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 881
Topic: 2. Trauma
When placing a headless compression screw for a scaphoid waist fracture via a volar approach, where should the starting point be located to maximize central screw placement down the central axis of the scaphoid?
Correct Answer & Explanation
. The scaphotrapeziotrapezoidal (STT) joint
Explanation
The volar percutaneous or mini-open approach utilizes the STT joint to access the distal pole. To place the screw in the central axis of the scaphoid, the starting point must be through the edge of the trapezium or the STT joint articular surface.
Question 882
Topic: 2. Trauma
A 24-year-old male presents with a non-displaced proximal pole scaphoid fracture confirmed on computed tomography (CT). Which of the following is the most appropriate recommended treatment to minimize the risk of nonunion?
Correct Answer & Explanation
. Surgical fixation with a headless compression screw
Explanation
Proximal pole scaphoid fractures have a high rate of avascular necrosis and nonunion due to retrograde blood supply. Surgical fixation is generally recommended even for non-displaced proximal pole fractures to optimize union rates.
Question 883
Topic: 2. Trauma
A neglected scaphoid waist fracture healing in a 'humpback' deformity is characterized by excessive volar flexion of the scaphoid. This uncouples carpal kinematics, classically leading to which of the following instability patterns?
Correct Answer & Explanation
. Dorsal intercalated segment instability (DISI)
Explanation
A scaphoid waist nonunion with volar collapse causes a humpback deformity. Without the stabilizing link of the distal scaphoid, the lunate extends along with the intact triquetrum, resulting in a DISI deformity.
Question 884
Topic: 2. Trauma
A 22-year-old competitive athlete sustains an acute, displaced proximal pole scaphoid fracture. Which of the following is the most appropriate management to minimize the risk of nonunion and achieve stable fixation?
Correct Answer & Explanation
. Open reduction and internal fixation via a dorsal approach.
Explanation
Displaced proximal pole scaphoid fractures have a high rate of nonunion and avascular necrosis. Open reduction and internal fixation via a dorsal approach is preferred, as it provides direct access to the proximal fragment and allows for biomechanically advantageous central screw placement.
Question 885
Topic: 2. Trauma
A 10-year-old boy falls onto his outstretched hand and sustains a displaced fracture of the distal pole of the scaphoid. What is the most appropriate management for this patient?
Correct Answer & Explanation
. Nonoperative management with a short arm cast for 4 to 6 weeks.
Explanation
Pediatric scaphoid fractures most commonly involve the distal pole and generally have an excellent prognosis due to a robust blood supply in this region. Nonoperative management with a short arm cast is highly successful, even with mild displacement, and remains the standard of care.
Question 886
Topic: 2. Trauma
A 55-year-old diabetic patient sustains a high-energy ankle injury. Initial radiographs show a complex distal tibia fracture. A CT scan is obtained, revealing a comminuted posterolateral pilon fracture with significant articular impaction and a 4mm articular step-off. The soft tissue envelope is swollen but without blistering or open wounds. Based on the case, which of the following statements regarding pre-operative planning and indications is most accurate?
Correct Answer & Explanation
. A CT scan is absolutely essential for this fracture pattern to plan the surgical approach and assess fragment morphology.
Explanation
Correct Answer: D - A CT scan is absolutely essential for this fracture pattern to plan the surgical approach and assess fragment morphology.The case explicitly states under 'Pre-Operative Planning & Patient Positioning' that aComputed Tomography (CT) Scan is absolutely essentialfor posterolateral pilon and posterior malleolus fractures. It provides invaluable information on fracture morphology, fragment size, number, location, articular surface details, and helps confirm the appropriateness of the posterolateral approach.Option A (MRI is essential):The case states that MRI is 'Rarely indicated acutely for fracture assessment' and 'not routinely needed for acute fracture planning.'Option B (The posterolateral approach is contraindicated):While diabetes is listed as a relative contraindication due to increased risk of wound complications, it is not an absolute contraindication, especially for a significantly displaced articular fracture like a pilon fracture. The case notes that 'uncontrolled diabetes mellitus' is a relative contraindication, implying that with control, surgery is possible.Option C (Immediate surgical fixation is indicated):The case highlights that 'High-energy pilon fractures or those with severe soft tissue compromise often require staged management, beginning with external fixation and delaying definitive internal fixation until the soft tissue swelling has subsided (e.g., 7-14 days).' While the soft tissue is currently 'swollen but without blistering,' the high-energy nature of a pilon fracture often necessitates waiting for the 'wrinkle sign' to return, making immediate fixation potentially risky for wound complications.Option E (Non-operative management with casting is a viable option):The case clearly states that for posterolateral pilon fractures, non-operative management is 'Extremely rare (e.g., minimally displaced, stable fissure fracture without articular step-off). Typically requires operative stabilization due to high-energy mechanism and articular involvement.' A 4mm articular step-off unequivocally indicates operative management.
