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 10441
Topic: 2. Trauma
In the evaluation and surgical planning of a displaced intra-articular calcaneus fracture, the Sanders classification is highly prognostic. This classification is primarily based on the number of articular fracture lines and their location on which specific imaging view?
Correct Answer & Explanation
. Lateral radiograph of the foot measuring Bohler's angle
Explanation
The Sanders classification is the most widely used system for intra-articular calcaneus fractures. It dictates prognosis and guides treatment. It is based solely on the number and location of primary fracture lines extending through the posterior articular facet, evaluated on the coronal CT image that demonstrates the widest dimension of the posterior facet of the calcaneus.
Question 10442
Topic: 2. Trauma
A 45-year-old male sustains an isolated scapula body fracture with involvement of the extra-articular glenoid neck after a high-speed fall. Which of the following radiographic parameters is a generally accepted indication for operative internal fixation of an extra-articular scapular neck fracture?
Correct Answer & Explanation
. Glenopolar angle of 40 degrees
Explanation
The glenopolar angle (GPA) is a measure of rotational deformity of the glenoid fragment in scapular neck fractures. The normal GPA is 30 to 45 degrees. A GPA of less than 22 degrees signifies severe rotational displacement and is associated with poor functional outcomes (e.g., impingement and altered rotator cuff mechanics), making it a strong indication for operative fixation. Other indications include medial/lateral translation > 20 mm and angular deformity > 45 degrees.
Question 10443
Topic: 2. Trauma
A 32-year-old female presents with a closed spiral fracture of the distal third of the humeral shaft resulting from a fall. On physical examination, she is unable to actively extend her wrist or her metacarpophalangeal joints. What is the most appropriate initial management of this injury?
Correct Answer & Explanation
. Immediate surgical exploration of the radial nerve with open reduction and internal fixation
Explanation
A distal third spiral humeral shaft fracture (Holstein-Lewis fracture) is frequently associated with a primary radial nerve palsy. However, in a closed fracture setting, this does not mandate immediate surgical exploration. The radial nerve neuropraxia in this scenario has a spontaneous recovery rate approaching 90%. The standard initial management is conservative fracture care with a coaptation splint or Sarmiento functional bracing, and observation for nerve recovery over 3-6 months. EMG is typically reserved for cases showing no clinical improvement at 6-12 weeks.
Question 10444
Topic: 2. Trauma
A 29-year-old female falls onto an outstretched hand and sustains a coronal shear fracture of the capitellum that extends medially to include a large portion of the trochlea (McKee modification of Bryan and Morrey Type IV). What is the optimal surgical approach to address this specific, complex fracture pattern?
Correct Answer & Explanation
. Medial approach to the elbow
Explanation
Coronal shear fractures of the distal humerus involving the capitellum and extending into the trochlea (Type IV) are best visualized and fixed using an extended lateral approach (e.g., utilizing the Kaplan or Kocher interval, extended proximally). This approach allows the anterior capsule to be elevated, providing excellent, direct visualization of the anterior articular surface of the distal humerus. This facilitates the accurate placement of anterior-to-posterior headless compression screws. Posterior approaches, including olecranon osteotomies, provide limited and poor visualization of the anterior coronal articular surface.
Question 10445
Topic: 2. Trauma
A 36-year-old male is struck by a heavy metal pipe on the forearm while defending himself. Radiographs reveal a displaced, short oblique fracture of the distal third of the radius with associated widening and disruption of the distal radioulnar joint (DRUJ). This specific injury pattern is best described as a:
Correct Answer & Explanation
. Monteggia fracture
Explanation
A Galeazzi fracture is defined as a fracture of the distal third of the radial shaft accompanied by a dislocation or severe subluxation of the distal radioulnar joint (DRUJ). Because of the deforming muscle forces (e.g., brachioradialis, pronator quadratus), it is an inherently unstable "fracture of necessity" in adults, requiring open reduction and internal fixation of the radius followed by intraoperative assessment and stabilization of the DRUJ. A Monteggia fracture involves the proximal third of the ulna with a radial head dislocation.
