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2. Trauma MCQs

Practice Set 426 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 8501

Topic: 2. Trauma

A 21-year-old collegiate track athlete presents with insidious onset of vague midfoot pain. Plain radiographs are normal, but an MRI confirms a navicular stress fracture extending through the dorsal cortical margin without complete displacement or fragmentation. What is the most appropriate initial management for this patient?

. Open reduction and internal fixation with a compression screw
. Short leg walking boot and weight-bearing as tolerated
. Strict non-weight-bearing in a short leg cast for 6 to 8 weeks
. Extra-corporeal shockwave therapy and immediate return to play
. Excision of the dorsal navicular fragment

Correct Answer & Explanation

. Strict non-weight-bearing in a short leg cast for 6 to 8 weeks

Explanation

For uncomplicated, non-displaced navicular stress fractures, the gold standard for initial conservative management is strict non-weight-bearing in a short leg cast for 6 to 8 weeks. Weight-bearing protocols have an unacceptably high rate of delayed union or nonunion due to the precarious blood supply to the central third of the navicular.

Question 8502

Topic: 2. Trauma

A 28-year-old professional soccer player sustains an acute, non-displaced fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal during a game. He wishes to return to play as quickly and safely as possible. What is the most appropriate definitive management for this patient to minimize the risk of nonunion and allow early return to sport?

. Non-weight-bearing in a short leg cast for 6 weeks
. Weight-bearing as tolerated in a stiff-soled shoe
. Intramedullary screw fixation
. Tension band wiring
. Dorsal bridge plating

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

Acute fractures of the fifth metatarsal metaphyseal-diaphyseal junction (Jones fractures) in high-level or professional athletes are typically treated with intramedullary screw fixation. This provides a significantly faster time to union and return to sport, and lowers the risk of nonunion compared to conservative management.

Question 8503

Topic: Lower Extremity Trauma

A 23-year-old football player presents with an acute rotational ankle injury. A syndesmotic sprain is suspected. On a standard AP radiograph of the ankle, what is the normal threshold for the tibiofibular clear space, measured 1 cm proximal to the tibial plafond?

. < 6 mm
. < 4 mm
. > 6 mm
. < 2 mm
. > 10 mm

Correct Answer & Explanation

. < 6 mm

Explanation

The tibiofibular clear space is the distance between the lateral border of the posterior tibial malleolus and the medial border of the fibula, measured 1 cm proximal to the joint line. A normal value is less than 6 mm on both AP and mortise views. Values greater than 6 mm are highly suggestive of syndesmotic injury.

Question 8504

Topic: 2. Trauma

A 19-year-old elite collegiate basketball player presents with acute lateral foot pain after landing awkwardly. Radiographs reveal a transverse fracture of the proximal fifth metatarsal at the metaphyseal-diaphyseal junction, extending into the fourth-fifth intermetatarsal articulation. Which of the following is the most appropriate management for this patient to minimize the risk of nonunion and expedite his return to competitive play?

. Short leg cast, non-weight-bearing for 6 weeks
. Hard-soled shoe, weight-bearing as tolerated
. Open reduction and internal fixation with a dorsal plate
. Percutaneous intramedullary screw fixation
. Primary excision of the proximal fragment and peroneus brevis advancement

Correct Answer & Explanation

. Percutaneous intramedullary screw fixation

Explanation

The patient has sustained a Zone II fracture of the proximal fifth metatarsal, commonly referred to as a Jones fracture. This region represents a vascular watershed area, placing these fractures at a substantially higher risk for delayed union and nonunion compared to Zone I (tuberosity avulsion) fractures. In high-demand or elite athletes, early surgical intervention with percutaneous intramedullary screw fixation is the standard of care to decrease nonunion rates and allow for a more reliable, accelerated return to sport.