Question 887
Topic: 2. Trauma
A 28-year-old athlete presents with an ankle fracture. CT imaging reveals a posterior malleolus fracture involving 28% of the distal tibial articular surface with 3mm of posterior displacement and evidence of PITFL disruption. The fibula is intact. Based on the biomechanical principles and indications outlined in the case, what is the most appropriate management strategy?
Correct Answer & Explanation
. Direct reduction and stable internal fixation of the posterior malleolus via a posterolateral approach.
Explanation
Correct Answer: C - Direct reduction and stable internal fixation of the posterior malleolus via a posterolateral approach.The case emphasizes that 'Displaced posterior malleolus fractures' with 'Fragment Size: Generally accepted threshold is >25-30% of the distal tibial articular surface involved' or 'Displacement: Any articular step-off or gap greater than 2mm' are indications for operative intervention. The patient's fracture involves 28% of the articular surface and has 3mm of displacement, meeting these criteria. Furthermore, the case states that 'The posterolateral approach offers direct visualization and facilitates anatomical reduction and stable internal fixation of these difficult-to-access fragments, crucial for restoring articular congruity and overall ankle stability.' PITFL disruption further supports the need for direct stabilization.Option A (Non-operative management):This is incorrect. The fragment size (28%) and displacement (3mm) exceed the thresholds for non-operative management (<10-15% and <2mm displacement).Option B (Indirect reduction and syndesmotic screw fixation):The case highlights that 'indirect reduction techniques... are often unreliable in achieving and maintaining anatomical congruity.' While syndesmotic instability is present, direct fixation of the posterior malleolus (which is the PITFL attachment site) is the primary goal, and often restores syndesmotic stability. An anterolateral approach would not provide direct access to the posterior malleolus.Option D (External fixation as a definitive treatment):External fixation is typically used as a temporizing measure for severe soft tissue compromise or highly comminuted pilon fractures, not as a definitive treatment for a posterior malleolus fracture requiring articular reduction.Option E (Medial approach for deltoid ligament repair and indirect reduction):A medial approach would address the deltoid ligament (if injured, though not specified here) but would not provide direct access for anatomical reduction of a posterior malleolus fracture. Indirect reduction is generally discouraged for displaced articular fragments.
Question 888
Topic: 2. Trauma
During a posterolateral approach for a displaced posterior malleolus fracture, the surgeon has successfully exposed the posterior aspect of the distal tibia. The posterior malleolus fragment is large and impacted. Which of the following is the most appropriate sequence of steps for reduction and temporary fixation of this fragment?
Correct Answer & Explanation
. Use a small osteotome to disimpact and elevate the articular surface, then manipulate the fragment with a ball-spiked pusher, and secure with temporary K-wires.
Explanation
Correct Answer: B - Use a small osteotome to disimpact and elevate the articular surface, then manipulate the fragment with a ball-spiked pusher, and secure with temporary K-wires.The case describes 'Reduction Techniques for Posterior Malleolus' under 'Detailed Surgical Approach Technique.' For impacted fragments, it states: 'For impacted fragments, a small osteotome or Freer elevator can be used to disimpact and elevate the articular surface.' For large fragments, it advises: 'If the posterior malleolus is a single, large fragment, use a ball-spiked pusher or a small pointed reduction clamp to manipulate it directly back into anatomical position.' Finally, for temporary fixation: 'Once anatomical reduction is achieved, maintain it with temporary K-wires (e.g., 1.2-1.6mm) drilled from posterior to anterior into the distal tibia.'Option A (Apply a posterior antiglide plate, then use lag screws, and finally assess syndesmotic stability):This sequence is incorrect. Fixation (plates and lag screws) comes after reduction and temporary fixation. Syndesmotic stability is assessed after posterior malleolus fixation.Option C (Perform indirect reduction by external rotation of the foot, followed by syndesmotic screw placement):Indirect reduction is generally discouraged for displaced articular fragments, and syndesmotic screw placement is not the primary step for posterior malleolus reduction.Option D (Immediately insert two 4.0mm lag screws):Lag screws are for definitive fixation after reduction and temporary stabilization, not as an immediate reduction step.Option E (Debride the fracture site, then apply a reduction clamp, and proceed directly to definitive plate fixation):While debridement is correct, proceeding directly to definitive plate fixation without temporary stabilization (K-wires) and fluoroscopic confirmation of reduction is not the safest or most precise method.
