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2. Trauma MCQs

Practice Set 48 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 941

Topic: 2. Trauma

Which of the following is an absolute contraindication for radial head excision in the management of a radial head fracture?

. Concomitant ipsilateral distal radius fracture
. Older, low-demand patient
. Associated interosseous membrane disruption (Essex-Lopresti lesion)
. Previous elbow surgery
. Type II radial head fracture

Correct Answer & Explanation

. Associated interosseous membrane disruption (Essex-Lopresti lesion)

Explanation

Correct Answer: CAssociated interosseous membrane disruption, characteristic of an Essex-Lopresti lesion, is an absolute contraindication for radial head excision. In these cases, the radial head plays a critical role in longitudinal forearm stability. Removing it would exacerbate proximal radial migration, leading to severe DRUJ disruption and chronic wrist pain. In such scenarios, radial head replacement is indicated to restore length and stability. Concomitant distal radius fracture is a relative contraindication but not absolute. Older, low-demand patients might be candidates for excision in certain scenarios. Previous elbow surgery is a relative consideration, and a Type II fracture may be amenable to ORIF or, in some cases, excision if small and non-reconstructible, but it is not an absolute contraindication.

Question 942

Topic: 2. Trauma

A 45-year-old male sustains a comminuted distal humerus fracture involving both columns and the articular surface (AO 13-C3) after a fall from a height. Clinically, he has significant swelling, pain, and a palpable ulnar nerve neuropraxia. Radiographs confirm the diagnosis, and a CT scan reveals severe comminution. Which of the following surgical approaches is generally considered the workhorse for achieving adequate exposure for anatomical reduction and stable fixation of such a fracture?

. Anterior approach (Henry)
. Medial approach
. Lateral approach (Kocher)
. Posterior approach with olecranon osteotomy
. Triceps-sparing posterior approach

Correct Answer & Explanation

. Posterior approach with olecranon osteotomy

Explanation

Correct Answer: DFor complex, comminuted intra-articular distal humerus fractures (AO 13-C3), a posterior approach with an olecranon osteotomy (e.g., Chevron osteotomy) provides the most extensive and direct visualization of the entire distal humeral articular surface and both columns. This allows for precise anatomical reduction of articular fragments and robust plate application. While triceps-sparing approaches are gaining popularity, they often provide less complete visualization for severely comminuted intra-articular fractures. Anterior, medial, and lateral approaches are typically reserved for specific fracture patterns (e.g., isolated capitellar or trochlear fractures) or for less complex supracondylar fractures.

Question 943

Topic: 2. Trauma

Regarding the surgical fixation of a complex intra-articular distal humerus fracture, what is the most biomechanically stable construct for dual plating?

. Two parallel plates on the posterior surface
. A single long plate spanning the medial and lateral columns
. Orthogonal plating (medial and posterior/posterolateral plates)
. Two plates applied to the anterior surface
. Parallel plating (two plates on the medial and lateral columns)

Correct Answer & Explanation

. Orthogonal plating (medial and posterior/posterolateral plates)

Explanation

Correct Answer: COrthogonal plating, typically with a medial plate and a posterior or posterolateral plate, creates a more stable construct biomechanically than parallel plating. This configuration provides support against both valgus/varus and torsional forces, acting as a '90-90' system (relative to each other, not the bone's long axis). Parallel plating (medial and lateral column plates) is also a strong construct, particularly for stabilizing the columns, but biomechanical studies often show orthogonal plating to be superior in complex fractures due to better load distribution and resistance to displacement. Posterior plates alone or anterior plates are insufficient for complex intra-articular fractures.

Question 944

Topic: 2. Trauma

Following open reduction and internal fixation (ORIF) of a severely comminuted intra-articular distal humerus fracture in a 68-year-old osteoporotic patient, what is the most common early complication directly related to the fixation construct in this patient population?

. Nonunion
. Heterotopic ossification
. Infection
. Hardware pull-out or failure
. Ulnar nerve palsy

Correct Answer & Explanation

. Hardware pull-out or failure

Explanation

Correct Answer: DIn osteoporotic patients, the primary concern for early complication after ORIF of a comminuted distal humerus fracture is hardware pull-out or failure. Poor bone quality provides inadequate purchase for screws, leading to loss of reduction and implant failure. This necessitates specific techniques like locking plates, longer screws, and sometimes bone augmentation. Nonunion and heterotopic ossification are typically later complications. Infection is a risk but not specifically heightened by osteoporosis itself. Ulnar nerve palsy is a risk from the surgery but not directly related to implant mechanics in osteoporotic bone.

Question 945

Topic: 2. Trauma

A 32-year-old presents with a displaced intra-articular distal humerus fracture (AO 13-C1). Initial assessment reveals a healthy patient with no neurovascular deficits. What is the most appropriate next step in management after initial stabilization and plain radiographs?

