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 921
Topic: 2. Trauma
What is the primary goal of surgical fixation of a Colles fracture with a volar locking plate?
Correct Answer & Explanation
. To restore anatomical alignment and allow early range of motion
Explanation
Correct Answer: CThe primary goal of surgical fixation, particularly with a volar locking plate, for an unstable Colles fracture is to restore anatomical alignment (radial length, inclination, and volar tilt) and articular congruence (if intra-articular), and to provide sufficient stability to allow for early range of motion of the wrist and digits. Early mobilization is critical to prevent stiffness, promote cartilage healing, and improve functional outcomes. While other options might be secondary benefits or unrelated, restoring anatomy and facilitating early motion are paramount.
Question 922
Topic: 2. Trauma
When performing closed reduction of a Colles fracture, what is the correct sequence of maneuvers after adequate anesthesia?
Correct Answer & Explanation
. Traction, supination, ulnar deviation, flexion
Explanation
Correct Answer: CThe classic sequence for closed reduction of a Colles fracture involves: 1. Disimpaction and traction (to restore length and separate fragments), 2. Exaggeration of deformity (dorsiflexion) to unlock fragments, followed by volar translation, 3. Supination (to correct pronation of the distal fragment, which is common with dorsal displacement), 4. Ulnar deviation (to restore radial inclination), and 5. Palmar flexion (to correct dorsal angulation and maintain reduction). Therefore, traction, supination, ulnar deviation, and flexion are the key components after disimpaction.
Question 923
Topic: 2. Trauma
A 7-year-old child falls onto an outstretched hand, sustaining an injury to the elbow. Radiographs show a fracture of the proximal ulna with an associated anterior dislocation of the radial head. Which of the following classifications best describes this injury pattern?
Correct Answer & Explanation
. Monteggia fracture-dislocation
Explanation
The description of a fracture of the proximal ulna with an associated dislocation of the radial head is the classic definition of a Monteggia fracture-dislocation. This injury pattern is crucial to recognize because the radial head dislocation can be easily missed if only the ulnar fracture is focused on. The Bado classification further categorizes Monteggia injuries based on the direction of radial head dislocation and the ulnar fracture pattern. Gartland Type III refers to a displaced supracondylar humerus fracture. Salter-Harris Type II is a physeal fracture involving the metaphysis. Galeazzi fracture-dislocation involves a fracture of the distal radius with associated dislocation of the distal radioulnar joint. Essex-Lopresti injury is a comminuted radial head fracture with disruption of the interosseous membrane and distal radioulnar joint dislocation.
Question 924
Topic: 2. Trauma
A 35-year-old male sustains a high-energy valgus injury to his knee in a motor vehicle accident. Radiographs show a comminuted fracture of the lateral tibial plateau with significant articular depression and widening. CT scan confirms a Schatzker Type VI fracture. Which of the following is the most appropriate definitive management?
Correct Answer & Explanation
. Emergent open reduction and internal fixation (ORIF) with dual plating.
Explanation
Correct Answer: CA Schatzker Type VI tibial plateau fracture is a bicondylar fracture with dissociation of the metaphysis and diaphysis, often involving significant articular depression and comminution. These are high-energy injuries that typically require emergent open reduction and internal fixation (ORIF) with dual plating (medial and lateral) to restore articular congruity, mechanical alignment, and stability. Non-weight bearing and cast immobilization (A) are insufficient for such unstable and comminuted fractures. External fixation (B) might be used as a temporary measure for severe soft tissue injury (damage control orthopedics) but is not the definitive treatment for articular reconstruction. Knee arthrodesis (D) or unicompartmental knee arthroplasty (E) are salvage procedures for end-stage arthritis or specific unicompartmental disease, respectively, and are not indicated for acute, repairable fractures.
Question 925
Topic: 2. Trauma
A 40-year-old male with a history of an open tibia fracture 2 years ago, treated with intramedullary nailing, presents with persistent pain, swelling, and a chronic draining sinus tract over the fracture site. Radiographs show cortical thickening and lucencies around the nail. Laboratory studies reveal a mildly elevated ESR and CRP. What is the most appropriate management strategy?
Correct Answer & Explanation
. Aggressive surgical debridement, hardware removal, and targeted intravenous antibiotics.
