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2. Trauma MCQs

Practice Set 542 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 10821

Topic: 2. Trauma

Which of the following radiographic parameters is the most reliable predictor of humeral head ischemia following a complex proximal humerus fracture, according to the Hertel criteria?

. Greater tuberosity displacement > 1 cm
. Metaphyseal head extension (calcar length) < 8 mm
. Angulation of the surgical neck > 45 degrees
. Shortening of the surgical neck > 10 mm
. Comminution of the lesser tuberosity

Correct Answer & Explanation

. Greater tuberosity displacement > 1 cm

Explanation

According to Hertel et al., the most reliable radiographic predictors of humeral head ischemia (and subsequent avascular necrosis) following a proximal humerus fracture are: 1) a metaphyseal head extension (calcar length) of less than 8 mm, 2) disruption of the medial hinge, and 3) an anatomic neck fracture pattern. These findings suggest disruption of the ascending branch of the anterior humeral circumflex artery and the intraosseous collateral blood supply.

Question 10822

Topic: Upper Extremity Trauma

During an anatomic coracoclavicular (CC) ligament reconstruction for a chronic type V acromioclavicular joint dislocation, the surgeon plans to drill the clavicle to recreate the conoid and trapezoid ligaments. Which of the following accurately describes the anatomic relationship of these ligaments?

. The conoid is anterolateral to the trapezoid
. The conoid is posteromedial to the trapezoid
. The conoid inserts 25 mm from the distal clavicle
. The trapezoid is a cord-like structure while the conoid is flat and broad
. Both ligaments originate from the medial aspect of the coracoid process

Correct Answer & Explanation

. The conoid is anterolateral to the trapezoid

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid ligaments. The conoid is the posteromedial structure, inserting roughly 45 mm from the distal clavicle. The trapezoid is anterolateral to the conoid and inserts roughly 25 mm from the distal end of the clavicle. Knowledge of this anatomy is crucial for anatomic tunnel placement during reconstruction.

Question 10823

Topic: 2. Trauma

A 25-year-old male is brought to the trauma bay after a high-speed motorcycle collision. His left upper extremity is pulseless, pale, and flail. Chest radiograph shows significant lateral displacement of the left scapula relative to the spine and a displaced clavicle fracture. What is the most critical next step in management?

. Immediate open reduction of the clavicle fracture
. Exploration of the brachial plexus
. CT angiogram of the left upper extremity
. Chest tube insertion for hemopneumothorax
. Closed reduction and spica casting

Correct Answer & Explanation

. Immediate open reduction of the clavicle fracture

Explanation

The patient is presenting with scapulothoracic dissociation, a severe, high-energy injury characterized by lateral displacement of the scapula. It is highly associated with devastating vascular (subclavian or axillary artery) and neurologic (brachial plexus avulsion) injuries. Given the pulseless limb, immediate vascular assessment with a CT angiogram is the most critical next step, often followed by emergent revascularization or amputation depending on viability.

Question 10824

Topic: 2. Trauma

Which of the following radiographic or demographic characteristics is most strongly associated with an increased risk of nonunion in conservatively managed midshaft clavicle fractures?

. Male sex
. Fracture shortening greater than 20 mm
. Age under 30 years
. Associated rib fractures
. Oblique fracture pattern without comminution

Correct Answer & Explanation

. Male sex

Explanation

Risk factors for nonunion of midshaft clavicle fractures treated nonoperatively include completely displaced fractures, shortening > 20 mm (2 cm), significant comminution (such as a Z-deformity), advanced age, and female sex. Fracture shortening > 20 mm is a widely accepted relative indication for operative fixation to decrease nonunion rates and improve functional outcomes.

Question 10825

Topic: 2. Trauma

A 35-year-old male sustains a direct blow to the shoulder and presents with anterior shoulder pain. Imaging reveals a fracture of the coracoid process base extending into the superior glenoid. According to the Ogawa classification, which type of fracture is this, and what is the typical management?

