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2. Trauma MCQs

Practice Set 486 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 9701

Topic: 2. Trauma

How does a pure triceps avulsion fracture differ from a typical olecranon fracture in terms of surgical repair considerations?

. Triceps avulsion always requires plate fixation.
. Olecranon fracture typically requires reattachment of soft tissue to bone.
. Triceps avulsion requires reattachment of tendon to bone.
. Olecranon fracture often involves the articular surface, while triceps avulsion does not.
. Triceps avulsion is never seen in conjunction with olecranon fracture.

Correct Answer & Explanation

. Triceps avulsion requires reattachment of tendon to bone.

Explanation

A pure triceps avulsion (C) involves the detachment of the triceps tendon from its insertion on the olecranon, with or without a small bony fleck. Surgical repair focuses on reattaching the tendon to the bone, often using suture anchors or transosseous sutures. Olecranon fractures (B) typically involve fixing bone fragments to bone fragments, often impacting the articular surface (D). While an olecranon fracture can disrupt the triceps insertion, a 'pure' triceps avulsion is a distinct entity focusing on tendon repair. Plate fixation (A) is for bony comminution/instability, not pure tendon repair. Triceps avulsion can occur with olecranon fractures (E), but the question asks about the difference inrepair considerationsfor a 'pure' avulsion.

Question 9702

Topic: 2. Trauma

An 80-year-old, low-demand patient presents with a severely comminuted olecranon fracture that is difficult to reconstruct anatomically, and the bone quality is poor. What might be a pragmatic treatment option to consider?

. Anatomical reduction and plate fixation
. Tension band wiring
. Excision of comminuted fragments and triceps advancement
. Total elbow arthroplasty
. Prolonged immobilization in full extension

Correct Answer & Explanation

. Total elbow arthroplasty

Explanation

For severely comminuted, unreconstructable olecranon fractures in elderly, low-demand patients with poor bone quality, total elbow arthroplasty (D) can be a viable salvage option. It provides immediate stability and allows for early motion, circumventing the challenges of fixation in poor bone and potentially leading to better functional outcomes than a complex, likely failed, reconstruction in this demographic. Excision and triceps advancement (C) is an option for smaller, very distal fragments. Anatomical reduction and plate (A) or tension band wiring (B) are likely to fail due to poor bone quality and comminution. Prolonged immobilization (E) would lead to severe stiffness.

Question 9703

Topic: 2. Trauma

A patient undergoes successful plate fixation of a comminuted olecranon fracture. What is the primary purpose of routine radiographic follow-up appointments in the first few weeks to months post-surgery?

. To assess for hardware prominence and plan for removal.
. To check for early signs of post-traumatic arthritis.
. To confirm fracture union and monitor for loss of reduction.
. To evaluate ulnar nerve decompression.
. To measure heterotopic ossification severity.

Correct Answer & Explanation

. To confirm fracture union and monitor for loss of reduction.

Explanation

The primary purpose of routine radiographic follow-up (C) in the early post-operative period is to confirm that the fracture remains reduced and fixed, and to monitor for signs of healing (union). Loss of reduction or fixation failure would necessitate further intervention. While other options (A, B, E) are considerations, they are typically secondary or longer-term assessments. Ulnar nerve decompression (D) is a clinical assessment, not primarily radiographic.

Question 9704

Topic: 2. Trauma

In a patient with an olecranon fracture, if intra-articular step-off or gap is present, which treatment option is generally mandated for optimal long-term outcome, especially in an active adult?

. Sling immobilization for 4 weeks
. Long arm cast immobilization for 6-8 weeks
. Open reduction and internal fixation (ORIF)
. Fragment excision without reconstruction
. Functional bracing with early motion

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF)

Explanation

Any significant intra-articular step-off or gap (typically >2mm) in an olecranon fracture mandates open reduction and internal fixation (ORIF) (C) for optimal long-term outcome, especially in an active adult. This is critical to restore articular congruity, reduce the risk of post-traumatic arthritis, and allow for early rehabilitation. Non-operative management (A, B) is appropriate only for non-displaced or minimally displaced fractures. Fragment excision (D) is reserved for very small, non-reconstructible fragments in low-demand patients. Functional bracing (E) is used post-fixation, not as primary treatment for displaced intra-articular fractures.

