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2. Trauma MCQs

Practice Set 495 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 9881

Topic: Pelvic & Acetabular Trauma

A 4-year-old child with developmental dysplasia of the hip (DDH) is scheduled for an innominate osteotomy. Which of the following osteotomies hinges at the pubic symphysis to redirect the entire acetabulum, requiring a complete cut through the ilium from the sciatic notch to the anterior inferior iliac spine?

. Dega osteotomy
. Salter osteotomy
. Pemberton osteotomy
. Chiari osteotomy
. Shelf procedure

Correct Answer & Explanation

. Salter osteotomy

Explanation

The Salter osteotomy is a complete, redirectional transiliac cut that hinges at the pubic symphysis. In contrast, Pemberton and Dega are incomplete, volume-reducing osteotomies that hinge at the triradiate cartilage.

Question 9882

Topic: 2. Trauma

A 9-year-old boy weighing 55 kg (121 lbs) sustains a midshaft femoral fracture. The surgeon considers intramedullary fixation using titanium elastic nails (TENs). Which complication is most highly associated with this choice of implant in this specific patient compared to alternative fixation methods?

. Avascular necrosis of the femoral head
. Premature distal femoral physeal closure
. Loss of reduction and malunion
. Deep infection requiring implant removal
. Overgrowth of the femur exceeding 3 cm

Correct Answer & Explanation

. Loss of reduction and malunion

Explanation

Titanium elastic nails have significantly higher complication rates, specifically loss of reduction and coronal/sagittal malunion, in patients weighing over 50 kg. For heavier children, alternative methods like submuscular plating or rigid lateral-entry intramedullary nails are preferred.

Question 9883

Topic: 2. Trauma
A 21-year-old collegiate runner presents with bilateral exertional leg pain localized to the anterolateral aspect of the lower legs. Pain begins 15 minutes into a run and resolves after 30 minutes of rest. Intracompartmental pressure testing is ordered. According to the Pedowitz criteria, which of the following values confirms the diagnosis of chronic exertional compartment syndrome (CECS)?
. Pre-exercise resting pressure > 15 mm Hg
. 1-minute post-exercise pressure > 30 mm Hg
. 5-minute post-exercise pressure > 20 mm Hg
. 15-minute post-exercise pressure > 5 mm Hg
. A difference of > 10 mm Hg between the anterior and lateral compartments at rest

Correct Answer & Explanation

. 1-minute post-exercise pressure > 30 mm Hg

Explanation

The Pedowitz criteria for diagnosing chronic exertional compartment syndrome (CECS) require one or more of the following: 1) Pre-exercise resting pressure ≥ 15 mm Hg; 2) 1-minute post-exercise pressure ≥ 30 mm Hg; or 3) 5-minute post-exercise pressure ≥ 20 mm Hg.

Question 9884

Topic: Upper Extremity Trauma

A 27-year-old male sustains an acromioclavicular (AC) joint separation following a fall onto the point of his shoulder. Radiographs demonstrate 150% superior displacement of the clavicle relative to the acromion.

Regarding the coracoclavicular (CC) ligaments ruptured in this injury, which statement accurately reflects their anatomy and biomechanical function?

. The conoid ligament is anterolateral and primarily restrains anterior-posterior translation
. The trapezoid ligament is posteromedial and primarily restrains superior-inferior translation
. The conoid ligament is posteromedial and provides the primary restraint to superior-inferior translation
. The trapezoid ligament is posteromedial and provides the primary restraint to axial compression
. Both ligaments blend together identically to provide equal restraint against posterior translation of the distal clavicle

Correct Answer & Explanation

. The conoid ligament is posteromedial and provides the primary restraint to superior-inferior translation

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid ligament is located posteromedial and is the primary restraint to superior translation of the clavicle. The trapezoid ligament is located anterolateral and is the primary restraint to axial compression (resisting medial displacement of the scapula relative to the clavicle).

Question 9885

Topic: 2. Trauma

A 23-year-old collegiate basketball player sustains a fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction (Jones fracture).

