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2. Trauma MCQs

Practice Set 42 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 821

Topic: 2. Trauma

A 48-year-old male has undergone successful ORIF of a Bado Type I Monteggia fracture-dislocation. He is now 5 days post-operative. The surgeon emphasizes the importance of a structured rehabilitation protocol. According to the case, what is the primary goal and initial approach during the early post-operative phase (Phase 1)?

. Achieve full active range of motion (AROM) in all planes immediately to prevent stiffness.
. Maintain strict immobilization for 6 weeks to ensure complete fracture healing.
. Reduce pain and swelling, protect the surgical repair, and initiate controlled active-assisted/passive range of motion (AAROM/PROM) within a safe arc.
. Begin progressive resistive strengthening exercises for the elbow and forearm.
. Allow immediate weight-bearing on the affected limb to promote bone healing.

Correct Answer & Explanation

. Reduce pain and swelling, protect the surgical repair, and initiate controlled active-assisted/passive range of motion (AAROM/PROM) within a safe arc.

Explanation

Correct Answer: CThe case describes the 'Phase Protection and Early Motion' (Phase 1) goals as: 'Reduce pain and swelling, protect surgical repair, initiate controlled early motion.' It further specifies for ROM: 'Begin with gentle active-assisted and passive range of motion (AAROM/PROM) within a safe arc determined by surgeon (e.g., 30-100 degrees flexion, neutral pronation/supination).'Option A (Achieve full active range of motion (AROM) in all planes immediately):This is too aggressive and could jeopardize the surgical repair and radial head stability. Early motion must be controlled and within a safe arc.Option B (Maintain strict immobilization for 6 weeks):The case states that 'The duration of strict immobilization is generally minimal, often just until initial pain and swelling subside (e.g., 3-7 days).' Prolonged immobilization is a known cause of stiffness.Option D (Begin progressive resistive strengthening exercises):Strengthening exercises are initiated in a later phase (Phase 2: Progressive Motion and Light Strengthening), starting with isometrics, not immediately post-op.Option E (Allow immediate weight-bearing):The case explicitly states 'Non-weight-bearing for the affected limb' during the early phase.

Question 822

Topic: 2. Trauma

A 68-year-old male with a history of head trauma presents with a severe, comminuted Bado Type II Monteggia fracture-dislocation. Due to the high-energy nature of the injury and his medical history, the surgeon is concerned about the development of heterotopic ossification (HO). Which prophylactic measure is commonly considered to reduce the risk of HO in such high-risk patients?

. Early aggressive, uncontrolled range of motion exercises.
. Prolonged immobilization of the elbow in a cast.
. Administration of perioperative non-steroidal anti-inflammatory drugs (NSAIDs) like indomethacin.
. High-dose systemic corticosteroids for several weeks post-operatively.
. Immediate surgical excision of any suspected early ossification.

Correct Answer & Explanation

. Administration of perioperative non-steroidal anti-inflammatory drugs (NSAIDs) like indomethacin.

Explanation

Correct Answer: CThe case states under 'Complications and Management' for Heterotopic Ossification (HO): 'Prevention: Prophylactic NSAIDs (e.g., indomethacin) or low-dose radiation therapy (controversial in acute setting, typically reserved for high-risk cases) can be used.' The patient's history of head trauma is a known risk factor for HO.Option A (Early aggressive, uncontrolled range of motion exercises):While early controlled motion is important, aggressive and uncontrolled motion can increase inflammation and potentially contribute to HO formation, not prevent it.Option B (Prolonged immobilization):Prolonged immobilization is a risk factor for elbow stiffness and does not prevent HO; in fact, it can sometimes be associated with it.Option D (High-dose systemic corticosteroids):Corticosteroids are not a standard prophylactic measure for HO in this context and carry significant side effects.Option E (Immediate surgical excision of any suspected early ossification):Surgical excision of HO is typically performed only for symptomatic, mature HO after 6-12 months, not immediately post-injury or for early suspected ossification.