Question 8505

Topic: 2. Trauma
A 32-year-old male sustains a high-energy motor vehicle accident resulting in a displaced talar neck fracture. Radiographs demonstrate a talar neck fracture with both subtalar and tibiotalar joint dislocation. Based on the Hawkins classification, what is his injury grade and the approximate associated risk of avascular necrosis (AVN) of the talar body?
. Hawkins I, <10% risk of AVN
. Hawkins II, 20-50% risk of AVN
. Hawkins III, 20-50% risk of AVN
. Hawkins III, 80-100% risk of AVN
. Hawkins IV, 20-50% risk of AVN

Correct Answer & Explanation

. Hawkins III, 80-100% risk of AVN

Explanation

This is a Hawkins Type III fracture, which is characterized by a displaced talar neck fracture with dislocation of both the subtalar and tibiotalar joints. The blood supply to the talar body is disrupted from the artery of the tarsal canal, artery of the sinus tarsi, and the superior neck vessels. The risk of AVN for a Type III fracture is historically 80-100%, though some modern series show slightly lower rates. Hawkins II involves subtalar subluxation/dislocation only (20-50% AVN risk).

Question 8506

Topic: 2. Trauma

A 21-year-old elite collegiate basketball player sustains an acute, non-displaced fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Zone 2). To facilitate the fastest safe return to play and minimize the risk of delayed union or nonunion, what is the treatment of choice?

. Short leg cast, strict non-weight-bearing for 6-8 weeks
. Weight-bearing as tolerated in a stiff-soled boot
. Intramedullary screw fixation
. Open reduction and small fragment plate fixation
. Percutaneous Kirschner wire fixation

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

Zone 2 fractures (Jones fractures) involve the metaphyseal-diaphyseal junction and are prone to nonunion due to a vascular watershed area. In elite or high-level athletes, early operative intervention with intramedullary screw fixation is recommended. It significantly decreases the time to clinical and radiographic union and lowers the rate of nonunion compared to non-operative management, allowing for an accelerated return to sport.

Question 8507

Topic: 2. Trauma
A 45-year-old construction worker falls from a roof and sustains a closed, displaced intra-articular calcaneus fracture (Sanders Type III). He undergoes open reduction and internal fixation via an extensile lateral approach. Which of the following patient factors is the most significant independent predictor for postoperative wound necrosis and deep infection?
. Body Mass Index > 30
. Diabetes mellitus
. Current tobacco smoking
. Age greater than 40 years
. Surgical delay greater than 7 days

Correct Answer & Explanation

. Current tobacco smoking

Explanation

The extensile lateral approach for calcaneus fractures is notorious for a high rate of wound complications (up to 25%). Current tobacco smoking is consistently identified as the most significant independent risk factor for wound edge necrosis, deep infection, and soft tissue flap failure. Delaying surgery until the 'wrinkle sign' appears (often taking 10-14 days) is actually protective against wound complications.

Question 8508

Topic: 2. Trauma

A 28-year-old male sustains a Hawkins Type II fracture of the talar neck and is treated with open reduction and internal fixation. He returns to the clinic for an 8-week postoperative follow-up. Which of the following radiographic findings reliably indicates that the talar body has a sufficient vascular supply and is unlikely to develop avascular necrosis?

. Diffuse sclerosis of the talar body
. Subchondral radiolucency in the talar dome
. Cystic degeneration at the fracture site
. Uniform joint space narrowing of the tibiotalar articulation
. Complete obliteration of the sinus tarsi

Correct Answer & Explanation

. Subchondral radiolucency in the talar dome

Explanation

Hawkins sign is characterized by a subchondral radiolucency (disuse osteopenia) observed in the talar dome on an AP or mortise radiograph of the ankle, typically appearing 6 to 8 weeks following a talar neck fracture. This localized osteopenia signifies that the bone retains an intact vascular supply, allowing for the active resorption of bone. The presence of a Hawkins sign effectively rules out avascular necrosis (AVN) of the talar body, whereas diffuse relative sclerosis of the talar body indicates AVN.

Question 8509

Topic: 2. Trauma

A 21-year-old collegiate basketball player sustains an acute fifth metatarsal fracture. Radiographs show a transverse fracture located 2 cm distal to the tuberosity, extending into the fourth-fifth intermetatarsal articulation, with no intramedullary sclerosis. Which of the following is the most appropriate treatment for this athlete?

