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2. Trauma MCQs

Practice Set 428 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 8541

Topic: 2. Trauma

A 28-year-old man sustains a closed spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture) following a fall. On examination in the emergency department, he is unable to extend his wrist or fingers and has decreased sensation over the dorsal first web space. What is the most appropriate initial management strategy for this patient?

. Immediate open reduction internal fixation (ORIF) and radial nerve exploration
. Application of a functional fracture brace or coaptation splint with close clinical observation
. Immediate external fixation
. Urgent magnetic resonance imaging (MRI) of the humerus
. Electromyography (EMG) of the upper extremity prior to any fracture management

Correct Answer & Explanation

. Application of a functional fracture brace or coaptation splint with close clinical observation

Explanation

A closed humeral shaft fracture with a primary radial nerve palsy (present immediately at the time of injury) is typically managed nonoperatively initially, as over 85% of cases resolve spontaneously with observation. Immediate surgical exploration is indicated only for open fractures, associated vascular injuries, or secondary radial nerve palsies that develop after a closed reduction attempt.

Question 8542

Topic: 2. Trauma

An 80-year-old female with osteoporosis presents with a severely comminuted, intra-articular distal humerus fracture (AO/OTA 13-C3) after a fall from a standing height. She lives independently and uses a walker for ambulation. Which of the following is the primary advantage of total elbow arthroplasty (TEA) compared to open reduction and internal fixation (ORIF) in this patient?

. Lifting restrictions are not required postoperatively
. Lower risk of long-term implant loosening
. Improved triceps strength
. More predictable early range of motion and functional recovery
. Decreased incidence of postoperative ulnar neuropathy

Correct Answer & Explanation

. More predictable early range of motion and functional recovery

Explanation

In elderly patients with poor bone quality and complex, comminuted intra-articular distal humerus fractures, TEA provides a more predictable and rapid recovery of function and allows for immediate early range of motion compared to ORIF. ORIF in this osteoporotic population is associated with a high rate of hardware failure, nonunion, and stiffness due to the inability to achieve stable enough fixation for early mobilization. However, patients with TEA must abide by a permanent 5- to 10-pound lifting restriction to prevent aseptic loosening and bushing wear. Rates of ulnar neuropathy are similar or slightly higher in TEA.

Question 8543

Topic: 2. Trauma

A 12-year-old male baseball pitcher presents with medial elbow pain after a hard throw. Radiographs demonstrate an avulsion fracture of the medial epicondyle with 10 mm of displacement. He wishes to return to competitive throwing. What is the most appropriate management?

. Cast immobilization for 6 weeks
. Excision of the medial epicondyle fragment with flexor-pronator mass advancement
. Open reduction and internal fixation
. Ulnar nerve anterior transposition alone
. Closed reduction and pinning

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

Medial epicondyle fractures in pediatric and adolescent patients can often be treated non-operatively if minimally displaced. Absolute indications for surgery include entrapment of the fragment in the joint and open fractures. Relative indications, particularly for high-demand overhead athletes with significant displacement (often >5 mm), typically lead to operative management. ORIF with a single cannulated screw or K-wires provides rigid fixation, allowing early range of motion and effectively addresses the valgus instability that is critical for returning to throwing.

Question 8544

Topic: 2. Trauma

A 24-year-old cyclist falls onto his left shoulder and sustains a midshaft clavicle fracture. Which of the following is considered an absolute indication for open reduction and internal fixation?

. 1.5 cm of fracture shortening
. Z-type comminution
. 150% superior displacement of the proximal fragment
. Open fracture
. Age of the patient

Correct Answer & Explanation

. Open fracture

Explanation

Absolute indications for ORIF of a clavicle fracture include an open fracture, associated neurovascular injury, skin tenting threatening to progress to an open fracture, and 'floating shoulder' in certain scenarios. Relative indications include shortening > 2 cm, 100% displacement, and severe comminution (such as a Z-type fragment). Therefore, an open fracture is the only absolute indication listed.

