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2. Trauma MCQs

Practice Set 425 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 8481

Topic: 2. Trauma

A 75-year-old woman sustains a Type II odontoid fracture after a fall. She is neurologically intact. Nonoperative management with a rigid cervical collar is being considered. Which of the following factors is most strongly associated with an increased rate of nonunion in this scenario?

. Age greater than 50 years
. Anterior fracture displacement of 2 mm
. Impacted fracture pattern
. Concomitant C1 posterior arch fracture
. Female gender

Correct Answer & Explanation

. Age greater than 50 years

Explanation

Type II odontoid fractures occur at the base of the dens, a region with a watershed blood supply, predisposing them to nonunion. Established risk factors for nonunion when treated nonoperatively include patient age greater than 50 years, initial displacement greater than 5 mm, posterior displacement, and angulation greater than 10 degrees. Age is one of the most critical determinants, with significantly higher nonunion rates seen in the elderly population.

Question 8482

Topic: 2. Trauma

Which of the following characteristics accurately defines a true Jones fracture and dictates its notoriously high risk for nonunion?

. Avulsion of the peroneus brevis insertion at the tuberosity
. Fracture extending into the 4th-5th intermetatarsal articulation
. Fracture located strictly in the diaphyseal region
. Fracture at the metaphyseal-diaphyseal junction involving the vascular watershed area
. Fracture of the distal third of the fifth metatarsal

Correct Answer & Explanation

. Fracture at the metaphyseal-diaphyseal junction involving the vascular watershed area

Explanation

A true Jones fracture occurs at the metaphyseal-diaphyseal junction of the fifth metatarsal, extending into the 4th-5th intermetatarsal articulation. This region is a vascular watershed area supplied poorly by both nutrient and metaphyseal arteries, significantly increasing nonunion risk.

Question 8483

Topic: 2. Trauma

A 20-year-old track athlete presents with vague dorsal midfoot pain. Plain radiographs are normal, but an MRI confirms a non-displaced stress fracture involving the central third of the navicular. What is the most appropriate initial management?

. Non-weight-bearing cast immobilization for 6 to 8 weeks
. Walking boot weight-bearing as tolerated for 4 weeks
. Immediate open reduction and internal fixation
. Extracorporeal shock wave therapy
. Corticosteroid injection and return to play

Correct Answer & Explanation

. Non-weight-bearing cast immobilization for 6 to 8 weeks

Explanation

Tarsal navicular stress fractures have a high risk of delayed union or nonunion due to a relatively avascular central third. Initial conservative management for non-displaced fractures strictly requires non-weight-bearing in a cast for 6 to 8 weeks.

Question 8484

Topic: 2. Trauma
A 30-year-old man undergoes surgical fixation of a Sanders Type III calcaneus fracture via a standard extensile lateral approach. Which of the following is the most common complication associated with this specific surgical approach?
. Sural nerve neuroma
. Wound dehiscence and infection
. Subtalar arthritis
. Hardware failure and nonunion
. Iatrogenic compartment syndrome

Correct Answer & Explanation

. Wound dehiscence and infection

Explanation

Wound healing complications, including dehiscence and deep infection, are the most common complication of the extensile lateral approach for calcaneus fractures, occurring in 10-25% of cases.

Question 8485

Topic: 2. Trauma

A 22-year-old gymnast presents with midfoot pain. A CT scan confirms a partial, nondisplaced stress fracture in the central third of the navicular. What is the most appropriate initial management?

. Controlled ankle motion (CAM) boot with full weight-bearing for 6 weeks
. Short leg cast, strict non-weight-bearing for 6 weeks
. Open reduction and internal fixation with compression screws
. Primary arthrodesis of the talonavicular joint
. Ultrasound-guided corticosteroid injection

Correct Answer & Explanation

. Short leg cast, strict non-weight-bearing for 6 weeks

Explanation

Nondisplaced navicular stress fractures have a high risk of nonunion due to the avascular nature of the central third. Strict non-weight-bearing in a cast for 6 to 8 weeks is the standard initial treatment.

Question 8486

Topic: 2. Trauma

A 21-year-old basketball player lands awkwardly and sustains a Zone 2 proximal fifth metatarsal fracture (Jones fracture). Which anatomical factor is the primary reason this specific fracture is prone to delayed union or nonunion?