Question 823

Topic: 2. Trauma

A 42-year-old male sustains a comminuted, displaced mid-shaft humeral fracture after a high-energy motor vehicle accident. Pre-operative imaging reveals significant anterior comminution and a suspected associated brachial artery injury. The patient also presents with a complete radial nerve palsy. Based on the case content, which of the following is the most appropriate indication for an anterior approach to the humeral shaft in this specific scenario?

. A. The presence of a complete radial nerve palsy, as it mandates primary nerve exploration via an anterior approach.
. B. The comminuted nature of the fracture, which is best addressed with an anterior locking plate for superior stability.
. C. The suspected brachial artery injury, necessitating anterior exploration and repair, combined with the open fracture.
. D. The patient's young age and high functional demand, favoring early operative intervention via the most direct route.
. E. The ability to avoid extensive dissection of the radial nerve, as it lies posterior to the brachialis in the distal two-thirds of the humerus.

Correct Answer & Explanation

. C. The suspected brachial artery injury, necessitating anterior exploration and repair, combined with the open fracture.

Explanation

Correct Answer: CThe case content explicitly lists 'Fractures associated with vascular injury requiring exploration and repair' and 'Open fractures with anterior soft tissue involvement' as indications for an anterior approach to the humeral shaft. In this scenario, the suspected brachial artery injury is a critical indication that necessitates an anterior approach for direct exploration and repair. The open fracture further supports this choice.Option A (The presence of a complete radial nerve palsy, as it mandates primary nerve exploration via an anterior approach):While radial nerve palsy can be an indication for primary nerve exploration, and an anterior approach can facilitate this (especially with a lateral extension), the case states that 'a posterior approach may offer better direct visualization of the nerve.' The primary driver for the anterior approach in this specific vignette is the vascular injury and open fracture, not solely the radial nerve palsy.Option B (The comminuted nature of the fracture, which is best addressed with an anterior locking plate for superior stability):While anterior locking plates are effective for comminuted fractures, the comminution itself does not exclusively dictate an anterior approach over other approaches (e.g., anterolateral or posterior) unless other specific factors are present.Option D (The patient's young age and high functional demand, favoring early operative intervention via the most direct route):While young, active patients often benefit from operative management, this is a general indication for surgery, not a specific reason to choose an anterior approach over others in the context of the given associated injuries.Option E (The ability to avoid extensive dissection of the radial nerve, as it lies posterior to the brachialis in the distal two-thirds of the humerus):This is a true statement about the anterior approach's advantage in protecting the radial nerve, but it's a benefit of the approach, not the primary indication for choosing it in the presence of a vascular injury and open fracture. The need for vascular exploration overrides this consideration as the primary determinant.

Question 824

Topic: 2. Trauma

A 55-year-old male undergoes open reduction and internal fixation of a displaced 4-part proximal humerus fracture using a locking plate via a deltopectoral approach. Post-operatively, radiographs show satisfactory reduction and hardware placement. However, at the 6-month follow-up, the patient develops increasing shoulder pain and crepitus, and repeat radiographs reveal superior migration of the humeral head with articular penetration by several locking screws. Based on the case content, which of the following is the most likely biomechanical factor contributing to this complication?

. A. Insufficient plate length, leading to inadequate working length and stress concentration.
. B. Excessive number of distal cortical screws, causing stress shielding of the fracture site.
. C. Lack of multi-directional locking screws, failing to capture fragments and resist varus collapse.
. D. Plate positioning too distal to the bicipital groove, resulting in poor screw trajectory into the humeral head.
. E. Inadequate inferomedial calcar support, leading to varus collapse and subsequent screw cutout.

Correct Answer & Explanation

. E. Inadequate inferomedial calcar support, leading to varus collapse and subsequent screw cutout.