. Type 1; typically managed nonoperatively
. Type 1; typically managed with open reduction internal fixation (ORIF)
. Type 2; typically managed nonoperatively
. Type 2; typically managed with open reduction internal fixation (ORIF)
. Type 3; typically managed with fragment excision

Correct Answer & Explanation

. Type 1; typically managed nonoperatively

Explanation

Ogawa Type 1 fractures occur proximal to the coracoclavicular (CC) ligaments (at the base of the coracoid). Because they disrupt the connection between the clavicle and the scapula (especially if associated with AC injuries) or involve the glenoid articular surface, they destabilize the superior shoulder suspensory complex and often require ORIF when displaced. Type 2 fractures are distal to the CC ligaments and are typically treated nonoperatively.

Question 10826

Topic: 2. Trauma

A 65-year-old female falls on her outstretched hand and sustains a displaced proximal humerus fracture. Which of the following radiographic findings (Hertel criteria) is considered the strongest predictor for the development of avascular necrosis (AVN) of the humeral head?

. Medial hinge disruption > 2 mm and calcar length < 8 mm
. Tuberosity displacement > 5 mm
. Fracture of the greater tuberosity
. Valgus angulation > 45 degrees
. Lesser tuberosity fracture with medial translation

Correct Answer & Explanation

. Medial hinge disruption > 2 mm and calcar length < 8 mm

Explanation

Hertel identified specific criteria that predict ischemia and subsequent AVN following proximal humerus fractures. The strongest predictors include a metaphyseal head extension (calcar length) of less than 8 mm, an intact medial hinge of less than 2 mm (thus a disruption >2 mm is a poor prognostic factor), and an anatomic neck fracture pattern.

Question 10827

Topic: 2. Trauma
A 35-year-old cyclist falls directly onto his shoulder and sustains a distal clavicle fracture. Radiographs show a fracture line medial to the coracoclavicular (CC) ligaments, with the proximal fragment displaced superiorly. The CC ligaments remain attached to the distal fragment. Which Neer classification type is this, and what is the expected nonunion rate if treated non-operatively?
. Type I; less than 5%
. Type IIA; up to 30%
. Type IIB; less than 5%
. Type III; up to 30%
. Type IV; 100%

Correct Answer & Explanation

. Type IIA; up to 30%

Explanation

The scenario describes a Neer Type IIA distal clavicle fracture, where the fracture is medial to the CC ligaments, and both the conoid and trapezoid ligaments remain intact on the distal fragment. The proximal fragment is displaced superiorly by the pull of the trapezius. Type II fractures are highly unstable and carry a high nonunion rate (up to 30-45%) with non-operative management. Surgical fixation is generally recommended.

Question 10828

Topic: Pelvic & Acetabular Trauma

A 19-year-old rugby player sustains a lateral compression injury to his shoulder. He presents to the ER with shortness of breath, a hoarse voice, and severe pain at the medial end of the clavicle. A CT scan confirms a posterior sternoclavicular joint dislocation. What is the most appropriate next step in management?

. Immediate open reduction through a standard anterior approach by an orthopedic surgeon alone
. Closed reduction under procedural sedation in the emergency department with posterior traction
. Closed reduction in the operating room under general anesthesia with a cardiothoracic surgeon on standby
. Sling immobilization and delayed reconstruction after 6 weeks to allow for tissue healing
. CT angiogram followed by discharge if vascular injury is excluded

Correct Answer & Explanation

. Immediate open reduction through a standard anterior approach by an orthopedic surgeon alone

Explanation

Posterior sternoclavicular (SC) joint dislocations are true orthopedic emergencies due to the proximity of mediastinal structures (trachea, esophagus, great vessels). Symptoms like dyspnea or dysphagia indicate compression. Management consists of urgent closed reduction (often using a towel clip on the clavicle with posterior/lateral traction) in the operating room under general anesthesia, with a cardiothoracic surgeon readily available in case of catastrophic vascular injury upon reduction.

Question 10829

Topic: 2. Trauma

Which of the following radiographic parameters is an accepted indication for operative fixation of an extra-articular scapular body or neck fracture?