. It occurs in a vascular watershed area at the metaphyseal-diaphyseal junction
. Constant dynamic pull of the peroneus brevis tendon
. Interposition of the lateral band of the plantar fascia
. High cortical to cancellous bone ratio in this zone
. Frequent associated injury to the sural nerve blood supply

Correct Answer & Explanation

. It occurs in a vascular watershed area at the metaphyseal-diaphyseal junction

Explanation

Zone 2 fractures (Jones fractures) occur at the metaphyseal-diaphyseal junction, an area with a tenuous vascular watershed supply. This lack of robust blood flow significantly increases the risk of nonunion.

Question 8487

Topic: Lower Extremity Trauma

Which radiographic parameter is considered the most reliable indicator of a syndesmotic injury on standard weight-bearing anteroposterior (AP) and mortise radiographs of the ankle?

. Tibiofibular overlap of less than 1 mm
. Medial clear space greater than 4 mm
. Talar tilt greater than 10 degrees
. Tibiofibular clear space greater than 5 mm
. Disruption of Shenton's line

Correct Answer & Explanation

. Tibiofibular clear space greater than 5 mm

Explanation

The tibiofibular clear space, measured 1 cm proximal to the joint line, is the most reliable radiographic indicator of syndesmotic widening. It should normally be less than 6 mm on both AP and mortise views.

Question 8488

Topic: 2. Trauma

A subchondral radiolucent band (Hawkins sign) seen in the talar dome on an AP mortise radiograph 6 to 8 weeks after a displaced talar neck fracture indicates which of the following?

. Impending avascular necrosis of the talar body
. Intact vascularity and subchondral bone resorption
. Development of post-traumatic subtalar arthritis
. Talar neck nonunion
. Infection of the talonavicular joint

Correct Answer & Explanation

. Intact vascularity and subchondral bone resorption

Explanation

The Hawkins sign represents subchondral osteopenia due to hyperemic bone resorption. Its presence at 6-8 weeks demonstrates intact vascularity to the talar body, making avascular necrosis highly unlikely.

Question 8489

Topic: 2. Trauma

A 24-year-old elite athlete sustains an acute fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction (Jones fracture). What is the recommended treatment to minimize the risk of nonunion and expedite return to sport?

. Non-weight-bearing short leg cast for 8 weeks
. Weight-bearing as tolerated in a hard-soled shoe
. Early intramedullary screw fixation
. Tension band wiring
. Primary excision of the proximal fragment

Correct Answer & Explanation

. Early intramedullary screw fixation

Explanation

Acute Zone II (Jones) fractures in competitive athletes have a high rate of delayed union or nonunion. Early intramedullary screw fixation provides stable compression, significantly reducing nonunion rates and shortening the time to return to play.

Question 8490

Topic: 2. Trauma
A 28-year-old man sustains a Hawkins type III talar neck fracture. Which of the following surgical approaches is most appropriate to ensure anatomic reduction and minimize varus malunion?
. Single anterolateral approach.
. Single anteromedial approach.
. Posterior approach.
. Combined anteromedial and anterolateral approaches.
. Medial malleolar osteotomy alone.

Correct Answer & Explanation

. Combined anteromedial and anterolateral approaches.

Explanation

Combined anteromedial and anterolateral approaches are standard for Hawkins type II and III fractures. This dual approach adequately visualizes the reduction, minimizing the risk of the common varus and apex dorsal malunion.

Question 8491

Topic: 2. Trauma

A 22-year-old collegiate basketball player sustains an acute Zone 2 fracture of the base of the fifth metatarsal. What is the recommended treatment to minimize nonunion and expedite return to play?

. Short leg walking cast for 6 weeks.
. Non-weight bearing cast for 6 weeks.
. Tension band wiring.
. Excision of the proximal fragment and peroneus brevis advancement.
. Intramedullary screw fixation.

Correct Answer & Explanation

. Intramedullary screw fixation.

Explanation

In high-level athletes, Zone 2 (Jones) fractures have an unacceptably high risk of nonunion with nonoperative care. Intramedullary screw fixation provides stable compression, leading to faster union times and earlier return to sport.

Question 8492

Topic: 2. Trauma

A 40-year-old man sustains a high-energy closed pilon fracture with severe soft tissue swelling and fracture blisters. What is the most appropriate initial management?

. Immediate ORIF of both tibia and fibula.
. Spanning external fixation and delayed ORIF of the tibia once soft tissues permit.
. Primary intramedullary nailing of the tibia.
. Circular frame (Ilizarov) application with immediate full weight-bearing.
. Open reduction without internal fixation and cast application.