Explanation

Correct Answer: EThe case content, under 'Biomechanics of Fixation' and 'Summary of Key Literature and Guidelines,' emphasizes the importance of 'multi-directional locking screws are critical to capture fragments and resist varus collapse' and 'adequate number and placement of locking screws (especially in the inferomedial quadrant for calcar support)' to minimize complications like screw cutout and avascular necrosis. Superior migration of the humeral head with articular penetration by screws (screw cutout) is a classic complication of varus collapse, which often occurs due to inadequate inferomedial calcar support, particularly in osteoporotic bone or comminuted fractures.Option A (Insufficient plate length, leading to inadequate working length and stress concentration):While insufficient plate length can contribute to hardware failure, it's less directly linked to superior screw cutout in the humeral head compared to the specific issue of calcar support.Option B (Excessive number of distal cortical screws, causing stress shielding of the fracture site):Stress shielding can be a concern, but it's not the primary mechanism for superior screw cutout in the humeral head. It's more related to diaphyseal healing.Option C (Lack of multi-directional locking screws, failing to capture fragments and resist varus collapse):While multi-directional screws are important, the specific issue of 'inferomedial calcar support' is a more precise biomechanical factor directly addressing varus collapse, which leads to screw cutout. Multi-directional screws help, but if the inferomedial support is poor, varus collapse can still occur.Option D (Plate positioning too distal to the bicipital groove, resulting in poor screw trajectory into the humeral head):The case states 'Position the plate laterally, usually 5-8 mm posterior to the bicipital groove, to avoid impingement and ensure optimal screw trajectory into the humeral head.' While incorrect plate positioning can lead to issues, positioning too distal might affect overall stability but is not the most direct cause of superior screw cutout due to varus collapse. Plate prominence (too proud) is more related to impingement.

Question 825

Topic: 2. Trauma

A 72-year-old female with osteoporosis presents with a displaced 2-part surgical neck fracture of the humerus. She is scheduled for ORIF via a deltopectoral approach. During pre-operative planning, the surgeon is considering the optimal plate placement and screw trajectory. According to the case content and current literature, which of the following statements regarding plate application for proximal humerus fractures is most accurate?

. A. The plate should be positioned directly over the bicipital groove to maximize screw purchase into the humeral head.
. B. The plate should be flush with the humeral head to prevent acromial impingement.
. C. Multi-directional locking screws are critical, especially in the inferomedial quadrant, to resist varus collapse.
. D. Conventional compression plates are preferred over locking plates in osteoporotic bone due to better bone-plate interface compression.
. E. Screw length should be maximized to ensure bicortical purchase in the humeral head for optimal stability.

Correct Answer & Explanation

. C. Multi-directional locking screws are critical, especially in the inferomedial quadrant, to resist varus collapse.

Explanation

Correct Answer: CThe case content, under 'Biomechanics of Fixation' and 'Summary of Key Literature and Guidelines,' states: 'Locking plates are particularly beneficial in osteoporotic bone or comminuted fractures, providing angular stability independent of bone-plate interface compression.' It further emphasizes: 'For proximal humerus fractures, multi-directional locking screws are critical to capture fragments and resist varus collapse.' And 'Literature consistently highlights the importance of anatomical reduction, adequate number and placement of locking screws (especially in the inferomedial quadrant for calcar support), avoidance of plate prominence, and careful protection of the axillary nerve.'Option A (The plate should be positioned directly over the bicipital groove to maximize screw purchase into the humeral head):The case states: 'Position the plate laterally, usually 5-8 mm posterior to the bicipital groove, to avoid impingement and ensure optimal screw trajectory into the humeral head.' Positioning directly over the bicipital groove is incorrect and can lead to impingement or damage to the biceps tendon.Option B (The plate should be flush with the humeral head to prevent acromial impingement):The case states: 'Ensure the plate is proud of the humeral head by approximately 5 mm to prevent acromial impingement.' A plate that is flush or recessed can lead to impingement. Being slightly proud helps prevent this.Option D (Conventional compression plates are preferred over locking plates in osteoporotic bone due to better bone-plate interface compression):This is incorrect. The case states: 'Locking plates are particularly beneficial in osteoporotic bone or comminuted fractures, providing angular stability independent of bone-plate interface compression.' Conventional plates rely on compression, which is poor in osteoporotic bone.Option E (Screw length should be maximized to ensure bicortical purchase in the humeral head for optimal stability):This is incorrect and dangerous. The case states: 'Ensure screws do not penetrate the articular surface – check with fluoroscopy.' Bicortical purchase in the humeral head would mean penetrating the articular surface, leading to joint damage and pain. Screws in the humeral head should be unicortical but long enough to provide good purchase without articular penetration.