. Medial/lateral displacement of 10 mm
. Glenopolar angle of 45 degrees
. Angulation of 15 degrees
. Glenopolar angle less than 22 degrees
. Presence of a nondisplaced coracoid fracture

Correct Answer & Explanation

. Medial/lateral displacement of 10 mm

Explanation

Operative indications for scapula body and neck fractures include severe deformity that compromises shoulder mechanics. Accepted criteria include medial/lateral translation (displacement) > 20 mm, angulation > 45 degrees, or a glenopolar angle (GPA) < 22 degrees. The normal GPA is between 30 and 45 degrees. A decreased GPA indicates an inferomedial tilting of the glenoid.

Question 10830

Topic: Upper Extremity Trauma
A 22-year-old football player sustains a direct blow to the point of his shoulder. Radiographs demonstrate an acromioclavicular (AC) joint injury. The clavicle is displaced posteriorly into or through the trapezius fascia, with normal coracoclavicular distance on the AP view but obvious posterior displacement on the axillary lateral view. Which Rockwood classification type is this?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type IV

Explanation

In the Rockwood classification of AC joint injuries, Type IV is characterized by posterior displacement of the distal clavicle into or through the trapezius muscle/fascia. This may not be obvious on a standard AP radiograph, making the axillary lateral view crucial. Type V is severe superior displacement (>100%), and Type VI is inferior displacement (subcoracoid).

Question 10831

Topic: 2. Trauma
An isolated fracture of the coracoid process is most commonly treated non-operatively. However, surgical fixation may be indicated in the presence of an associated fracture of the acromion or distal clavicle. This combination disrupts a critical anatomical ring that provides stability to the upper extremity. What is this structural concept called?
. Superior shoulder suspensory complex (SSSC)
. Coracoacromial arch
. Glenohumeral capsuloligamentous complex
. Quadrilateral space
. Rotator interval

Correct Answer & Explanation

. Superior shoulder suspensory complex (SSSC)

Explanation

The Superior Shoulder Suspensory Complex (SSSC) is a bony/soft tissue ring composed of the glenoid, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromion. A single disruption (e.g., isolated coracoid fracture) is stable. A 'double disruption' (e.g., coracoid fracture + distal clavicle fracture or acromion fracture) creates instability of the SSSC and is generally an indication for surgical fixation of at least one of the lesions to restore stability.

Question 10832

Topic: 2. Trauma

A 26-year-old male is brought to the emergency department following a high-speed motorcycle collision. He is hypotensive with a systolic BP of 80 mmHg. Laboratory results show a serum lactate of 4.8 mmol/L, a base deficit of -9, and a core temperature of 34.5°C. Radiographs reveal bilateral severely comminuted midshaft femur fractures. What is the most appropriate initial skeletal management?

. Bilateral antegrade reamed intramedullary nailing
. Unilateral antegrade intramedullary nailing and contralateral external fixation
. Bilateral spanning external fixation
. Bilateral distal femoral skeletal traction
. Bilateral retrograde unreamed intramedullary nailing

Correct Answer & Explanation

. Bilateral antegrade reamed intramedullary nailing

Explanation

This patient is in extremis based on the 'lethal triad' parameters and markers of poor perfusion (lactate > 4.0 mmol/L, base deficit < -8, hypothermia). According to Damage Control Orthopedics (DCO) principles, early total care (ETC) with reamed intramedullary nailing is contraindicated as it may exacerbate the systemic inflammatory response and lead to ARDS or multi-organ failure. The most appropriate initial management is rapid temporary stabilization with bilateral external fixation.

Question 10833

Topic: Pelvic & Acetabular Trauma
A hemodynamically unstable 35-year-old male presents after a crush injury. An AP radiograph of the pelvis demonstrates a symphyseal diastasis of 4 cm and disruption of the anterior sacroiliac ligaments. You decide to apply a circumferential pelvic binder to aid in resuscitation. To maximize its biomechanical efficacy in reducing pelvic volume, the binder should be centered precisely over which of the following anatomic landmarks?
. Anterior superior iliac spines (ASIS)
. Iliac crests
. Greater trochanters
. Pubic symphysis
. Ischial tuberosities

Correct Answer & Explanation

. Greater trochanters

Explanation

Circumferential pelvic binders are critical in the acute resuscitation of patients with unstable pelvic ring injuries (e.g., APC II or III). To effectively close the pelvic ring and reduce the intrapelvic volume, the binder must be centered over the greater trochanters. Placing the binder too proximally (over the iliac crests or ASIS) is a common error that can paradoxically widen the pelvic outlet or fail to reduce the diastasis.