. Immediate surgical exploration and ORIF
. Application of a long-arm cast and follow-up in 2 weeks
. Order a CT scan with 3D reconstructions of the elbow
. Begin immediate active range of motion exercises
. Administer broad-spectrum antibiotics and admit for observation

Correct Answer & Explanation

. Order a CT scan with 3D reconstructions of the elbow

Explanation

Correct Answer: CWhile surgical fixation is likely indicated, a CT scan with 3D reconstructions is crucial for operative planning of intra-articular distal humerus fractures. Plain radiographs often underestimate the degree of articular comminution and displacement. The CT scan provides detailed information about fragment size, location, and the extent of articular involvement, which guides the choice of surgical approach and fixation strategy. Immediate ORIF without CT is suboptimal. A cast is inappropriate for displaced intra-articular fractures, and immediate ROM is contraindicated pre-operatively. Antibiotics are not indicated unless an open fracture is suspected.

Question 946

Topic: 2. Trauma

What is the primary role of the olecranon osteotomy in the surgical management of complex distal humerus fractures?

. To provide a tension band effect for the triceps muscle
. To facilitate ulnar nerve decompression
. To allow direct, panoramic visualization of the articular surface and distal humerus
. To prevent heterotopic ossification in the olecranon fossa
. To shorten the healing time of the overall fracture

Correct Answer & Explanation

. To allow direct, panoramic visualization of the articular surface and distal humerus

Explanation

Correct Answer: CThe primary advantage of an olecranon osteotomy is to provide a wide, direct, and panoramic surgical exposure of the entire distal humeral articular surface and both columns. This enables accurate anatomical reduction of often numerous small articular fragments under direct vision, which is paramount for restoring elbow function and minimizing post-traumatic arthritis. While an ulnar nerve decompression can be performed concomitantly, it's not the primary role of the osteotomy. The osteotomy itself is a separate fracture that requires fixation and has its own potential complications, and it doesn't directly prevent HO or shorten overall healing time.

Question 947

Topic: 2. Trauma

A 75-year-old female with severe osteoporosis sustains a highly comminuted distal humerus fracture (AO 13-C3) with significant bone loss. She has a low functional demand but is medically fit for surgery. What surgical option might be considered in this specific scenario, even if ORIF is technically possible but challenging to achieve stable fixation?

. Functional bracing and early mobilization
. Total elbow arthroplasty (TEA)
. Elbow fusion
. Excision arthroplasty
. Hemiarthroplasty of the distal humerus

Correct Answer & Explanation

. Total elbow arthroplasty (TEA)

Explanation

Correct Answer: BFor elderly, osteoporotic patients with highly comminuted distal humerus fractures where stable ORIF is unlikely to be achieved, or if stable fixation will not allow early motion, Total Elbow Arthroplasty (TEA) is an increasingly accepted option, particularly in patients with low functional demands. It allows for immediate stability and early motion, which is critical in this population to prevent stiffness. Functional bracing is unlikely to yield a good result with a highly comminuted, unstable fracture. Elbow fusion would be highly disabling for a low-demand patient. Excision arthroplasty is rarely performed today due to poor outcomes. Hemiarthroplasty of the distal humerus is not a standard procedure for complex distal humerus fractures due to the articulation challenges with the native ulna and radius.

Question 948

Topic: 2. Trauma

Following ORIF of a distal humerus fracture, a patient develops severe progressive elbow stiffness. What is the most common cause of this complication after successful fracture healing?

. Nonunion of the fracture
. Post-traumatic heterotopic ossification (HO)
. Ulnar nerve entrapment
. Chronic infection
. Radial head subluxation

Correct Answer & Explanation

. Post-traumatic heterotopic ossification (HO)

Explanation

Correct Answer: BPost-traumatic heterotopic ossification (HO) is a common cause of severe elbow stiffness after distal humerus fractures and their surgical treatment, even after successful fracture healing. It can restrict motion significantly. While nonunion can cause pain and instability, it doesn't directly cause stiffness in the same way HO does. Ulnar nerve entrapment typically causes paresthesia and weakness, not direct mechanical stiffness. Chronic infection is possible but less common than HO. Radial head subluxation is not a typical complication leading to global stiffness after a distal humerus fracture.

Question 949

Topic: 2. Trauma
Which of the following is an absolute indication for surgical intervention in a distal humerus fracture?
. An open fracture
. Neurovascular deficit (motor only)
. Intra-articular displacement > 2mm
. Age greater than 65 years
. Associated olecranon fracture

Correct Answer & Explanation

. An open fracture

Explanation

An open fracture is an absolute indication for surgical débridement and fixation due to the high risk of infection. Other options listed are relative indications or patient factors.