Explanation
Correct Answer: CThis patient's presentation is classic for chronic osteomyelitis, likely associated with retained hardware from a previous open fracture. The persistent draining sinus, pain, swelling, and radiographic changes (cortical thickening, lucencies) indicate ongoing infection. The cornerstone of chronic osteomyelitis treatment, especially with hardware, is aggressive surgical debridement of all infected and necrotic bone and soft tissue, removal of the hardware (if the fracture is healed or stable enough), followed by a prolonged course of targeted intravenous antibiotics based on intraoperative cultures. Oral antibiotics alone (A) are insufficient for established chronic osteomyelitis with sequestrum and biofilm formation on hardware. Removal of the nail alone (B) without debridement will likely lead to recurrence. Hyperbaric oxygen therapy (D) can be an adjunct but is not a primary treatment. While repeat cultures (E) are important, they must be obtained intraoperatively from bone and tissue, not just the draining sinus, and surgical debridement is still paramount.
Question 926
Topic: 2. Trauma
A 25-year-old male sustains a high-energy trauma resulting in a vertical, completely displaced femoral neck fracture (Pauwels type III). He is hemodynamically stable and has no other associated injuries. What is the most appropriate surgical management to minimize the risk of varus collapse?
Correct Answer & Explanation
. Sliding hip screw with a derotation screw
Explanation
Young patients with high-shear, vertical femoral neck fractures (Pauwels III) have a high rate of varus collapse and nonunion. A sliding hip screw with a derotation screw or a fixed-angle device provides superior biomechanical stability compared to multiple cancellous screws.
Question 927
Topic: 2. Trauma
A 40-year-old male presents with a high-energy Schatzker VI tibial plateau fracture. During the initial evaluation, he complains of escalating leg pain, particularly with passive stretch of the hallux, and paresthesias in the first web space. What is the most appropriate next step in management?
Correct Answer & Explanation
. Fasciotomy of the four compartments of the leg
Explanation
Escalating pain out of proportion and pain with passive stretch in the setting of a high-energy fracture are classic signs of acute compartment syndrome. The paresthesias in the first web space indicate deep peroneal nerve ischemia, necessitating urgent four-compartment fasciotomy.
Question 928
Topic: 2. Trauma
A 35-year-old male sustains a closed midshaft tibia fracture. Four hours post-injury, he complains of severe pain out of proportion to the injury. Which of the following pressure measurements is the most reliable threshold for diagnosing acute compartment syndrome and proceeding with four-compartment fasciotomies?
Correct Answer & Explanation
. Diastolic blood pressure minus compartment pressure <= 30 mmHg
Explanation
The delta pressure (diastolic blood pressure minus compartment pressure) is the most reliable indicator of compartment syndrome. A delta pressure of 30 mmHg or less is an absolute indication for emergency fasciotomy.
Question 929
Topic: Pelvic & Acetabular Trauma
A 32-year-old male is brought to the trauma bay after a motorcycle collision. Pelvic radiographs demonstrate widening of the pubic symphysis to 3.5 cm and widening of the anterior sacroiliac joints, consistent with an Anteroposterior Compression II (APC II) injury. Which of the following posterior pelvic ligaments remain intact in this injury pattern?
Correct Answer & Explanation
. Sacrospinous ligament
Explanation
An APC II pelvic ring injury involves diastasis of the pubic symphysis, disruption of the anterior sacroiliac ligaments, and tearing of the sacrotuberous and sacrospinous ligaments. The posterior sacroiliac ligaments remain intact, providing vertical stability.
Question 930
Topic: Pelvic & Acetabular Trauma
A 45-year-old male is involved in a high-speed motorcycle collision and sustains an APC-III pelvic ring injury. He is hemodynamically unstable upon arrival. Following application of a pelvic binder, his blood pressure remains 70/40 mmHg and his heart rate is 130 bpm. A FAST exam is negative. What is the most appropriate next step in management?
Correct Answer & Explanation
. Preperitoneal pelvic packing and/or angiography
Explanation
In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST exam, retroperitoneal hemorrhage is the likely source. Immediate preperitoneal pelvic packing or angioembolization is indicated to control the bleeding.
Question 931
Topic: 2. Trauma
A 25-year-old male presents with persistent radial-sided wrist pain 8 months after a fall onto an outstretched hand. Radiographs reveal a scaphoid waist fracture nonunion with cystic changes and a "humpback" deformity. MRI confirms avascular necrosis of the proximal pole. What is the most appropriate surgical intervention?
Correct Answer & Explanation
. Vascularized bone graft and rigid internal fixation
Explanation
A scaphoid nonunion with proximal pole AVN and a "humpback" deformity requires both structural support to correct the deformity and a reliable blood supply. A vascularized bone graft (e.g., 1,2-ICSRA or medial femoral condyle) with internal fixation is the treatment of choice.
Question 932
Topic: 2. Trauma
A 42-year-old female sustains a high-energy Schatzker VI tibial plateau fracture. The limb is grossly swollen, and the patient has exquisite pain with passive stretch of the hallux. Stryker needle measurement reveals an anterior compartment pressure of 45 mmHg with a diastolic blood pressure of 60 mmHg. What is the next best step?