Question 10834

Topic: 2. Trauma

A 40-year-old male sustains an ipsilateral displaced femoral neck fracture and a comminuted midshaft femur fracture. Which of the following is the most appropriate surgical strategy and sequence to minimize complications?

. Fixation of the femoral shaft with an antegrade nail, followed by the neck with cannulated screws
. Fixation of the femoral shaft with a retrograde nail, followed by the neck with a dynamic hip screw
. Fixation of the femoral neck with cannulated screws or a dynamic hip screw first, followed by the shaft with a retrograde nail
. Simultaneous fixation of both using a standard reconstruction nail utilizing a piriformis entry point
. Temporary external fixation of the shaft, followed by hemiarthroplasty of the hip

Correct Answer & Explanation

. Fixation of the femoral shaft with an antegrade nail, followed by the neck with cannulated screws

Explanation

In ipsilateral femoral neck and shaft fractures, the priority is anatomic reduction and stable fixation of the femoral neck to minimize the risk of avascular necrosis and nonunion. Fixing the femoral neck first prevents further displacement of the neck fracture during the manipulation and reaming required for shaft fixation. A common and highly successful approach is to fix the neck with cannulated screws or a DHS, followed by a retrograde intramedullary nail for the shaft.

Question 10835

Topic: 2. Trauma

A 30-year-old pedestrian is struck by a vehicle and sustains a severe open tibia fracture. After initial debridement, a 6 cm bone defect is present in the middle third of the tibial diaphysis with exposed bone devoid of periosteum.

Which of the following local muscle flaps is most appropriate for soft tissue coverage of this specific defect?

. Medial gastrocnemius rotational flap
. Lateral gastrocnemius rotational flap
. Soleus rotational flap
. Gracilis free flap
. Sural artery fasciocutaneous flap

Correct Answer & Explanation

. Medial gastrocnemius rotational flap

Explanation

For soft tissue coverage of the lower extremity, the leg is classically divided into thirds. The proximal third is best covered by the gastrocnemius flap (medial > lateral). The middle third is best covered by the soleus rotational flap. The distal third typically requires a free tissue transfer (e.g., latissimus dorsi, gracilis, ALT) due to the lack of adequate local muscle bulk, although reverse sural flaps can sometimes be used.

Question 10836

Topic: Lower Extremity Trauma

A 45-year-old male sustains a severe valgus stress injury to the knee, resulting in a Schatzker IV tibial plateau fracture with significant posteromedial depression. You plan a posteromedial surgical approach. The standard internervous/intermuscular plane for this approach is developed between which of the following structures?

. Semimembranosus and semitendinosus
. Medial head of the gastrocnemius and the pes anserinus
. Tibialis posterior and flexor digitorum longus
. Sartorius and gracilis
. Popliteus and soleus

Correct Answer & Explanation

. Semimembranosus and semitendinosus

Explanation

The posteromedial approach to the tibial plateau is critical for reducing and buttressing posteromedial shear fragments. The surgical interval is developed between the medial head of the gastrocnemius (retracted posteriorly/laterally) and the pes anserinus tendons (semitendinosus, gracilis, sartorius; retracted anteriorly/medially). Care must be taken to protect the saphenous nerve and great saphenous vein.

Question 10837

Topic: 2. Trauma

A 24-year-old male sustains a closed comminuted tibial shaft fracture. Eight hours post-injury, he complains of intractable pain out of proportion to the injury. His blood pressure is 110/70 mmHg. The intracompartmental pressure of the anterior compartment is measured at 45 mmHg. What is his Delta P, and is a fasciotomy definitively indicated?