Question 8545

Topic: 2. Trauma

A 65-year-old man sustains a severely comminuted, displaced olecranon fracture extending into the coronoid process. What is the most biomechanically stable construct for fixation of this fracture?

. Tension band wiring using Kirschner wires
. Tension band wiring using cancellous screws
. Intramedullary screw fixation
. Posterior pre-contoured locking plate
. Excision of the proximal fragment and triceps advancement

Correct Answer & Explanation

. Posterior pre-contoured locking plate

Explanation

Comminuted olecranon fractures, particularly those extending distal to the sublime tubercle or involving the coronoid, are rotationally and axially unstable. Tension band wiring relies on the conversion of tension forces on the posterior cortex into compressive forces at the articular surface, which requires an intact anterior cortex to prevent shortening and collapse. Therefore, in the presence of comminution or associated instability, a posterior pre-contoured locking plate is the most biomechanically stable construct to restore anatomy and permit early range of motion.

Question 8546

Topic: 2. Trauma

A 78-year-old woman with a history of severe osteoporosis falls and sustains a highly comminuted, intra-articular fracture of the distal humerus (AO/OTA type 13-C3). She is a community ambulator and lives independently. Intraoperatively, open reduction and internal fixation (ORIF) is attempted but deemed technically impossible due to severe 'eggshell' comminution and poor bone quality. What is the most appropriate alternative surgical option to maximize her functional recovery?

. Total elbow arthroplasty
. Hemiarthroplasty of the distal humerus
. Hinged external fixation
. Cast immobilization for 6 weeks
. Excision of the distal humerus fragments and fascial arthroplasty

Correct Answer & Explanation

. Total elbow arthroplasty

Explanation

Total elbow arthroplasty (TEA) is the treatment of choice for severely comminuted intra-articular distal humerus fractures in elderly patients with poor bone quality where ORIF is not feasible. TEA allows for immediate postoperative range of motion, providing rapid and reliable pain relief and functional restoration compared to prolonged immobilization or attempts at fixing osteoporotic bone which frequently fail.

Question 8547

Topic: 2. Trauma

A 34-year-old man presents with weakness of finger and thumb extension after sustaining a closed humerus shaft fracture initially treated with a functional brace. His neurological exam at the time of injury was intact, but 3 weeks post-injury he developed a complete wrist drop. Electrodiagnostic testing at 12 weeks shows no motor unit potentials or signs of reinnervation in the brachioradialis or extensor digitorum communis. What is the most appropriate next step in management?

. Continue functional bracing and re-evaluate in 3 months
. Nerve transfer of the median nerve fascicles to the radial nerve
. Tendon transfers (e.g., pronator teres to extensor carpi radialis brevis)
. Surgical exploration of the radial nerve
. Immediate shoulder disarticulation

Correct Answer & Explanation

. Surgical exploration of the radial nerve

Explanation

A radial nerve palsy that develops AFTER a closed reduction (a secondary palsy) or one that fails to show any clinical or electromyographic signs of recovery by 3 to 4 months (12-16 weeks) is an absolute indication for surgical exploration of the radial nerve. While many primary radial nerve palsies associated with humerus fractures (e.g., Holstein-Lewis) resolve spontaneously, the lack of EMG recovery at 12 weeks requires direct visualization to address potential entrapment, laceration, or neuroma formation.

Question 8548

Topic: 2. Trauma

A 27-year-old healthy male sustains an isolated, completely displaced, and 2.5 cm shortened midshaft clavicle fracture. He is counseled on operative versus nonoperative treatment. Compared to nonoperative management with a sling, operative fixation with plate and screws is associated with which of the following?

. Higher rate of overall complications including DVT
. Significantly better functional shoulder scores at 2 years
. Increased rate of nonunion
. Lower rate of symptomatic malunion
. Decreased rate of subsequent surgeries

Correct Answer & Explanation

. Increased rate of nonunion

Explanation

Large randomized controlled trials have demonstrated that operative fixation of completely displaced, shortened midshaft clavicle fractures significantly decreases the rates of nonunion and symptomatic malunion compared to nonoperative treatment. However, operative fixation does not clearly provide superior long-term (2+ years) functional outcomes. Furthermore, operative treatment is associated with a higher rate of subsequent surgeries, primarily for symptomatic hardware removal.