He demands the quickest safe return to play. What is the current standard of care for a competitive athlete with an acute Jones fracture?

. Non-weight bearing short leg cast for 6 weeks
. Weight-bearing in a stiff-soled boot for 4 weeks
. Percutaneous intramedullary screw fixation
. Open reduction internal fixation with a lateral neutralization plate
. Excision of the proximal fragment and peroneus brevis advancement

Correct Answer & Explanation

. Percutaneous intramedullary screw fixation

Explanation

Acute Jones fractures (Zone II) in high-level competitive athletes are best treated with intramedullary screw fixation. This approach significantly decreases the time to clinical and radiographic union, decreases the nonunion rate, and allows for a much earlier return to play compared to conservative management.

Question 9886

Topic: 2. Trauma

A 28-year-old female sustains an elbow injury following an axial load combined with a varus stress. Imaging reveals a specific fracture pattern pathognomonic for varus posteromedial rotatory instability (VPMRI). Which anatomic structure is characteristically fractured in this injury mechanism?

. Anteromedial facet of the coronoid
. Tip of the coronoid process
. Base of the coronoid process
. Sublime tubercle of the ulna
. Lateral facet of the coronoid

Correct Answer & Explanation

. Anteromedial facet of the coronoid

Explanation

Varus posteromedial rotatory instability (VPMRI) typically results from an axial load combined with varus stress. It is characterized by a fracture of the anteromedial facet of the coronoid process and avulsion or rupture of the lateral collateral ligament (LCL) complex, often leading to rapid post-traumatic osteoarthritis if left unreduced.

Question 9887

Topic: Upper Extremity Trauma

A 26-year-old cyclist sustains a Type V acromioclavicular (AC) joint separation requiring surgical reconstruction. The surgeon plans to drill tunnels mimicking the native coracoclavicular (CC) ligaments. Which of the following accurately describes the anatomic relationship of the CC ligaments?

. The trapezoid is lateral and the conoid is medial
. The trapezoid is medial and the conoid is lateral
. Both ligaments attach strictly to the acromion
. The conoid inserts on the coracoid apex while the trapezoid inserts on the base
. The trapezoid blends seamlessly with the coracoacromial ligament

Correct Answer & Explanation

. The trapezoid is lateral and the conoid is medial

Explanation

The coracoclavicular (CC) ligaments consist of the lateral trapezoid ligament and the medial conoid ligament. The trapezoid attaches to the clavicle approximately 1.5-2.5 cm from the distal end, and the conoid attaches more medially, approximately 3.0-4.5 cm from the distal end.

Question 9888

Topic: 2. Trauma

A 78-year-old female with severe, long-standing rheumatoid arthritis sustains a comminuted distal humerus fracture. A linked (semi-constrained) total elbow arthroplasty (TEA) is planned. What is the primary biomechanical advantage of utilizing a linked prosthesis over an unlinked prosthesis in this scenario?

. It relies heavily on intact medial and lateral collateral ligaments
. It requires perfect anatomic preservation of the radial head
. It acts as a completely unconstrained surface replacement
. It allows for dynamic stabilization exclusively via the triceps
. It provides intrinsic stability and prevents dislocation in cases of severe ligamentous insufficiency

Correct Answer & Explanation

. It provides intrinsic stability and prevents dislocation in cases of severe ligamentous insufficiency

Explanation

A linked (semi-constrained) TEA features a mechanical linkage between the humeral and ulnar components, providing intrinsic stability. This is highly advantageous in patients with poor bone stock or deficient collateral ligaments (such as in severe rheumatoid arthritis or trauma), preventing postoperative dislocation.

Question 9889

Topic: 2. Trauma

A 32-year-old male sustains a simple transverse fracture of the olecranon and undergoes tension band wiring. Which of the following biomechanical principles correctly describes how this construct facilitates fracture healing?