Question 10446
Topic: 2. Trauma
A 27-year-old man sustains a severe open tibia fracture following a motorcycle crash. Operative exploration reveals extensive soft tissue stripping, muscle necrosis, and a large segmental soft tissue defect over the anterior leg with exposed, devascularized bone. The vascular surgeon confirms that distal pulses are palpable and major arteries are intact, but the orthopedic and plastic surgeons agree that a free muscle flap will be required for adequate coverage. According to the Gustilo-Anderson classification, what is the grade of this open fracture?
Correct Answer & Explanation
. Type IIIB
Explanation
A Gustilo-Anderson Type IIIB fracture is defined as a high-energy open fracture with extensive soft-tissue injury, severe periosteal stripping, and bone exposure, which cannot be closed primarily and requires a local rotational or free soft-tissue transfer (flap) for coverage. Type IIIA implies extensive lacerations but adequate local soft tissue to cover the fractured bone without requiring a flap. Type IIIC involves an arterial injury that mandates vascular repair to salvage the limb, regardless of the soft tissue defect size.
Question 10447
Topic: 2. Trauma
A 55-year-old female presents with a displaced intra-articular fracture of the distal radius. Radiographs demonstrate a fracture characterized by a volar marginal articular fragment (involving the lunate facet) that has displaced proximally and volarly along with the entire carpus. Which of the following internal fixation constructs is biomechanically optimal to prevent loss of reduction of this specific, highly unstable fragment?
Correct Answer & Explanation
. Dorsal spanning plate
Explanation
This injury describes a volar Barton fracture, which is a volar marginal shear fracture of the distal radius. The volar fragment is pulled proximally by the strong volar radiocarpal ligaments, carrying the carpus with it. This pattern is notoriously unstable. The most biomechanically sound fixation is a volar plate that acts as a physical buttress against the shear forces. Modern volar locking plates, placed as distally as possible (often just proximal to the watershed line) to capture and support the small volar lunate facet fragment, provide the most stable construct to prevent volar subluxation of the carpus.
Question 10448
Topic: 2. Trauma
A 34-year-old male is brought to the trauma bay after a severe high-speed motor vehicle collision. He has closed, bilateral comminuted femoral shaft fractures, a grade III spleen laceration, pulmonary contusions, and a moderate traumatic brain injury. His admission labs show a lactate of 5.5 mmol/L, pH of 7.20, and a base excess of -8. Under the principles of Damage Control Orthopedics (DCO), what is the most appropriate initial orthopedic management for his bilateral femur fractures?
Correct Answer & Explanation
. Rapid application of bilateral spanning external fixators
Explanation
This polytrauma patient is physiologically unstable (often termed 'borderline' or 'in extremis') as evidenced by severe metabolic acidosis (pH < 7.24, base excess < -5.5), high lactate, and concurrent major torso and brain injuries. He is a poor candidate for Early Total Care (ETC) with intramedullary nailing, as the prolonged surgery, blood loss, and medullary canal pressurization can cause a 'second hit' phenomenon, exacerbating ARDS, coagulopathy, and secondary brain injury. Damage Control Orthopedics (DCO) dictates the rapid, temporary stabilization of major long bone fractures with external fixators to mitigate ongoing hemorrhage and systemic inflammatory response, allowing the patient to be resuscitated in the ICU.
Question 10449
Topic: 2. Trauma
A 35-year-old male sustains a high-energy trauma resulting in a distal femur fracture. CT scan reveals a coronal plane fracture of the lateral femoral condyle. Which of the following is the most appropriate surgical approach and fixation strategy for this specific fracture pattern?
Correct Answer & Explanation
. Medial parapatellar approach, anterior-to-posterior lag screws
Explanation
A coronal plane fracture of the femoral condyle is known as a Hoffa fracture. It most commonly affects the lateral condyle. The standard treatment is anatomic reduction and rigid internal fixation, typically achieved via a lateral approach. Interfragmentary lag screws are usually placed from anterior to posterior to compress the fragment, as this avoids the articular surface of the posterior condyle.