Correct Answer & Explanation

. Spanning external fixation and delayed ORIF of the tibia once soft tissues permit.

Explanation

High-energy pilon fractures with severe soft tissue compromise are best managed with a staged protocol. Initial spanning external fixation protects soft tissues, followed by definitive ORIF when swelling subsides and the skin "wrinkle test" is positive.

Question 8493

Topic: 2. Trauma

A 20-year-old Division I collegiate basketball player sustains a 5th metatarsal fracture during practice. Radiographs demonstrate a transverse fracture at the metaphyseal-diaphyseal junction extending into the fourth-fifth intermetatarsal facet. There is no evidence of intramedullary sclerosis. To maximize his chances of returning to play this season and minimize the risk of nonunion, which management strategy is most appropriate?

. Non-weight-bearing in a short leg cast for 6-8 weeks
. Weight-bearing as tolerated in a stiff-soled shoe or walking boot
. Open reduction and internal fixation using a dorsal bridging plate
. Percutaneous intramedullary screw fixation
. Excision of the proximal fragment and advancement of the peroneus brevis tendon

Correct Answer & Explanation

. Percutaneous intramedullary screw fixation

Explanation

The patient has a Zone 2 fracture of the proximal fifth metatarsal, commonly known as a Jones fracture. Because of the precarious blood supply in this vascular watershed area, Jones fractures have a high rate of delayed union or nonunion with conservative management. In elite or highly competitive athletes, early percutaneous intramedullary screw fixation is the treatment of choice. It results in significantly faster clinical and radiographic union times and a quicker return to sports compared to non-operative treatment.

Question 8494

Topic: 2. Trauma

A 22-year-old collegiate basketball player sustains an acute Zone 2 proximal fifth metatarsal fracture (Jones fracture). To minimize the risk of nonunion and facilitate an early return to play, intramedullary screw fixation is planned. To prevent an iatrogenic medial cortical breach of the metatarsal shaft during drilling and screw insertion, what is the ideal entry point?

. Plantar and lateral to the tip of the tuberosity
. Dorsal and medial to the tip of the tuberosity
. Directly at the anatomic insertion of the peroneus brevis
. Plantar and medial to the tip of the tuberosity
. Dorsal and lateral to the tip of the tuberosity

Correct Answer & Explanation

. Dorsal and lateral to the tip of the tuberosity

Explanation

The fifth metatarsal shaft exhibits both a lateral and a plantar bow. When placing a straight intramedullary screw, starting centrally on the tuberosity often results in a medial or plantar cortical breach. To accommodate the natural curvature of the bone and ensure the drill/screw remains within the medullary canal, the ideal starting point is slightly dorsal (high) and medial to the tip of the tuberosity.

Question 8495

Topic: 2. Trauma

A 35-year-old male sustained a Hawkins Type II talar neck fracture and underwent open reduction and internal fixation. At 8 weeks postoperatively, an AP radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

. Early onset of osteonecrosis of the talar body
. Impending nonunion of the talar neck
. Intact vascular supply to the talar body
. Septic arthritis of the tibiotalar joint
. Failure of the internal fixation

Correct Answer & Explanation

. Intact vascular supply to the talar body

Explanation

The subchondral radiolucent band described is the Hawkins sign. It represents subchondral osteopenia secondary to disuse and hyperemia, which indicates that the talar body has an intact vascular supply. Its presence is a strong negative predictor for the development of avascular necrosis (AVN).

Question 8496

Topic: 2. Trauma

A professional football player sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint, resulting in a severe turf toe injury. MRI confirms a complete tear of the plantar plate complex. Which of the following is an absolute indication for surgical repair of this injury?

. Dorsal capsular avulsion
. Grade 1 sprain with point tenderness
. Grade 2 sprain with mild ecchymosis
. Complete tear of the plantar plate with diastasis of the bipartite medial sesamoid
. Asymptomatic proximal migration of the sesamoids

Correct Answer & Explanation

. Complete tear of the plantar plate with diastasis of the bipartite medial sesamoid

Explanation

Grade 3 turf toe injuries involve a complete tear of the plantar plate complex. Indications for surgical intervention include significant proximal retraction of the sesamoids, intra-articular loose bodies, fracture or traumatic diastasis of a sesamoid, and vertical instability of the MTP joint. Diastasis of a bipartite sesamoid or a true sesamoid fracture combined with a complete plantar plate tear severely disrupts the windlass mechanism and mandates repair in a high-demand athlete.

