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 841
Topic: 2. Trauma
A 32-year-old male presents with the injury seen in the provided image.
Assuming this represents a Bado II Monteggia equivalent with an associated comminuted radial head fracture, what is the most appropriate sequence of surgical management?
Correct Answer & Explanation
. Anatomic rigid internal fixation of the ulna followed by assessment and management of the radial head
Explanation
In Monteggia fractures and equivalents, the principle of management is to first restore the length, alignment, and rotation of the ulna with rigid internal fixation. This establishes a stable foundation before addressing the radial head.
Question 842
Topic: 2. Trauma
When utilizing parallel plating versus orthogonal (90-90) plating for comminuted distal humerus fractures, which biomechanical advantage makes parallel plating particularly beneficial in elderly patients?
Correct Answer & Explanation
. It provides superior stability under sagittal bending and torsional loads in osteoporotic bone.
Explanation
Parallel plating with interdigitating screws through the condyles provides a more robust architectural construct, offering superior resistance to sagittal bending and torsional forces, which is especially critical in osteoporotic bone.
Question 843
Topic: 2. Trauma
A 55-year-old male sustains a closed midshaft humerus fracture and is managed non-operatively with a Sarmiento brace. Which of the following residual alignments exceeds the acceptable criteria for non-operative management and warrants consideration for surgery?
Correct Answer & Explanation
. 40 degrees of varus angulation
Explanation
Acceptable alignment parameters for non-operative management of humeral shaft fractures include up to 20 degrees of anterior angulation, 30 degrees of varus angulation, and up to 3 cm of shortening. 40 degrees of varus exceeds these limits.
Question 844
Topic: 2. Trauma
A 7-year-old child presents with a missed Bado Type I Monteggia fracture that occurred 8 months ago. Radiographs show a healed, malaligned ulnar shaft with a chronically dislocated radial head. What is the most appropriate surgical management to restore function and prevent progressive arthrosis?
Correct Answer & Explanation
. Ulnar osteotomy, open reduction of the radial head, and annular ligament reconstruction
Explanation
In chronic, missed Monteggia fractures in children, the treatment of choice is an ulnar lengthening/angulation osteotomy to indirectly pull the radial head into place, combined with open reduction of the joint and often annular ligament reconstruction.
Question 845
Topic: 2. Trauma
Which of the following defines a Bado Type IV Monteggia injury?
Correct Answer & Explanation
. Fractures of the shafts of both the radius and ulna with an anterior radial head dislocation
Explanation
The Bado classification describes Monteggia fractures. Type I is anterior, Type II is posterior, Type III is lateral, and Type IV involves fractures of both the radius and ulna shafts with an anterior dislocation of the radial head.
Question 846
Topic: 2. Trauma
A 35-year-old male sustains a Bado Type I Monteggia fracture-dislocation. Intraoperatively, anatomic length and alignment of the ulna are achieved with compression plating, but the radial head remains persistently subluxated. What is the most likely anatomic block to reduction?
Correct Answer & Explanation
. Interposed annular ligament
Explanation
The annular ligament is the primary stabilizer of the radial head. When torn during a Monteggia fracture-dislocation, it can become interposed within the radiocapitellar joint, preventing successful closed reduction of the radial head.
Question 847
Topic: 2. Trauma
A 25-year-old male presents with a closed, transverse midshaft humerus fracture. Neurological examination reveals an absent brachioradialis reflex, inability to extend the wrist, and numbness over the dorsal first web space. What is the most appropriate initial management?
Correct Answer & Explanation
. Functional bracing/coaptation splinting and nerve observation
Explanation
Primary radial nerve palsy in closed humeral shaft fractures is typically a neurapraxia. Functional bracing or coaptation splinting with observation for spontaneous recovery (usually over 3-4 months) is the standard of care.
Question 848
Topic: 2. Trauma
A 42-year-old female sustains a distal third spiral humerus fracture. After closed reduction in the emergency department, she develops a new-onset complete radial nerve palsy. What is the most appropriate next step in management?
Correct Answer & Explanation
. Surgical exploration and internal fixation
Explanation
A secondary (post-reduction) radial nerve palsy, particularly in a Holstein-Lewis type fracture (distal third spiral), is a strong indication for surgical exploration. This is due to the high risk of the nerve being entrapped or lacerated within the fracture site.
Question 849
Topic: Upper Extremity Trauma
A surgeon plans a posterior extensile approach with an olecranon osteotomy to treat an intra-articular distal humerus fracture. To minimize articular disruption and facilitate anatomic reduction, the apex of the chevron osteotomy should be directed toward which structure?
Correct Answer & Explanation
. The bare area of the sigmoid notch
Explanation
A chevron-type olecranon osteotomy should be directed at the "bare area" of the sigmoid notch. This specific area is naturally devoid of articular cartilage, which minimizes damage to the articular surface.