. Delta P is 25 mmHg; Fasciotomy is indicated
. Delta P is 65 mmHg; Fasciotomy is not indicated
. Delta P is 35 mmHg; Fasciotomy is indicated
. Delta P is 25 mmHg; Fasciotomy is not indicated
. Delta P is 65 mmHg; Fasciotomy is indicated

Correct Answer & Explanation

. Delta P is 25 mmHg; Fasciotomy is indicated

Explanation

Delta P is calculated as Diastolic Blood Pressure minus Intracompartmental Pressure (Diastolic BP - ICP). In this patient, 70 mmHg - 45 mmHg = 25 mmHg. A Delta P of 30 mmHg or less is widely accepted as an absolute indication for emergency four-compartment fasciotomy, as capillary perfusion pressure is inadequate to prevent ischemic muscle necrosis.

Question 10838

Topic: 2. Trauma

When utilizing a modern distal femoral locking plate for a comminuted metaphyseal distal femur fracture, the surgeon decides to leave several screw holes empty in the plate directly over the fracture site. What is the primary biomechanical advantage of increasing this 'working length'?

. Increases the absolute stiffness of the construct, promoting primary bone healing
. Decreases the risk of plate pullout from the diaphysis
. Decreases construct stiffness, allowing interfragmentary strain that promotes secondary bone healing
. Increases the pullout strength of the distal locking screws in osteoporotic bone
. Prevents cold welding of the locking screws to the plate

Correct Answer & Explanation

. Increases the absolute stiffness of the construct, promoting primary bone healing

Explanation

In bridge plating of comminuted fractures with locking plates, absolute rigidity can lead to nonunion due to inadequate mechanical stimulation (too little strain). Increasing the 'working length' (the span of plate without screws across the fracture) decreases the overall stiffness of the construct. This allows for controlled micromotion at the fracture site (increasing interfragmentary strain into the optimal window), which robustly stimulates callus formation and secondary bone healing.

Question 10839

Topic: 2. Trauma

A 55-year-old female presents with a high-energy closed distal tibia (Pilon) fracture.

The limb is grossly swollen with fracture blisters developing. A spanning ankle external fixator is applied in the emergency department. Definitive open reduction and internal fixation (ORIF) is planned. What is the most reliable clinical indicator that the soft tissues are amenable to definitive surgical incisions?

. Resolution of all fracture blisters
. Erythrocyte sedimentation rate (ESR) returning to normal
. Appearance of skin wrinkles on the anterior and medial ankle
. A waiting period of exactly 14 days
. Negative wound cultures from the blister beds

Correct Answer & Explanation

. Resolution of all fracture blisters

Explanation

The classic and most reliable clinical sign that swelling has sufficiently subsided to safely perform incisions for Pilon fractures (and other severe periarticular lower extremity trauma like calcaneus fractures) is the 'wrinkle sign'. This refers to the reappearance of normal skin lines and wrinkles when the ankle is dorsiflexed or passively manipulated. This typically occurs between 10 and 21 days post-injury.

Question 10840

Topic: 2. Trauma

A 75-year-old female sustains a 3-part proximal humerus fracture.

According to the Hertel criteria, which of the following radiographic findings is most highly predictive of subsequent ischemia and avascular necrosis of the humeral head?

. A medial metaphyseal hinge of greater than 2 mm
. An anatomic neck fracture pattern with a calcar segment shorter than 8 mm
. Displacement of the greater tuberosity by 5 mm
. A surgical neck angulation of 25 degrees
. Presence of a longitudinal diaphyseal split

Correct Answer & Explanation

. A medial metaphyseal hinge of greater than 2 mm

Explanation

Hertel described specific criteria predicting ischemia of the humeral head after proximal humerus fractures. The strongest predictors of ischemia are: 1) A calcar length (metaphyseal extension attached to the head) of less than 8 mm, 2) Disruption of the medial metaphyseal hinge, and 3) An anatomic neck fracture pattern. An intact medial hinge (>2 mm) is a predictor of maintained perfusion.

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