. It relies purely on static intramedullary fixation to bypass the fracture site
. It converts tensile forces at the posterior cortex into dynamic compression forces at the articular surface during elbow flexion
. It acts as a bridge plate, providing relative stability to promote secondary bone healing
. It prevents anterior translation of the radial head by overriding the coronoid fossa
. It utilizes absolute stability via interfragmentary lag screw fixation exclusively

Correct Answer & Explanation

. It converts tensile forces at the posterior cortex into dynamic compression forces at the articular surface during elbow flexion

Explanation

The tension band wiring technique is ideal for simple transverse olecranon fractures. It follows the biomechanical principle of placing the implant on the tension side (the posterior cortex). As the triceps pulls during elbow flexion, the tensile distraction forces are converted by the wire into dynamic compression forces across the anterior articular surface.

Question 9890

Topic: 2. Trauma
A 45-year-old female presents after a fall with a complex elbow fracture. Advanced imaging identifies a coronal shear fracture that involves the capitellum and extends medially to include most of the trochlea. According to the modified Bryan and Morrey classification (McKee modification), what type of fracture is this?
. Hahn-Steinthal fracture (Type I)
. Kocher-Lorenz fracture (Type II)
. Broberg-Morrey fracture (Type III)
. McKee modification (Type IV)
. Osborne-Cotterill fracture

Correct Answer & Explanation

. McKee modification (Type IV)

Explanation

In the Bryan and Morrey classification for capitellum fractures: Type I is a large osseous piece (Hahn-Steinthal), Type II is a sleeve of cartilage with minimal bone (Kocher-Lorenz), and Type III is comminuted. McKee added the Type IV fracture, which is a massive coronal shear fracture encompassing the capitellum and extending medially to involve the majority of the trochlea.

Question 9891

Topic: 2. Trauma

A 24-year-old motorcyclist is involved in a high-speed collision and presents with massive soft tissue swelling around the shoulder girdle. AP chest radiograph shows severe lateral displacement of the scapula relative to the spinous processes and a widely displaced clavicle fracture. Examination shows a pulseless, flail upper extremity. In the setting of this suspected scapulothoracic dissociation, what is the most reliable prognostic indicator for long-term functional recovery of the limb?

. The rapidity of vascular surgical revascularization
. The degree of lateral scapular displacement on initial radiographs
. The severity of the concomitant brachial plexus injury
. The ability to primarily close the soft tissue defects
. The anatomic reduction of the displaced clavicle

Correct Answer & Explanation

. The severity of the concomitant brachial plexus injury

Explanation

Scapulothoracic dissociation is a devastating, high-energy injury characterized by lateral displacement of the scapula and is highly associated with severe vascular (subclavian/axillary artery) and neurological injuries. While vascular injury is an acute limb-threatening emergency, the long-term functional outcome of the limb is almost entirely dependent on the severity of the brachial plexus injury (often complete avulsion), which dictates whether the limb will function or remain a flail, insensate appendage.

Question 9892

Topic: 2. Trauma

A 22-year-old male is involved in a high-speed motorcycle collision. On examination, he has massive swelling over the shoulder girdle and a complete lack of motor and sensory function in his left upper extremity. Radiographs demonstrate marked lateral displacement of the scapula. Which radiographic parameter is most strongly predictive of a major vascular injury in this condition?

. A complete acromioclavicular (AC) joint separation
. A scapulothoracic index greater than 1.07
. The presence of a displaced middle-third clavicle fracture
. Fracture of the coracoid process base
. Inferior displacement of the glenoid > 2 cm

Correct Answer & Explanation

. A scapulothoracic index greater than 1.07

Explanation

This patient has scapulothoracic dissociation, a devastating injury involving closed disruption of the scapulothoracic articulation. The normal scapulothoracic ratio (index) is 1.0. A scapulothoracic ratio greater than 1.07 indicates significant lateral displacement of the scapula and correlates strongly with severe brachial plexus injuries and major vascular trauma (subclavian or axillary artery tears) requiring emergent surgical exploration.