Question 10450
Topic: 2. Trauma
A 45-year-old man presents with a subtrochanteric femoral fracture. The proximal fragment is typically flexed, abducted, and externally rotated. Which muscle group is primarily responsible for the external rotation of the proximal fragment?
Correct Answer & Explanation
. Iliopsoas
Explanation
In a subtrochanteric fracture, the proximal fragment is acted upon by several deforming forces: it is flexed by the iliopsoas, abducted by the gluteus medius and minimus, and externally rotated by the short external rotators (piriformis, superior/inferior gemelli, obturator internus/externus, and quadratus femoris). The distal fragment is pulled proximally and medially by the adductors.
Question 10451
Topic: Pelvic & Acetabular Trauma
A 28-year-old female is brought to the ED after a motor vehicle collision. She is hemodynamically unstable. A pelvic binder is applied. Radiographs show a widened symphysis pubis > 2.5 cm and disruption of the anterior sacroiliac ligaments, but intact posterior sacroiliac ligaments. According to the Young-Burgess classification, what type of injury is this, and what is the most common primary source of bleeding?
Correct Answer & Explanation
. APC II, venous plexus
Explanation
Anterior Posterior Compression (APC) II injuries involve symphyseal widening > 2.5 cm with disruption of the anterior SI ligaments, sacrotuberous, and sacrospinous ligaments, but the posterior SI ligaments remain intact, providing vertical stability but rotational instability. The primary source of life-threatening hemorrhage in pelvic fractures, especially open book types, is the presacral venous plexus, though arterial bleeding can also occur.
Question 10452
Topic: 2. Trauma
A 32-year-old man sustained a talar neck fracture 8 weeks ago. He is being followed up in the clinic. Radiographs reveal a subchondral radiolucent band in the dome of the talus. What does this finding (Hawkins sign) indicate?
Correct Answer & Explanation
. Impending avascular necrosis
Explanation
The Hawkins sign is a subchondral radiolucent band seen in the talar dome on an AP or mortise radiograph 6 to 8 weeks post-injury. It indicates subchondral atrophy due to hyperemia, confirming that the talar body has an intact blood supply and that avascular necrosis (AVN) is highly unlikely.
Question 10453
Topic: 2. Trauma
A 24-year-old male sustains a closed tibial shaft fracture. Two hours post-admission, he complains of severe pain out of proportion to the injury. On examination, pain is exacerbated by passive stretch of the toes. Intracompartmental pressure testing is performed. Which of the following pressure readings is the most widely accepted absolute indication for a four-compartment fasciotomy?
Correct Answer & Explanation
. Absolute intracompartmental pressure > 20 mmHg
Explanation
The most reliable and widely accepted parameter for diagnosing acute compartment syndrome and indicating the need for fasciotomy is a Delta P < 30 mmHg. Delta P is calculated as the patient's diastolic blood pressure minus the measured intracompartmental pressure. Relying on an absolute pressure value can lead to unnecessary fasciotomies in hypotensive patients or missed diagnoses in hypertensive patients.
Question 10454
Topic: 2. Trauma
A 30-year-old male presents with a closed, isolated spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). On examination, he is unable to extend his wrist or fingers. What is the most appropriate initial management for the nerve injury?
Correct Answer & Explanation
. Immediate surgical exploration and nerve repair
Explanation
A primary radial nerve palsy in the setting of a closed humeral shaft fracture (including Holstein-Lewis fractures) is generally a neuropraxia. The most appropriate initial management is conservative treatment of the fracture (e.g., coaptation splint followed by functional bracing) and observation of the nerve function. Nerve recovery is typically seen within 3 to 4 months. If no clinical or EMG signs of recovery are present by 3-4 months, surgical exploration is indicated.
Question 10455
Topic: 2. Trauma
A 42-year-old female pedestrian is struck by a car. Radiographs of her knee show a split-depression fracture of the lateral tibial plateau. According to the Schatzker classification, what is the type of this fracture?