Question 8497

Topic: 2. Trauma



A 21-year-old Division I collegiate basketball player presents with acute lateral foot pain after landing awkwardly. Radiographs reveal a transverse fracture of the fifth metatarsal located at the metaphyseal-diaphyseal junction, extending into the fourth-fifth intermetatarsal facet articulation. There is no significant sclerosis at the fracture margins. To minimize the risk of nonunion and expedite his return to competitive play, what is the most widely recommended treatment?

. Non-weight-bearing in a short leg cast for 8 weeks
. Weight-bearing as tolerated in a stiff-soled walking boot
. Surgical fixation with an intramedullary screw
. Open reduction and internal fixation with a lateral tension band wiring
. Excision of the proximal fragment with peroneus brevis advancement

Correct Answer & Explanation

. Surgical fixation with an intramedullary screw

Explanation

The patient has sustained an acute Jones fracture (Zone 2 fracture of the proximal fifth metatarsal). This area represents a vascular watershed zone, making these fractures prone to delayed union and nonunion. While non-operative management (strict non-weight-bearing) is acceptable for less active individuals, the standard of care for high-level, elite athletes is early surgical intervention with intramedullary screw fixation. This approach significantly decreases the time to clinical and radiographic union, lowers the rate of nonunion, and allows for a much faster and more predictable return to competitive sports compared to conservative management.

Question 8498

Topic: 2. Trauma

A 21-year-old elite collegiate basketball player sustains a fracture of the fifth metatarsal. Radiographs demonstrate a transverse fracture line located at the metaphyseal-diaphyseal junction, which extends into the fourth-fifth intermetatarsal articulation. To optimize the patient's safe return to play and minimize the risk of nonunion, what is the most appropriate management?

. Short leg non-weight-bearing cast for 6 to 8 weeks
. Walking boot with weight-bearing as tolerated
. Intramedullary screw fixation
. Excision of the proximal fracture fragment and peroneus brevis advancement
. Open reduction and plate fixation

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

The patient has a Zone 2 fracture of the fifth metatarsal, commonly referred to as a Jones fracture. This area represents a vascular watershed zone, predisposing these fractures to delayed union or nonunion. In elite athletes, conservative management (such as casting) is associated with an unacceptably high rate of nonunion and prolonged time away from sports. Intramedullary screw fixation is the gold standard for high-level athletes with Zone 2 fractures, as it provides compression across the fracture site, significantly reduces the nonunion rate, and accelerates the timeline for returning to athletic competition.

Question 8499

Topic: 2. Trauma

A 32-year-old male sustained a displaced talar neck fracture treated with open reduction and internal fixation. At 8 weeks postoperatively, an anteroposterior radiograph of the ankle shows a subchondral lucency in the talar dome.

What does this radiographic finding indicate?

. Impending talar dome collapse
. Intact vascularity to the talar body
. Septic arthritis of the ankle joint
. Nonunion of the talar neck
. Avascular necrosis of the talar head

Correct Answer & Explanation

. Intact vascularity to the talar body

Explanation

The subchondral radiolucent band seen in the talar dome 6 to 8 weeks after a talar neck fracture is known as the Hawkins sign. It represents subchondral bone resorption secondary to disuse osteopenia. Because bone resorption requires an active blood supply, the presence of a Hawkins sign indicates intact vascularity to the talar body, forecasting a very low likelihood of avascular necrosis.

Question 8500

Topic: 2. Trauma

A 19-year-old collegiate basketball player sustains an acute fifth metatarsal fracture. Radiographs show a transverse fracture at the metaphyseal-diaphyseal junction involving the fourth-fifth intermetatarsal articulation. Given the patient's athletic status and the fracture location, which of the following is the most appropriate management?

. Non-weight bearing in a short leg cast for 6-8 weeks
. Weight-bearing as tolerated in a stiff-soled shoe
. Intramedullary screw fixation
. Excision of the proximal fragment and peroneus brevis advancement
. Open reduction and dual-plate fixation

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

This is a classic Jones fracture (Zone 2), occurring at the metaphyseal-diaphyseal junction extending into the 4th-5th intermetatarsal articulation. Due to the watershed blood supply, these fractures have a high rate of delayed union or nonunion. In high-level competitive athletes, early intramedullary screw fixation is recommended. It significantly decreases the time to union and allows a faster, more predictable return to sport compared to conservative management.

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