Question 9705

Topic: Upper Extremity Trauma

The vascular supply to the olecranon is primarily from branches of which artery?

. Brachial artery
. Radial artery
. Ulnar artery
. Posterior interosseous artery
. Anterior interosseous artery

Correct Answer & Explanation

. Ulnar artery

Explanation

The vascular supply to the olecranon and proximal ulna is robust, primarily deriving from a periosteal network fed by recurrent branches of the ulnar artery (C), specifically the posterior ulnar recurrent artery, and to a lesser extent, the interosseous arteries. The brachial (A) artery is more proximal, and radial (B) artery branches are more lateral/distal.

Question 9706

Topic: 2. Trauma

Which of the following describes the typical appearance of a stable olecranon fracture on a lateral radiograph after fixation with tension band wiring?

. Proximal fragment distracted by triceps pull.
. Absence of Kirschner wires across the fracture site.
. A 'figure-of-eight' wire loop providing compression across the fracture line.
. Evidence of joint subluxation or dislocation.
. Screws extending into the elbow joint.

Correct Answer & Explanation

. A 'figure-of-eight' wire loop providing compression across the fracture line.

Explanation

Tension band wiring involves Kirschner wires placed longitudinally across the fracture and a 'figure-of-eight' wire loop (C) that converts the tensile force of the triceps into compression across the fracture site, ensuring stability. Distraction (A) would indicate failure. Absence of wires (B) would mean no fixation. Joint subluxation (D) or intra-articular screws (E) are complications or malfixation.

Question 9707

Topic: 2. Trauma

A patient sustained an olecranon fracture due to a fall, and a palpable defect is noted. What immediate action is paramount to prevent further soft tissue damage and reduce pain before definitive treatment?

. Perform vigorous range of motion exercises.
. Apply hot compresses to the elbow.
. Administer strong oral opioids and discharge.
. Immobilize the elbow in a comfortable position, typically 30-45 degrees of flexion.
. Attempt a closed reduction without imaging.

Correct Answer & Explanation

. Immobilize the elbow in a comfortable position, typically 30-45 degrees of flexion.

Explanation

Immobilizing the elbow in a comfortable position (D), typically around 30-45 degrees of flexion where the triceps tension is minimized, is paramount. This prevents further soft tissue damage, reduces pain, and protects neurovascular structures until definitive treatment. Vigorous range of motion (A) and attempting closed reduction without imaging (E) are harmful. Hot compresses (B) are inappropriate for acute trauma. Discharging with just opioids (C) without proper immobilization is negligent.

Question 9708

Topic: 2. Trauma

A patient presents with an olecranon fracture that is comminuted and involves a significant portion of the trochlear notch. What specific post-operative complication is of highest concern for this patient, even with good fixation?

. Radial head subluxation
. Distal radioulnar joint instability
. Ulnar neuropathy
. Post-traumatic arthritis
. Hardware failure

Correct Answer & Explanation

. Post-traumatic arthritis

Explanation

When a comminuted olecranon fracture involves a significant portion of the trochlear notch (the articular surface), there is a high risk of residual articular incongruity, even with meticulous fixation. This articular disruption is the most significant predisposing factor for the development of post-traumatic arthritis (D) due to increased contact pressures and cartilage degeneration. While ulnar neuropathy (C) and hardware failure (E) are common complications, post-traumatic arthritis is a direct consequence of intra-articular injury and is of high concern for long-term function. Radial head subluxation (A) and DRUJ instability (B) are associated with other specific injury patterns (e.g., Essex-Lopresti).