Question 8549

Topic: 2. Trauma

A 28-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture) following a wrestling injury. On examination, he has a wrist drop and inability to extend his fingers, which was not present immediately after the injury but developed after a closed reduction and splinting attempt in the emergency department. What is the most appropriate next step in management?

. Observation and electromyography (EMG) at 6 weeks
. Immediate surgical exploration and internal fixation
. Ultrasound-guided nerve block
. Removal of the splint and placement in a hanging arm cast
. Re-manipulation under conscious sedation

Correct Answer & Explanation

. Immediate surgical exploration and internal fixation

Explanation

A secondary (post-reduction) radial nerve palsy in the setting of a humeral shaft fracture, particularly a Holstein-Lewis fracture (distal third spiral fracture), is an absolute indication for immediate surgical exploration. The nerve is at high risk of having become entrapped within the fracture site or the lateral intermuscular septum during reduction maneuvers. Observation is appropriate primarily for primary radial nerve palsies present before manipulation.

Question 8550

Topic: 2. Trauma

A 22-year-old competitive cyclist presents with a closed, isolated midshaft clavicle fracture after a fall. Radiographs demonstrate 100% displacement and 2.5 cm of shortening. Which of the following represents the most scientifically supported rationale for choosing open reduction and internal fixation (ORIF) over nonoperative management in this specific patient?

. Decreased risk of thoracic outlet syndrome
. Improved ultimate shoulder range of motion compared to nonoperative management
. Decreased risk of symptomatic nonunion
. Accelerated radiographic union time
. Prevention of cosmetic deformity

Correct Answer & Explanation

. Decreased risk of symptomatic nonunion

Explanation

For completely displaced midshaft clavicle fractures with significant shortening (>2 cm), multiple prospective randomized controlled trials have demonstrated that operative fixation (ORIF) significantly decreases the rate of nonunion and symptomatic malunion compared to nonoperative treatment. While cosmetic deformity is improved and early functional return may be faster, the ultimate range of motion at 1 year is generally comparable between both groups. The most compelling evidence-based reason for surgery in highly displaced/shortened midshaft fractures is the significant reduction in nonunion risk.

Question 8551

Topic: 2. Trauma

A 65-year-old woman sustains a 3-part proximal humerus fracture. Open reduction and internal fixation with a locking plate is planned. To minimize the risk of avascular necrosis of the humeral head and promote fracture healing, preservation of which of the following vascular structures is most critical during the surgical approach and dissection?

. Anterior humeral circumflex artery
. Ascending branch of the anterior humeral circumflex artery
. Posterior humeral circumflex artery
. Thoracoacromial artery
. Circumflex scapular artery

Correct Answer & Explanation

. Posterior humeral circumflex artery

Explanation

Historically, the anterolateral ascending branch of the anterior humeral circumflex artery was thought to provide the main blood supply to the humeral head. However, modern anatomical injection studies have demonstrated that the posterior humeral circumflex artery provides the predominant blood supply (approximately 64% of the humeral head). Preservation of the posteromedial capsular hinge and the posterior humeral circumflex vessels is critical to minimizing the risk of avascular necrosis.

Question 8552

Topic: 2. Trauma

A 19-year-old male is brought to the trauma bay after a rugby tackle, complaining of severe pain in his medial clavicle, shortness of breath, and dysphagia. Examination shows a palpable depression over the medial clavicle on the affected side. Which of the following is the most appropriate next step in management?

. Closed reduction in the emergency department with procedural sedation
. Urgent CT scan of the chest and clavicle
. Discharge with a figure-of-eight brace and outpatient orthopedic follow-up
. Immediate open reduction in the operating room without further imaging
. Diagnostic bedside ultrasound of the chest wall

Correct Answer & Explanation

. Urgent CT scan of the chest and clavicle

Explanation

The clinical presentation (depression of the medial clavicle, shortness of breath, and dysphagia) is highly suspicious for a posterior sternoclavicular (SC) joint dislocation. This is an orthopedic emergency due to the potential for compression or injury to mediastinal structures (trachea, esophagus, great vessels). An urgent CT scan is the gold standard to confirm the direction of dislocation and assess for mediastinal structure compromise prior to any reduction attempt. Reduction should ideally be performed in the operating room with a thoracic surgeon available.