Correct Answer & Explanation
. Immediate four-compartment fasciotomy
Explanation
The patient exhibits clinical signs of acute compartment syndrome with a delta pressure (diastolic BP minus compartment pressure) of 15 mmHg. A delta pressure of less than 30 mmHg is an absolute indication for immediate four-compartment fasciotomy.
Question 933
Topic: 2. Trauma
A 22-year-old collegiate soccer player presents with acute right knee pain and instability after a non-contact pivoting injury. Clinical examination reveals a Grade III Lachman test, a high-grade pivot shift, and mild gapping with valgus stress at 30 degrees of flexion. Plain radiographs show a subtle avulsion fracture from the lateral aspect of the proximal tibia. Which of the following statements best describes the significance of the radiographic finding and its associated injury?
Correct Answer & Explanation
. It is a Segond fracture, pathognomonic for an ACL rupture and indicating anterolateral capsular injury.
Explanation
The case explicitly states that a subtle, small elliptic avulsion fracture arising from the lateral aspect of the proximal tibia, just distal to the articular surface, was identified on plain radiographs. This finding is known as a Segond fracture. It represents an avulsion of the anterolateral capsule and anterolateral ligament (ALL) and is considered pathognomonic for an anterior cruciate ligament (ACL) tear. Its presence indicates a higher degree of anterolateral rotatory instability, which aligns with the clinical finding of a high-grade pivot shift.
Question 934
Topic: Lower Extremity Trauma
A 23-year-old skier sustains a twisting injury to his knee. MRI demonstrates the bone bruise pattern shown.
What is the primary mechanism of injury associated with this classic bone bruise pattern?
Correct Answer & Explanation
. Valgus stress with internal tibial rotation
Explanation
This bone bruise pattern on the lateral femoral condyle and posterolateral tibial plateau is pathognomonic for an anterior cruciate ligament (ACL) tear. It occurs due to the pivot-shift mechanism, which involves valgus stress coupled with internal rotation of the tibia.
Question 935
Topic: Lower Extremity Trauma
Review the provided sagittal MRI. In the setting of an acute non-contact pivoting injury resulting in an ACL rupture, which specific pattern of secondary trabecular microfractures (bone bruises) is classically observed on MRI?
Correct Answer & Explanation
. Lateral femoral condyle and posterolateral tibial plateau
Explanation
The classic mechanism for an ACL tear is a pivot shift (valgus and internal rotation). This mechanism causes the lateral femoral condyle to impact the posterolateral tibial plateau, resulting in the pathognomonic 'kissing' bone bruises seen in these locations on MRI.
Question 936
Topic: 2. Trauma
A 45-year-old active male presents to the emergency department after a fall directly onto his shoulder. He complains of severe pain and inability to move his left arm. Physical examination reveals significant swelling and tenderness over the left shoulder, with ecchymosis developing. Neurovascular status is intact distally. Radiographs are obtained, as shown below.
Based on the provided radiographs and the patient's presentation, what is the most appropriate Neer classification for this fracture?
Correct Answer & Explanation
. B. Three-part fracture involving the greater tuberosity
Explanation
Correct Answer: BThe provided radiographs (AP and axillary lateral views) demonstrate a displaced proximal humerus fracture. Careful examination reveals that the humeral head is separated from the shaft, and the greater tuberosity is also displaced. The lesser tuberosity appears to remain attached to the humeral head fragment. This pattern, involving displacement of the humeral head, shaft, and greater tuberosity, constitutes a three-part fracture according to the Neer classification system. The Neer classification divides the proximal humerus into four segments: the articular segment (humeral head), the greater tuberosity, the lesser tuberosity, and the humeral shaft. A 'part' is defined as a major segment that is displaced by more than 1 cm or angulated by more than 45 degrees.Option A (Two-part surgical neck fracture):While there is a surgical neck fracture, the presence of a displaced greater tuberosity fragment makes it more than a two-part fracture.Option C (Four-part fracture with articular involvement):A four-part fracture would involve displacement of all four segments (head, greater tuberosity, lesser tuberosity, and shaft). In this image, the lesser tuberosity appears to be with the head fragment.Option D (Two-part anatomical neck fracture):An anatomical neck fracture involves the fracture line through the articular cartilage, which is not clearly depicted as the primary fracture pattern here, and it would still be more than two parts due to the displaced tuberosity.Option E (Three-part fracture involving the lesser tuberosity):While it is a three-part fracture, the displaced tuberosity is the greater tuberosity, not the lesser tuberosity, which appears to be with the head fragment.