Question 889
Topic: 2. Trauma
A 70-year-old patient with a history of peripheral vascular disease and well-controlled diabetes undergoes a posterolateral approach for a displaced posterior malleolus fracture. Post-operatively, the patient develops increasing pain, erythema, and purulent discharge from the wound. Despite oral antibiotics, the infection progresses, and deep tissue involvement is suspected. Based on the case, what is the most appropriate next step in managing this deep surgical site infection?
Correct Answer & Explanation
. Initiate intravenous antibiotics and consider surgical debridement.
Explanation
Correct Answer: B - Initiate intravenous antibiotics and consider surgical debridement.Under 'Complications & Management,' for 'Wound Complications,' the case states: 'Deep Infection: Surgical debridement, intravenous antibiotics, potentially hardware removal (once fracture is healed), antibiotic beads, or negative pressure wound therapy.' The patient's symptoms (increasing pain, erythema, purulent discharge, suspected deep tissue involvement) indicate a deep infection requiring aggressive management.Option A (Continue oral antibiotics):Oral antibiotics are typically for superficial infections. A deep infection requires intravenous antibiotics and often surgical intervention.Option C (Remove all hardware immediately):Hardware removal is generally considered once the fracture is healed, as immediate removal in an acute setting can lead to fracture instability and nonunion. It's not the first step for a deep infection unless the hardware itself is the source of infection and stability can be maintained.Option D (Apply negative pressure wound therapy as the sole treatment):Negative pressure wound therapy (NPWT) is a valuable adjunct for wound management but is not a sole treatment for a deep infection; it must be combined with debridement and antibiotics.Option E (Perform a skin graft):A skin graft is used to cover a clean wound defect after infection has been controlled and viable tissue is present, not as an initial treatment for an active deep infection.
Question 890
Topic: 2. Trauma
A 42-year-old male undergoes a posterolateral approach for a stable fixation of a posterior malleolus fracture. The surgeon confirms anatomical reduction and stable fixation intraoperatively. According to the post-operative rehabilitation protocols outlined in the case, what is the typical initial weight-bearing status and duration for this patient?
Correct Answer & Explanation
. Non-weight bearing for 6-8 weeks in a posterior splint, then walking boot.
Explanation
Correct Answer: C - Non-weight bearing for 6-8 weeks in a posterior splint, then walking boot.Under 'Post-Operative Rehabilitation Protocols,' in 'Phase 1 Immobilization & Early Healing,' the case states for 'Weight Bearing': 'Non-Weight Bearing (NWB):Essential for 6-8 weeks, or longer for complex pilon fractures or if significant comminution/bone graft was utilized.' It also mentions 'Immediately post-op: Well-padded posterior splint (neutral dorsiflexion/plantarflexion) for 2-3 weeks. Transition to: Removable walking boot (CAM walker) at 2-3 weeks.'Option A (Full weight bearing immediately):This is incorrect. Full weight bearing is not allowed immediately after stable fixation of an ankle fracture via this approach.Option B (Partial weight bearing (25%) in a cast for 2-3 weeks):Partial weight bearing typically begins at 6-8 weeks, not 2-3 weeks, and the initial immobilization is a splint, then a boot, not necessarily a cast.Option D (Touch-down weight bearing for 4 weeks, then full weight bearing):While touch-down weight bearing is for balance, the NWB period is longer (6-8 weeks), and progression to FWB is gradual, not immediately after 4 weeks.Option E (Non-weight bearing for 2 weeks, then transition to full weight bearing):The NWB period is typically 6-8 weeks, not just 2 weeks, and the transition to FWB is gradual, not immediate.