Question 9709

Topic: 2. Trauma

What type of olecranon fracture typically results from a sudden, forceful contraction of the triceps brachii muscle against resistance (e.g., attempting to break a fall)?

. Highly comminuted fracture
. Transverse fracture at the base of the olecranon
. Avulsion fracture of the olecranon tip
. Oblique fracture extending into the ulna shaft
. Impaction fracture

Correct Answer & Explanation

. Avulsion fracture of the olecranon tip

Explanation

A sudden, forceful contraction of the triceps brachii muscle against resistance can cause an avulsion fracture of the olecranon tip (C), where the triceps tendon pulls off a fragment of bone. Highly comminuted fractures (A) and impaction fractures (E) are more common with direct trauma. Transverse (B) or oblique (D) fractures can occur from various mechanisms but a pure 'avulsion' mechanism is most typical for the tip fragment under triceps pull.

Question 9710

Topic: 2. Trauma

In an active individual, what is the minimum acceptable goal for elbow range of motion (flexion-extension arc) following rehabilitation from an olecranon fracture?

. 0-150 degrees
. 30-130 degrees
. 60-120 degrees
. 90-110 degrees
. Full extension and flexion

Correct Answer & Explanation

. 30-130 degrees

Explanation

While full extension and flexion (E) is ideal, a functional range of motion for most activities of daily living is generally considered to be 30 to 130 degrees of flexion-extension (B). Achieving this range is a realistic and acceptable goal after complex elbow trauma such as an olecranon fracture, balancing stability and mobility. Less than 30 degrees of extension loss or 130 degrees of flexion loss would significantly impair function.

Question 9711

Topic: 2. Trauma
In a patient with an open Gustilo-Anderson Type IIIA both bones forearm fracture, what is the most appropriate immediate definitive management strategy after initial debridement and stabilization?
. Application of a long arm cast after wound closure.
. Open reduction and internal fixation (ORIF) with dual plates.
. Application of an external fixator with delayed definitive fixation.
. Flexible intramedullary nailing of both bones.
. Serial debridement and delayed primary closure, followed by casting.

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) with dual plates.

Explanation

For Gustilo-Anderson Type IIIA open both bones forearm fractures, immediate definitive internal fixation with plates is generally recommended after thorough debridement. Unlike Type IIIB or IIIC, where external fixation might be used initially due to massive soft tissue loss, Type IIIA has adequate soft tissue coverage for internal fixation. This approach aims to achieve stable osteosynthesis, allowing for early soft tissue coverage and rehabilitation. Casting is inadequate for open, unstable diaphyseal fractures. Flexible intramedullary nailing is primarily for children. Serial debridement is necessary for high-grade open fractures, but the question asks about definitive management after initial debridement, implying stable fixation should be pursued.

Question 9712

Topic: 2. Trauma

Which complication is most commonly associated with intramedullary nailing of both bones forearm fractures in adults, making it generally less preferred than plating?

. Delayed union
. Synostosis
. Loss of rotational stability and malunion
. Deep infection
. Prominent hardware requiring removal

Correct Answer & Explanation

. Loss of rotational stability and malunion

Explanation

Intramedullary nailing of both bones in adults, while offering less soft tissue stripping, often results in loss of rotational stability and a higher incidence of rotational malunion (Option C). The cylindrical shape of the intramedullary nail provides poor rotational control, especially in the forearm where precise alignment between the radius and ulna is crucial for pronation/supination. Plating offers superior rotational control. Delayed union (Option A), deep infection (Option D), and prominent hardware (Option E) can occur with both methods, but rotational instability/malunion is a specific drawback of IM nailing in the adult forearm. Synostosis (Option B) is primarily a plating complication.

Question 9713

Topic: 2. Trauma

A 10-year-old boy presents with a Greenstick fracture of both radius and ulna at the mid-diaphysis. There is 15 degrees of volar angulation but otherwise acceptable alignment. What is the most appropriate management?