Question 850
Topic: 2. Trauma
During a posterior triceps-splitting approach for a mid-distal humerus fracture, the surgeon must identify and protect the radial nerve. At what approximate distance proximal to the radiocapitellar joint does the radial nerve cross the posterior humerus from medial to lateral?
Correct Answer & Explanation
. 14 to 20 cm
Explanation
The radial nerve runs along the spiral groove and consistently crosses the posterior humerus from medial to lateral approximately 14 to 20 cm proximal to the radiocapitellar joint (or roughly 10 cm proximal to the olecranon fossa).
Question 851
Topic: Upper Extremity Trauma
An 8-year-old boy presents after a fall. Radiographs demonstrate a fracture of the ulnar diaphysis and a displaced fracture of the radial neck, but the radiocapitellar articulation remains intact without true dislocation. Which of the following best describes this injury pattern?
Correct Answer & Explanation
. Monteggia equivalent lesion
Explanation
A Monteggia equivalent lesion involves an ulnar shaft fracture associated with a radial neck fracture, epiphyseal separation, or radial head fracture, rather than a classic true dislocation of the radial head.
Question 852
Topic: 2. Trauma
While functional bracing (Sarmiento) is highly effective for many closed humeral shaft fractures, which of the following fracture characteristics is generally considered an indication for surgical fixation?
Correct Answer & Explanation
. Greater than 30 degrees of varus angulation
Explanation
Acceptable alignment parameters for functional bracing of the humeral shaft include <20 degrees anterior angulation, <30 degrees varus angulation, and <3 cm of shortening. Angulation exceeding 30 degrees of varus is unacceptable and warrants surgery.
Question 853
Topic: 2. Trauma
A 30-year-old polytrauma patient undergoes intramedullary (IM) nailing of a midshaft humerus fracture. Compared to open reduction and internal fixation (ORIF) with a plate and screws, IM nailing of the humerus is associated with a significantly higher incidence of which complication?
Correct Answer & Explanation
. Shoulder pain and decreased range of motion
Explanation
Multiple randomized controlled trials show no significant difference in union or radial nerve palsy rates between IM nailing and plating. However, IM nailing is associated with a significantly higher rate of shoulder pain and decreased shoulder function.
Question 854
Topic: 2. Trauma
A 50-year-old female presents after a fall with a fracture of the ulnar diaphysis demonstrating posterior angulation, along with a posterior dislocation of the radial head. According to the Bado classification, what type of Monteggia lesion is this?
Correct Answer & Explanation
. Type II
Explanation
A Bado Type II Monteggia lesion is characterized by a fracture of the ulnar diaphysis with posterior angulation and a posterior dislocation of the radial head. It is the most common Monteggia pattern seen in adults.
Question 855
Topic: 2. Trauma
Which of the following represents an absolute indication for operative fixation of an acute, isolated humeral shaft fracture?
Correct Answer & Explanation
. Brachial artery laceration requiring repair
Explanation
Absolute indications for operative fixation of humeral shaft fractures include vascular injury requiring repair, open fractures, and compartment syndrome. Primary radial nerve palsy, specific fracture patterns, and angulation within acceptable limits are relative indications or can be managed nonoperatively.
Question 856
Topic: 2. Trauma
During operative fixation of a proximal humerus fracture via a deltopectoral approach, preservation of the humeral head blood supply is paramount. Recent anatomic injection studies (e.g., Hettrich et al.) have demonstrated that the predominant arterial supply to the humeral head articular segment is provided by which of the following?
Correct Answer & Explanation
. Posterior humeral circumflex artery
Explanation
Recent quantitative studies have shown that the posterior humeral circumflex artery supplies roughly 64% of the blood supply to the humeral head. This updates the classic teaching that the anterior humeral circumflex artery (via the anterolateral branch) was the main supply.
Question 857
Topic: 2. Trauma
Which of the following clinical scenarios is an absolute indication for immediate surgical exploration of the radial nerve in the setting of a humeral shaft fracture?
Correct Answer & Explanation
. Open humeral shaft fracture with a primary complete radial nerve palsy
Explanation
An open fracture with an associated radial nerve palsy is an absolute indication for immediate surgical exploration of the nerve. Closed fractures with primary nerve palsies are typically observed, and while secondary palsy is highly debated, open fracture requires immediate irrigation, debridement, and nerve exploration.
Question 858
Topic: 2. Trauma
A 48-year-old pianist with erosive osteoarthritis of the index finger PIP joint desires to preserve motion and opts for pyrocarbon arthroplasty. During the surgical procedure, after exposing the joint, the surgeon begins preparing the bone. Which of the following steps is most critical for the successful implantation of a pyrocarbon PIP joint prosthesis?
Correct Answer & Explanation
. Precise bone cuts using specific cutting guides to ensure proper implant fit and alignment.