Question 891
Topic: 2. Trauma
A 50-year-old male presents with a high-energy ankle injury. CT scan reveals a comminuted posterolateral pilon fracture with significant articular impaction and a large metaphyseal defect. The fibula is also fractured. During the posterolateral approach, after debridement and initial reduction of the articular fragments, what is the most appropriate sequence of fixation steps, considering the principles outlined in the case?
Correct Answer & Explanation
. Fix the fibula first to restore length, then address the pilon fracture with lag screws and a locking plate, and finally bone graft the metaphyseal defect.
Explanation
Correct Answer: A - Fix the fibula first to restore length, then address the pilon fracture with lag screws and a locking plate, and finally bone graft the metaphyseal defect.The case states under 'Reduction Techniques for Posterolateral Pilon Fractures': 'Restoration of Fibular Length: If a fibula fracture is present, ensure its length and rotation are restored first, as this can help guide the reduction of the posterior tibial fragments (often performed via the same posterolateral incision, plating the posterior aspect of the fibula).' It then discusses 'Lag Screws' for articular reduction and 'Locking Plate Fixation' for buttressing and stability. Finally, for 'Bone Grafting,' it states: 'If significant metaphyseal bone loss or impaction exists beneath reduced articular fragments, bone graft (autograft or allograft) should be placed to provide structural support and prevent collapse.'Option B (Address the pilon fracture first):This is incorrect. The fibula should be fixed first to restore length and guide tibial reduction. Bone grafting is essential for significant defects, not just if instability persists.Option C (Perform a primary ankle arthrodesis):This is a salvage procedure, not the primary treatment for a reconstructible pilon fracture.Option D (Apply an external fixator as definitive treatment):External fixation is typically a temporizing measure for complex pilon fractures with severe soft tissue compromise, not a definitive treatment for articular reconstruction.Option E (Fix the fibula, then apply a posterior antiglide plate to the pilon, and use syndesmotic screws to compress the articular fragments):While fibula fixation is correct, a posterior antiglide plate is more commonly for posterior malleolus, and for pilon, specialized locking plates are often used. Syndesmotic screws are for syndesmotic stability, not for compressing articular fragments into a defect.
Question 892
Topic: 2. Trauma
A 32-year-old male presents with an ankle fracture. Initial radiographs show a posterior malleolus fracture. A subsequent CT scan reveals a posterior malleolus fragment involving 12% of the distal tibial articular surface with 2.5mm of posterior displacement. The syndesmosis appears stable on initial clinical examination. Based on the evolving literature guidelines summarized in the case, what is the most appropriate management decision?
Correct Answer & Explanation
. Direct reduction and stable internal fixation of the posterior malleolus via a posterolateral approach, given the displacement.
Explanation
Correct Answer: C - Direct reduction and stable internal fixation of the posterior malleolus via a posterolateral approach, given the displacement.Under 'Summary of Key Literature Guidelines,' the case states: 'While historically a 25-30% involvement of the articular surface was the most common threshold for posterior malleolus fixation, recent literature suggests that smaller fragments may warrant fixation if they are displaced (>2mm step-off/gap) or contribute to syndesmotic instability.' The patient's fracture, despite being 12% (below the traditional threshold), has 2.5mm of displacement, which exceeds the 2mm displacement threshold for operative intervention. The posterolateral approach is the preferred method for direct reduction and stable fixation.Option A (Non-operative management):This is incorrect. While the fragment size is below the traditional threshold, the significant displacement (>2mm) is a clear indication for operative management according to current literature.Option B (Indirect reduction and syndesmotic screw fixation):Indirect reduction is generally unreliable for displaced articular fragments. While syndesmotic instability can be associated, the primary issue here is the displaced articular fragment, which requires direct reduction.Option D (External fixation as a temporizing measure):External fixation is typically reserved for severe soft tissue compromise or highly comminuted pilon fractures, not for an isolated posterior malleolus fracture requiring articular reduction.Option E (Medial approach):A medial approach does not provide direct access to the posterior malleolus for anatomical reduction.