Question 826

Topic: 2. Trauma

A 35-year-old male presents with a complex, comminuted 4-part proximal humerus fracture. Pre-operative planning is underway for ORIF via a deltopectoral approach. The surgeon is particularly concerned about understanding the precise fracture morphology and fragment orientation to plan screw trajectories and avoid articular penetration. Which imaging modality is explicitly highlighted in the case as indispensable for this purpose?

. A. Standard anteroposterior and lateral plain radiographs.
. B. Scapular Y view radiographs.
. C. Magnetic Resonance Imaging (MRI).
. D. Computed Tomography (CT) scan with 3D reconstructions.
. E. Angiography.

Correct Answer & Explanation

. D. Computed Tomography (CT) scan with 3D reconstructions.

Explanation

Correct Answer: DThe case content, under 'Pre-Operative Planning' and 'Imaging Review,' states: 'Computed Tomography (CT) Scan: Indispensable for complex fractures, especially 3- and 4-part proximal humerus fractures, humeral head splits, comminuted shaft fractures, non-unions, or tumors. 3D reconstructions aid in understanding fracture morphology, fragment orientation, and surgical approach planning.'Option A (Standard anteroposterior and lateral plain radiographs):While essential, plain radiographs provide 2D views and may not fully elucidate complex 3D fracture morphology and fragment orientation, especially for 4-part fractures.Option B (Scapular Y view radiographs):This is part of the trauma series for the shoulder and is critical for characterization, but like other plain films, it lacks the 3D detail of a CT scan.Option C (Magnetic Resonance Imaging (MRI)):MRI is useful for assessing soft tissue injuries, rotator cuff integrity, or characterizing tumors, but it is not typically the primary modality for detailed bone fracture morphology and fragment orientation, especially when compared to CT with 3D reconstructions.Option E (Angiography):Angiography is indicated if vascular injury is suspected, not primarily for detailed fracture morphology.

Question 827

Topic: 2. Trauma
A 78-year-old female with severe osteoporosis presents with a highly comminuted 4-part proximal humerus fracture. She is a low-demand patient with multiple comorbidities. The orthopedic team is debating between operative (ORIF with locking plate via deltopectoral approach) and non-operative management. Based on the findings of the PROFHER trial, which of the following statements best reflects the current understanding regarding the superiority of ORIF for such a patient?
. ORIF with locking plates consistently demonstrates superior functional outcomes and lower complication rates compared to non-operative management in elderly, osteoporotic patients.
. The PROFHER trial concluded that ORIF with locking plates is the gold standard for all displaced proximal humeral fractures, regardless of patient age or bone quality.
. For elderly, low-demand patients with osteoporotic proximal humerus fractures, the PROFHER trial found no significant difference in patient-reported outcomes between operative and non-operative management.
. Locking plate technology has eliminated the challenges of fixation in osteoporotic bone, making ORIF universally superior for complex proximal humerus fractures.
. Non-operative management is only suitable for minimally displaced fractures, and all 4-part fractures in the elderly require ORIF for acceptable outcomes.