Question 950

Topic: 2. Trauma

A 55-year-old male undergoes ORIF of a distal humerus fracture. Post-operatively, he develops severe pain, swelling, and bullae around the elbow. What is the most appropriate initial management step to prevent catastrophic complications?

. Elevate the limb and administer oral analgesics
. Immediate release of constrictive dressings and fasciotomy if compartment syndrome is suspected
. Start intravenous antibiotics immediately
. Perform a diagnostic ultrasound to rule out DVT
. Apply a hot pack to reduce swelling

Correct Answer & Explanation

. Immediate release of constrictive dressings and fasciotomy if compartment syndrome is suspected

Explanation

Correct Answer: BSevere pain, swelling, and bullae post-operatively are highly concerning for evolving compartment syndrome, particularly in the forearm. Immediate release of all constrictive dressings (splints, casts, bandages) is paramount. If suspicion remains high or objective signs (e.g., pain out of proportion, pain with passive stretch) are present, emergent fasciotomy is indicated to prevent irreversible ischemic damage. While elevation is good, and antibiotics might be considered later if infection is suspected, the immediate life-altering threat is compartment syndrome. Ultrasound for DVT is not relevant to acute swelling and pain in this context, and hot packs would worsen swelling.

Question 951

Topic: Pelvic & Acetabular Trauma
A 30-year-old male is brought to the trauma bay after a motorcycle collision. His blood pressure is 70/40 mmHg. A FAST exam is negative. Pelvic radiographs show an APC III pelvic ring injury. A pelvic binder is appropriately applied, and he receives 2 units of uncrossmatched PRBCs, but his blood pressure only improves to 75/40 mmHg. What is the most appropriate next step in management?
. Exploratory laparotomy
. Removal of the binder and placement of an anterior external fixator
. Preperitoneal pelvic packing or pelvic angiography
. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) placement in Zone III
. Immediate definitive open reduction and internal fixation

Correct Answer & Explanation

. Preperitoneal pelvic packing or pelvic angiography

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and negative FAST, a pelvic binder is the initial step. If instability persists despite initial resuscitation and binder application, preperitoneal packing or angiography (based on institutional protocol) is indicated to control hemorrhage.

Question 952

Topic: 2. Trauma

A 45-year-old female sustains a high-energy trauma resulting in a distal femur fracture. CT imaging reveals a Hoffa fracture. Which of the following statements is most accurate regarding this injury pattern?

. The medial condyle is the most commonly involved fragment.
. It is best visualized on an anteroposterior (AP) radiograph.
. It represents a sagittal plane fracture of the femoral condyle.
. It requires anterior-to-posterior (AP) or posterior-to-anterior (PA) directed interfragmentary screw fixation.
. Nonoperative management in a hinged knee brace is preferred for non-displaced variants.

Correct Answer & Explanation

. It requires anterior-to-posterior (AP) or posterior-to-anterior (PA) directed interfragmentary screw fixation.

Explanation

A Hoffa fracture is a coronal plane shear fracture of the femoral condyle, most commonly involving the lateral condyle. Because of the shear mechanism and intra-articular nature, AP or PA directed interfragmentary screws are required to provide stable, orthogonal compression.

Question 953

Topic: Lower Extremity Trauma

A 55-year-old male sustains a severe Schatzker VI bicondylar tibial plateau fracture. An external fixator is placed initially. Three weeks later, definitive fixation is planned. What is the optimal surgical approach to directly address and buttress a displaced posteromedial shear fragment?

. Anterolateral approach
. Direct posterior approach through the popliteal fossa
. Posteromedial approach
. Medial parapatellar approach
. Anteromedial approach

Correct Answer & Explanation

. Posteromedial approach

Explanation

The posteromedial approach utilizes the interval between the medial head of the gastrocnemius and the pes anserinus. It allows for direct visualization and optimal placement of a buttress plate to prevent varus collapse of a posteromedial shear fragment.

Question 954

Topic: 2. Trauma

A 40-year-old female sustains a high-energy Schatzker IV tibial plateau fracture. Which surgical approach and fixation strategy is most appropriate for addressing the primary deforming force in this injury pattern?

. Anterolateral approach with a locked lateral plate
. Posteromedial approach with an antiglide/buttress plate
. Direct anterior approach with dual plating
. Percutaneous cannulated screw fixation from lateral to medial
. External fixation only, avoiding internal fixation

Correct Answer & Explanation

. Posteromedial approach with an antiglide/buttress plate

Explanation

A Schatzker IV fracture typically involves a medial plateau fracture with a posteromedial fragment that tends to displace in a varus and posterior direction. A posteromedial approach with a buttress plate effectively neutralizes these shear forces.

