibial recurrent artery. This leads to bleeding directly into the anterior compartment of the leg, placing the patient at high risk for acute compartment syndrome. Clinicians must have a high index of suspicion and perform serial compartment examinations.

Question 8237

Topic: 2. Trauma

A 9-year-old boy presents to the emergency department with acute right arm pain after throwing a baseball. Radiographs demonstrate a centrally located, expansile, purely lytic lesion in the proximal humeral metaphysis that involves the entire medullary canal. A cortical fragment is seen resting in the dependent portion of the cystic cavity. There is a minimally displaced pathologic fracture through the lesion. What is the most appropriate initial management?

. Immediate intralesional curettage and structural bone grafting
. Aspiration of the lesion and injection of methylprednisolone
. Immobilization in a sling to allow the fracture to heal
. Percutaneous intramedullary nailing of the humerus to prevent displacement
. Wide surgical en bloc resection and allograft reconstruction

Correct Answer & Explanation

. Immobilization in a sling to allow the fracture to heal

Explanation

The radiographic description of a centrally located, lytic metaphyseal lesion involving the entire width of the bone with a dependent cortical fragment ('fallen leaf' or 'fallen fragment' sign) is pathognomonic for a unicameral bone cyst (UBC). The most appropriate initial management of a pathologic fracture through a UBC in the upper extremity is immobilization (e.g., sling or splint) to allow the fracture to heal. Surgery or adjuvant treatments (such as steroid or bone marrow aspirate injections) are not indicated acutely. Up to 15-20% of UBCs may heal spontaneously following a fracture, though many will require subsequent treatment if the cyst persists and poses a continued fracture risk.

Question 8238

Topic: 2. Trauma

A 4-year-old boy sustains a closed, isolated midshaft femur fracture with 1 cm of shortening. He weighs 18 kg (40 lbs). What is the most appropriate definitive management?

. Pavlik harness
. Immediate single-leg spica cast
. Flexible intramedullary nailing
. Rigid antegrade locked intramedullary nail
. Open reduction and plate fixation

Correct Answer & Explanation

. Immediate single-leg spica cast

Explanation

For children aged 6 months to 5 years weighing less than 20 kg with isolated, length-stable femur fractures, early spica casting is the standard of care. Flexible nails are generally reserved for older, heavier children.

Question 8239

Topic: 2. Trauma

A 45-year-old physically active man is considering a hip resurfacing arthroplasty for severe osteoarthritis. Which of the following is a recognized surgical risk factor for early femoral neck fracture following this procedure?

. Male gender
. Large femoral head size (>50 mm)
. Notching of the superior femoral neck during preparation
. Acetabular component placed in excessive anteversion
. Valgus placement of the femoral component

Correct Answer & Explanation

. Notching of the superior femoral neck during preparation

Explanation

Femoral neck fracture is a devastating early complication of hip resurfacing arthroplasty. Surgical risk factors include varus placement of the femoral component and notching of the superior femoral neck during cylindrical reaming. Superior neck notching creates a significant stress riser, predisposing the neck to fracture under load. Patient-specific risk factors include female gender, small femoral head size (<50 mm), and the presence of large cystic lesions in the femoral head/neck. Valgus placement is actually protective as it reduces shear stresses across the neck.

Question 8240

Topic: 2. Trauma
A 75-year-old woman sustains a closed fracture of her distal femur following a mechanical fall. Radiographs show a comminuted supracondylar femur fracture extending to the flange of her posterior-stabilized femoral component. The femoral component is noted to be grossly loose on fluoroscopy. What is the most appropriate surgical management?
. Open reduction and internal fixation with a lateral locking plate
. Retrograde intramedullary nailing
. Distal femoral replacement
. Revision TKA with a standard hinged knee and short stems
. Cast immobilization

Correct Answer & Explanation

. Distal femoral replacement

Explanation

For a periprosthetic distal femur fracture with severe comminution and a loose femoral component (Felix Type IIB or Rorabeck Type III), a distal femoral replacement is the most reliable treatment to restore stability and allow early mobilization.

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