Correct Answer & Explanation

. For elderly, low-demand patients with osteoporotic proximal humerus fractures, the PROFHER trial found no significant difference in patient-reported outcomes between operative and non-operative management.

Explanation

The PROFHER trial (Prospective Randomised Orthopaedic Fracture Trial in the Elderly with a Humeral fracture) by Rangan et al. (2015), a landmark multicenter randomized controlled trial, found no significant difference in patient-reported outcomes (Oxford Shoulder Score) between operative (ORIF with locking plate) and non-operative management for displaced proximal humeral fractures in patients over 16 years. This study emphasized the importance of patient selection and the potential for good outcomes with non-operative care in many cases.

Question 828

Topic: 2. Trauma

A 28-year-old male presents with a closed, displaced transverse fracture of the humeral shaft resulting from a direct blow. He is treated with functional bracing. Which of the following defines the maximum acceptable deformity for non-operative management of a humeral shaft fracture?

. 10 degrees of anterior angulation, 10 degrees of varus, and 1 cm of shortening
. 20 degrees of anterior angulation, 30 degrees of varus, and 3 cm of shortening
. 30 degrees of anterior angulation, 20 degrees of varus, and 2 cm of shortening
. 15 degrees of anterior angulation, 15 degrees of varus, and 4 cm of shortening
. 40 degrees of anterior angulation, 10 degrees of varus, and 2 cm of shortening

Correct Answer & Explanation

. 20 degrees of anterior angulation, 30 degrees of varus, and 3 cm of shortening

Explanation

The criteria for acceptable alignment in non-operative management of humeral shaft fractures include up to 20 degrees of anterior/posterior angulation, 30 degrees of varus/valgus angulation, and 3 cm of shortening. The shoulder and elbow joints possess extensive compensatory motion that clinically masks these deformities.

Question 829

Topic: 2. Trauma

A 50-year-old female presents with a Bado Type II Monteggia fracture-dislocation. Compared to other Bado types in the adult population, which of the following associated injuries is most frequently seen with this specific pattern?

. Posterior interosseous nerve (PIN) neurapraxia
. Ulnar nerve laceration
. Radial head and/or coronoid fractures
. Essex-Lopresti injury
. Distal radioulnar joint (DRUJ) dislocation

Correct Answer & Explanation

. Radial head and/or coronoid fractures

Explanation

Bado Type II (posterior) Monteggia fractures are the most common type in adults and are highly associated with concomitant fractures of the radial head and coronoid process. This pattern poses a high risk for postoperative elbow stiffness and instability.

Question 830

Topic: 2. Trauma

In the treatment of an adult Monteggia fracture-dislocation, the surgeon performs anatomic reduction and rigid plate fixation of the ulnar shaft fracture. Intraoperative fluoroscopy reveals that the radial head remains persistently subluxated. What is the most common cause of this finding?

. Interposition of the median nerve
. Malreduction of the ulnar fracture
. Rupture of the quadrate ligament
. Spasm of the biceps brachii
. Interposition of the extensor carpi radialis brevis

Correct Answer & Explanation

. Malreduction of the ulnar fracture

Explanation

The most common cause of persistent radial head instability after fixation of a Monteggia fracture is malreduction (usually length or rotation) of the ulna. If the ulna is anatomically reduced and the radial head remains subluxated, soft tissue interposition (such as the annular ligament or capsule) should be suspected.

Question 831

Topic: 2. Trauma

A 35-year-old male sustains a distal third spiral humerus fracture (Holstein-Lewis) and presents with a secondary radial nerve palsy immediately after closed reduction and splinting. What is the most appropriate next step in management?

. Immediate surgical exploration and internal fixation
. Electromyography (EMG) and nerve conduction studies
. Continued observation and functional bracing
. Corticosteroid injection at the lateral intermuscular septum
. Immediate tendon transfers

Correct Answer & Explanation

. Continued observation and functional bracing

Explanation

Modern evidence supports continued observation for secondary radial nerve palsies developing after closed reduction of humeral shaft fractures, provided acceptable alignment is maintained. Surgical exploration is generally reserved for open fractures, vascular compromise, or failure of nerve recovery at 3 to 4 months.