. Non-weight bearing in a short leg cast for 6 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 dorsal plating

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

The patient has an acute Jones fracture (Zone 2: metaphyseal-diaphyseal junction extending into the 4th-5th intermetatarsal articulation). Because this occurs in a vascular watershed area, it has a higher risk of delayed union or nonunion. In elite or high-level athletes, early surgical intervention with intramedullary screw fixation is recommended as it significantly decreases time to union, lowers the nonunion rate, and allows a faster return to sports compared to non-operative management.

Question 8510

Topic: 2. Trauma

A 22-year-old marathon runner complains of progressive bilateral anterolateral leg pain that reliably begins 3 miles into her run and resolves after 30 minutes of rest. She occasionally experiences numbness on the dorsum of her foot. Resting compartment pressures are 12 mmHg. Five minutes post-exercise, the anterior compartment pressure is 35 mmHg. What is the most appropriate next step in management if she wishes to continue long-distance running?

. Immediate single-incision four-compartment fasciotomy
. Physical therapy focusing on heel-strike running mechanics
. Electromyography (EMG) of the common peroneal nerve
. Elective anterior and lateral compartment fasciotomy
. Botulinum toxin injection into the tibialis anterior muscle

Correct Answer & Explanation

. Elective anterior and lateral compartment fasciotomy

Explanation

The patient's clinical presentation and diagnostic compartment pressures confirm Chronic Exertional Compartment Syndrome (CECS) of the anterior and lateral compartments. The Pedowitz criteria for CECS include one or more of the following: pre-exercise pressure >= 15 mmHg, 1-minute post-exercise pressure >= 30 mmHg, or 5-minute post-exercise pressure >= 20 mmHg. Given her desire to continue running and failure to modify activities, the definitive treatment is an elective fasciotomy of the involved compartments. Transitioning to a forefoot strike (not heel-strike) is sometimes recommended to lower anterior pressures, but is not the best definitive option here.

Question 8511

Topic: 2. Trauma

A 22-year-old elite collegiate basketball player sustains an acute foot injury during a game. Radiographs confirm a transverse fracture through the metaphyseal-diaphyseal junction of the fifth metatarsal base (Zone 2). To minimize the risk of nonunion and facilitate an accelerated return to competitive play, what is the recommended definitive management?

. Non-weight bearing in a short leg cast for 6 to 8 weeks
. Weight-bearing as tolerated in a stiff-soled fracture boot
. Percutaneous intramedullary screw fixation
. Open reduction and application of a locking compression plate
. Excision of the proximal pole fragment with peroneus brevis advancement

Correct Answer & Explanation

. Percutaneous intramedullary screw fixation

Explanation

A fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal is defined as a Jones fracture (Zone 2). This area represents a vascular watershed zone, predisposing these fractures to delayed union and nonunion. In high-level, elite athletes, surgical management with early percutaneous intramedullary screw fixation is strongly recommended. This approach yields significantly higher union rates and allows for a faster return to sport compared to conservative management (casting or booting).

Question 8512

Topic: 2. Trauma

A 22-year-old elite collegiate basketball player sustains an acute, non-displaced fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction. He wishes to return to play as safely and quickly as possible. What is the most appropriate management?

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

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

Acute fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal (Jones fractures) occur in a vascular watershed area, predisposing them to a higher rate of nonunion. In a young, high-demand athlete, early intramedullary screw fixation is recommended to decrease the time to union, lower the risk of nonunion, and facilitate an earlier return to sports compared to conservative management.

Question 8513

Topic: 2. Trauma

A 40-year-old roofer falls from a height and sustains a closed, displaced intra-articular calcaneus fracture. He smokes 1 pack of cigarettes per day and has a BMI of 32. If an extensile lateral approach is chosen for open reduction and internal fixation, which of the following is the most significant independent risk factor for wound complications?