Explanation
Correct Answer: BThe 'Detailed Surgical Approach / Technique' section, under 'Pyrocarbon Arthroplasty Surgical Approach,' emphasizes: 'Precise bone cuts are critical for pyrocarbon implants. Using an oscillating saw and specific cutting guides provided by the implant system: Resect the proximal phalanx head, preserving the collateral ligament origins. Resect the middle phalanx base, preserving the volar plate and collateral ligament insertions.' This precision is essential for proper implant fit, stability, and kinematics.Incorrect Options:A:Collateral ligaments are crucial for joint stability. The case states that pyrocarbon implants 'require precise bone cuts and good collateral ligament integrity.' Extensive resection would lead to instability and implant failure.C:While medullary canals are reamed, aggressive reaming to accommodate oversized stems is incorrect. Reaming should be precise to fit the implant stems without compromising bone stock or causing iatrogenic fracture.D:For arthroplasty, the articular cartilage is removed to expose bleeding cancellous bone, allowing for direct bone-to-implant contact and integration, not to leave a thin layer of cartilage.E:The extensor mechanism (including the central slip) is meticulously repaired after arthrodesis or arthroplasty to restore function and prevent extensor lag. Leaving it unrepaired would lead to significant functional deficit.
Question 859
Topic: 2. Trauma
A 70-year-old female undergoes arthrodesis of her index finger PIP joint for severe erosive osteoarthritis. Six months post-operatively, she continues to experience localized pain at the fusion site, and radiographs show persistent lucency at the bone-bone interface with no evidence of bridging bone. She has been compliant with her post-operative rehabilitation protocol. What is the most likely complication and its primary surgical salvage strategy?
Correct Answer & Explanation
. Non-union; revision arthrodesis with bone grafting and more rigid internal fixation.
Explanation
Correct Answer: CThe clinical scenario describes persistent pain and radiographic lucency at the fusion site 6 months post-arthrodesis, indicating a failure of the bones to unite. This is the definition of a non-union. The 'Complications & Management' section explicitly lists 'Non-Union' as a complication of arthrodesis (5-20% incidence). For management, it states: 'Surgical: Revision arthrodesis with bone grafting (autograft or allograft), more rigid internal fixation (e.g., plate and screws), re-preparation of bone ends.' This aligns perfectly with option C.Incorrect Options:A:While infection is a complication, the description of persistent lucency at the bone-bone interface is more indicative of a non-union than an active infection, which would typically present with signs of inflammation, drainage, or systemic symptoms.B:Implant fracture is a complication of arthroplasty, not arthrodesis. Revision arthroplasty would not be the salvage for a failed arthrodesis.D:CRPS is a possibility after any hand surgery, but the specific radiographic finding of persistent lucency at the fusion site points more directly to a non-union.E:Malunion implies that the bones have fused, but in an incorrect alignment. Here, the problem is a lack of fusion (non-union), not fusion in a wrong position.
Question 860
Topic: 2. Trauma
A 14-year-old male presents to the ED after a soccer injury. On examination, you note significant diffuse edema, moderate ecchymosis, and a subtle deformity with the foot in slight external rotation. Palpation reveals marked tenderness circumferentially around the distal tibia and fibula, maximal over the distal tibial metaphysis, physis, and epiphysis. Distal pulses are palpable and strong.
Given these findings and the provided image, which of the following is the most appropriate next step in the immediate management of this patient?
Correct Answer & Explanation
. Order standard orthogonal radiographs of the ankle (AP, lateral, mortise views).
Explanation
Correct Answer: CThe most appropriate immediate next step for any acute ankle injury with suspected fracture is to obtain standard orthogonal radiographs (anteroposterior, lateral, and mortise views) of the ankle. These initial diagnostic modalities are crucial for identifying the presence of a fracture, assessing its general morphology, and guiding further management. The clinical findings of significant edema, ecchymosis, deformity, and marked tenderness are highly indicative of a fracture, making radiographic evaluation mandatory.Option A is incorrect because applying a cast and discharging without definitive diagnosis and assessment of displacement is inappropriate and could lead to missed significant injury or inadequate treatment. Option B is incorrect; formal stress testing or stress radiographs are typically deferred in the acute setting due to severe pain and are not the initial diagnostic step. Gross instability was appreciated, but formal stress testing is usually done after initial imaging and often under anesthesia if surgery is planned. Option D is incorrect; while compartment syndrome is a serious concern, the case states distal pulses were palpable and strong, and there were no signs of impending compartment syndrome. Therefore, emergent fasciotomy is not indicated at this stage. Prophylactic antibiotics are given preoperatively, not as an immediate ED step without a confirmed open fracture. Option E is incorrect; attempting a closed reduction without full radiographic assessment, including potentially a CT scan, is premature and could be harmful, especially given the complex nature of these transitional fractures where soft tissue interposition is common.
Test Yourself
Switch to an interactive, timed exam simulation to truly master this topic.