Correct Answer & Explanation
. Type II
Explanation
The Schatzker classification organizes tibial plateau fractures. Type I is a pure split of the lateral plateau (typically seen in younger patients with strong cancellous bone). Type II is a split-depression fracture of the lateral plateau. Type III is a pure central depression of the lateral plateau (typically seen in older, osteoporotic patients). Type IV involves the medial plateau. Type V is a bicondylar fracture. Type VI includes metaphyseal-diaphyseal dissociation.
Question 10456
Topic: 2. Trauma
A 50-year-old man is involved in a high-speed MVC. AP pelvis and Judet views show an acetabular fracture.
The obturator oblique view shows disruption of the iliopectineal line, and the iliac oblique view shows an intact ilioischial line. Which of the following fracture patterns is most consistent with these radiographic findings?
Correct Answer & Explanation
. Posterior column fracture
Explanation
In the Judet radiographic evaluation of the acetabulum, the obturator oblique view highlights the anterior column (iliopectineal line) and the posterior wall. The iliac oblique view highlights the posterior column (ilioischial line) and the anterior wall. Disruption of the iliopectineal line with an intact ilioischial line indicates an isolated anterior column fracture.
Question 10457
Topic: 2. Trauma
A 28-year-old male motorcyclist sustains an open midshaft tibial fracture. The wound is 12 cm long with extensive soft tissue stripping and visible muscle necrosis, but there is adequate periosteal coverage and the soft tissue can be approximated without a flap. According to the Gustilo-Anderson classification, what is the grade of this open fracture?
Correct Answer & Explanation
. Grade IIIA
Explanation
Gustilo-Anderson Grade IIIA involves a high-energy trauma with extensive soft-tissue laceration (typically >10 cm) and adequate bone coverage. Despite the extensive soft tissue damage, stripping, and high energy mechanism, the key distinguishing factor from Grade IIIB is that there is adequate periosteal coverage, and local or free flaps are not required for wound closure.
Question 10458
Topic: 2. Trauma
A 22-year-old man falls on an outstretched hand. He has anatomic snuffbox tenderness. Radiographs show a fracture through the proximal pole of the scaphoid. This fracture is at high risk of avascular necrosis (AVN). Which of the following best describes the primary blood supply to the scaphoid?
Correct Answer & Explanation
. Palmar branches of the radial artery entering distally and supplying retrograde
Explanation
The primary blood supply to the scaphoid (approx. 70-80%) comes from the dorsal carpal branch of the radial artery, which enters the bone at the dorsal ridge near the distal pole and waist. This vascular network flows in a retrograde fashion to supply the proximal pole. Thus, fractures at the waist or proximal pole disrupt this supply, putting the proximal pole at a high risk for AVN and nonunion.
Question 10459
Topic: 2. Trauma
A 45-year-old male falls from a ladder and sustains a high-energy tibial pilon fracture with severe soft tissue swelling and fracture blisters. What is the most appropriate initial management?
Correct Answer & Explanation
. Immediate open reduction and internal fixation (ORIF) with a medial plate
Explanation
High-energy pilon fractures are associated with significant soft tissue compromise. Immediate ORIF carries a very high risk of wound breakdown and deep infection. The standard of care is a staged approach: initial application of a spanning external fixator (with or without fibular fixation) to restore length and alignment while allowing the soft tissues to recover, followed by definitive ORIF once the soft tissue envelope permits (e.g., wrinkle sign present), usually at 10-21 days.
Question 10460
Topic: 2. Trauma
A 6-year-old boy falls off monkey bars. Radiographs show a fracture of the proximal third of the ulna with an associated dislocation of the radial head. According to the Bado classification, what is the most common type of Monteggia fracture-dislocation?
Correct Answer & Explanation
. Type I: Anterior dislocation of the radial head with anterior angulation of the ulnar fracture
Explanation
Bado Type I is the most common type of Monteggia fracture-dislocation, accounting for approximately 60% of cases. It is characterized by an anterior dislocation of the radial head and a fracture of the ulnar diaphysis with anterior apex angulation. Bado II is posterior, Bado III is lateral, and Bado IV involves fractures of both forearm bones.
Test Yourself
Switch to an interactive, timed exam simulation to truly master this topic.