. Time to surgery of 5 days
. BMI of 32
. Patient age over 35 years
. Smoking 1 pack of cigarettes per day
. Early range of motion exercises

Correct Answer & Explanation

. Smoking 1 pack of cigarettes per day

Explanation

Smoking is a profoundly significant independent risk factor for wound complications following the extensile lateral approach for calcaneus fractures. Studies have consistently shown that smokers have an exponentially higher rate of marginal skin necrosis, deep infection, and the need for secondary soft tissue coverage procedures compared to non-smokers. Smoking cessation and waiting for the wrinkle sign are critical preoperative optimization steps.

Question 8514

Topic: 2. Trauma

A 21-year-old elite collegiate basketball player sustains an acute zone 2 fracture of the proximal fifth metatarsal (Jones fracture). What is the recommended treatment to minimize the risk of nonunion and allow the fastest return to competitive play?

. Non-weight-bearing in a short leg cast for 6 weeks
. Weight-bearing as tolerated in a stiff-soled shoe
. Intramedullary screw fixation
. Dorsal bridge plating
. Excision of the proximal fragment and peroneus brevis advancement

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

A zone 2 proximal fifth metatarsal fracture (Jones fracture) involves the vascular watershed area, putting it at high risk for delayed union or nonunion. In high-level athletes, conservative management is associated with unacceptably high rates of nonunion and prolonged time away from sports. Early intramedullary screw fixation has been shown to significantly increase the union rate, decrease the time to union, and facilitate a much faster return to play.

Question 8515

Topic: 2. Trauma

A 21-year-old professional soccer player complains of lateral foot pain after a cutting maneuver. Radiographs demonstrate a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal, extending into the fourth-fifth intermetatarsal articulation, without significant sclerosis or medullary obliteration. He wishes to return to play as safely and quickly as possible. 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
. Excision of the proximal fragment and peroneus brevis advancement
. Intramedullary screw fixation
. Open reduction and internal fixation with a mini-fragment plate

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

The patient has a Zone 2 fracture of the fifth metatarsal base (Jones fracture), which involves the metaphyseal-diaphyseal junction and extends into the 4th-5th intermetatarsal facet. These fractures have a higher risk of nonunion due to the watershed blood supply in this region. In high-demand or elite athletes, acute intramedullary screw fixation is recommended because it significantly decreases the time to clinical and radiographic union and lowers the risk of nonunion compared to non-operative management, allowing for a quicker return to sports.

Question 8516

Topic: 2. Trauma

A 32-year-old male sustains a high-energy motor vehicle collision resulting in a displaced talar neck fracture with subtalar subluxation. Open reduction and internal fixation is performed within 24 hours. At 8 weeks postoperatively, a mortise radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

. Intact vascular supply to the talar body
. Osteonecrosis of the talar body
. Impending collapse of the talar dome
. Nonunion of the talar neck
. Early subtalar arthritis

Correct Answer & Explanation

. Intact vascular supply to the talar body

Explanation

The subchondral radiolucent band in the talar dome is known as the Hawkins sign. It represents subchondral osteopenia secondary to hyperemia from an intact vascular supply. Its presence at 6-8 weeks post-injury is a highly reliable indicator that the talar body has not undergone avascular necrosis.

Question 8517

Topic: 2. Trauma

A 40-year-old roofer falls from a ladder and sustains a closed, displaced intra-articular calcaneus fracture (Sanders type II). He is a heavy smoker (2 packs per day). He asks about the risks of surgical treatment. Which of the following is the most common complication following open reduction and internal fixation (ORIF) of a calcaneus fracture via an extensile lateral approach?

. Wound healing complications
. Compartment syndrome
. Sural nerve transection
. Nonunion
. Avascular necrosis of the calcaneus

Correct Answer & Explanation

. Wound healing complications

Explanation

Wound healing complications are the most common and feared complication following ORIF of calcaneus fractures via an extensile lateral approach. The risk is significantly increased in patients who smoke, have diabetes, or are obese. Careful tissue handling, waiting for the 'wrinkle sign', and smoking cessation are crucial.