. Immediate ORIF with flexible IM nails.
. Complete the fracture and then cast.
. Closed reduction and long-arm cast without completing the fracture.
. Surgical observation and serial radiographs.
. Application of a short-arm cast.

Correct Answer & Explanation

. Complete the fracture and then cast.

Explanation

For a Greenstick fracture with acceptable alignment but significant angulation (e.g., >10-15 degrees in older children, or any angulation that could lead to functional impairment), it is often necessary to complete the fracture (Option B) under anesthesia to allow for full reduction and stability, followed by casting. Simply casting with residual angulation (Option C) can lead to malunion, especially in older children where remodeling is less. Immediate ORIF (Option A) is typically for unstable, irreducible, or highly displaced fractures. Observation (Option D) is inappropriate, and a short-arm cast (Option E) is insufficient for forearm shaft fractures.

Question 9714

Topic: 2. Trauma

What is the primary role of the interosseous membrane in the context of both bones forearm fractures?

. Primary blood supply to the radius and ulna.
. Site of attachment for pronator quadratus.
. Acts as a ligamentous stabilizer, transferring load between radius and ulna.
. Facilitates smooth gliding between the two bones during rotation.
. Houses the anterior interosseous nerve.

Correct Answer & Explanation

. Acts as a ligamentous stabilizer, transferring load between radius and ulna.

Explanation

The interosseous membrane (IOM) acts as a crucial ligamentous stabilizer (Option C), transferring axial load from the radius to the ulna and providing stability against longitudinal and rotational forces. Its integrity is vital for maintaining the relative positions of the radius and ulna, especially during forearm rotation. Disruption of the IOM (e.g., in Essex-Lopresti injuries) leads to severe instability. While the pronator quadratus attaches distally (Option B), and the AIN lies on it (Option E), its primarybiomechanicalrole in fracture context is stabilization and load transfer. It's not a primary blood supply (Option A) and doesn't facilitate gliding (Option D).

Question 9715

Topic: 2. Trauma

A 50-year-old male undergoes ORIF of both bones forearm fractures. Post-operatively, he develops progressive swelling, pain, and limited finger extension. Neurological examination reveals weakness in wrist flexion and thumb interphalangeal joint flexion, with sensory loss in the index finger pulp. Which compartment syndrome is most likely?

. Superficial volar compartment
. Deep volar compartment
. Dorsal compartment
. Mobile wad compartment
. Combined dorsal and volar compartments

Correct Answer & Explanation

. Deep volar compartment

Explanation

The symptoms described are consistent with anterior interosseous nerve (AIN) compromise (weakness in wrist flexion via FPL, FDP to index/middle, and pronator quadratus) and median nerve sensory deficit, which are hallmark signs of deep volar compartment syndrome (Option B). The deep volar compartment contains the FDP, FPL, and pronator quadratus muscles, and the median and AIN nerves. The superficial volar compartment primarily affects the superficial flexors (FDS, FCR, FCU, palmaris longus). Dorsal compartment issues primarily affect extensors. Mobile wad involves brachioradialis, ECRL, ECRB.

Question 9716

Topic: 2. Trauma

Which of the following describes the preferred plate application technique for most simple diaphyseal forearm fractures to achieve rigid fixation and promote primary bone healing?

. Neutralization plating.
. Bridge plating.
. Compression plating.
. Buttress plating.
. Lag screw fixation.

Correct Answer & Explanation

. Compression plating.

Explanation

Compression plating (Option C) is the preferred technique for most simple, transverse or short oblique diaphyseal forearm fractures. It involves applying axial compression across the fracture site using dynamic compression plates (DCP) or limited contact dynamic compression plates (LC-DCP), promoting primary bone healing. Neutralization plating (Option A) protects lag screws. Bridge plating (Option B) is used for comminuted fractures without direct fracture site compression. Buttress plating (Option D) is for metaphyseal fractures to prevent shear or collapse. Lag screw fixation (Option E) is a component that can be used with a plate but is not the sole technique.