Question 955

Topic: Pelvic & Acetabular Trauma
A 35-year-old male arrives in the trauma bay in hemorrhagic shock following a pelvic crush injury. Radiographs show an anteroposterior compression (APC) type III pelvic ring injury. To achieve the most effective mechanical stabilization and volume reduction, a pelvic binder should be placed centered over which anatomic landmark?
. The anterior superior iliac spines
. The iliac crests
. The greater trochanters
. The pubic symphysis
. The umbilicus

Correct Answer & Explanation

. The greater trochanters

Explanation

Pelvic binders should be centered over the greater trochanters to effectively compress the pelvic ring and reduce pelvic volume. Placement over the iliac crests is ineffective and can paradoxically open the pelvis in certain fracture patterns.

Question 956

Topic: 2. Trauma

A 28-year-old male presents with severe pain in his leg out of proportion to exam 12 hours after a closed tibial shaft fracture. You suspect acute compartment syndrome. If the anterior compartment is predominantly involved, what sensory deficit is most likely to be found early on?

. Decreased sensation over the medial aspect of the leg
. Decreased sensation over the sole of the foot
. Decreased sensation in the first dorsal web space
. Decreased sensation over the lateral border of the foot
. Decreased sensation over the anterior thigh

Correct Answer & Explanation

. Decreased sensation in the first dorsal web space

Explanation

The deep peroneal nerve runs within the anterior compartment of the leg. Ischemia of this nerve in anterior compartment syndrome leads to decreased sensation in its autonomous sensory zone, the first dorsal web space of the foot.

Question 957

Topic: 2. Trauma
A 45-year-old male sustains a Gustilo-Anderson Type IIIB open fracture of the distal third of the tibia. Following serial debridements, the wound is clean but has 5 cm of exposed anterior tibia devoid of periosteum. Which of the following is the most appropriate soft tissue coverage option?
. Split-thickness skin graft
. Gastrocnemius rotational flap
. Soleus rotational flap
. Reverse sural artery flap
. Free tissue transfer (e.g., Anterolateral thigh flap)

Correct Answer & Explanation

. Free tissue transfer (e.g., Anterolateral thigh flap)

Explanation

Defects of the distal third of the tibia with exposed bone lack local muscle bulk for rotational coverage. Free tissue transfer is the gold standard for Type IIIB open fractures in the distal third of the lower extremity.

Question 958

Topic: 2. Trauma
A patient with a complex proximal humerus fracture is scheduled for open reduction and internal fixation with a locking plate. To minimize the risk of varus collapse postoperatively, it is crucial to ensure adequate placement of which of the following?
. Inferomedial calcar screws
. Superior metaphyseal screws
. A posterior buttress plate
. An intramedullary fibular strut allograft only
. A transfixing pin through the acromion

Correct Answer & Explanation

. Inferomedial calcar screws

Explanation

Inferomedial locking screws (calcar screws) provide essential mechanical support to the medial hinge. Proper placement significantly reduces the risk of postoperative varus collapse in proximal humerus fractures.

Question 959

Topic: 2. Trauma

A 55-year-old female presents with progressive lateral thigh pain over the past 3 months. She has been on oral alendronate for 8 years. Radiographs reveal focal lateral cortical thickening of the proximal femoral diaphysis with a subtle transverse radiolucent line. What is the most appropriate management?

. Discontinue alendronate and prescribe teriparatide exclusively
. Protected weight bearing and serial radiographs
. Prophylactic intramedullary nailing of the femur
. Open biopsy to rule out a metastatic lesion
. Core decompression of the femoral head

Correct Answer & Explanation

. Prophylactic intramedullary nailing of the femur

Explanation

This patient has an impending atypical femur fracture associated with long-term bisphosphonate use. Because she has pain and an incomplete fracture line (the "dreaded black line") on the lateral cortex, prophylactic intramedullary nailing is indicated to prevent completion of the fracture.

Question 960

Topic: 2. Trauma
A 24-year-old male sustains a vertically oriented, displaced basicervical femoral neck fracture (Pauwels Type III) after a motorcycle collision. He is hemodynamically stable. Which of the following is the most appropriate surgical fixation construct to minimize the risk of shear-induced failure?
. Three parallel cancellous screws in an inverted triangle configuration
. Sliding hip screw with a derotation screw
. Proximal femoral intramedullary nail with a single recon screw
. Bipolar hemiarthroplasty
. Total hip arthroplasty

Correct Answer & Explanation

. Sliding hip screw with a derotation screw

Explanation

Pauwels Type III fractures are highly unstable due to significant vertical shear forces. A fixed-angle device, such as a sliding hip screw with an anti-rotation screw, provides superior biomechanical stability compared to multiple cancellous screws in young patients with preserved bone quality.

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