Question 9893

Topic: Upper Extremity Trauma

A 45-year-old male loses his footing and falls directly onto a flexed elbow. He is unable to actively extend his elbow against gravity, and a palpable gap is felt posteriorly. During operative repair of this distal triceps tendon rupture, understanding the native footprint is crucial. Which of the following describes the normal anatomic insertion of the triceps tendon on the olecranon?

. A narrow transverse band immediately adjacent to the proximal articular margin
. A V-shaped insertion blending completely with the anconeus fascia on the lateral ulna
. A broad, dome-shaped area approximately 1.1 to 1.4 cm distal to the tip of the olecranon
. A dual insertion with the medial head attaching to the sublime tubercle and the lateral head to the supinator crest
. A single discrete circular footprint exactly at the apogee of the olecranon process

Correct Answer & Explanation

. A broad, dome-shaped area approximately 1.1 to 1.4 cm distal to the tip of the olecranon

Explanation

Anatomic studies demonstrate that the triceps tendon does not insert precisely at the tip of the olecranon. The footprint is broad and dome-shaped, beginning approximately 1.1 to 1.4 cm distal to the tip of the olecranon. Repairing the tendon to the absolute tip can lead to prominent hardware and abnormal kinematics.

Question 9894

Topic: 2. Trauma
A 6-year-old child presents after a fall from monkey bars. Radiographs reveal a fracture of the proximal third of the ulnar diaphysis with an anterior dislocation of the radial head. According to the Bado classification, what type of Monteggia lesion is this, and what is the classically described mechanism of injury?
. Bado Type I; a hyperpronation injury of the forearm
. Bado Type II; an axial load on a flexed elbow
. Bado Type III; a direct lateral blow to the ulna
. Bado Type IV; a severe hyperextension injury
. Bado Type I; a direct varus force on a supinated forearm

Correct Answer & Explanation

. Bado Type I; a hyperpronation injury of the forearm

Explanation

The Bado classification categorizes Monteggia fracture-dislocations based on the direction of radial head dislocation. Type I (most common) is an anterior radial head dislocation with an anteriorly angulated ulnar fracture. The classically described mechanism for a Type I lesion is an excessive forced hyperpronation injury (or hyperextension).

Question 9895

Topic: 2. Trauma

A 35-year-old male sustains a closed, extra-articular fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). On initial presentation in the emergency department, examination reveals a complete radial nerve palsy. According to current orthopaedic guidelines, what is the most appropriate initial management for the nerve palsy in this specific scenario?

. Immediate open exploration of the radial nerve with concurrent ORIF of the humerus
. Observation of the nerve palsy and initial conservative management of the fracture with a functional brace
. Immediate EMG and nerve conduction studies to confirm the severity of axonal injury
. Ultrasound-guided diagnostic nerve block to reduce local muscle spasms
. Emergent external fixation of the humerus to prevent progressive nerve tethering

Correct Answer & Explanation

. Observation of the nerve palsy and initial conservative management of the fracture with a functional brace

Explanation

In the setting of a closed humeral shaft fracture, even a Holstein-Lewis type, presenting with a primary radial nerve palsy, the standard of care remains initial observation of the nerve and conservative fracture management (e.g., coaptation splint transitioning to a functional brace). Most palsies are neuropraxias that will resolve spontaneously. Immediate exploration is indicated for open fractures, severe vascular compromise, or if the nerve palsy developsafterclosed reduction attempts (secondary palsy).

Question 9896

Topic: 2. Trauma

A 24-year-old motorcyclist is brought to the trauma bay after a high-speed collision. He presents with massive swelling over the shoulder girdle and a pulseless, flail upper extremity. Radiographs show significant lateral displacement of the scapula relative to the thoracic spine and an intact clavicle. Which of the following associated injuries is the most critical determinant of the long-term functional salvageability of this limb?