Question 8553

Topic: 2. Trauma

A 25-year-old man sustains a closed, transverse mid-shaft humerus fracture in a motor vehicle collision. On initial examination in the emergency department, his distal pulses are intact, but he is unable to actively extend his wrist or digits, and has decreased sensation in the first dorsal web space. Which of the following represents the most appropriate initial management for the nerve injury?

. Immediate surgical exploration of the radial nerve and ORIF of the humerus.
. Application of a coaptation splint or functional brace and clinical observation for nerve recovery.
. Emergent Electromyography (EMG) and nerve conduction studies.
. Emergent MRI of the arm to evaluate nerve continuity.
. Prophylactic carpal tunnel release and tendon transfers.

Correct Answer & Explanation

. Application of a coaptation splint or functional brace and clinical observation for nerve recovery.

Explanation

A primary radial nerve palsy associated with a closed humeral shaft fracture is predominantly a neurapraxia or axonotmesis. The standard of care is conservative management of both the fracture and the nerve, utilizing a coaptation splint or functional brace, along with close clinical observation. More than 85% of primary palsies spontaneously recover. Immediate exploration is only indicated for open fractures, associated vascular injuries requiring repair, or secondary nerve palsies that develop after a closed reduction attempt.

Question 8554

Topic: 2. Trauma

A 24-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture) following a wrestling injury. In the emergency department, his initial neurologic exam reveals intact wrist and finger extension. Following closed reduction and application of a coaptation splint, the patient immediately demonstrates a complete inability to extend his wrist, thumb, and metacarpophalangeal joints. What is the most appropriate next step in management?

. Observation and electromyography (EMG) at 6 weeks
. Immediate surgical exploration of the radial nerve and fracture fixation
. Removal of the splint and placement in a hanging arm cast
. Immediate high-resolution ultrasound of the radial nerve
. Administration of intravenous corticosteroids and observation

Correct Answer & Explanation

. Immediate surgical exploration of the radial nerve and fracture fixation

Explanation

A secondary radial nerve palsy (one that develops after closed reduction or splint application) in the setting of a humeral shaft fracture is a classic, absolute indication for immediate surgical exploration and fracture fixation. The primary concern is that the radial nerve has become entrapped or lacerated within the fracture site during the reduction maneuver. Primary radial nerve palsies (present on initial presentation before manipulation) are generally observed.

Question 8555

Topic: 2. Trauma

A 21-year-old collegiate cyclist sustains an isolated, closed, midshaft clavicle fracture. Radiographs demonstrate completely displaced fracture fragments with 2.8 cm of shortening and z-deformity. The overlying skin is intact but tented. If the surgeon elects for open reduction and internal fixation (ORIF) over nonoperative management, the patient should be counseled that ORIF will most likely result in which of the following?

. A lower rate of nonunion and improved early functional outcomes
. A higher rate of nonunion but a decreased risk of hardware-related complications
. Equivalent nonunion rates but earlier radiographic consolidation
. A higher risk of symptomatic malunion
. An equal time to return to competitive sports with improved cosmesis

Correct Answer & Explanation

. A lower rate of nonunion and improved early functional outcomes

Explanation

In young, active patients with completely displaced midshaft clavicle fractures with significant shortening (>2 cm), operative fixation (ORIF) significantly decreases the rate of nonunion (approximately 1-2% compared to 15% for nonoperative management) and improves early functional outcomes (DASH and Constant scores) compared to nonoperative treatment. However, ORIF carries surgical risks, including a higher rate of hardware irritation requiring secondary removal.