Question 893
Topic: 2. Trauma
A 38-year-old male presents to the emergency department after a 10-foot fall from a ladder onto both feet, experiencing severe bilateral heel pain and inability to bear weight. Given the high-energy axial loading mechanism of injury, which of the following associated injuries is MOST crucial to rule out during the initial assessment?
Correct Answer & Explanation
. Lumbar spine fracture
Explanation
Correct Answer: CExplanation:The case explicitly states, 'Upon initial assessment, specific inquiry was made regarding other potential injuries, especially those associated with high-energy axial loading. This included symptoms referable to the lumbar spine, which is crucial given the incidence of concomitant spinal fractures (up to 10-15% in calcaneal fractures).' High-energy axial load injuries, such as falls from height, transmit significant force through the entire kinetic chain, making the lumbar spine particularly vulnerable to compression fractures. Therefore, ruling out a lumbar spine fracture is a critical initial step.Incorrect Options:A. Contralateral talar neck fracture:While talar fractures can occur with high-energy mechanisms, and a contralateral injury is possible, the incidence of concomitant spinal fractures with calcaneal fractures is higher and carries greater potential for neurological deficit, making it a more critical initial screen.B. Tibial pilon fracture:Pilon fractures are also high-energy injuries, but the primary mechanism for calcaneal fractures (axial load through the heel) is distinct from the typical mechanism for pilon fractures (axial load driving the talus into the distal tibia). While possible, it's not as commonly associated as lumbar spine fractures.D. Midfoot compartment syndrome:Compartment syndrome of the foot is a serious complication that must be monitored, but it is a consequence of the foot injury itself rather than a distinct associated injury in a different anatomical region. The initial assessment focuses on ruling out injuries that might be overlooked due to the obvious foot pain.E. Achilles tendon avulsion:While avulsion fractures of the calcaneal tuberosity can occur, a pure Achilles tendon avulsion is less common with a direct axial load mechanism that causes intra-articular calcaneal fractures. The case notes the Achilles tendon was intact.
Question 894
Topic: 2. Trauma
During the clinical examination, the patient exhibited Mondor's sign on the left foot. What is the significance of this finding in the context of a calcaneal fracture?
Correct Answer & Explanation
. It is pathognomonic for a calcaneal fracture and signifies significant deep hematoma tracking along fascial planes.
Explanation
Correct Answer: BExplanation:The case states, 'The presence of Mondor's signโa plantar ecchymosis extending along the plantar fasciaโis pathognomonic for a calcaneal fracture and indicates significant deep hematoma tracking along fascial planes.' This sign is a classic indicator of a calcaneal fracture due to the extensive cancellous bone and the deep location of the injury.Incorrect Options:A. It indicates impending compartment syndrome of the foot:While compartment syndrome is a concern, Mondor's sign itself is not a direct indicator of impending compartment syndrome. It signifies deep bleeding, which can contribute to swelling, but compartment syndrome has specific clinical signs like pain out of proportion and pain with passive stretch.C. It suggests a concomitant sural nerve injury requiring immediate exploration:Mondor's sign is related to hematoma, not directly to nerve injury. Sural nerve injury is a risk with these fractures and surgical approaches, but it's assessed by sensory examination, not ecchymosis.D. It is a sign of an open fracture with communication to the skin:Mondor's sign is subcutaneous ecchymosis, indicating a closed injury with deep bleeding, not an open fracture.E. It implies a severe talar body fracture rather than a calcaneal fracture:Mondor's sign is specifically associated with calcaneal fractures due to the unique anatomy and mechanism of injury, not talar fractures.
Question 895
Topic: 2. Trauma
Based on the CT analysis described in the case and the provided coronal CT image of the left calcaneus, what is the most appropriate Sanders classification for this fracture?
Correct Answer & Explanation
. Sanders Type IIIBC
Explanation
The case explicitly states, 'The CT analysis of the left calcaneus revealed a highly comminuted posterior facet. The coronal cuts demonstrated three distinct articular fragments with fracture lines located centrally and laterally within the posterior facet, consistent with a Sanders Type IIIBC classification.' The image provided shows two fracture lines through the posterior facet, creating three articular fragments. One fracture line is central (B) and the other is lateral (C), with the medial fragment (A) remaining attached to the sustentaculum. This precisely matches the definition of a Sanders Type IIIBC fracture.