Question 937
Topic: 2. Trauma
A 45-year-old active male presents with a displaced three-part proximal humerus fracture, as seen in the provided radiographs. He has high functional demands and wishes to return to his prior level of activity, including recreational sports. Based on the case discussion, which of the following is the most appropriate initial management strategy for this patient?
Correct Answer & Explanation
. B. Open reduction and internal fixation (ORIF) with a proximal humerus locking plate.
Explanation
Correct Answer: BThe case explicitly states that for a more active or physiologically younger patient, surgery (specifically, fixation with a proximal humerus locking plate) is recommended to achieve the best functional outcome and avoid painful mal- or non-union. The patient's age (45 years) and high functional demands align with the criteria for surgical intervention.Option A (Immediate sling immobilization with early passive range of motion exercises):While non-operative treatment is an option for patients with very low functional demands, it is generally not recommended for displaced three-part fractures in active, younger patients due to the higher risk of malunion, nonunion, and poorer functional outcomes compared to surgical fixation.Option C (Hemiarthroplasty of the shoulder):Hemiarthroplasty is typically reserved for complex four-part fractures, head-splitting fractures, or fractures with significant osteonecrosis risk, especially in older patients, where ORIF is unlikely to achieve a good outcome. It is generally not the first choice for a three-part fracture in a 45-year-old.Option D (Reverse total shoulder arthroplasty):Reverse total shoulder arthroplasty is usually indicated for older patients with irreparable rotator cuff tears, severe comminution, or failed previous surgeries, not typically for an acute three-part fracture in a 45-year-old.Option E (Closed reduction and percutaneous pinning):While percutaneous pinning can be used for certain two-part or minimally displaced fractures, it is generally insufficient for a displaced three-part fracture, especially in an active patient where stable fixation for early rehabilitation is desired.
Question 938
Topic: 2. Trauma
Following successful open reduction and internal fixation (ORIF) of a displaced proximal humerus fracture with a locking plate in an active 45-year-old male, the patient is counseled on potential complications. Which of the following complications, specifically mentioned in the case, is a significant concern following this procedure?
Correct Answer & Explanation
. C. Osteonecrosis of the humeral head
Explanation
Correct Answer: CThe case explicitly lists several risks specific to proximal humerus fracture surgery, including "osteonecrosis." Osteonecrosis of the humeral head is a well-known and significant complication following displaced proximal humerus fractures, particularly those involving the anatomical neck or with severe disruption of the blood supply to the humeral head. Locking plate fixation, while providing stable fixation, does not eliminate this risk, and in some cases, extensive dissection can further compromise vascularity.Option A (Deep vein thrombosis (DVT)):DVT is a general surgical risk, but not specifically highlighted as a unique risk for this particular injury and operation in the case description.Option B (Heterotopic ossification):Heterotopic ossification can occur around the shoulder, especially after trauma or surgery, but it is not specifically mentioned as a primary risk in the case's patient counseling section.Option D (Compartment syndrome):Compartment syndrome is extremely rare in the shoulder and upper arm following proximal humerus fractures or their fixation.Option E (Radial nerve palsy):The radial nerve is at risk during humeral shaft fractures or distal humerus surgery, but it is not the primary neurovascular structure at risk during a deltopectoral approach for proximal humerus plating. The axillary nerve is more commonly at risk in this region. The case mentions "neurovascular injury" generally, but osteonecrosis is a distinct and specific risk highlighted.
Question 939
Topic: 2. Trauma
The case mentions the PROFHER trial, which compared surgical and non-surgical treatment for displaced proximal humerus fractures. What was the primary conclusion of this multi-center randomized trial after 2 years?
Correct Answer & Explanation
. There was no significant difference in outcomes between surgically and non-surgically treated patients.
Explanation
The PROFHER trial did not find any difference in the outcomes of surgically and non-surgically treated patients after 2 years. This is a key takeaway from the trial, which challenged the assumption that surgery was always superior for displaced proximal humerus fractures.
Question 940
Topic: 2. Trauma
Which of the following associated injuries is *most* commonly missed in the initial evaluation of an isolated radial head fracture?
Correct Answer & Explanation
. Distal radio-ulnar joint (DRUJ) instability
Explanation
Correct Answer: DWhile all listed injuries can occur with radial head fractures, DRUJ instability, indicative of an Essex-Lopresti lesion or other forearm axis disruption, is often missed initially. It presents as insidious wrist pain and instability that becomes apparent days or weeks after the initial injury to the radial head. Coronoid and MCL injuries are typically associated with terrible triad injuries involving elbow dislocation. Capitellum chondral injuries are less common and often only seen on arthroscopy or MRI. Olecranon fractures are usually obvious on initial X-rays.
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