Question 832

Topic: 2. Trauma

A 65-year-old female sustains a displaced, multi-part proximal humerus fracture. Recent anatomical studies regarding the vascularity of the proximal humerus have shifted the traditional understanding. Which artery is now recognized as providing the dominant blood supply to the humeral head?

. Ascending branch of the anterior circumflex humeral artery
. Posterior circumflex humeral artery
. Thoracoacromial artery
. Profunda brachii artery
. Subscapular artery

Correct Answer & Explanation

. Posterior circumflex humeral artery

Explanation

Recent studies (e.g., Hettrich et al.) demonstrated that the posterior circumflex humeral artery supplies approximately 64% of the humeral head. This refutes the historical belief that the ascending branch of the anterior circumflex humeral artery (arcuate artery) was the dominant supply.

Question 833

Topic: 2. Trauma
A 25-year-old male sustains a humeral shaft fracture located strictly between the insertion of the pectoralis major and the insertion of the deltoid. What is the characteristic deforming force on the proximal fracture fragment?
. Abduction and external rotation
. Adduction and internal rotation
. Extension and external rotation
. Flexion and abduction
. Distal translation

Correct Answer & Explanation

. Adduction and internal rotation

Explanation

For fractures between the pectoralis major and deltoid insertions, the proximal fragment is pulled into adduction and internal rotation by the pectoralis major, latissimus dorsi, and teres major. The distal fragment is pulled laterally (abducted) by the deltoid and proximally by the biceps and triceps.

Question 834

Topic: 2. Trauma

A 55-year-old female undergoes open reduction and internal fixation of an OTA type 13-C (intercondylar) distal humerus fracture via an olecranon osteotomy. During the osteotomy closure, what is the biomechanical rationale for using a tension band construct rather than a simple positional screw?

. It prevents ulnar nerve entrapment at the osteotomy site
. It completely neutralizes all rotational forces at the joint
. It converts tensile forces on the posterior cortex into compressive forces at the articular surface during elbow flexion
. It accelerates secondary bone healing via callus formation
. It allows for earlier weight-bearing through the upper extremity

Correct Answer & Explanation

. It converts tensile forces on the posterior cortex into compressive forces at the articular surface during elbow flexion

Explanation

The tension band principle relies on placing a device (wire or suture) on the tension side of a bone. During active elbow flexion, the pull of the triceps creates tensile forces posteriorly, which the tension band converts into dynamic compression across the articular surface of the osteotomy.

Question 835

Topic: 2. Trauma

A 60-year-old female presents with a highly comminuted, displaced midshaft humeral fracture. The surgeon elects to proceed with open reduction and internal fixation. To maximize biomechanical stability and reduce the risk of nonunion, what is the minimum recommended number of cortices of screw purchase in the diaphysis on each side of the fracture?

. 4 cortices
. 6 to 8 cortices
. 10 to 12 cortices
. 3 cortices
. 14 cortices

Correct Answer & Explanation

. 6 to 8 cortices

Explanation

For diaphyseal humeral shaft fractures treated with plate osteosynthesis, current AO principles recommend a minimum of 6 to 8 cortices of screw purchase above and below the fracture site. This provides adequate working length and construct stability to prevent hardware failure and nonunion.

Question 836

Topic: 2. Trauma

A 38-year-old construction worker sustains a distal humerus intercondylar fracture (OTA 13-C). The surgeon decides to use dual plate fixation. Which biomechanical statement comparing orthogonal (90-90) versus parallel plating techniques for the distal humerus is most accurate based on current evidence?