Question 896
Topic: 2. Trauma
The case describes the patient's fracture as a 'tongue-type variant' according to the Essex-Lopresti classification. What is the defining characteristic that distinguishes a tongue-type calcaneal fracture from a joint depression type?
Correct Answer & Explanation
. The secondary fracture line exits posteriorly through the calcaneal tuberosity.
Explanation
Correct Answer: CExplanation:The case clearly defines the Essex-Lopresti classification: 'Tongue Type: The secondary fracture line exits posteriorly through the calcaneal tuberosity. The posterior facet remains attached to the posterior tuberosity fragment.' This distinction is crucial for understanding the fracture morphology and guiding reduction maneuvers.Incorrect Options:A. The presence of significant comminution of the posterior facet:Both tongue-type and joint depression type fractures can have significant posterior facet comminution. This is not the distinguishing feature between the two Essex-Lopresti types.B. The secondary fracture line exits superiorly, just posterior to the posterior facet:This describes the joint depression type, not the tongue type. The case explicitly contrasts this with the tongue type.D. Involvement of the calcaneocuboid joint with an anterior process fracture:Calcaneocuboid joint involvement can occur with either type but is not the defining characteristic of the Essex-Lopresti classification, which focuses on the posterior aspect of the calcaneus.E. The degree of varus deformity of the calcaneal tuberosity:Varus deformity is a common feature of displaced intra-articular calcaneal fractures in general, regardless of whether they are tongue-type or joint depression type.
Question 897
Topic: 2. Trauma
The patient is an active smoker with a 15 pack-year history, and clinical examination revealed a negative wrinkle test on the left hindfoot. Considering the surgical decision-making process for this Sanders IIIBC fracture, what is the most appropriate next step regarding the timing of open reduction and internal fixation (ORIF)?
Correct Answer & Explanation
. Delay surgery until the swelling has completely subsided and the wrinkle test is positive, typically 10 to 21 days post-injury.
Explanation
The case emphasizes the critical importance of soft tissue status and the patient's smoking history: 'To mitigate the soft tissue risk, surgery must be delayed until the swelling has completely subsided and the wrinkle test is positive, typically 10 to 21 days post-injury.' A negative wrinkle test indicates severe interstitial edema, and proceeding with an extensile lateral approach in this state carries an unacceptably high risk of postoperative wound dehiscence and necrosis, especially in a smoker.
Question 898
Topic: 2. Trauma
A 45-year-old male sustains a closed, displaced, intra-articular calcaneus fracture after a fall from a roof. The foot is severely swollen with fracture blisters. The surgeon plans an extensile lateral approach for open reduction and internal fixation. Which of the following is the most reliable clinical indicator that the soft tissue envelope is safe for surgical incision?
Correct Answer & Explanation
. Appearance of skin wrinkles on the lateral aspect of the hindfoot
Explanation
The presence of a positive 'wrinkle sign' indicates that postoperative swelling has subsided enough to allow safe surgical incision. Operating through severely swollen soft tissues significantly increases the risk of wound dehiscence and deep infection.
Question 899
Topic: 2. Trauma
A 28-year-old male sustains an ankle injury during a rugby tackle. Radiographs reveal an irreducible fracture-dislocation of the ankle. The lateral radiograph shows the proximal fragment of the fractured fibula entrapped behind the posterior tubercle of the distal tibia. What is the correct eponym for this injury?
Correct Answer & Explanation
. Bosworth fracture
Explanation
A Bosworth fracture is an irreducible fracture-dislocation where the proximal fibular shaft fragment becomes entrapped behind the posterior tubercle of the distal tibia. It typically requires open reduction to free the entrapped fibula.
Question 900
Topic: 2. Trauma
When utilizing the Sanders classification for intra-articular calcaneus fractures, which imaging modality and specific anatomical view/location are required to determine the fracture type?
Correct Answer & Explanation
. Coronal CT scan at the widest portion of the posterior facet
Explanation
The Sanders classification is based on the number and location of articular fracture lines through the posterior facet. It is assessed on a coronal CT image at the widest portion of the posterior facet of the calcaneus.
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