. Subclavian artery transaction
. Complete avulsion of the brachial plexus roots
. Fracture of the coracoid process
. Rupture of the rhomboid and trapezius muscle insertions
. Ipsilateral multiple rib fractures

Correct Answer & Explanation

. Complete avulsion of the brachial plexus roots

Explanation

This patient has a scapulothoracic dissociation, a severe injury caused by a massive lateral traction force resulting in complete disruption of the scapulothoracic articulation. It is highly associated with severe vascular (subclavian artery) and neurologic injuries. While vascular injury can often be repaired with a bypass graft, complete avulsion of the brachial plexus roots is a devastating, irreversible injury that leaves the arm completely flail and insensate. The severity of the brachial plexus injury is the primary prognostic factor for limb salvage, often ultimately necessitating early forequarter amputation if the plexus is avulsed.

Question 9897

Topic: 2. Trauma

A 65-year-old female sustains a 4-part proximal humerus fracture. Which of the following radiographic findings is the strongest predictor of ensuing humeral head ischemia according to Hertel criteria?

. Calcar length less than 8 mm attached to the articular segment
. Disruption of the lateral hinge
. Greater tuberosity displacement greater than 1 cm
. Head-split fracture pattern
. Varus angulation greater than 45 degrees

Correct Answer & Explanation

. Calcar length less than 8 mm attached to the articular segment

Explanation

According to Hertel et al., a metaphyseal calcar length of < 8 mm attached to the articular segment, a disrupted medial hinge, and a basicervical fracture pattern are the most accurate predictors of ischemia. Of these, a calcar length < 8 mm has the highest positive predictive value for avascular necrosis.

Question 9898

Topic: Upper Extremity Trauma

During the surgical reconstruction of a chronic type V acromioclavicular (AC) joint separation, the surgeon reconstructs the coracoclavicular (CC) ligaments. The native conoid ligament inserts on the clavicle at what distance from the distal clavicle, and what is its primary biomechanical role?

. 4.5 cm / Resists anterior translation
. 4.5 cm / Resists superior translation
. 4.5 cm / Resists axial compression
. 2.5 cm / Resists posterior translation
. 2.5 cm / Resists superior translation

Correct Answer & Explanation

. 4.5 cm / Resists superior translation

Explanation

The conoid ligament inserts approximately 4.5 cm medial to the distal clavicle and primarily resists superior translation of the clavicle. The trapezoid ligament inserts more distally (approximately 2.5 cm) and primarily resists axial compression.

Question 9899

Topic: Upper Extremity Trauma

A 19-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft. Which bundle of the native UCL is the primary restraint to valgus stress between 30 and 120 degrees of flexion, and where does it insert?

. Anterior bundle / Sublime tubercle
. Posterior bundle / Sublime tubercle
. Transverse bundle / Olecranon
. Anterior bundle / Coronoid tip
. Posterior bundle / Radial neck

Correct Answer & Explanation

. Anterior bundle / Sublime tubercle

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress from 30 to 120 degrees of elbow flexion. It originates on the medial epicondyle and inserts on the sublime tubercle located on the anteromedial coronoid facet.

Question 9900

Topic: 2. Trauma

A 45-year-old male develops severe heterotopic ossification (HO) and elbow stiffness following a distal humerus fracture treated with ORIF 6 months ago. His ROM is currently 60 to 90 degrees. What is the optimal timing and prerequisite for surgical excision of the HO?

. At 3 months regardless of radiographic appearance
. When serum alkaline phosphatase normalizes and a bone scan is cold
. Once the HO demonstrates mature trabecular patterns on radiographs and range of motion has plateaued
. Immediate excision followed by single-dose radiation
. Wait a minimum of 24 months post-injury

Correct Answer & Explanation

. Once the HO demonstrates mature trabecular patterns on radiographs and range of motion has plateaued

Explanation

Current guidelines recommend excising heterotopic ossification when mature trabecular bone is seen on radiographs and clinical range of motion has plateaued, typically around 6 months post-injury. Waiting for a normal alkaline phosphatase level or a 'cold' bone scan is no longer considered necessary and can unnecessarily delay beneficial surgery.

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