Question 8518

Topic: 2. Trauma

A 22-year-old male sustains a completely displaced midshaft clavicle fracture following a cycling fall. In evaluating whether to proceed with non-operative management versus open reduction and internal fixation (ORIF), which of the following physical examination or radiographic findings is considered an absolute or strong relative indication for immediate ORIF?

. Displacement with 1.0 cm of overriding
. Impending skin breakdown (skin tenting with blanching)
. Presence of a stable butterfly fragment
. Coracoclavicular distance of 1.2 cm
. The fracture being located at the junction of the medial and middle thirds

Correct Answer & Explanation

. Impending skin breakdown (skin tenting with blanching)

Explanation

Absolute or strong relative indications for acute operative fixation of clavicle fractures include open fractures, impending skin breakdown (characterized by skin tenting with blanching or necrosis), associated neurovascular injury, and 'floating shoulder' (ipsilateral displaced scapular neck fracture). While shortening is a relative indication, modern literature typically uses a threshold of >2 cm (not 1 cm) of shortening to justify the benefits of surgery versus non-operative treatment.

Question 8519

Topic: 2. Trauma

A 22-year-old athlete sustains a proximal pole scaphoid fracture. Due to the high risk of nonunion and avascular necrosis, operative fixation is planned. Which surgical approach and fixation strategy is most appropriate for this specific fracture pattern?

. Volar approach with a headless compression screw placed distal-to-proximal
. Volar approach with a headless compression screw placed proximal-to-distal
. Dorsal approach with a headless compression screw placed distal-to-proximal
. Dorsal approach with a headless compression screw placed proximal-to-distal
. Lateral percutaneous approach with K-wire fixation

Correct Answer & Explanation

. Dorsal approach with a headless compression screw placed proximal-to-distal

Explanation

The scaphoid receives its blood supply predominantly from the dorsal carpal branch of the radial artery, which enters at the distal waist and flows in a retrograde fashion to the proximal pole. Proximal pole fractures are highly prone to avascular necrosis. Due to the intra-articular position of the proximal pole and the natural flexion of the scaphoid, a dorsal approach is strongly preferred. It allows for direct visualization of the proximal pole, preservation of the remaining blood supply, and placement of a central axis screw from proximal to distal, which biomechanically provides superior compression and stability for this specific region.

Question 8520

Topic: 2. Trauma

A 25-year-old man sustains a closed, distal-third spiral fracture of the humeral shaft (Holstein-Lewis fracture). Upon initial presentation in the emergency department, he exhibits a complete inability to extend his wrist, thumb, and metacarpophalangeal joints, along with numbness in the first dorsal web space. According to current orthopedic guidelines, what is the most appropriate initial management of this injury?

. Immediate open reduction and internal fixation with radial nerve exploration
. Application of a coaptation splint or functional brace with clinical observation of the nerve palsy
. Immediate nerve conduction studies (EMG/NCS) to determine the extent of nerve injury
. Closed reduction with application of a shoulder spica cast
. External fixation of the humerus to prevent further nerve tethering

Correct Answer & Explanation

. Application of a coaptation splint or functional brace with clinical observation of the nerve palsy

Explanation

The patient has a primary radial nerve palsy associated with a closed distal-third spiral humeral shaft fracture (Holstein-Lewis fracture). Despite the high historical association of radial nerve entrapment or laceration with this specific fracture pattern, the vast majority (>85%) of these injuries represent a neuropraxia (axonotmesis) that will spontaneously recover. Current AAOS and orthopedic trauma guidelines stipulate that the presence of a primary radial nerve palsy in the setting of a closed humeral shaft fracture is not an absolute indication for immediate surgical exploration. The standard of care is nonoperative fracture management (e.g., coaptation splint followed by a functional Sarmiento brace) and observation of the nerve palsy for 3 to 4 months. Surgical exploration is reserved for open fractures, failure to achieve closed reduction, vascular injury, or failure of the nerve to show clinical or EMG recovery by 3-4 months.

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