. Orthogonal plating is significantly stronger in axial compression than parallel plating
. Parallel plating provides significantly increased resistance to sagittal bending forces compared to orthogonal plating
. Orthogonal plating requires absolute rigid fixation of the articular segment, which parallel plating does not
. Parallel plating requires routine ulnar nerve transposition, whereas orthogonal plating does not
. There is no biomechanical difference in any testing vector between the two techniques

Correct Answer & Explanation

. Parallel plating provides significantly increased resistance to sagittal bending forces compared to orthogonal plating

Explanation

Biomechanical studies have shown that parallel plating provides superior stability in sagittal bending compared to orthogonal plating, though both constructs provide adequate stability for clinical union. Clinical outcomes between the two plating configurations are generally comparable when executed correctly.

Question 837

Topic: Upper Extremity Trauma

During a transverse osteotomy of the olecranon for access to a complex distal humerus fracture, which specific anatomical location is targeted to minimize damage to the articular cartilage of the greater sigmoid notch?

. The exact center of the trochlear notch
. The coronoid process base
. The bare area between the olecranon and coronoid articular surfaces
. The sublime tubercle
. The radioulnar articulation

Correct Answer & Explanation

. The bare area between the olecranon and coronoid articular surfaces

Explanation

An olecranon osteotomy (typically an apex-distal chevron) is directed toward the 'bare area' (transverse groove) of the greater sigmoid notch. This area is devoid of articular cartilage, thereby minimizing intra-articular damage during the osteotomy.

Question 838

Topic: 2. Trauma

A 24-year-old male sustains a closed, spiral fracture of the distal third of the humerus (Holstein-Lewis fracture) following a fall. On examination, he is unable to extend his wrist or fingers. During operative exploration, the radial nerve is found to be entrapped. Which of the following anatomic structures is the most common site for radial nerve entrapment in this specific fracture pattern?

. The arcade of Frohse
. The lateral intermuscular septum
. The spiral groove of the posterior humerus
. Between the brachialis and brachioradialis
. The leash of Henry

Correct Answer & Explanation

. The lateral intermuscular septum

Explanation

In a Holstein-Lewis fracture (spiral fracture of the distal third of the humerus), the radial nerve is at high risk of tethering and entrapment as it pierces the lateral intermuscular septum to pass from the posterior to the anterior compartment.

Question 839

Topic: 2. Trauma

A 35-year-old female presents with a Bado Type I Monteggia fracture-dislocation. She undergoes open reduction and internal fixation. Which of the following principles is most critical regarding the biomechanics of plate placement for the ulnar fracture in this scenario?

. The plate should be placed on the anterior surface to avoid prominent hardware.
. The plate should be placed on the posterior (tension) surface of the ulna.
. A dynamic compression plate should be avoided to prevent ulnar shortening.
. The plate must span at least 15 holes to bypass the radial head dislocation.
. The plate should be applied to the medial surface to protect the ulnar nerve.

Correct Answer & Explanation

. The plate should be placed on the posterior (tension) surface of the ulna.

Explanation

The posterior aspect of the ulna is the tension side. Applying the plate to the posterior border provides a tension-band effect, which maximizes biomechanical stability and prevents apex-anterior angulation.

Question 840

Topic: 2. Trauma

A 45-year-old trauma patient sustains a closed midshaft humerus fracture. In which of the following scenarios is operative fixation (ORIF) of the humerus considered an absolute indication?

. A primary radial nerve palsy present at the time of injury
. A Holstein-Lewis fracture pattern
. Associated brachial artery injury requiring vascular repair
. An obese patient unable to tolerate a Sarmiento brace
. Angulation of 15 degrees in the coronal plane

Correct Answer & Explanation

. Associated brachial artery injury requiring vascular repair

Explanation

A vascular injury requiring repair is an absolute indication for operative fixation of a humerus fracture to protect the vascular anastomosis. Primary radial nerve palsy in a closed fracture is a relative indication or can be observed.

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