Question 8556

Topic: 2. Trauma

A 72-year-old female with long-standing, medically managed rheumatoid arthritis sustains a closed, highly comminuted intra-articular fracture of the distal humerus (AO/OTA 13-C3) following a mechanical fall. Her bone quality is evaluated as markedly osteopenic. What is the most appropriate definitive surgical intervention that prioritizes early mobilization and functional recovery?

. Open reduction and internal fixation with orthogonal dual plating
. Open reduction and internal fixation with parallel dual plating
. Total elbow arthroplasty (TEA)
. Hemiarthroplasty of the distal humerus
. Application of an articulated external fixator

Correct Answer & Explanation

. Total elbow arthroplasty (TEA)

Explanation

In elderly patients with highly comminuted intra-articular distal humerus fractures, particularly those with compromised bone quality and pre-existing inflammatory arthropathy (such as rheumatoid arthritis), total elbow arthroplasty (TEA) provides more predictable outcomes. Studies show that TEA offers superior pain relief and allows for immediate postoperative mobilization compared to open reduction and internal fixation (ORIF), which carries a high rate of hardware failure, nonunion, and post-traumatic stiffness in this specific demographic.

Question 8557

Topic: 2. Trauma

A 35-year-old male suffers a closed, midshaft humeral fracture. He has a complete radial nerve palsy on initial presentation. What is the most appropriate initial management?

. Immediate surgical exploration of the radial nerve and ORIF of the humerus
. Application of a coaptation splint and observation of the nerve palsy
. MRI of the humerus to evaluate the nerve
. Nerve conduction studies and EMG
. External fixation of the humerus

Correct Answer & Explanation

. Application of a coaptation splint and observation of the nerve palsy

Explanation

Primary radial nerve palsy with a closed humeral shaft fracture is managed nonoperatively initially, as 70-90% resolve spontaneously. Surgical exploration is indicated for open fractures, vascular injury, or palsy developing after closed reduction.

Question 8558

Topic: Upper Extremity Trauma
A 22-year-old football player sustains an acromioclavicular (AC) joint injury. Radiographs show posterior displacement of the distal clavicle into the trapezius fascia. What is the correct classification and recommended treatment?
. Type III, nonoperative management
. Type IV, surgical reconstruction
. Type V, nonoperative management
. Type II, surgical reconstruction
. Type VI, surgical reconstruction

Correct Answer & Explanation

. Type IV, surgical reconstruction

Explanation

Posterior displacement of the distal clavicle into the trapezius characterizes a Type IV AC joint injury. It is generally an absolute indication for surgical reconstruction due to significant pain and functional impairment.

Question 8559

Topic: 2. Trauma

A 25-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). On initial presentation in the emergency department, he is noted to have a complete radial nerve palsy. After closed reduction and splinting, his radial nerve palsy persists but is unchanged. What is the most appropriate management regarding the radial nerve?

. Immediate surgical exploration of the radial nerve
. Observation and clinical follow-up with EMG at 6 weeks if no recovery
. Immediate MRI of the humerus to evaluate nerve continuity
. Primary nerve grafting within 1 week
. Tendon transfers should be performed immediately during fracture fixation

Correct Answer & Explanation

. Observation and clinical follow-up with EMG at 6 weeks if no recovery

Explanation

Primary radial nerve palsy associated with a closed humeral shaft fracture is typically a neurapraxia and managed observationally. Immediate exploration is only indicated for open fractures, severe vascular injury, or a secondary palsy that appears onlyafterclosed reduction attempts.

Question 8560

Topic: 2. Trauma

A 25-year-old cyclist sustains a midshaft clavicle fracture after a high-speed crash. Which of the following radiographic findings is considered the strongest relative indication for operative fixation over nonoperative management in this patient?

. 5 mm of superior displacement
. 10 mm of shortening
. 22 mm of shortening
. Presence of a single butterfly fragment
. Angulation of 10 degrees

Correct Answer & Explanation

. 22 mm of shortening

Explanation

Shortening of greater than 20 mm (or 2 cm) in midshaft clavicle fractures is a well-recognized relative indication for surgical fixation. This degree of shortening is associated with increased rates of symptomatic nonunion, malunion, and decreased shoulder muscle endurance.

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