Question 9717

Topic: 2. Trauma

A 38-year-old male with a 4-month-old mid-shaft radius non-union after prior failed non-operative management presents with pain and forearm stiffness. There is no evidence of infection. What is the most appropriate management strategy?

. Continue with conservative management and physiotherapy.
. Bone graft stimulation via percutaneous injection.
. Open reduction, rigid internal fixation with plate and screws, and bone grafting.
. Application of an external fixator with bone transport.
. Conversion to intramedullary nail with reaming.

Correct Answer & Explanation

. Open reduction, rigid internal fixation with plate and screws, and bone grafting.

Explanation

For an established non-union of the radial shaft in an adult, particularly with symptoms, open reduction, rigid internal fixation with a plate and screws, and bone grafting (Option C) is the gold standard. Bone grafting provides osteoinductive and osteoconductive properties to stimulate healing. Intramedullary nailing (Option E) is generally less favored for adult forearm non-unions due to rotational stability issues. External fixation (Option D) might be considered for infected non-unions or significant bone loss. Conservative management (Option A) has failed, and percutaneous stimulation (Option B) is usually for delayed unions or hypertrophic non-unions without significant bone loss.

Question 9718

Topic: 2. Trauma

Which specific nerve injury is most commonly associated with a Monteggia fracture-dislocation?

. Median nerve
. Ulnar nerve
. Radial nerve
. Posterior interosseous nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The posterior interosseous nerve (PIN) (Option D) is the most commonly injured nerve in Monteggia fracture-dislocations. The PIN is a motor branch of the radial nerve and can be stretched or entrapped during the anterior dislocation of the radial head, leading to weakness or paralysis of wrist and finger extensors. The radial nerve (Option C) itself can be injured, but specifically the PIN branch is more frequently implicated.

Question 9719

Topic: 2. Trauma

A 14-year-old active adolescent sustains a closed, highly comminuted mid-diaphyseal both bones forearm fracture. Non-operative management is unlikely to succeed. What is the most appropriate surgical intervention?

. Flexible intramedullary nailing of both bones.
. Open reduction and internal fixation (ORIF) with dual plates and screws.
. External fixation with eventual conversion to internal fixation.
. Bone grafting and casting.
. Observation with functional bracing.

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) with dual plates and screws.

Explanation

For a highly comminuted mid-diaphyseal forearm fracture in an adolescent, especially if unstable, open reduction and internal fixation with dual plates and screws (Option B) is the most appropriate treatment. While FIN (Option A) is excellent for simple pediatric fractures, it offers less stability for comminuted fractures in older, larger adolescents where remodeling potential is decreasing. Plating provides the rigid anatomical fixation needed for these complex fractures. External fixation (Option C) is typically reserved for open fractures or severe soft tissue compromise. Bone grafting (Option D) might be an adjunct, but not the primary fixation. Observation (Option E) is inappropriate for comminuted, unstable fractures.

Question 9720

Topic: 2. Trauma

What characteristic differentiates a Galeazzi fracture-dislocation from a both bones forearm fracture?

. Fracture of both radius and ulna.
. Associated nerve injury.
. Fracture of the distal radius with associated distal radioulnar joint (DRUJ) dislocation.
. Fracture near the elbow joint.
. Open wound over the fracture site.

Correct Answer & Explanation

. Fracture of the distal radius with associated distal radioulnar joint (DRUJ) dislocation.

Explanation

A Galeazzi fracture-dislocation (Option C) is specifically defined as a fracture of the distal or mid-shaft radius with an associated dislocation or subluxation of the distal radioulnar joint (DRUJ). This contrasts with a simple 'both bones forearm fracture' where both the radius and ulna are fractured along their shafts, but the DRUJ may or may not be involved in a specific dislocating pattern. Options A, B, D, E can occur with either type of fracture.

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